Nasal Spray Calcium Channel Blocker for SVT

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Written by Clay Smith

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Nasally administered etripamil was more effective than placebo at converting SVT to normal sinus rhythm (NSR) and is now moving on to phase 3 trials.  Stay tuned.

Why does this matter?
Normally I wouldn’t cover a treatment that is still in phase 2 and not ready to be used in practice, but sometimes it is exciting to peek into the future.  Current “pill-in-the-pocket” oral beta blockers, calcium channel blockers (CCB), or flecainaide are <50% effective and may take 30-60 minutes to work.  So there is a need for a better drug.  Don't forget simple vagal maneuvers, including REVERT for SVT.

Nasal spray that slows your heart! That’s just cool!
This was a phase 2, industry funded, dose finding randomized double-blinded trial of etripamil, a nasally administered, non-dihydropyridine CCB (with short, 20-minute half-life) for SVT.  The study acronym was NODE-1.  Personally, I think NOSE-1 would have been better.  Patients with SVT had it induced in the EP lab and received placebo or 1 of 4 etripamil doses (35, 70, 105, or 140mg) by nasal insufflation.  In those who got active drug, 65-95% converted to NSR from SVT vs only 35% in the placebo group.  Median time to NSR was <3 minutes.  The 3 highest dose groups were all statistically significantly better than placebo.  The highest dose group was most effective (95%) but had the greatest BP lowering.  Also, those with active drug had minor nasal irritation.  Now this drug is ready for the next stage of clinical trials.  Keep in mind, in REVERT 17% converted with standard vagal maneuvers and 43% using the modified Valsalva with leg lift.  Clearly, there must be some vagal stimulation just from sniffing something up your nose, with the placebo group achieving 35% conversion in this study.  I am looking forward to seeing if this drug works for use in clinical practice.  It would certainly be a convenient way for patients with SVT to regain NSR.

Source
Etripamil Nasal Spray for Rapid Conversion of Supraventricular Tachycardia to Sinus Rhythm.  J Am Coll Cardiol. 2018 Jul 31;72(5):489-497. doi: 10.1016/j.jacc.2018.04.082.
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Reviewed by Thomas Davis