SOTALOL HYDROCHLORIDE 40MG TABLETS
Active substance(s): SOTALOL HYDROCHLORIDE
NAME OF THE MEDICINAL PRODUCT
Sotalol Hydrochloride 40mg Tablets
QUALITATIVE AND QUANTITATIVE COMPOSITION
Each tablet contains Sotalol hydrochloride 40mg.
Excipient with known effect:
Each tablet contains 13.37mg of lactose (as lactose monohydrate).
For the full list of excipients, see section 6.1.
Tablets for oral administration.
White, round, biconvex tablets of diameter 5.4mm–5.6mm and height of 2.8mm3.0mm, marked “SOT” on one side.
Sotalol hydrochloride tablets are indicated for:
Ventricular arrhythmias: treatment of life-threatening ventricular tachyarrhythmias;
treatment of symptomatic non-sustained ventricular tachyarrhythmias.
Supraventricular arrythmias: prophylaxis of paroxysmal atrial tachycardia,
paroxysmal atrial fibrillation, paroxysmal A-V nodal re-entrant tachycardia,
paroxysmal A-V re-entrant tachycardia using accessory pathways, and paroxysmal
supraventricular tachycardia after cardiac surgery; maintenance of normal sinus
rhythm following conversion of atrial fibrillation or atrial flutter.
Posology and method of administration
The initiation of treatment or changes in dosage with Sotalol hydrochloride should
follow an appropriate medical evaluation including ECG control with measurement of
the corrected QT interval, and assessment of renal function, electrolyte balance, and
concomitant medications (see 4.4 Warnings and precautions).
As with other antiarrhythmic agents, it is recommended that Sotalol hydrochloride be
initiated and doses increased in a facility capable of monitoring and assessing cardiac
rhythm. The dosage must be individualized and based on the patient’s response.
Proarrhytbmic events can occur not only at initiation of therapy, but also with each
upward dosage adjustment.
In view of its β-adrenergic blocking properties, treatment with Sotalol hydrochloride
should not be discontinued suddenly, especially in patients with ischaemic heart
disease (angina pectoris, prior acute myocardial infarction) or hypertension, to
prevent exacerbation of the disease (see 4.4 Warnings).
The following dosing schedule can be recommended:
The initial dose is 80mg, administered in either one or two divided doses. Oral dosage
of Sotalol Hydrochloride 40mg Tablets should be adjusted gradually allowing 2-3
days between dosing increments in order to attain steady state and to allow
monitoring of QT intervals.
Most patients will respond to a daily dose of 160 – 320mg administered in two
divided doses at approximately 12 hour intervals. Some patients with life-threatening
refractory ventricular arrhythmias may require doses as high as 480 -640 mg/day.
These doses should be used under specialist supervision and should only be
prescribed when the potential benefit outweighs the increased risk of adverse events,
particularly proarrhythmias (see 4.4 Warnings).
Sotalol hydrochloride is not intended for administration to children.
Dosage in renally impaired patients
Because sotalol hydrochloride is excreted mainly in urine, the dosage should be
reduced when the creatinine clearance is less than 60 ml/min according to the
½ recommended Sotalol
¼ recommended Sotalol
The creatinine clearance can be estimated from serum creatinine by the Cockroft and
(140 – age) x weight (kg)
72 x serum creatinine (mg/dl)
idem x 0.85
When serum creatinine is given in μ mol/l, divide the value by 88.4 (1mg/dl = 88.4 μ
Dosage in hepatically impaired patients
No dosage adjustment is required in hepatically impaired patients.
Hypersensitivity to the active substance or to any of the excipients listed in section
Sotalol hydrochloride tablets are contraindicated in the following:
Evidence of sick sinus syndrome.
Second and third degree A – V heart block unless a functioning pacemaker is utilised.
Congenital or acquired long QT syndromes.
Torsades de Pointes.
Symptomatic sinus bradycardia.
Uncontrolled congestive heart failure.
Anaesthesia that produces myocardial depression.
Hypotension (except due to arrhythmia).
Raynaud’s phenomenon and severe peripheral circulatory disturbances.
History of chronic obstructive airway disease or bronchial asthma (a warning will
appear on the label).
