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Procainamide: Drug information

Procainamide: Drug information
(For additional information see "Procainamide: Patient drug information" and see "Procainamide: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Drug-induced lupus erythematosus-like syndrome:

The prolonged administration of procainamide often leads to the development of a positive antinuclear antibody (ANA) test, with or without symptoms of a lupus erythematosus-like syndrome. If a positive ANA titer develops, the benefits versus risks of continued procainamide therapy should be assessed.

Mortality:

In the National Heart, Lung and Blood Institute's Cardiac Arrhythmia Suppression Trial (CAST), a long-term, multicenter, randomized, double-blind study in patients with asymptomatic non-life-threatening ventricular arrhythmias who had myocardial infarction more than 6 days but less than 2 years previously, an excessive mortality or nonfatal cardiac arrest rate (7.7%) was seen in patients treated with encainide or flecainide compared with that seen in patients assigned to matched placebo-treated group (3%). The average duration of treatment with encainide or flecainide in this study was 10 months.

The applicability of the CAST results to other populations (eg, those without recent myocardial infarctions) is uncertain. Considering the known proarrhythmic properties of procainamide and the lack of evidence of improved survival for any antiarrhythmic drug in patients without life-threatening arrhythmias, the use of procainamide as well as other antiarrhythmic agents should be reserved for patients with life-threatening ventricular arrhythmias.

Blood dyscrasias:

Agranulocytosis, bone marrow depression, neutropenia, hypoplastic anemia and thrombocytopenia in patients receiving procainamide HCl have been reported at a rate of approximately 0.5%. Most of these patients received procainamide within the recommended dosage range. Fatalities have occurred (with approximately 20 to 25% mortality in reported cases of agranulocytosis). Since most of these events have been noted during the first 12 weeks of therapy, it is recommended that complete blood counts including white cell, differential and platelet counts be performed at weekly intervals for the first 3 months of therapy, and periodically thereafter. Complete blood counts should be performed promptly if the patient develops any signs of infection (such as fever, chills, sore throat or stomatitis), bruising or bleeding. If any of those hematologic disorders are identified, procainamide therapy should be discontinued. Blood counts usually return to normal within 1 month of discontinuation. Caution should be used in patients with preexisting marrow failure or cytopenia of any type.

Pharmacologic Category
  • Antiarrhythmic Agent, Class Ia
Dosing: Adult

Note: Use ideal body weight for weight-based doses (Ref). Consider monitoring procainamide and N-acetyl procainamide serum concentrations.

Supraventricular arrhythmias

Supraventricular arrhythmias:

Atrial fibrillation with preexcitation (off-label use): IV: Loading dose: Up to 17 mg/kg administered at a rate of 20 to 50 mg/minute or 100 mg (administered at a rate of 20 to 50 mg/minute) every 5 minutes; administer until arrhythmia is controlled, hypotension occurs, QRS complex widens by 50% of its original width, or until a maximum dose of 17 mg/kg is given. After arrhythmia is controlled and in the absence of adverse effects, may continue 1 to 4 mg/minute for ongoing control (Ref).

Ventricular arrhythmias, stable monomorphic ventricular tachycardia

Ventricular arrhythmias, stable monomorphic ventricular tachycardia:

Note: Not recommended to treat cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia due to prolonged administration time and lack of efficacy (Ref).

Hemodynamically stable, sustained monomorphic ventricular tachycardia (off label):

IV: Loading dose: Up to 17 mg/kg administered at a rate of 20 to 50 mg/minute or 100 mg (administered at a rate of 20 to 50 mg/minute) every 5 minutes; administer until arrhythmia is controlled, hypotension occurs, QRS complex widens by 50% of its original width, or until a maximum dose of 17 mg/kg is given. After arrhythmia is controlled and in the absence of adverse effects, may continue 1 to 4 mg/minute for ongoing control (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

Note: Monitor procainamide and N-acetylprocainamide (NAPA) concentrations.

Altered kidney function:

CrCl >50 mL/minute: No dosage adjustment necessary (Ref).

CrCl 10 to 50 mL/minute: Reduce continuous infusion dose by 25% to 50% (Ref).

CrCl <10 mL/minute: Reduce continuous infusion dose by 50% to 75% (Ref).

