Vagomimetic effects of fingolimod: physiology and clinical implications.
Fingolimod is a sphingosine 1-phosphate (S1P) receptor modulator approved to treat relapsing-remitting multiple sclerosis (MS). Initiation of treatment with fingolimod has been found to produce transient bradycardia and/or slowing of atrioventricular impulse conduction in a small proportion of patients. This effect is thought to be due to the interaction of fingolimod with S1P receptors on the surface membrane of atrial myocytes causing a vagomimetic effect, similar to the action of acetylcholine on muscarinic receptors. As a precaution, patients are under electrocardiogram (ECG) monitoring for 6 h after receiving their first dose. Fingolimod is contraindicated in patients with overt or concealed cardiac diseases. However, the Fingolimod Initiation and caRdiac Safety Trial (FIRST), which was designed specifically to investigate the cardiac profile of fingolimod, did not show an increased risk of clinically relevant cardiac events with fingolimod. This review examines the electrophysiology and pathophysiology of cardiac impulse formation in the context of fingolimod. It concludes that these vagomimetic effects should be considered benign and should not prevent the effective use of fingolimod in the treatment of patients with MS.
Cardiology Section, Department of Molecular Medicine, University of Pavia, Pavia, Italy; Cardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Italy.
Emilio
E
Vanoli
Francesco
F
Pentimalli
Gianluca
G
Botto
D000818:Animals; D054537:Atrioventricular Block / Q000139:chemically induced*; D001919:Bradycardia / Q000139:chemically induced*; D004562:Electrocardiography; D000068876:Fingolimod Hydrochloride; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects* / Q000494:pharmacology; D008246:Lysophospholipids / Q000378:metabolism; D020529:Multiple Sclerosis, Relapsing-Remitting / Q000188:drug therapy*; D011409:Propylene Glycols / Q000009:adverse effects* / Q000494:pharmacology; D049349:Receptors, Lysosphingolipid / Q000378:metabolism; D013110:Sphingosine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000378:metabolism / Q000494:pharmacology
D007166:Immunosuppressive Agents; D008246:Lysophospholipids; D011409:Propylene Glycols; D049349:Receptors, Lysosphingolipid; C060506:sphingosine 1-phosphate; D000068876:Fingolimod Hydrochloride; D013110:Sphingosine
Atrioventricular block; Bradycardia; Cardiac electrophysiology; Fingolimod