Hypersensitivity to any of the components of the formulation.
Renal failure (creatinine clearance < 10 ml/min).
Special warnings and precautions for use
The safety and efficacy of sotalol hydrochloride 40mg tablets in children has not yet
No data are available.
Hypersensitivity to catecholamines is observed in patients withdrawn from betablocker therapy. Occasional cases of exacerbation of angina pectoris, arrhythmias and
myocardial infarction have been reported after abrupt discontinuation of therapy.
Patients should be carefully monitored when discontinuing chronically administered
sotalol hydrochloride, particularly those with ischaemic heart disease. The dose
should, if possible, be gradually reduced over a period of one or two weeks, in
tandem with the initiation of any necessary replacement therapy. Abrupt
discontinuation of sotalol hydrochloride may unmask latent coronary insufficiency,
and hypertension may also develop.
The most dangerous adverse effect of Class I and Class III antiarrhythmic drugs (such
as sotalol hydrochloride) is the aggravation of pre-existing arrhythmias or the
provocation of new arrhythmias. Drugs that prolong the QT-interval may cause
torsades de pointes, a polymorphic ventricular tachycardia associated with
prolongation of the QT-interval. Experience to date indicates that the risk of torsades
de pointes is associated with the prolongation of the QT-interval, reduction of the
heart rate, reduction in serum potassium and magnesium, high plasma sotalol
concentrations and with the concomitant use of sotalol hydrochloride and other
medications which have been associated with torsades de pointes (see ‘Interaction
with other medicinal products and other forms of interaction’ section 4.5.)
Females may be at increased risk of developing torsades de pointes.
The incidence of torsades de pointes is dose dependent. Torsades de pointes, usually
occurs early after initiating therapy or escalation of the dose and can progress to
In clinical trials of patients with sustained VT/VF the incidence of severe
proarrhythmia (torsades de pointes or new sustained VT/VF) was <2% at doses up to
320mg. The incidence more than doubled at higher doses.
Other risk factors for torsades de pointes were excessive prolongation of the QTc and
history of cardiomegaly or congestive heart failure. Patients with substandard
ventricular tachycardia and a history of congestive heart failure have the highest risk
of serious proarrhythmia (7%). Proarrhythmic events must be anticipated not only on
initiating therapy but with every upward dose adjustment. Initiating therapy at 80mg
with gradual upward dose titration thereafter reduces the risk of proarrthymia. In
patients already receiving sotalol hydrochloride, caution should be used if the QTc
exceeds 500msec whilst on therapy, and serious consideration should be given to
dose reduction or discontinuation of therapy when the QTc –interval exceeds 550
msec. Due to multiple risk factors associated with torsades de pointes however,
caution should be exercised regardless of the QTc-interval.
Sotalol hydrochloride should not be used in patients with hypokalaemia or
hypomagnesaemia before correction of the imbalance, since conditions of this nature
can exaggerate the degree of QT prolongation and increase the potential for torsades
de pointes. Special attention should be given to electrolyte and acid-base balance in
patients experiencing severe or prolonged diarrhoea, or patients receiving
concomitant magnesium- and/or potassium-depleting drugs.
Congestive heart failure
Beta-blockade may further depress myocardial contractility and precipitate more
severe heart failure. Caution is advised when initiating therapy in patients with left
ventricular dysfunction controlled by therapy (i.e. ACE inhibitors, diuretics, digitalis
etc); a low initial dose and careful dose titration is appropriate.
Recent myocardial infarction
In post-infarction patients with impaired left ventricular function, the risk-versusbenefit of sotalol administration must be considered. Careful monitoring and dose
titration are critical during initiation and follow-up of therapy. Sotalol hydrochloride
should be avoided in patients with left ventricular ejection fractions < 40% without
serious ventricular arrhythmias.
Excessive prolongation of the QT-interval >500 msec can be a sign of toxicity and
should be avoided (see ‘Proarrhythmias’ section above). Sinus bradycardia has been
observed very commonly in arrhythmia patients receiving sotalol hydrochloride in
clinical trials. Bradycardia increases the risk of torsades de pointes. Sinus pause, sinus
arrest and sinus node dysfunction occur in less than 1% of patients. The incidence of
2nd- or 3rd-degree AV block is approximately 1%.
