Amiodarone Intravenous Intravenously administered amiodarone causes heart block or bradycardia in 4.9 percent of patients and hypotension in 16 percent.2 If these conditions occur, infusion of the drug should be discontinued, or the rate of infusion should be reduced. May follow with 0.125 to 0.25 mg IV q2-6h until 0.75 to 1.5 mg is given over 24hrs. Initial dose: 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen: No adjustment recommended Assistance in calculating accurate rates of medication administration. Thyroid abnormalities have been described in up to 10 percent of patients receiving long-term amiodarone therapy.2 Hyperthyroidism may result from an excess of iodine or acute thyroiditis.20 Hypothyroidism is two to four times more common than hyperthyroidism.2, In hypothyroid patients with a strong clinical indication for amiodarone, the drug may be continued with appropriate thyroid hormone supplementation. DOSE RECOMMENDATIONS -- FIRST 24 HOURS -- Loading infusions. FDA-approved for acute termination of A-flutter/A-fib (may be alternative to cardioversion): 1mg IV over 10min. WebA = Airway - Assess for airway obstruction, assess for breathing, perform intubation B = Breathing - Ventilate with 100% oxygen, 10-24 breaths/minute C = Circulation - Assess for heart beat and pulses if absent, begin chest compressions, 100-120 compressions/minute Begin ADVANCED life support Obtain Electrocardiogram and Determine Arrest Rhythm Initiate this drug in a clinical setting where continuous ECGs and cardiac resuscitation are available. These symptoms often are dosage related and usually improve when the dosage is reduced. IV Drip Rate Calculator Druga PO to IV Considerations Comments Amiodarone (Cordarone) Use an IV dose thats 50% of the PO maintenance Infusion*: <1 week Liver enzyme levels three times higher than normal. Clinical effects of intravenous to oral amiodarone transition Pulmonary toxicity has been fatal about 10% of the time. Not preferred drug for PSVT because it is not rapidly effective (may take up to 60 minutes). 4 0 obj Pre- and post-treatment with amiodarone may promote successful and sustained cardioversion. Patients' on the "floors" may receive once daily IV maintenance doses, however, IV loading regimens (multiple doses) are restricted to pts on a monitor- ICU's. FOIA Consensus follow-up recommendations from the NASPE are summarized in Table 4.4 A form to guide patient monitoring is provided in Figure 1. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Monitor ECG for at least 4hr . Stop amiodarone; initiate corticosteroid therapy. Amiodarone Hydrochloride Injection, 50 mg/mL is supplied in: formulation contains 50 mg of amiodarone HCl, 20.2 mg of benzyl alcohol, 100 mg of polysorbate 80, and water for injection. metoprolol, propranolol, atenolol, diltiazem, amiodarone, lidocaine, bisoprolol, verapamil, flecainide, Tenormin. Recommendations for conversion to intravenous amiodarone after oral administration: During long-term amiodarone therapy (ie, 4 months), the mean plasma-elimination half-life of the active metabolite of amiodarone is 61 days. The drug prevents the recurrence of life-threatening ventricular arrhythmias and produces a modest reduction of sudden deaths in high-risk patients. Reconstitution/preparation techniques: The manufacturer product information should be consulted. The bioavailability of amiodarone is variable but generally poor, ranging from 22 to 95 percent.1 Absorption is enhanced when the drug is taken with food.2 Amiodarone is highly lipid soluble and is stored in high concentrations in fat and muscle, as well as in the liver, lungs, and skin. (an inline 0.22 micron filter should be used). Amiodarone hydrochloride should only be used when facilities exist for cardiac monitoring, defibrillation, and cardiac pacing. Subscribe to Drugs.com newsletters for the latest medication news, new drug approvals, alerts and updates. Amiodarone is eliminated primarily by hepatic metabolism and biliary excretion and there is negligible excretion of amiodarone or DEA in urine. When the maintenance dose is given IV, the onset and peak will occur earlier, however the duration of action is the same. This can be followed by a CRI (1020 mcg/kg/min). Infusion*: <1 week Initial Daily Dose of Oral Cordarone : 800-1600 mg, Duration of Cordarone I.V. When long-term amiodarone therapy is used, potential drug toxicity and interactions must be