Hemodialysis, intermittent (thrice weekly): Procainamide: Moderately hemodialyzable (20% to 50%); NAPA: Not dialyzable (0% to 5%): supplementation may be necessary (Ref).

Peritoneal dialysis: Not significantly dialyzable (procainamide and NAPA) (Ref).

CRRT: Reduce maintenance dose by 50%. In patients with anuria receiving CRRT, further dosage reduction may be required (Ref).

Dosing: Hepatic Impairment: Adult

Note: Monitor procainamide and N-acetyl procainamide concentrations.

Child-Pugh score 8 to 10: Reduce continuous infusion dose by 25% (Ref).

Child-Pugh score >10: Reduce continuous infusion dose by 50% (Ref).

Dosing: Older Adult

Refer to adult dosing. Initiate doses at lower end of dosage range.

Dosing: Pediatric

(For additional information see "Procainamide: Pediatric drug information")

Note: Cardiology consultation strongly recommended prior to use; use caution when administering procainamide with other drugs that prolong QT interval (eg, amiodarone). Dose must be individualized and titrated based on patient's blood pressure, ECG, and arrhythmia control; monitor serum concentrations (procainamide and N-acetylprocainamide [NAPA]) and QRS complex to avoid toxicity.

Tachyarrhythmia, treatment

Tachyarrhythmia (including junctional ectopic tachycardia [JET], supraventricular tachycardia [SVT], atrial fibrillation, and atrial flutter), treatment: Limited data available:

Infants, Children, and Adolescents:

IV, Intraosseous:

Loading dose: Note: Monitor telemetry and blood pressure closely during administration; if arrhythmia terminates, consider discontinuing loading dose; discontinue or hold loading dose if blood pressure drops below acceptable range:

10 to 15 mg/kg as a single dose infused over 30 to 60 minutes (maximum total loading dose: 500 mg) or the total loading dose may also be divided and given in 2 to 6 mg/kg/dose increments (up to 100 mg/dose) infused over ≥5 minutes and may be repeated every 10 to 30 minutes as needed; maximum adult total loading dose: 1,000 mg; may follow with continuous infusion as clinically appropriate (Ref).

Maintenance: Continuous IV infusion: 20 to 80 mcg/kg/minute; maximum daily dose: 2,000 mg/24 hours (Ref).

Oral: 15 to 50 mg/kg/day divided every 3 to 6 hours; maximum daily dose: 4,000 mg/24 hours (Ref).

Resuscitation

Resuscitation (Pediatric Advanced Life Support [PALS]):

Supraventricular tachycardia, hemodynamically unstable and shock-refractory (Ref): Limited data available:

Infants, Children, and Adolescents: IV, Intraosseous: 15 mg/kg infused over 30 to 60 minutes, rate of infusion depends on urgency of clinical scenario; may give additional doses if clinical endpoint not achieved and no signs of toxicity exist; monitor ECG and blood pressure.

Wide-complex tachycardia of unknown origin (atrial or ventricular), hemodynamically stable (Ref): Limited data available:

Infants, Children, and Adolescents: IV, Intraosseous: 15 mg/kg infused over 30 to 60 minutes; monitor ECG and blood pressure; stop the infusion if hypotension occurs or QRS complex widens by >50% of baseline.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

Infants, Children, and Adolescents: There are no specific recommendations provided in the manufacturer's labeling; dose must be individualized and titrated to patient's response; close monitoring of procainamide and N-acetylprocainamide (NAPA) serum concentrations, if facilities are available for measurement, and clinical effectiveness recommended. Some have suggested the following (Ref): Note: Renally adjusted dose recommendations are based on a dose of loading dose of 15 mg/kg total.

GFR <10 mL/minute/1.73 m2:

Loading dose: Reduce dose to 12 mg/kg

Maintenance infusion: Start at lower end of continuous infusion range of 20 to 80 mcg/kg/minute

Dialysis: All patients:

Procainamide: Moderately hemodialyzable (20% to 50%): Monitor procainamide/NAPA levels; supplementation may be necessary

NAPA: Not dialyzable (0% to 5%)

Procainamide/NAPA: Not peritoneal dialyzable (0% to 5%)

Procainamide/NAPA: Replace by blood level during continuous arteriovenous or venovenous hemofiltration