Patients with a history of anaphylactic reaction to a variety of allergens may have a
more severe reaction on repeated challenge while taking beta blockers, and may be
unresponsive to the usual doses of adrenaline used to treat allergic reaction.
As with other beta-blocking agents sotalol hydrochloride should be used with caution
in patients undergoing surgery, and in association with anaesthetics that cause
myocardial depression, such as cyclopropane or trichloroethylene (see ‘Interaction
with other medicinal products and other forms of interaction’ section 4.5.).
Caution should be exercised in patients with diabetes (especially labile diabetes) or
with a history of episodes of spontaneous hypoglycaemia, since beta-blockade may
mask some important signs of the onset of hypoglycaemia, e.g. tachycardia.
Beta-blockade may mask certain clinical signs of hyperthyroidism (e.g. tachycardia).
Patients suspected of developing thyrotoxicosis should be carefully managed to avoid
abrupt withdrawal of beta-blockade which might be followed by the exacerbation of
symptoms of hyperthyroidism, including thyroid storm.
As sotalol is mainly eliminated via the kidneys the dose should be adjusted in patients
with renal impairment (see ‘Posology and method of administration’ section 4.2.).
Beta-blocking drugs have been reported rarely to exacerbate the symptoms of
Patients with rare hereditary problems of galactose intolerance, the Lapp lactase
deficiency or glucose-galactose malabsorption should not take this medicine because
it contains lactose
Interaction with other medicinal products and other forms of interaction
Class IA antiarrhythmic drugs (e.g. disopyramide, quinidine and procainamide) and
other antiarrhythmics such as amiodarone and bepridil are not recommended for
concomitant therapy with sotalol hydrochloride because of their propensity to prolong
refractoriness (see section 4.4 Special Warning and precaution). Use of other betablockers with sotalol hydrochloride may result in additive Class II defects.
Other drugs prolonging the QT-interval
Use sotalol hydrochloride with great caution with drugs that prolong QT-interval such
as phenothiazines, pimozide, tricyclic antidepressants, terfenadine, mizolastine,
levacetylmethadol and astemizole. Drugs that have been associated with an increased
risk of torsades de pointes include erythromycin IV, halofantrine, pentamidine, and
Beta-adrenergic blocking agents may impede the compensatory cardiovascular
reactions associated with hypotension or shock that may be produced by floctafenine.
Calcium channel blockers
Simultaneous use of beta-blocking agents and calcium channel blockers, have
resulted in hypotension, bradycardia, conduction defects and cardiac failure.
Cardiodepressant calcium channel blockers such as verapamil and diltiazem
demonstrate additive effects on atrioventricular conduction and ventricular function,
Potassium – Depleting Diuretics:
Hypokalaemia or hypomagnesaemia may occur, increasing the potential for torsade
de pointes (see Special Warnings and Precautions for Use).
Other Potassium-depleting diuretics
amphotericin B (IV), corticosteroids (systemic administration) and some laxatives
(also potassium-depleting) may be associated with the hypokalemia. Potassiumlevels
should be monitored and corrected appropriately during concommitant administration
Beta-blocking drugs may potentiate the rebound hypertension sometimes observed
after the discontinuation of clonidine. Therefore the beta-blocker should be
discontinued slowly several days before the gradual withdrawal of clonidine.
Single and multiple doses of sotalol hydrochloride do not significantly affect serum
digoxin levels. Proarrhythmic events were more common in sotalol hydrochloride
treated patients also receiving digitalis glycosides; however, this may be related to the
presence of CHF, a known risk factor for proarrhythmia, in patients receiving digitalis
glycosides. Association of digitalis glycosides with beta-blockers may increase
auriculo-ventricular conduction time.
Concomitant use of catecholamine-depleting drugs, such as reserpine, guanethidine,
or alpha methyldopa, with a beta-blocker may produce an excessive reduction of
resting sympathetic nervous tone. Patients should be closely monitored for evidence
of hypotension and/or marked bradycardia which may produce syncope.
Insulin and oral hypoglycaemics
Hyperglycaemia may occur, and the dosage of antidiabetic drugs may require
adjustment. Symptoms of hypoglycaemia (tachycardia) may be masked by betablocking agents.
