Raimundo Carmona Puerta

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OPINION ARTICLE
Thirteen Reasons not to Give Up Using Quinidine 
and to Avoid its Withdrawal from the market
RAIMUNDO CARMONA PUERTA1
Since 2006, the news about the withdrawal from the 
market of quinidine sulfate produced by Astra Zeneca 
began to go around the internet. (1) More recently, 
the same happened with quinidine polygalacturonate 
(Ritmocor, Malesci, Bagno A Ripoli, Italy) in Italy 
where quinidine sulfate was not in circulation any 
more. Only hydroquinidine was available, from which 
its real correspondence with polygalacturonate is 
known; 275 mg of polygalacturonate are equivalent to 
200 mg of quinidine sulfate, but, as it was mentioned 
before, in Italy there is no quinidine sulfate. (2) In 
several countries, quinidine is difficult to be found 
and the decision to withdraw this drug from the 
market was not consulted with prestigious societies 
in charge of gathering worldwide experts in cardiac 
arrhythmias. (3) This decision had a commercial basis 
and not a scientific one, as it is shown in the following 
evidences: 
1. Quinidine is the only antiarrhythmic agent with 
 significant inhibiting properties of Ito that exists 
 in the market. (4)
2. Quinidine prevents ventricular fibrillation (VF) 
 induced by programmed electrical stimulation 
 (5-8) and in patients with Brugada syndrome and 
 idiopathic VF at long-term. (8)
3.  Quinidine is effective to avoid arrhythmic storm in 
 Brugada syndrome (6, 7), and idiopathic VF, 
 (9) apart from reducing appropriate shocks of 
 the implantable cardioverter defibrillator (ICD) 
 which makes more bearable the coexistence with 
 the equipment. 
4. Quinidine could be the indication in asymptomatic 
 Brugada syndrome with positive electrophysiologic 
 study, since more recent evidences have not shown 
 that these cases could be risky, (9, 10) generating an 
 unnecessary expense due to ICD implantations 
 which will never work (only 1% per year of 
 these patients will have a spontaneous VF) and 
 complications related to the implantation 
 (prevalence of 28-32% in young patients). (7)  
5. Quinidine may represent a temporary state until 
 ICD implantation in young patients with short QT 
 syndrome. (11)
6. Oral quinidine may offer an alternative to ICD in 
 old asymptomatic patients with short QT syndrome 
 and negative history of sudden cardiac death. (12)
7. Belhassen et al. have used quinidine successfully 
 for more than 20 years in idiopathic VF. (13)
8. Quinidine and verapamil used together may 
 reduce afterdepolarizations produced by class I 
 and II antiarrhythmic agents. Afterdepolarizations 
 induce torsade de pointes, apart from preventing 
 high ventricular frequencies that may be generated 
 due to vagolytic effect of quinidine. (4)
9. The aforementioned combination may be compared 
 with sotalol in the prevention of atrial fibrillation 
 recurrence after electrical cardioversion. (4)
10. Quinidine for pharmacological cardioversion of 
 atrial fibrillation is safe and effective (successful in 
 84% of the cases) in patients with coronary 
 disease and recent myocardial revascularization 
 or percutaneous coronary intervention, even with 
 previous myocardial infarction; besides, this 
 kind of cardioversion is also safe and effective in 
 patients with valvular disease who underwent 
 valve replacement with revascularization or 
 without it and in other structural heart diseases 
 already operated. (14)
11. According to the biggest series of pharmacological 
 cardioversion with quinidine published up to now 
 (501 patients), the risk of proarrhythmia is 
 minimized if the following factors are controlled 
 (14):           
 - LVEF ≥ 35%.
 - Absolute QT interval < 500 ms.
 - Serum potassium > 4.3 mEq/L.
 - Concomitant use with verapamil or beta 
 blockers.
12. A significant part of lethal complications observed 
 before the eighties could have been associated with 
 the combination quinidine-digoxin, since quinidine 
 reduces renal tubular secretion of the digital and 
 there is a need to reduce the dose of digoxin in up 
 to 50%, so that some complications could have been 
 secondary to lethal digitalis toxicity due to an 
 increase in the concentration of this drug. Besides, 
 high doses of digoxin (800-1800 mg/day) were used 
 in old studies. (4)
13. Quinidine is indicated as the first option 
 of pharmacological treatment of class IA of 
 antiarrhythmic agents in a pregnant woman 
 with ventricular and supraventricular 
 tachycardias, atrial fibrillation in particular, atrial 
 flutter and atrioventricular reciprocal tachycardia. 