Dosing: Hepatic Impairment: Pediatric

There are no pediatric-specific recommendations; based on experience in adult patients, dosing adjustment suggested. Use with caution, closely monitor procainamide and NAPA concentrations.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

>10%:

Hematologic & oncologic: Positive ANA titer (≤50%)

Neuromuscular & skeletal: Lupus-like syndrome (≤30%, increased incidence with long-term therapy or slow acetylators; syndrome may include abdominal pain, arthralgia, arthritis, chills, fever, hepatomegaly, myalgia, pericarditis, pleural effusion, pulmonary infiltrates, skin rash)

1% to 10%:

Cardiovascular: Hypotension (intravenous: ≤5%)

Dermatologic: Skin rash

Gastrointestinal: Diarrhea (oral: 3% to 4%), dysgeusia (oral: 3% to 4%), nausea (oral: 3% to 4%), vomiting (oral: 3% to 4%)

<1%, postmarketing, and/or case reports: Agranulocytosis, angioedema, anorexia, aplastic anemia, arthralgia, asystole, bone marrow depression, cerebellar ataxia, confusion, demyelinating disease (demyelinating polyradiculoneuropathy), depression, depression of myocardial contractility, disorientation, dizziness, drug fever, exacerbation of cardiac arrhythmia, exacerbation of myasthenia gravis, fever, first degree atrioventricular block, flushing, gastrointestinal pseudo-obstruction, granulomatous hepatitis, hallucination, hemolytic anemia, hepatic failure, hyperbilirubinemia, hypoplastic anemia, increased serum alkaline phosphatase, increased serum transaminases, intrahepatic cholestasis, leukopenia, maculopapular rash, mania, myocarditis, myopathy, neuromuscular blockade, neutropenia, pancreatitis, pancytopenia, peripheral neuropathy, pleural effusion, polyneuropathy, positive direct Coombs test, prolonged QT interval on ECG, psychosis, pruritus, pulmonary embolism, second degree atrioventricular block, tachycardia, thrombocytopenia, torsades de pointes, urticaria, vasculitis, ventricular fibrillation, ventricular tachycardia (paradoxical; in atrial fibrillation/flutter), weakness

Contraindications

Hypersensitivity to procainamide, procaine, other ester-type local anesthetics, or any component of the formulation; complete heart block; second-degree AV block or various types of hemiblock (without a functional artificial pacemaker); systemic lupus erythematosus; torsade de pointes.

Canadian labeling: Additional contraindications (not in US labeling): Myasthenia gravis; severe heart failure; kidney failure; shock.

Warnings/Precautions

Concerns related to adverse effects:

• Blood dyscrasias: [US Boxed Warning]: Potentially fatal blood dyscrasias (eg, agranulocytosis) have occurred with therapeutic doses; weekly monitoring is recommended during the first 3 months of therapy and periodically thereafter. Discontinue procainamide if this occurs.

• Conduction disturbances: Reduce dose if first-degree heart block occurs.

• Drug-induced lupus erythematosus-like syndrome: [US Boxed Warning]: Long-term administration leads to the development of a positive antinuclear antibody (ANA) test in 50% of patients which may result in a drug-induced lupus erythematosus-like syndrome (in 20% to 30% of patients); discontinue procainamide with rising ANA titers or with SLE symptoms and choose an alternative agent.

• Proarrhythmic effects: Watch for proarrhythmic effects; monitor and adjust dose to prevent QTc prolongation. Avoid use in patients with QT prolongation.

Disease-related concerns:

• Atrial fibrillation/flutter: May increase ventricular response rate in patients with atrial fibrillation or flutter; control AV conduction before initiating.

• Electrolyte imbalance: Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy.

• Heart failure: Use with caution or avoid in patients with heart failure; may precipitate or exacerbate condition due to negative inotropic actions.

• Kidney impairment: Use with caution in patients with kidney impairment; dosage reduction recommended.

• Myasthenia gravis: Avoid use in myasthenia gravis; may worsen condition.

Dosage form specific issues:

• Sodium metabisulfite: The injectable product may contain sodium metabisulfite, which can cause allergic-type reactions, including anaphylactic symptoms and life-threatening asthmatic episodes in susceptible people; this is seen more frequently in patients with asthma.