Neuromuscular blocking agents
Neuromuscular blockade is prolonged by beta-blocking agents.
Beta-2-receptor stimulants: Patients in need of beta-agonists should not normally
receive sotalol hydrochloride. However, if concomitant therapy is necessary betaagonists may have to be administered in increased dosages.
The presence of sotalol in the urine may result in falsely elevated levels of urinary
metanephrine, if measured photometrically. Patients being treated with sotalol
hydrochloride and suspected of having phaeochromocytoma should have their urine
screened by HPLC analysis with solid phase extraction.
Fertility, pregnancy and lactation
Animal studies with sotalol hydrochloride have shown no evidence of teratogenicity
or other harmful effects on the foetus. Although there are no adequate and wellcontrolled studies in pregnant women. sotalol hydrochloride has been shown to cross
the placenta and is found in amniotic fluid. Beta-blockers reduce placental perfusion,
which may result in intrauterine foetal death, immature and premature deliveries. In
addition, adverse effects, (especially hypoglycaemia and bradycardia), may occur in
the foetus and neonate. Therefore sotalol hydrochloride should be used in pregnancy
only if the potential benefits outweigh the possible risk to the foetus. . The neonate
should be monitored very carefully for 48 - 72 hours after delivery if it was not
possible to interrupt maternal therapy with Sotalol hydrochloride 2-3 days before the
Most beta-blockers, particularly lipophilic compounds, will pass into breast milk
although to a variable extent. Breast feeding is therefore not recommended during
administration of these compounds.
Effects on ability to drive and use machines
There are no data available but the occasional occurrence of side-effects such
as dizziness and fatigue should be taken into account (see section 4.8
The most frequent side effects arise from beta blockade properties. Adverse effects
are normally transient in nature and rarely necessitate interruption or withdrawal from
If they do occur, they usually disappear when the dosage is reduced. The most
significant adverse effects, however, are those due to proarrhythmia, including
torsades de pointes (See ‘Proarrhythmias’,’ Special warnings and precautions for
use’ section 4.4).
The following occur in 1% or more of patients treated with sotalol hydrochloride:
Cardiovascular: Bradycardia, dysponoea, chest pain, palpitations, oedema, ECG
abnormalities, hypotension, proarrhythmia, syncope, heart failure, presyncope.
Gastro-intestinal: Nausea/vomiting, diarrhoea, dyspepsia, abdominal pain,
Nervous/psychiatric: Fatigue, dizziness, asthenia, lightheadedness, headache, sleep
disturbances, depression, paresthesia, mood changes, anxiety.
Urogenital: Sexual dysfunction.
Special senses: Visual disturbances, taste abnormalities, hearing disturbances.
In trials of patients with cardiac arrhythmia, the most common adverse events leading
to discontinuation of sotalol hydrochloride were fatigue 4%, bradycardia (<50 bpm)
3%, dyspnoea 3%, proarrhythmia 2%, asthenia 2%, and dizziness 2%.
Cold and cyanotic extremities, Raynaud's phenomenon, increase in existing
intermittent claudication and dry eyes have been seen in association with other betablockers.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is
important. It allows continued monitoring of the benefit/risk balance of the medicinal
product. Healthcare professionals are asked to report any suspected adverse reactions
via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard
Intentional or accidental overdose with sotalol hydrochloride has rarely resulted in
The most common signs of sotalol overdose are bradycardia, congestive heart failure,
hypotension, bronchospasm and hypoglycaemia.
In patients who have taken large intentional overdoses (2-16g) hypotension,
bradycardia, prolongation of QT-interval, premature ventricular complexes,
ventricular tachycardia and torsades de pointes have been found.
Haemodialysis will assist in reduction of high plasma levels of sotalol.
If overdose occurs, therapy with sotalol hydrochloride should be discontinued and the
patient observed closely. In addition, if required, the following therapeutic measures
Bradycardia: Can be treated by atropine (0.5 to 2mg IV) administered intravenously,
and if need be isoprenaline (approximately 5 micrograms per minute, up to 25
microgram) by slow intravenous injection or transvenous cardiac pacing.
