Symptomatic bradycardia associated with topical brimonidine gel (Mirvaso) administration: a case report

Bradycardia can have a number of different aetiologies, including as a side effect of medications. Brimonidine is a rare, but recognized, cause of bradycardia. Brimonidine is indicated in the treatment of facial erythema in rosacea when given as topical brimonidine gel (Mirvaso). It may also be administered as eye drops for raised intraocular pressure in open-angle glaucoma and ocular hypertension. Brimonidine is an alpha-2 agonist, which if systemically absorbed can present with bradycardia, hypotension, and dizziness. The authors are unaware of any other case reports regarding topical administration of Mirvaso in an adult and symptomatic bradycardia.

We present the case of a 78-year-old man with a background of rosacea, benign prostatic hyperplasia, and hypertension who had two separate admissions with symptomatic bradycardia. Electrocardiograms showed sinus bradycardia with AV block first degree, with rate recorded as low as 31 b.p.m. during a syncopal episode. These episodes of symptomatic bradycardia were intermittent and had a temporal association with topical administration of Mirvaso. He had no further episodes of bradycardia on discontinuation of Mirvaso and has remained symptom free for over 6 months.

The topical administration of Mirvaso should be avoided to broken or inflamed skin. This is owing to the increased risk of systemic absorption, which as in this case report, may present with bradycardia. This case reiterates the importance of completing a full medication history including all topical and parenteral medications in patients with arrhythmia.