Drug Interactions between digoxin and sunitinib

MONITOR: There is clinical evidence that sunitinib can prolong the PR interval of the electrocardiogram in some patients. Theoretically, coadministration with other agents that prolong the PR interval (e.g., beta blockers, calcium channel blockers, atazanavir, lopinavir, digoxin, lacosamide, mefloquine) may result in additive effects and increased risk of conduction disturbances and atrioventricular block. In a phase I clinical study of patients with advanced solid tumors who received sunitinib 150 mg on days 3 and 9 and 50 mg on days 4 to 8, mean placebo-adjusted changes in the PR interval were positive at all time points, with the maximum increase occurring 7 to 12 hours postdose, followed by a decline at 24 hours. Outlier analyses for the PR interval (>200 msec) showed a shift toward a higher proportion of outliers in patients treated with sunitinib. Excessive PR interval prolongation can result in AV block. On days 3 and 9, heart rate decreased progressively over the 24-hour period following sunitinib dosing, but was not affected by the positive control. During the study, an event of bradycardia occurred that was considered treatment-related, and dizziness was experienced by 7 of 48 patients. Bradycardia and AV block are recognized risk factors for torsade de pointes arrhythmia. Because sunitinib can also cause QTc prolongation, particular concerns exist with respect to its proarrhythmic potential.

MANAGEMENT: Caution is advised if sunitinib is used concomitantly with other agents that prolong the PR interval, especially in the elderly and patients with known conduction problems (e.g., marked first-degree AV block; second-degree or higher AV block; sick sinus syndrome without pacemaker) or severe cardiac disease such as myocardial ischemia or heart failure. Patients should be advised to notify their doctor if they experience dizziness, lightheadedness, fainting, or irregular heartbeat.