Azilsartan/carteolol/verapamil interaction
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Bradycardia Shock: case report An 84-year-old woman from Japan developed bradycardia shock following concomitant administration of azilsartan, verapamil and carteolol [not all dosages stated]. The woman presented with chest discomfort and shortness of breath for three days. She was admitted and found to be frail. She had a history of hypertension, glaucoma and chronic kidney disease (CKD). She had right eye blindness due to glaucoma, and her left eye had been treated with ophthalmic carteolol eye drop and travoprost for the last few years. She had been also receiving oral azilsartan for hypertension along with diet therapy and various other concomitant medications. Five days prior to admission, she was diagnosed with symptomatic paroxysmal atrial fibrillation (PAF), for which she started receiving oral verapamil 40mg twice daily. Before the initiation of verapamil, her heart rate was about 60–80 beats/minute (bpm). On admission, her heart rate was 29 bpm and BP could not be obtained. Bradycardia shock was considered. Investigations showed elevated serum potassium (hyperkalaemia), liver enzymes and lactate levels. ECG revealed heart rate of 24 bpm and narrow QRS rhythm, followed by retrograde P-waves with a Wenckebach phenomenon. Transthoracic echocardiography showed normal left ventricular function. Chest X-ray showed enlargement of the cardiothoracic ratio with pulmonary oedema. Due to bradycardia shock with hyperkalaemia, the woman underwent a temporary pacing catheter placement through the right internal jugular vein. Right ventricular pacing was performed with administration of calcium gluconate hydrate and glucose insulin therapy for hyperkalaemia. Following this treatment, the shock resolved immediately and her symptoms disappeared. Treatment with verapamil and azilsartan was discontinued. She was treated with a pacing rhythm till the next day. The morning after she was hospitalised, her heart rhythm normalised with a heart rate of 63 bpm. Following discussion with the ophthalmologist, the carteolol treatment was switched to dorzolamide hydrochloride. After cessation of treatment and normalisation of potassium level, no bradycardia was noted. However, symptomatic PAF was observed on day 1 of the hospitalisation. She temporarily had a backup pacing due to sick sinus syndrome. She underwent pacemaker implantation on day 14 of the hospitalisation. Finally, her BP, arrhythmia and glaucoma were controlled with the pacemaker implantation and medication adjustment. On day 20 of the hospitalisation, she was discharged in good health. It was considered that the interaction between azilsartan, verapamil and carteolol led to bradycardia shock. Additionally, verapamil or azilsartan-related hyperkalaemia might have contributed to the development of bradycardia shock. Arai R, et al. A Case of Bradycardia Shock Caused by the Combined Use of Carteolol Eye Drops and Verapamil in an Elderly Patient with Atrial Fibrillation and Chronic 803502076 Kidney Disease. Internal Medicine : 22 Aug 2020. Available from: URL: http://
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