considered. Amiodarone is a potent antiarrhythmic agent that is used to treat ventricular arrhythmias and atrial fibrillation. Treatments of amiodaroneinduced hyperthyroidism include the withdrawal of amiodarone (if this can be done safely), the addition of antithyroid medications or prednisone, and surgical thyroidectomy.20, Liver toxicity, manifested by elevation of liver transaminase levels, is common in patients who are receiving long-term amiodarone therapy. Amiodarone injection is contraindicated in patients with known hypersensitivity to any of the components of amiodarone injection, including iodine, or in patients with cardiogenic shock, marked sinus bradycardia, and second- or third-degree AV block unless a functioning pacemaker is available. Crcl 10-30 ml/min: Administer every 36-48 hours. PROARRHYTHMIC EFFECTS: Like other antiarrhythmics, this drug can exacerbate the arrhythmia, e.g., by making the arrhythmia less well tolerated or more difficult to reverse. Renal Dosing: CRCL >60 ml/min: Administer 500 mcg twice daily. Factors that increase likelihood of digoxin toxicity: Hypokalemia, hypomagnesaemia, hypothyroidism, renal dysfunction, interacting drugs (eg quinidine, verapamil). Amiodarone is metabolized to desethylamiodarone by the cytochrome P450 (CYP450) enzyme group, specifically cytochrome P450 3A4 (CYP3A4) and CYP2C8. Infusion: 1 to 3 weeks Initial Daily Dose of Oral Cordarone : 600-800 mg. %PDF-1.7 For control of postoperative hypertension, as many as one-third of patients may require higher doses (250-300 mcg/kg/minute) to control blood pressure; the safety of doses >300 mcg/kg/minute has not been studied. National Institutes of Health, U.S. National Library of Medicine, DailyMed Database. Prevention of ventricular arrhythmias in patients with ICDs to decrease risk of shocks. Stopping the infusion and restarting at a slower rate may help if infusion-related reactions occur. WebAmiodarone 300 mg (6 mL from TWO ampoules) added to 100 mL glucose 5%, administer by IV infusion over 20 minutes. Contraindicated in: sinus bradycardia; > 1st degree heart block; overt cardiac failure. 2014 AATS guidelines for prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. The Fab fragment-digoxin complex accumulates in the blood, from which it is excreted by the kidney. PO to IV Amiodarone Switch-Medscape-Apr22,2004. 2010;55:13701376. concentrations should not exceed 2 mg/mL unless a central venous catheter is used. [720 mg / 500 ml ] [See comments] If severe, stop amiodarone or insert pacemaker. Major adverse reactions: proarrhythmic events: VT, PVC's, BC, AV block, torsades de pointes, etc. To comment please, Comments on Medscape are moderated and should be professional in tone and on topic. Lidocaine (xylocaine ) Ventricular arrhythmia: 1-1.5 mg/kg IV bolus over 2-3 minutes; may repeat doses of 0.5-0.75 mg/kg in 5-10 minutes up to a total of 3 mg/kg; The patient is obviously at great risk during this time and may need prolonged hospitalization. Advise patients that most manufacturers of corneal refractive laser surgery devices consider corneal refractive laser surgery contraindicated in patients taking this drug. Loading infusions: 150 mg over the first 10 minutes (15 mg/min), followed by 360 mg over the next 6 hours (1 mg/min), Maintenance infusion: 540 mg over the remaining 18 hours (0.5 mg/min), Supplemental infusions: 150 mg over 10 minutes (15 mg/min) for breakthrough episodes of ventricular fibrillation (VF) or hemodynamically unstable ventricular tachycardia (VT). government site. If the potassium concentration exceeds 5 mEq/L in the setting of severe digitalis intoxication, therapy with DIGIBIND is indicated. Note: Decrease dose in patients with CHF, elderly, hepatic disease. Copyright 1993-2021 Serum levels: 0.5 to 2.0 ng/ml. Amiodarone exhibits complex disposition characteristics after intravenous administration. Attempts to substitute other antiarrhythmic agents when this drug must be stopped will be made difficult by the gradually, but unpredictably, changing body burden of this drug. Disclaimer. Before A naive look at this scenario gives the impression that the patient has not been started on an oral loading dose of amiodarone. Obtain baseline and periodic liver transaminases and discontinue or reduce dose if the increase exceeds three times normal, or doubles in a patient with an elevated baseline. infusion: 140 mcg/kg/minute for 6 minutes using