Special populations:

• Older adult: Use caution and dose cautiously; renal clearance of procainamide/N-acetyl procainamide declines in patients ≥50 years of age (independent of CrCl reductions) and in the presence of concomitant renal impairment.

Other warnings/precautions:

• CAST trial: [US Boxed Warning] In the Cardiac Arrhythmia Suppression Trial (CAST), recent (>6 days but <2 years ago) myocardial infarction patients with asymptomatic, non-life-threatening ventricular arrhythmias did not benefit and may have been harmed by attempts to suppress the arrhythmia with flecainide or encainide. An increased mortality or nonfatal cardiac arrest rate (7.7%) was seen in the active treatment group compared with patients in the placebo group (3%). The applicability of the CAST results to other populations is unknown. Procainamide should be reserved for patients with life-threatening ventricular arrhythmias.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Injection, as hydrochloride:

Generic: 100 mg/mL (10 mL); 500 mg/mL (2 mL)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Procainamide HCl Injection)

100 mg/mL (per mL): $10.20 - $72.00

500 mg/mL (per mL): $360.00

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Injection, as hydrochloride:

Generic: 100 mg/mL (10 mL)

Administration: Adult

IV:

Loading dose: Administer at a rate of 20 to 50 mg/minute.

Continuous infusion: Administer at a rate of 1 to 4 mg/minute (Ref).

Administration: Pediatric

Parenteral: IV: Note: Infusion rate should be decreased if QT interval becomes prolonged or patient develops heart block; discontinue the infusion if patient develops hypotension or QRS interval widens to >50% of baseline; severe hypotension can occur with rapid IV administration (Ref).

Loading dose:

Neonates: Administer over 60 minutes (Ref).

Infants, Children, and Adolescents: Note: Close monitoring is recommended to assess clinical response and adverse drug reactions; rate of administration varies depending on type of dosing; use precaution:

Single loading dose (10 to 15 mg/kg up to 500 mg): Administer total dose over 30 to 60 minutes (Ref); Note: Usual adult infusion rate: 20 to 50 mg/minute (Ref).

Divided loading doses (2 to 6 mg/kg/dose up to 100 mg/dose): Administer over ≥5 minutes (Ref).

Continuous IV infusion: Administer via an infusion pump.

Usual Infusion Concentrations: Adult

IV infusion: 1000 mg in 500 mL (concentration: 2 mg/mL), 1000 mg in 250 mL (concentration: 4 mg/mL), or 2000 mg in 250 mL (concentration: 8 mg/mL) of D5W or NS

Use: Labeled Indications

Ventricular arrhythmias, life threatening: Treatment of life-threatening ventricular arrhythmias.

Use: Off-Label: Adult

Atrial fibrillation with preexcitation; Ventricular arrhythmia, stable monomorphic ventricular tachycardia

Medication Safety Issues
Sound-alike/look-alike issues:

Procanbid may be confused with probenecid, Procan SR

Pronestyl may be confused with Ponstel

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.

Administration issues:

Procainamide hydrochloride is available in 10 mL vials of 100 mg/mL and in 2 mL vials with 500 mg/mL. Note that BOTH vials contain 1 gram of drug; confusing the strengths can lead to massive overdoses or underdoses.

Other safety concerns:

PCA is an error-prone abbreviation (mistaken as patient controlled analgesia)

Metabolism/Transport Effects

Substrate of CYP2D6 (minor), OCT1, OCT2; Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Ajmaline: May enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). QT-prolonging Class IA Antiarrhythmics (Highest Risk) may increase the serum concentration of Ajmaline. Risk X: Avoid combination

Amiodarone: QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of Amiodarone. Management: Consider alternatives to this drug combination. If combined, consider dose reductions of the class IA antiarrhythmic (30% to 50%) and monitor for QTc interval prolongation and ventricular arrhythmias. Risk D: Consider therapy modification

Amisulpride (Oral): QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Amisulpride (Oral). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even greater risk. Risk D: Consider therapy modification

Azithromycin (Systemic): QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Azithromycin (Systemic). Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Carbetocin: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Ceritinib: May enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of Ceritinib. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Chloroquine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Chloroquine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Cimetidine: May increase the serum concentration of Procainamide. Management: Consider an alternative H2-receptor antagonist in patients taking procainamide. If combined, monitor for increased therapeutic effects/toxicity of procainamide. Risk D: Consider therapy modification