 Quinidine is useful in the woman that is feeding 
 the baby due to the concentration of it in the 
 mother’s milk is less than 70% in comparison with 
 the mother’s blood. (15) There is certainty that 
 the use of this drug is safe during pregnancy, the 
 use is backed by a worldwide medical experience 
Abbreviations > ICD    Implantable cardioverter defibrillator 
LVEF  Left ventricular ejection fraction
VF   Ventricular fibrillation
Department of Clinical Cardiac Electrophysiology and Stimulation. Cardiocentro de Santa Clara “Ernesto Che Guevara”. Cuba
1 Physiology and Physiopathology Specialist 
Address for reprints: Calle B.15 entre Maceo y Manuel Ruiz Rpto. Villa Josefa. Santa Clara - Villa Clara. Cuba - e-mail: raimundo@cardiovc.sld.cu
THIRTEEN REASONS NOT TO GIVE UP USING QUINIDINE AND TO AVOID ITS WITHDRAWAL FROM THE MARKET / Raimundo Carmona Puerta 441
 of more than 70 years. Recently, quinidine was 
 used with success to control an electrical storm in 
 a young pregnant woman with Brugada syndrome. 
 (16) 
With the advent of new antiarrhythmic agents, 
the sales of quinidine are reduced; however, exposed 
evidences allow us to conclude that there will always 
be consumption of this substance, especially among 
certain subgroups of patients in which this drug is the 
only option of treatment with implications for life in 
absence of the drug. In this article we support authors 
that through their work, predominantly in English 
and hardly nonexistent in Spanish, are opposed to the 
market withdrawal of quinidine.
BIBLIOGRAPHY
1. AstraZeneca personal communication: Notification of 
discontinuation of Kinidin Durules (quinidin bisulphate). Disponible 
en: http://www.nelm.nhs.uk/en/NeLM-Area/News/489074/489276/48
9288/?query=Notification+of+discontinuation+of+Kinidin+Duru
les&rank=100(2006).
2. Inama G, Durin O, Pedrinazzi C, Berisso MZ, Furlanello F. Orphan 
drugs in cardiology: nadolol and quinidine. J Cardiovasc Med 
2010;11:143-4.
3. Viskin S, Antzelevitch C, Marquez MF, Velasen B. Quinidine: a 
valuable medication joins the list of endangered species. Europace 
2007;9:1105-6.
4. Yang F, Hanon S, Lam P, Schweitzer P. Quinidine revisited. Am J 
Med 2009;122:317-21.
5. Carmona PR, Ramos RR, Padron PG, Chavez GE, Rodriguez LA, 
Cruz EJM. La nueva era de la quinidina amenazada de extinción. 
Rev Fed Arg Cardiol 2009;38(3):173-5.
6. Viskin S, Rogowski O. Asymptomatic Brugada syndrome: a cardiac 
ticking time-bomb? Europace 2007;9:707-10.
7. Viskin S, Wilde AAM, Tan HL, Antzelevitch C, Shimizu W, Belhassen 
B. Empiric quinidine therapy for asymptomatic Brugada syndrome: 
time for a prospective registry. Heart Rhythm 2009;6:401-4.
8. Belhassen B, Glick A, Viskin S. Excellent long-term reproducibility 
of the electrophysiologic efficacy of quinidine in patients with 
idiopathic ventricular fibrillation and Brugada syndrome. Pacing 
Clin Electrophysiol 2009;32(3):294-301.
9. Haissaguerre M, Sacher F, Nogami A, Komiya N, Bernard A, 
Probst V, et al. Characteristics of recurrent ventricular fibrillation 
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therapy. J Am Coll Cardiol 2009;53:612-9.
10. Paul M, Gerss J, Shulzc-Bahr E, Wichter T, Vahlhaus C, Wilde 
AAM, et al. Role of programmed ventricular stimulation in patients 
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data. Eur Heart J 2007;28(17):2126-33.
11. Probst V, Veltmann C, Eckardt L, Meregall PG, Gaita F, Tan 
HL, et al. Long-term prognosis of patients diagnosed with Brugada 
syndrome. Results from the FINGER Brugada syndrome registry. 
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short QT syndrome. Ind Pacing Electrophysiol J 2010;10(2):86-95.
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Leniado S. Idiopathic ventricullar fibrillation inducibility and 
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14. Schwaab B, Katalinic A, Boge UM, Loh J, Blanck P, Kolzow T, et al. 
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Electrocardiol 2009;14(2):128-36.
15. Tan HL, Lie KI. Treatment of tachyarrhythmias during 
pregnancy and lactation. Eur Heart J 2001;22:458-64.
16. Sharif-Kazemi MB, Emkanjoo Z, Tavoosi A, Kafi M, Kheirkhah 
J, Alizadeh A, et al. Electrical storm in Brugada syndrome during 
pregnancy. Pacing Clin Electrophysiol 2010 Mar 26. [Epub ahead of 
print].


Thirteen Reasons not to Give Up Using Quinidine and to Avoid its Withdrawal from the market

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Thirteen Reasons not to Give Up Using Quinidine and to Avoid its Withdrawal from the market

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