syringe or columetric infusion pump; total dose: 0.84 mg/kg. The easiest way to lookup drug information, identify pills, check interactions and set up your own personal medication records. Consider stopping amiodarone; causal relationship is uncertain. In contrast, a recent study comparing the use of amiodarone and lidocaine in patients with shock-resistant, out-of-hospital ventricular fibrillation showed that amiodarone therapy substantially improves survival and hospital admission rates.17 [Evidence level A, RCT]. The recommended starting dose of Cordarone I.V. is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen: CORDARONE I.V. DOSE RECOMMENDATIONS FIRST 24 HOURS Loading infusions First Rapid: 150 mg over the FIRST 10 minutes (15 mg/min). These intracellular metabolites of adenosine are not vasoactive. Cordarone I.V is not intended for maint therapy. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. If the starting dose was 125 mcg twice daily, then adjust to 125 mcg every day. This drug should be used at the lowest effective dose in order to prevent the occurrence of side effects. RECOMMENDATIONS FOR ORAL DOSAGE AFTER I.V. Photosensitivity is common in patients receiving amiodarone therapy. Laboratory studies to assess liver and thyroid function should be performed at least every six months. There has been limited experience in patients receiving intravenous amiodarone for longer than 3 weeks. A steady state will be achieved after five cycles of the drug half-life (T1/2), which is approximately 7 to 10 days in the average subject. Although the U.S. Food and Drug Administration (FDA) has labeled amiodarone only for the treatment of life-threatening ventricular arrhythmias, the drug also is used to treat atrial fibrillation. 4.Volume of fluid in bag. Maintenance dose should be determined according to antiarrhythmic effect as assessed by patient tolerance as well as symptoms, Holter recordings, and/or programmed electrical stimulation; some patients may require up to 600 mg/day while some can be controlled on lower doses. 2017;52:665672. Time to steady state: 5-7 days (average) ESRD: 15-20 days. Cordarone IV Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material. Supplied: 225 mg, 325 mg, 425 mg extended release cap. If the starting dose is 500 mcg twice daily, then adjust to 250 mcg twice daily. CRCL 20-39 ml/min: Administer 125 mcg twice daily. Various practice guidelines recommend amiodarone as a second-line drug in the long-term treatment of atrial fibrillation in patients with structural heart disease and in highly symptomatic patients without heart disease.10 Several smaller studies have shown that amiodarone is similar to quinidine and sotalol in the treatment of atrial fibrillation in these patients.11,12 In one randomized controlled trial (RCT),12 sinus rhythm was maintained successfully for 16 months in 65 percent of patients treated with amiodarone, compared with 37 percent of patients treated with sotalol or propafenone (ARR, 28 percent; NNT, 3.6). The only information that I could find about PO to IV conversion involved patients who are stabilized on amiodarone PO for 4 months or longer. Renal impairment does not influence the pharmacokinetics of amiodarone. Amiodarone: I.V. Maintenance dose: Digoxin clearance= [CRCL + 40] x 1.44 (add 20 instead of 40 if pt has CHF). endobj Amiodarone and DEA cross the placenta and both appear in breast milk. There is no established relationship between drug concentration and therapeutic response for short-term intravenous use. Because implantable cardioverter-defibrillators (ICDs) are more effective than amiodarone in reducing mortality in high-risk patients with previous myocardial infarction, primary treatment should be an ICD.69 [Reference6 Evidence level A, meta-analysis] In these patients, amiodarone may be used as an adjunct to reduce the frequency of ICD shocks or to control atrial fibrillation in selected highly symptomatic patients. DOSE RECOMMENDATIONS -- FIRST 24 HOURS -- Loading infusions. Intravenously administered amiodarone is being used with increasing frequency in the acute treatment of atrial fibrillation. Postoperative atrial fibrillation following cardiac surgery: a persistent complication. All Rights Reserved. Infusion: whenever possible administer through a central venous catheter. by 25% full replacement dose qwk if hyperactivity risk; give PO form on empty stomach, 30-60min