Citalopram: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Citalopram. Risk X: Avoid combination

Clarithromycin: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Clarithromycin. Risk X: Avoid combination

Clofazimine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Clofazimine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

ClomiPRAMINE: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

CloZAPine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of CloZAPine. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Crizotinib: QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of Crizotinib. Crizotinib may enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Crizotinib may increase the serum concentration of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Dabrafenib: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Dasatinib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Dasatinib. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Domperidone: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Domperidone. Risk X: Avoid combination

Doxepin-Containing Products: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Doxepin-Containing Products. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

DroPERidol: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of DroPERidol. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Encorafenib: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Entrectinib: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Risk X: Avoid combination

Erdafitinib: May increase the serum concentration of OCT2 Substrates (Clinically Relevant with Inhibitors). Management: Consider alternatives to this combination when possible. If combined, monitor for increased effects/toxicities of OCT2 substrates and consider OCT2 substrate dose reductions when appropriate. Risk D: Consider therapy modification

Erythromycin (Systemic): QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of Erythromycin (Systemic). Erythromycin (Systemic) may enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Erythromycin (Systemic) may increase the serum concentration of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Escitalopram: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Escitalopram. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Etelcalcetide: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Fexinidazole: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Risk X: Avoid combination

Fingolimod: May enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Risk X: Avoid combination

Flecainide: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Flecainide. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Fluconazole: May enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Fluorouracil Products: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Fluorouracil Products. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Flupentixol: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Flupentixol. Risk X: Avoid combination

Foslevodopa: May increase the serum concentration of MATE1/2-K Substrates (Clinically Relevant with Inhibitors). Risk C: Monitor therapy

Gadobenate Dimeglumine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Gadobenate Dimeglumine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Gemifloxacin: May enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Risk X: Avoid combination

Gilteritinib: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this combination. If use is necessary, monitor for QTc interval prolongation and arrhythmias. Risk D: Consider therapy modification

Halofantrine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Halofantrine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Haloperidol: QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of Haloperidol. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

HydrOXYzine: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Risk C: Monitor therapy

Iboga: May enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Imipramine: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Inotuzumab Ozogamicin: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Inotuzumab Ozogamicin. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Lacosamide: QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the adverse/toxic effect of Lacosamide. Specifically the risk for bradycardia, ventricular tachyarrhythmias, or a prolonged PR interval may be increased. Risk C: Monitor therapy

LamoTRIgine: May increase the serum concentration of Procainamide. Management: Consider monitoring for increased procainamide concentrations and/or systemic effects in patients receiving procainamide with lamotrigine. The lamotrigine Canadian product monograph states that coadministration of these agents is not recommended. Risk C: Monitor therapy

Levofloxacin-Containing Products (Systemic): May enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Risk X: Avoid combination

Levoketoconazole: QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of Levoketoconazole. Risk X: Avoid combination

Lofexidine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Lofexidine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Meglumine Antimoniate: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Methadone: QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of Methadone. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Midostaurin: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Midostaurin. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Moxifloxacin (Systemic): QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Moxifloxacin (Systemic). Risk X: Avoid combination

Neuromuscular-Blocking Agents: Procainamide may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Nilotinib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Nilotinib. Risk X: Avoid combination

OLANZapine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of OLANZapine. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Ondansetron: QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of Ondansetron. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Osimertinib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Osimertinib. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Oxytocin: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Pacritinib: May increase the serum concentration of OCT1 Substrates (Clinically Relevant with Inhibitors). Risk X: Avoid combination

PAZOPanib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of PAZOPanib. Risk X: Avoid combination

Pentamidine (Systemic): QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Pentamidine (Systemic). Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Pilsicainide: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Pilsicainide. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Pimozide: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Pimozide. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk X: Avoid combination

Piperaquine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Piperaquine. Risk X: Avoid combination

Probucol: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Probucol. Risk X: Avoid combination

Propafenone: May enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Risk X: Avoid combination

Propofol: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

QT-prolonging Agents (Indeterminate Risk - Avoid): May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy

QT-prolonging Agents (Indeterminate Risk - Caution): May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy

QT-prolonging Class IA Antiarrhythmics (Highest Risk): May enhance the QTc-prolonging effect of other QT-prolonging Class IA Antiarrhythmics (Highest Risk). Risk X: Avoid combination

