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Department of medicine, section of pulmonary/critical care

DOFETILIDE (TIKOSYN)
INITIATION OF
PAGE 1 OF 2
Cardiologist:
1.

Only cardiologists on the Tikosyn Prescriber Registry may order this agent
(pharmacy to verify by calling manufacturer if necessary).
Admit or transfer patient to one of the following areas: ICU, CCU, or PICU. Only a Tikosyn credentialed RN may administer dofetilide. Verify the patient has not taken verapamil (Isoptin/Calan), ketoconazole (Nizoral), cimetidine (Tagamet), trimethoprim Trimpex), trimethoprim/sulfamethoxazole (Bactrim), megesterol (Megace), prochlorperazine (Compazine) or any Class I or Class III anti-arrhythmic within the last 3 days. Assess the baseline QTc interval. Is patient appropriate for dofetilide therapy?
Tikosyn is contraindicated if the QTc is >440 msec (500msec in patients with
ventricular conduction abnormalities).

Baseline QTc __________msec
_____ Yes _____ No
Does patient have a ventricular conduction abnormality? _____ Yes _____ No
Serum creatinine if not already collected. Calculated Creatinine Clearance ________ ml/min
Dosing Table:
Creatinine Clearance (CrCl) = (140-age) (weight)
Give Dofetilide (Tikosyn) ___________ mcg PO every 12 hours.
Cardiologist’s Signature: _______________________________ Date/Time: ____________
Nurse’s Signature: ___________________________________ Date/Time: ____________
11/02; Rev. 8/03

Page 2 of 2

DOFETILIDE (TIKOSYN)
INITIATION OF
Nurse:
1.

Give dofetilide by mouth every 12 hours. Per manufacturer recommendations, dofetilide
capsules should not be opened.
Patient must be able to take capsules by mouth.
Electronic QTc calculation for further monitoring.
a) Obtain the QTc interval off of the 12 lead EKG after doses 1 through 5.
b) Contact cardiologist if the QTc after doses 1 - 5 is either
• >500 msec in patients without ventricular conduction abnormalities or
• >550 msec in patients with ventricular conduction abnormalities (refer to page 1, order #5)
Case Management consult for follow up regarding obtaining medication after discharge. If the patient converts to normal sinus rhythm, obtain 12 lead EKG. Notify physician if QTc interval is: • >500 msec in patients without ventricular conduction abnormalities or
• >550 msec in patients with ventricular conduction abnormalities (refer to page 1, order #5)
Patient may not be discharged until at least 8 hours after fifth dose of dofetilide is administered or
until 12 hours after converting to normal sinus rhythm, whichever is greater (unless dofetilide is
discontinued).
Medications that prolong the QT interval and/or increase plasma concentrations of dofetilide should be avoided. These include: Amitriptylline (Elavil) Amiodarone (Cordarone/Pacerone) Chlorpromazine (Thorazine)
C
ardiologist’s Signature: _______________________________ Date/Time: ____________
Nurse’s Signature: ___________________________________ Date/Time: _____________
11/02; Rev. 8/03

Source: http://www.sjhealthcare.net/upload/assets/DrForms/10_DofetilideOrders1102.pdf

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