Amiodarone

- 150 mg/3 ml,  450 mg/9 ml and 900 mg/18 ml vials (IV).

- 100, 200 and 400 mg tablets (PO).

Executive Summary

(September 22, 2023)


Amiodarone is classified as a class III antiarrhythmic, affecting all phases of the action potential by inhibiting K+ efflux channels, Na+ channels, and L-type Ca2+ channels. Furthermore, it exhibits a non-competitive blockade action on beta receptors, resulting in a potent antiarrhythmic effect (3, 4, 26).


Adult dose for cardiac arrest with shockable rhythms (VF and Pulseless VT (pVT))(25, 29)

It is only recommended in cases of persistent VF/pVT despite defibrillation attempts and the administration of epinephrine (see ACLS algorithm):


Adult dose for stable ventricular tachycardia (21, 22)


Adult dose for rate control of atrial fibrillation / flutter (14, 30)

Adult dose

Adult dose for cardiac arrest with shockable rhythms (VF and Pulseless VT (pVT))(25, 29)

It is only recommended in cases of persistent VF/pVT despite defibrillation attempts and the administration of epinephrine (see ACLS algorithm):


Adult dose for stable ventricular tachycardia (22, 21)


Adult dose for rate control of atrial fibrillation / flutter (14, 30)

Indications


Mechanism of action

References 1, 2, 3, 4, and 26.

Amiodarone is well known for its multiple electrophysiologic and cardiovascular effects:



Amiodarone for atrial fibrillation / flutter (A-fib/AFL)

Amiodarone may be used for sinus conversion and rate control of atrial fibrillation and flutter. If used for rate control in prolonged A-fib/AFL (consensus limit of >48 hours), it also will carry the risk of sinus conversion and subsequent cardiac embolization and stroke. Consider that both effects cannot be completely separated.

Amiodarone and monomorphic ventricular tachycardia

Acute management of sustained monomorphic ventricular tachycardia (SMVT):



Amiodarone and polymorphic ventricular tachycardia in acute coronary syndromes

Ventricular arrhythmias (VA) are not uncommon in ACS patients (6-8% of STEMI patients develop hemodynamically significant VA). They are related to both ischemic and reperfusion phenomena. In the latter case, they are usually self-limited and typically have no major clinical impact.


First option amiodarone, second option lidocaine. 


In haemodynamically unstable patients with refractory VA, mechanical circulatory support may be considered (32).

Amiodarone and cardiac arrest

Cautions






These chronic complications carry little weight in the ED compared to patients requiring acute treatment for life-threatening conditions, so if necessary, the risk must be evaluated against the benefit.




Periprocedural risk of thromboembolic events in A-fib patients undergoing cardioversion

A 2020 narrative review thoroughly analyzes this topic (28):


Criticism of amiodarone in current practice


Suggested articles:

Pharmacology

Clinical pharmacology of amiodarone (26):

Renal, hepatic and age adjustements

Pregnancy and lactation

Pregnancy risk classification


Lactation (33)

High risk medication for the infant. Use safer alternatives or interrupt breastfeeding 3 to 7 T ½ (elimination half-lives).

References

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