QT-prolonging Class III Antiarrhythmics (Highest Risk): QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of QT-prolonging Class III Antiarrhythmics (Highest Risk). Risk X: Avoid combination

QT-Prolonging Inhalational Anesthetics (Moderate Risk): May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

QT-prolonging Kinase Inhibitors (Highest Risk): May enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

QT-prolonging Miscellaneous Agents (Highest Risk): QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of QT-prolonging Miscellaneous Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

QT-prolonging Strong CYP3A4 Inhibitors (Highest Risk): QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of QT-prolonging Strong CYP3A4 Inhibitors (Highest Risk). Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

QUEtiapine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of QUEtiapine. Risk X: Avoid combination

Quizartinib: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

RaNITIdine (Withdrawn from US Market): May increase the serum concentration of Procainamide. Ranitidine may also increase the concentration of the active N-acetyl-procainamide (NAPA) metabolite. Risk C: Monitor therapy

Ribociclib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Ribociclib. Risk X: Avoid combination

Risdiplam: May increase the serum concentration of MATE1/2-K Substrates (Clinically Relevant with Inhibitors). Management: Avoid use of risdiplam with MATE substrates if possible. If the combination cannot be avoided, monitor closely for adverse effects. Consider a reduced dose of the MATE substrate according to that substrate's labeling if appropriate. Risk D: Consider therapy modification

RisperiDONE: QT-prolonging Agents (Highest Risk) may enhance the CNS depressant effect of RisperiDONE. QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of RisperiDONE. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Saquinavir: QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of Saquinavir. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Sertindole: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Risk X: Avoid combination

Sparfloxacin: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Sparfloxacin. Risk X: Avoid combination

SUNItinib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of SUNItinib. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Tafenoquine: May increase the serum concentration of MATE1/2-K Substrates (Clinically Relevant with Inhibitors). Management: Avoid use of MATE substrates with tafenoquine, and if the combination cannot be avoided, monitor closely for evidence of toxicity of the MATE substrate and consider a reduced dose of the MATE substrate according to that substrate's labeling. Risk D: Consider therapy modification

Tafenoquine: May increase the serum concentration of OCT2 Substrates (Clinically Relevant with Inhibitors). Management: Avoid use of OCT2 substrates with tafenoquine, and if the combination cannot be avoided, monitor closely for evidence of toxicity of the OCT2 substrate and consider a reduced dose of the OCT2 substrate according to that substrate's labeling. Risk D: Consider therapy modification

Terbutaline: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Thioridazine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Thioridazine. Risk X: Avoid combination

Toremifene: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Toremifene. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Trimethoprim: May increase serum concentrations of the active metabolite(s) of Procainamide. Trimethoprim may increase the serum concentration of Procainamide. Management: Consider alternatives to trimethoprim-containing regimens to avoid this interaction. If coadministered, monitor for increased procainamide adverse effects (increased QTc) if trimethoprim is initiated/dose increased. Risk D: Consider therapy modification

Vemurafenib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Vemurafenib. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

Voriconazole: QT-prolonging Class IA Antiarrhythmics (Highest Risk) may enhance the QTc-prolonging effect of Voriconazole. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Pregnancy Considerations

Procainamide crosses the placenta (Dumesic 1982; Oudijk 2002); procainamide and its active metabolite (N-acetyl procainamide) can be detected in the cord blood and neonatal serum (Pittard 1983). Intravenous procainamide may be considered for the acute treatment of SVT in pregnant women. Due to adverse events (lupus-like syndrome), long-term therapy should be avoided unless other options are not available (Page [ACC/AHA/HRS 2016]).

Breastfeeding Considerations

Procainamide and its metabolite are present in breast milk and concentrations may be higher than in the maternal serum. In a case report, procainamide was used throughout pregnancy with a dose of 2 g/day prior to delivery. After birth (39 weeks' gestation), milk and maternal serum concentrations were obtained over 15 hours of a dosing interval. Mean maternal serum concentrations were procainamide 1.1 mcg/mL and N-acetyl procainamide 1.6 mcg/mL. Mean milk concentrations were procainamide 5.4 mcg/mL and N-acetyl procainamide 3.5 mcg/mL (Pittard 1983). According to the manufacturer, the decision to continue or discontinue breastfeeding during therapy should take into account the risk of exposure to the infant and the benefits of treatment to the mother.

