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Amiodarone: Guidelines for Use and Monitoring LYLE A

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Amiodarone: Guidelines for Use and Monitoring LYLE A CLINICAL PHARMACOLOGY Amiodarone: Guidelines for Use and Monitoring LYLE A. SIDDOWAY, M.D., York Hospital, York, Pennsylvania Amiodarone is a potent antiarrhythmic agent that is used to treat ventricular arrhyth- mias and atrial fibrillation. The drug prevents the recurrence of life-threatening ven- tricular arrhythmias and produces a modest reduction of sudden deaths in high-risk patients. Amiodarone is more effective than sotalol or propafenone in preventing recurrent atrial fibrillation in patients for whom a rhythm-control strategy is chosen. When long-term amiodarone therapy is used, potential drug toxicity and interactions must be considered. The dosage of amiodarone should be kept at the lowest effective level. In patients who also are taking digoxin and warfarin, physicians must pay close attention to digoxin levels and prothrombin time, keeping in mind that the effects of interaction with amiodarone do not peak until seven weeks after the initiation of con- comitant therapy. Laboratory studies to assess liver and thyroid function should be performed at least every six months. (Am Fam Physician 2003;68:2189-96. Copyright 2003© American Academy of Family Physicians.) Richard W. Sloan, miodarone (Cordarone) is a tions in fat and muscle, as well as in the liver, M.D., R.Ph., coordina- complex antiarrhythmic agent lungs, and skin. Amiodarone crosses the pla- tor of this series, is chairman and residency with multiple electrophysio- centa and reaches measurable levels in breast program director of logic effects, unusual pharma- milk. the Department of cokinetics, and numerous po- The major metabolite of amiodarone is Family Medicine at Atentially harmful drug interactions and desethylamiodarone (DEA), which is known York (Pa.) Hospital and adverse effects. Although the U.S. Food and to have antiarrhythmic properties. Grapefruit clinical associate pro- fessor in family and Drug Administration (FDA) has labeled juice can inhibit amiodarone metabolism and 3 community medicine at amiodarone only for the treatment of life- lead to elevated drug levels, but the impact of the Milton S. Hershey threatening ventricular arrhythmias, the drug this interaction on the long-term efficacy and Medical Center, Penn- also is used to treat atrial fibrillation. Because toxicity of amiodarone is not known. sylvania State Univer- of the complexity and widespread use of this The elimination half-life of amiodarone is sity, Hershey, Pa. agent, other treatment decisions often are highly variable and unusually long, averaging affected. This article reviews the pharmacol- about 58 days. The long half-life is thought to ogy, indications, adverse effects, and drug be a result of the drug’s slow release from interactions of amiodarone, and outlines a lipid-rich tissues.2 strategy for surveillance of patients who are taking this drug. ELECTROPHYSIOLOGIC EFFECTS Amiodarone is considered to be a class III Clinical Pharmacology drug (Vaughan Williams classification), which PHARMACOKINETICS indicates that it prolongs the QT interval. Amiodarone is an iodine-containing com- However, the drug has many other effects: it pound with some structural similarity to thy- slows heart rate and atrioventricular nodal roxine. The drug’s high iodine content likely is conduction (via calcium channel and beta- a factor in its effects on the thyroid gland. The receptor blockade), prolongs refractoriness bioavailability of amiodarone is variable but (via potassium and sodium channel block- generally poor, ranging from 22 to 95 per- ade), and slows intracardiac conduction (via cent.1 Absorption is enhanced when the drug sodium channel blockade). See page 2113 for 2 definitions of strength- is taken with food. Amiodarone is highly The relationship between plasma amio- of-evidence levels. lipid soluble and is stored in high concentra- darone concentrations and effect, as well as Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2003 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. tality rate from 24.3 percent to 19.9 percent Amiodarone is approved for use in the secondary prevention (ARR, 4.4 percent; NNT, 23). Because of life-threatening ventricular arrhythmias. implantable cardioverter-defibrillators (ICDs) are more effective than amiodarone in reduc- ing mortality in high-risk patients with previ- ous myocardial infarction, primary treatment the contribution of the metabolite DEA, is not should be an ICD.6-9 [Reference 6—Evidence well established.2 Routine monitoring of the level A, meta-analysis] In these patients, amio- amiodarone plasma level is not recom- darone may be used as an adjunct to reduce mended.4 [Evidence level C, consensus/ expert the frequency of ICD shocks or to control guidelines] atrial fibrillation in selected highly sympto- matic patients. The relative efficacy of amio- Indications darone and ICDs in preventing sudden death LONG-TERM TREATMENT in patients without coronary disease is under Amiodarone is approved for use in the sec- investigation. ondary prevention of life-threatening ven- Amiodarone is used in the treatment of tricular arrhythmias. The North American atrial fibrillation, although the FDA has not Society for Pacing and Electrophysiology approved this indication. Various practice (NASPE) recommends amiodarone as the guidelines recommend amiodarone as a sec- antiarrhythmic agent of choice in patients ond-line drug in the long-term treatment of who have survived sustained ventricular tachy- atrial fibrillation in patients with structural arrhythmias, particularly those with left ven- heart disease and in highly symptomatic tricular dysfunction.4 patients without heart disease.10 Several Studies on the use of amiodarone for the smaller studies have shown that amiodarone primary prevention of sudden death in high- is similar to quinidine and sotalol in the treat- risk patients have had mixed results. One ment of atrial fibrillation in these patients.11,12 meta-analysis of 13 studies of patients with In one randomized controlled trial (RCT),12 congestive heart failure or recent myocardial sinus rhythm was maintained successfully for infarction showed a small reduction in total 16 months in 65 percent of patients treated annual mortality, from 12.3 percent to 10.9 with amiodarone, compared with 37 percent percent (absolute risk reduction [ARR], 2.4 of patients treated with sotalol or propa- percent; number needed to treat [NNT], 42).5 fenone (ARR, 28 percent; NNT, 3.6). However, [Evidence level A, meta-analysis] The benefit recent studies have shown that aggressive of amiodarone therapy was more pronounced attempts to maintain sinus rhythm using in the patients who had congestive heart fail- amiodarone or other drugs do not improve ure, with treatment reducing the annual mor- outcomes in relatively asymptomatic pa- tients.13,14 Therefore, long-term amiodarone therapy, with its potential for toxicity, does not The Author appear to be justified in patients who are tak- ing anticoagulant drugs if rate-control strate- LYLE A. SIDDOWAY, M.D., is director of the cardiac electrophysiology laboratory at York (Pa.) Hospital and assistant clinical professor in the Department of Medicine at gies can provide satisfactory symptomatic Pennsylvania State University College of Medicine, Hershey. After receiving his medical improvement. degree from Johns Hopkins University School of Medicine, Baltimore, Dr. Siddoway completed an internal medicine residency and clinical pharmacology and cardiology ACUTE TREATMENT fellowships at Vanderbilt University Medical Center, Nashville. Intravenously administered amiodarone is Address correspondence to Lyle A. Siddoway, M.D., 25 Monument Rd., Suite 200, York, PA 17403 (e-mail: [email protected]). Reprints are not available from effective for the emergency treatment of ven- the author. tricular tachyarrhythmias. Onset of the antiar- 2190 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 68, NUMBER 11 / DECEMBER 1, 2003 TABLE 1 Dosage Guidelines for Amiodarone (Cordarone) Administration Indication route and setting Dosage Potential adverse effects Life-threatening IV, inpatient 150-mg IV bolus over 10 minutes (if necessary, bolus may Hypotension, bradycardia, arrhythmia treatment be repeated in 10 to 30 minutes); then 1 mg per minute atrioventricular block for 6 hours; then 0.5 mg per minute for 18 hours; then reduce IV dosage or convert to oral dosing when possible.2 Ventricular Oral, inpatient 800 to 1,600 mg per day in divided doses until a total of Bradycardia, QT prolongation, arrhythmia treatment 10 g has been given; then 200 to 400 mg per day.2 GI upset, constipation; rarely, torsades de pointes Atrial fibrillation Oral, inpatient 600 to 800 mg per day in divided doses until a total of Bradycardia, QT prolongation, or outpatient 10 g has been given (may use higher initial dosage or IV GI upset, constipation; rarely, treatment dosing in unstable inpatients); then 200 mg per day10 torsades de pointes IV = intravenous; GI = gastrointestinal. Information from references 2 and 10. rhythmic effect of intravenous amiodarone similar to other antiarrhythmic drugs in its occurs in less than 30 minutes.15 ability to convert patients to normal sinus In the Advanced Cardiac Life Support rhythm (72.1 percent for amiodarone com- (ACLS) guidelines published in 2000, amio- pared with 71.9 percent for other antiarrhyth- darone and procainamide are recommended mic drugs).18 [Evidence level A,
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