Heart block of second or third degree: Can be treated by transvenous cardiac pacing.
Hypotension: Adrenaline rather than isoprenaline or noradrenaline may be useful,
depending on associated factors.
Bronchospasm: Aminophylline or aerosol beta-2-receptor stimulant.
Torsades de Pointes: DC cardioversion, transvenous cardiac pacing, adrenaline and/or
Pharmacotherapeutic group: Anti- Estrogens
ATC Code: C07AA07
D,l-sotalol is a non-selective hydrophilic beta-adrenergic receptor blocking
agent, devoid of intrinsic sympathomimetic activity or membrane stabilizing
activity. Sotalol hydrochloride has both beta-adrenoreceptor blocking
(Vaughan Williams Class II) and cardiac action potential duration
prolongation (Vaughan Williams Class III) antiarrhythmic properties. Sotalol
hydrochloride has no known effect on upstroke velocity and therefore no
effect on the depolarisation phase..
Sotalol hydrochloride uniformly prolongs the action potential duration in
cardiac tissues by delaying the repolarisation phase. Its major effects are
prolongation of the atrial, ventricular and accessory pathway effective
The Class II and III properties may be reflected on the surface
electrocardiogram by a
lengthening of the PR, QT and QTC (QT corrected for heart rate) intervals
significant alteration in the QRS duration.
The d- and l-isomers of sotalol hydrochloride have similar Class III
antiarrhythmic effects while the
l-isomer is responsible for virtually all of the beta-blocking activity. Although
significant beta-blockade may occur at oral doses as low as 25 mg, Class III
are usually seen at daily doses of greater than 160 mg.
The beta-adrenergic activity in sotalol hydrochloride causes reduction in heart
rate (negative chronotropic effect) and a limited reduction in the force of
contraction (negative inotropic effect). These cardiac changes reduce
myocardial oxygen consumption and cardiac work.
Like other beta-blockers, sotalol hydrochloride inhibits renin release. The
renin-suppressive effect of sotalol hydrochloride is significant both at rest and
Like other beta-adrenergic blocking agents, sotalol hydrochloride produces a
gradual but significant reduction in both systolic and diastolic blood pressures
in hypertensive patients. 24 hour control of blood pressure is maintained both
in the supine and upright positions with a single daily dose.
The bioavailability of oral sotalol hydrochloride is essentially complete (greater than
90%). After oral administration peak levels are reached in 2.5 to 4 hours and steady
state plasma levels are attained within 2-3 days. The absorption is reduced by
approximately 20% when administered with a standard meal, in comparison to fasting
Over the dosage range 40-640mg/day sotalol hydrochloride displays dose
proportionality with respects to plasma levels. Distribution occurs to a central
(plasma) and a peripheral compartment, with an elimination half-life of 10-20 hours.
Sotalol hydrochloride does not bind to plasma proteins and is not metabolised.
There is very little inter-subject variability in plasma levels. Sotalol hydrochloride
crosses the blood brain barrier poorly, with cerebrospinal fluid concentrations only
10% of those in plasma. The primary route of elimination is renal excretion.
Approximately 80 to 90% of a dose is excreted unchanged in the urine, while the
remainder is excreted in the faeces. Lower doses are necessary in conditions of renal
impairment (see Dosage and Administration in patients with renal dysfunction).Age
does not significantly alter the pharmacokinetics, although impaired renal function in
the geriatric patients can decrease the excretion rate, resulting in increased drug
Preclinical safety data
No further information is presented.
List of excipients
Sodium starch glycollate
Colloidal silicon dioxide
Special precautions for storage
Store below 25°C. Store in the original package in order to protect from light.
Nature and contents of container
Polypropylene/Aluminium or PVDC/ PVC/Aluminium blister packs in a cardboard
28, 56 tablets.
Not all pack sizes may be marketed.
Special precautions for disposal
Any unused medicinal product or waste material should be disposed of in accordance
with local requirements.
MARKETING AUTHORISATION HOLDER
Tillomed Laboratories Ltd
MARKETING AUTHORISATION NUMBER(S)
DATE OF FIRST AUTHORISATION/RENEWAL OF THE
03/03/1998 / 23/02/2009
DATE OF REVISION OF THE TEXT