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Intravenous Dilution Guidelines

Quinidine gluconate

The authors make no claims of the accuracy of the information contained herein; and these suggested doses and/or guidelines are not a substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the preparation of this document shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.    PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.

Usual Diluents

D5W, NS

Standard Dilutions   [Amount of drug] [Infusion volume] [Infusion rate]

--------- Malaria ---------------
Intermittent infusion:
Loading regimen:
[15 mg/kg of quinidine base (24 mg/kg of quinidine gluconate)] [250 mL NS] [4 hours]
Maintenance regimen:
[7.5 mg/kg of base (12 mg/kg of quinidine gluconate)] [250 mL NS] [4 hours]

Continuous infusion (Pre-loading solution):
[ 6.25 mg/kg of quinidine base (10 mg/kg of quinidine gluconate)]
[ 5 mL/kg of NS ] [ 1–2 hours]

------- OTHER INDICATIONS ---------------
See current package insert for other dilutions (arrhythmias etc).

Review the latest guidelines and dilution data contained in the current package insert or visit the Eli Lilly website. Source for current monograph: Quinidine gluconate injection [package insert]. Indianapolis, Indiana: Eli Lilly Company, February 2000.

Stability / Miscellaneous


Note: An overly rapid infusion rate of quinidine has been associated with nausea, vomiting, peripheral vascular collapse, and severe hypotension. If quinidine is to be administered intravenously, patients should be closely monitored with continuous electrocardiographic and blood pressure measurements


Supplied: [80 mg/mL, 10 mL Multiple–Dose Vial]
(Quinidine Gluconate) solution: Quinidine is an antimalarial schizonticide and an antiarrhythmic agent with class 1a activity; it is the d–isomer of quinine. Each vial of Quinidine Gluconate Injection contains 800 mg (1.5 mmol) of quinidine gluconate (500 mg of quinidine) in 10 mL of Sterile Water for Injection, 0.005% of edetate disodium, 0.25% phenol, and (as needed) D–gluconic acid d–lactone to adjust the pH.

INDICATIONS AND USAGE
Treatment of malaria - Quinidine gluconate injection is indicated for the treatment of life-threatening Plasmodium falciparum malaria.

Conversion of atrial fibrillation/flutter -- Quinidine gluconate injection is also indicated (when rapid therapeutic effect is required, or when oral therapy is not feasible) as a means of restoring normal sinus rhythm in patients with symptomatic atrial fibrillation/flutter whose symptoms are not adequately controlled by measures that reduce the rate of ventricular response. If this use of quinidine gluconate does not restore sinus rhythm within a reasonable time, then its use should be discontinued.

Treatment of ventricular arrhythmias -- Quinidine gluconate injection is also indicated for the treatment of documented ventricular arrhythmias, such as sustained ventricular tachycardia, that in the judgement of the physician are life-threatening. Because of the proarrhythmic effects of quinidine, its use with ventricular arrhythmias of lesser severity is generally not recommended, and treatment of patients with asymptomatic ventricular premature contractions should be avoided. Where possible, therapy should be guided by the results of programmed electrical stimulation and/or Holter monitoring with exercise. Antiarrhythmic drugs (including quinidine) have not been shown to enhance survival in patients with ventricular arrhythmias.

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DOSAGE AND ADMINISTRATION:
Because the kinetics of absorption may vary with the patient's peripheral perfusion, intramuscular injection of quinidine gluconate is not recommended.

Treatment of P. falciparum malaria — Two regimens have each been shown to be effective, with or without concomitant exchange transfusion. There are no data indicating that either should be preferred to the other.
In Regimen A, each patient received a loading dose of 15 mg/kg of quinidine base (that is, 24 mg/kg of quinidine gluconate) in 250 mL of normal saline infused over 4 hours. Thereafter, each patient received a maintenance regimen of 7.5 mg/kg of base (12 mg/kg of quinidine gluconate) infused over 4 hours every 8 hours, starting 8 hours after the beginning of the loading dose. This regimen was continued for 7 days, except that in patients able to swallow, the maintenance infusions were discontinued, and approximately the same daily doses of quinidine were supplied orally, using 300–mg tablets of quinidine sulfate.

In Regimen B, each patient received a loading dose of 6.25 mg/kg of quinidine base (that is, 10 mg/kg of quinidine gluconate) in approximately 5 mL/kg of normal saline over 1–2 hours. Thereafter,each patient received a maintenance infusion of 12.5 µg/kg/min of base (that is, 20 µg/kg/min of quinidine gluconate). In patients able to swallow, the maintenance infusion was discontinued, and eight–hourly oral quinine sulfate was administered to provide approximately as much daily quinine base as the patient had been receiving quinidine base (for example, each adult patient received 650 mg of quinine sulfate every eight hours). Quinidine/quinine therapy was continued for 72 hours or until parasitemia had decreased to 1% or less, whichever came first.

After completion of quinidine/quinine therapy, adults able to swallow received a single 1500–mg/75–mg dose of sulfadoxine/pyrimethamine (FANSIDAR®, Roche Laboratories) or a seven–day course of tetracycline (250 mg four times daily), while those unable to swallow received seven–day courses of intravenous doxycycline hyclate (VIBRAMYCIN®, Roerig), 100 mg twice daily. Most of the patients described as having been treated with this regimen also underwent exchange transfusion. Small children have received this regimen without dose adjustment and with apparent good results, notwithstanding the known differences in quinidine pharmacokinetics between pediatric patients and adults .

Even in patients without preexisting cardiac disease, antimalarial use of quinidine has occasionally been associated with hypotension, QTc prolongation, and cinchonism (See package insert for warnings). Inappropriate infusion rate: Overly rapid infusion of quinidine may cause peripheral vascular collapse and severe hypotension.

Treatment of symptomatic atrial fibrillation/flutter — A patient receiving an intravenous infusion of quinidine must be carefully monitored, with frequent or continuous electrocardiography and blood–pressure measurement. The infusion should be discontinued as soon as sinus rhythm is restored: the QRS complex widens to 130% of its pre–treatment duration; the QTc interval widens to 130% of its pre–treatment duration, and is then longer than 500 ms; P waves disappear; or the patient develops significant tachycardia, symptomatic bradycardia, or hypotension.


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Preparation / Infusion:
To prepare quinidine for infusion, the contents of the supplied vial (80 mg/mL) should be diluted to 50 mL (16 mg/mL) with 5% dextrose. The resulting solution may be stored for up to 24 hours at room temperature or up to 48 hours at 4°C (40°F). An infusion of quinidine must be delivered slowly, preferable under control of a volumetric pump, no faster than 0.25 mg/kg/min (that is, no faster than 1 mL/kg/hour). During the first few minutes of the infusion, the patient should be monitored especially closely for possible hypersensitive or idiosyncratic reactions. Most arrhythmias that will respond to intravenous quinidine will respond to a total dose of less than 5 mg/kg, but some patients may require as much as 10 mg/kg. If conversion to sinus rhythm has not been achieved after infusion of 10 mg/kg, then the infusion should be discontinued, and other means of conversion (eg, direct–currentcardioversion) should be considered.


Reference (source):
Quinidine gluconate injection [package insert]. Indianapolis, Indiana: Eli Lilly Company, February 2000.
Disclaimer
The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.  PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.
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