Minor side effects are usually transient because of adenosine s very short half-life. AV block greater than first degree or SA node dysfunction (in absence of pacemaker) Reactive airway disease Concomitant use of verapamil or digoxin WPW Beta blockers Esmolol 500-mcg/kg IV bolus over 1 min Infusion at 50 300 mcg/ kg/min, with repeat boluses between each dosing increase Hypotension, worsening HF, bronchospasm, bradycardia AV block greater than first degree or SA node dysfunction (in absence of pacemaker) Decompensated systolic HF Hypotension Cardiogenic shock Reactive airway disease Renal dysfunction Drugs with SA and/or AV nodal blocking properties Metoprolol tartrate bolus over 2 min Can repeat 2.5- to 5.0- mg IV bolus in 10 min, up to 3 doses Hypotension, worsening HF, bronchospasm, bradycardia AV block greater than first degree or SA node dysfunction (in absence of pacemaker) Decompensated systolic HF Hypotension Reactive airway disease Drugs with SA and/or AV nodal blocking properties Propranolol 1 mg IV over 1 min Can repeat 1 mg IV at 2-min intervals, up to 3 doses Hypotension, worsening HF, bronchospasm, bradycardia AV block greater than first degree or SA node dysfunction (in absence of pacemaker) Cardiogenic shock Reactive airway disease Decompensated HF Hypotension Hepatic or renal dysfunction Drugs with SA and/or AV nodal blocking properties Nondihydropyridine calcium channel antagonists Diltiazem 0.25-mg/kg IV bolus over 2 min Infusion at 5 10 mg/h, up to 15 mg/h Hypotension, worsening HF in patients with pre-existing ventricular dysfunction, bradycardia, abnormal liver function studies, acute hepatic injury (rare) AV block greater than first degree or SA node dysfunction (in absence of pacemaker) WPW with AF/atrial flutter Hypotension Decompensated systolic HF/LV dysfunction Drugs with SA and/or AV nodal blocking properties Hepatic or renal dysfunction Diltiazem is a substrate of CYP3A4 (major) and a moderate CYP3A4 inhibitor Apixaban, itraconazole, bosutinib, ceritinib, cilostazol, cyclosporine, everolimus, ibrutinib, idelalisib, ivabradine, lomitapide, olaparib, posaconazole, ranolazine, rifampin, simeprevir, voriconazole (Continued) Page et al 2015 ACC/AHA/HRS SVT Guideline e525 bolus over 2 min If no response, can give an additional 10 mg after first dose; then infusion at 0.005 mg/ kg/min Hypotension, worsening HF in patients with pre-existing ventricular dysfunction, pulmonary edema in patients with hypertrophic cardiomyopathy, bradycardia AV block greater than first degree or SA node dysfunction (in absence of pacemaker) Decompensated systolic HF/LV dysfunction Drugs with SA and/or AV nodal blocking properties Hypotension Cardiogenic shock WPW with AF/atrial flutter Hepatic or renal dysfunction Verapamil is a moderate CYP3A4 inhibitor and also inhibits P-glycoprotein Contraindicated with dofetilide Itraconazole, bosutinib, ceritinib, cilostazol, colchicine, cyclosporine, everolimus, dabigatran, edoxaban, flecainide, ibrutinib, ivabradine, olaparib, posaconazole, ranolazine, rivaroxaban, rifampin, silodosin, simeprevir, rivaroxaban, rifampin, simvastatin, topotecan, trabectedin, vincristine, voriconazole, grapefruit juice Cardiac glycosides Digoxin 0.25 0.5-mg IV bolus Can repeat 0.25-mg IV bolus, up to maximum dose of 1.0 mg over 24 h (ie, maximum loading dose 8 12 mcg/kg), given at 6 8-h intervals; maintenance dose based on patient s age, lean body weight, renal function, and concomitant drugs (IV 2.4 3.6 mcg/kg/d) Anorexia, nausea, vomiting, visual changes and cardiac arrhythmias if digoxin toxicity (associated with levels >2 ng/mL, although symptoms may also occur at lower levels) Renal dysfunction WPW with AF/atrial flutter AV block greater than first degree or SA node dysfunction (in absence of pacemaker) Drugs with AV nodal-blocking properties Digoxin is a P-glycoprotein substrate Dronedarone (reduce dose by at least 50%), amiodarone (reduce dose by 30% 50%) Verapamil, clarithromycin, cyclosporine, erythromycin, flecainide, itraconazole, posaconazole, propafenone, voriconazole: Monitor digoxin levels A large retrospective study suggested an increased risk in mortality in patients who were treated with digoxin for newly diagnosed AF or atrial flutter; although the data were collected from a population that was different from SVT patients, digoxin should be used with caution.118 Class III antiarrhythmic agents Amiodarone 150 mg IV over Infusion at 1 mg/min (360 mg) over next 6 h; mg) over remaining 18 h Hypotension, bradycardia, phlebitis, QT prolongation, torsades de pointes (rare), increased INR Sinus or AV conduction disease (in absence of pacemaker) Inflammatory lung disease (acute) Hepatic dysfunction Drugs with SA and/or AV nodal blocking properties Amiodarone is a substrate of and inhibits p-glycoprotein and CYP2C9 (moderate), CYP2D6 (moderate), and CYP3A4 (weak); amiodarone is a substrate for CYP3A4 (major) and CYP2C8 (major);amiodarone is an inhibitor of OCT2 Reduce warfarin dose by 50% and reduce digoxin dose by 30% 50% Agalsidase alfa, agalsidase beta, azithromycin, bosutinib, ceritinib, colchicine, dabigatran, edoxaban, flecainide, ivabradine, ledipasvir/sofosbuvir, lopinavir, lopinavir/ritonavir, lovastatin, nelfinavir, pazopanib, propafenone, simvastatin, ritonavir, rivaroxaban, saquinavir, sofosbuvir, topotecan, vincristine, grapefruit juice (Continued) Table 6. 