Medication Management in Brugada Syndrome

Introduction to Contraindicated Medications

The European Society of Cardiology recommends that patients with Brugada syndrome should strictly avoid all sodium channel blockers, certain psychotropics, specific anesthetic agents, and any medication that prolongs the QT interval or induces ST segment elevation in the right precordial leads 1, 2

Flecainide, ajmaline, procainamide, and pilsicainide are absolutely contraindicated as they can unmask or exacerbate the type 1 Brugada electrocardiographic pattern and precipitate ventricular fibrillation 1, 2
Propafenone should also be avoided due to its sodium channel blocking effect 3

Amiodarone, sotalol, and dofetilide should be avoided due to the risk of QT prolongation and torsades de pointes 4, 3
Quinidine is a notable exception, as it is recommended for the treatment of Brugada syndrome because it suppresses the I(to) current and reduces arrhythmic events 1, 2

Tricyclic antidepressants (such as amitriptyline, imipramine) can induce a Brugada-like electrocardiographic pattern and cause ventricular tachycardia resistant to cardioversion 4
Antipsychotics like thioridazine and haloperidol significantly prolong the QT interval and can cause torsades de pointes 4

Certain anesthetic agents can precipitate ventricular arrhythmias and should be avoided, although the specific agents vary 5
Cocaine is specifically contraindicated 5

Rifampicin should be avoided because it decreases quinidine plasma concentrations and can cause therapeutic failures 5
Digoxin requires a 30-50% dose reduction if used with amiodarone, and close monitoring of levels is necessary 3

Sodium channel blockers like flecainide and ajmaline are used paradoxically as a diagnostic test to unmask Brugada syndrome in patients with suspected but non-spontaneous type 1 pattern 1, 2, 5
This test should only be performed in a monitored hospital setting and should be terminated immediately if ventricular arrhythmias, marked QRS widening, or type 1 Brugada pattern develop 5

The American College of Cardiology recommends that all patients should receive information about www.brugadadrugs.org, an updated database that lists safe and hazardous medications specifically for Brugada syndrome 1, 2, 5
Fever can precipitate cardiac arrest in patients with Brugada syndrome, so any fever should be treated aggressively with antipyretics 1, 2, 5
Excessive alcohol consumption and large meals are triggers that should be avoided 1, 2, 5