A 62-year-old with paroxysmal atrial fibrillation and a prior inferior MI is started on sotalol. Which precaution is essential during initiation of this drug?

• A Baseline echocardiography repeated monthly to detect negative inotropic failure
• B Hospital telemetry for QT prolongation with dose adjustment according to creatinine clearance ✓
• C Concurrent amiodarone cover for the first two weeks
• D Serum potassium kept deliberately high, above 5.5 mEq/L, to prevent proarrhythmia

Explanation

Sotalol combines nonselective beta blockade with class III IKr blockade and carries a dose-dependent risk of torsades de pointes. Because it is eliminated almost entirely by the kidneys, impaired renal function raises plasma levels and prolongs QT further, so initiation is done in hospital with ECG monitoring and doses scaled to creatinine clearance. Hypokalemia, not hyperkalemia, predisposes to torsades. Amiodarone coadministration would add QT risk rather than provide protection.

Reference: Katzung's Basic and Clinical Pharmacology, 16th ed.

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