Monitoring Parameters

ECG (with attention to the QRS duration and QT interval), BP, kidney and liver function; with prolonged use monitor CBC with differential and platelet count; procainamide and N-acetyl procainamide blood concentrations, especially in patients with kidney or liver impairment or receiving a continuous infusion for longer than 24 hours.

Reference Range

Timing of serum samples: Draw 6 to 12 hours after IV infusion has started.

Therapeutic concentrations (approximate): Procainamide: 4 to 10 mcg/mL; N-acetyl procainamide 10 to 30 mcg/mL; combined: 10 to 30 mcg/mL. Therapeutic index is wide and varies between patients. An effective serum concentration in one patient may cause toxicity in another (Bauer 2008; Boro 2004; Connolly 1982; Giardina 1984).

Toxic concentration: Procainamide: >10 to 12 mcg/mL (occasional toxicity); 12 to 15 mcg/mL (more toxicity); >15 mcg/mL (commonly causes toxicity) (manufacturer’s labeling).

Mechanism of Action

Decreases myocardial excitability and conduction velocity and may depress myocardial contractility, by increasing the electrical stimulation threshold of ventricle, His-Purkinje system and through direct cardiac effects

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: IM 10 to 30 minutes

Distribution: Vd: Children: 2.2 L/kg; Adults: 2 L/kg; decreased with congestive heart failure or shock

Protein binding: 15% to 20%

Metabolism: Hepatic via acetylation to produce N-acetyl procainamide (NAPA) (active metabolite)

Half-life elimination:

Procainamide (hepatic acetylator, phenotype, cardiac and renal function dependent): Children: 1.7 hours; Adults: 2.5 to 4.7 hours; Anephric: 11 hours

NAPA (dependent upon renal function): Children: 6 hours; Adults: 6 to 8 hours; Anephric: 42 hours

Time to peak, serum: IM: 15 to 60 minutes

Excretion: Urine (30% to 60% unchanged procainamide; 6% to 52% as NAPA); feces (<5% unchanged procainamide. Note: >80% of formed NAPA is renally eliminated in contrast to procainamide which is ~50% renally eliminated (Gibson, 1977).

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: Elimination half-life is prolonged.

Older adult: Elimination half-life is prolonged.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Pronestyl;
  • (AU) Australia: Pronestyl;
  • (BE) Belgium: Pronestyl;
  • (BG) Bulgaria: Procainamid;
  • (BR) Brazil: Procamide;
  • (CN) China: Procainamide;
  • (CZ) Czech Republic: Apo procainamide;
  • (ES) Spain: Biocoryl;
  • (FI) Finland: Procamid;
  • (FR) France: Pronestyl;
  • (GB) United Kingdom: Procainamide | Pronestyl;
  • (GR) Greece: Pronestyl;
  • (HK) Hong Kong: Procainamide | Pronestyl;
  • (HU) Hungary: Procainamid;
  • (IE) Ireland: Pronestyl;
  • (IL) Israel: Pronestyl;
  • (IT) Italy: Procamide;
  • (JP) Japan: Amisalin | Procainamide hcl yoshitomi | Pronestyl;
  • (KR) Korea, Republic of: Procainamide HCL | Pulcan;
  • (LT) Lithuania: Novocainamid | Procainamid;
  • (LV) Latvia: Novocainamid | Procainamid;
  • (MY) Malaysia: Pronestyl;
  • (NL) Netherlands: Pronestyl;
  • (NZ) New Zealand: Pronestyl;
  • (PK) Pakistan: Pronestyl;
  • (PL) Poland: Procainamidum;
  • (PR) Puerto Rico: Procainamide HCL | Procanbid | Pronestyl;
  • (RU) Russian Federation: Novocainamid | Novocainamide;
  • (SE) Sweden: Pronestyl;
  • (SG) Singapore: Procainamide;
  • (SK) Slovakia: Apo-procainamide;
  • (TH) Thailand: Pronestyl;
  • (TW) Taiwan: Procamide | Pronestyl;
  • (UA) Ukraine: Novocainamid;
  • (UY) Uruguay: Pronestyl;
  • (ZA) South Africa: Pronestyl
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