before morning meal; IM/IV dose is 50-75% of PO dose [>12 yo, growth/puberty complete] E.T. CLINICAL PHARMACOLOGY After intravenous injection of Digoxin Immune Fab (Ovine) in the baboon, digoxin-specific Fab fragments are excreted in the urine with a biological half-life of about 9 to 13 hours.1 In humans with normal renal function, the half-life appears to be 15 to 20 hours.2 Experimental studies in animals indicate that these antibody fragments have a large volume of distribution in the extracellular space, unlike whole antibody which distributes in a space only about twice the plasma volume.1 Ordinarily, following administration of DIGIBIND, improvement in signs and symptoms of digitalis intoxication begins within one-half hour or less.2,3,4,5. Age, sex, renal disease, and hepatic disease (cirrhosis) do not have marked effects on the disposition of amiodarone or DEA. Add 18 mL of Cordarone I.V. Advise patients to avoid consumption of grapefruit juice during treatment with this drug. levothyroxine: Dosing, contraindications, side effects, and pill This dose can be used in patients in acute distress or when a serum concentration is not available. INFUSION, Recommendations for conversion to intravenous amiodarone after oral administration, HONcode standard for trust- worthy health, Skeletal Muscle Index And Ovarian Cancer Prognosis: A Meta-Analysis, 7 Natural Remedies for Rheumatoid Arthritis. 3.Drug in bag. Oral Loading - Half-life elimination: 40-55 days (range: 26-107 days); Administration of Cordarone in divided doses with meals is suggested for total daily doses of 1,000 mg or higher, or when gastrointestinal intolerance occurs.) RECOMMENDATIONS FOR ORAL DOSAGE AFTER I.V. WARNINGS A much less common presentation is adult respiratory distress syndrome. In addition to blocking sodium channels, amiodarone blocks myocardial potassium channels, which contributes to slowing of conduction and prolongation of refractoriness. Replacement therapy may not be necessary in such patients if oral therapy is discontinued for a period <2 weeks, since any changes in serum amiodarone concentrations during this period may not be clinically significant. <> All of these events should be manageable in the proper clinical setting in most cases. 800 to 1,600 mg per day in divided doses until a total of 10 g has been given; then 200 to 400 mg per day. The patient is now taking nothing by mouth (NPO), and the physician would like to switch to intravenous (IV) amiodarone. Intravenous Inhibit salivation and secretions (preanesthesia): 0.4-0.6 mg (IM, IV, SQ) 30 to 60 minutes preop - repeat every 4-6 hours as needed. Crcl 40-60 ml/min: Administer every 24 hours. Patients treated with amiodarone should be followed regularly to assess ongoing need for amiodarone, efficacy of the drug, appropriateness of dosage, adverse effects, and potential drug interactions. Infuse over 30 minutes-- must use 0.22 micron filter. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Adverse reactions: sinus bradyarrhythmias; AV block; N/V/D; yellow vision and hallucinations; supra and ventricular arrhythmias. In clinical trials, after 48 hours of continued infusions (125, 500, or 1000 mg/day) plus supplemental (150 mg) infusions (for recurrent arrhythmias), amiodarone mean serum concentrations between 0.7 to 1.4 mg/L were observed (n=260). Amiodarone is considered to be a class III drug (Vaughan Williams classification), which indicates that it prolongs the QT interval. Amiodarone injection is used to treat life-threatening heart rhythm problems called ventricular arrhythmias. Amiodarone: I.V. Neurologic toxicity associated with amiodarone therapy can include ataxia, paresthesias, and tremor. Recommendations for conversion to intravenous amiodarone after oral administration: During long-term amiodarone therapy (ie, 4 months), the mean plasma-elimination half-life of the active metabolite of amiodarone is 61 days. A filter is not required for IV direct administration. Add 3 mL of Cordarone I.V. 2004;4(1)2004Medscape. Peak levels after 150 mg of supplemental infusions in patients with VT/VF range between 7 and 26 mg/L. If the starting dose was 250 mcg twice daily, then adjust to 125 mcg twice daily. Adverse reactions: Severe hypotension; bradycardia; ventricular standstill in digitalized patients; asystole; respiratory failure. Infusion: >3 weeks From in vitro studies, the protein binding of amiodarone is >96%. concentrations greater than 2 mg/mL should be administered via a central venous catheter). Amiodarone : I.V. DOSE RECOMMENDATIONS -- FIRST 24 HOURS -- Loading infusions. The recommended starting dose of Cordarone I.V. is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen: First Rapid: 150 mg over the FIRST - 10 minutes (15 mg/min). Add 3 mL of Cordarone I.V. (150 mg) to 100 mL D5W. A patient started on oral (PO) amiodarone approximately 1 week ago (400 mg/day). Loading Dose (Daily): (Ventricular Arrhythmias) 800 to 1,600 mg x 1-3 weeks, then 600 to 800 mg x ~1 month, then start maintenance of 400mg/day. WebIntravenous procainamide (Procainamide Hydrochloride Injection) is effective in cardioversion in up to 60 percent of patients in uncontrolled series. Bookshelf The dosage of amiodarone should be kept at the lowest effective level. Once inside the cell, adenosine is rapidly phosphorylated by adenosine kinase to adenosine monophosphate, or deaminated by adenosine deaminase to inosine. Restated: Duration of IV infusion < 1 week: 800-1600mg/day po initially x 1-2 weeks or complete current week; 1-3 weeks: 600-800mg/day po initially - total therapy ~ 1 month counting IV infusion ; >3 weeks: 400mg po qd initially. The discoloration resolves over several months after amiodarone is discontinued. Amiodarone has been associated with toxicity involving the lungs, thyroid gland, liver, eyes, skin, and nerves (Table 2).2,5,11,19 The frequency of most adverse effects is related to the total amiodarone exposure (i.e., dosage and duration of treatment). The initial rate of infusion should be monitored closely and should not exceed that prescribed in DOSAGE AND ADMINISTRATION. Drip preparation: Add 2.5 grams/ 250 ml D5W or NS [Drip rate (ml/hr)= wt(kg) x mcg/min x 0.006 ]. If you believe a loading dose is appropriate, then start him/her on IV loading while NPO. The initial infusion rate should not exceed 30 mg/min. ATRIUM CE Final Gale Watson 2010;11:5763. HlTn6}W#\)XM6E/-le1C?b9vC_ E5W7+x^}dh (Glass bottle or polyolefin container) Heart Views. Recommendations for conversion to intravenous amiodarone after oral administration: During long-term amiodarone therapy (ie, 4 months), the mean plasma-elimination half-life of the active metabolite of amiodarone is 61 days. In children, a Class III electrophysiological effect can be seen at daily doses of 210 mg/m2 body surface area (BSA). Its vasodilatory action can decrease cardiac workload and consequently myocardial oxygen consumption. (Doses <0.5 mg have been associated with paradoxical bradycardia.). WebUse oral administration wherever possible. Thyroid function test should be performed where appropriate prior to therapy in all patients. WebDose: individualize dose PO qd; Start: 2-3 mcg/kg/dose PO qd, then adjust dose q2wk; Info: adjust dose based on TFTs; start 25% full replacement dose, then incr. contains polysorbate 80, which is known to leach di-(2-ethylhexyl)phthalate (DEHP) from polyvinylchloride (PVC) (see DOSAGE AND ADMINISTRATION). DOSAGE AND ADMINISTRATION The only recommended dosage of MULTAQ is 400 mg twice daily in adults. Corneal microdeposits are visible on slit-lamp examination in nearly all patients treated with amiodarone.19 These deposits seldom affect vision and rarely necessitate discontinuation of the drug. The North American Society for Pacing and Electrophysiology (NASPE) recommends amiodarone as the antiarrhythmic agent of choice in patients who have survived sustained ventricular tachyarrhythmias, particularly those with left ventricular dysfunction.4. Amiodarone: Dosage, Mechanism/Onset of Action, Half-Life Supplied: 200 mg, 300 mg tab (sulfate). See labeling for oral amiodarone. Such patients should not be given dronedarone. Cordarone I.V. After absorption, the drug undergoes extensive enterohepatic circulation. (900 mg) to 500 mL D5W (conc = 1.8 mg/mL). sharing sensitive information, make sure youre on a federal Storage requirements: The manufacturer product information should be consulted. Onset of action: 2-10 minutes. Followed by Slow: 360 mg over the NEXT 6 hours (1 mg/min). Cardiac Arrest: First dose: Give 300 mg (6 mL) IV direct UNDILUTED. The recommended starting dose of Cordarone I.V. Although the frequency of such proarrhythmic events does not appear greater with this drug than with many other agents used in this population, the effects are prolonged when they occur. In most of the cases, the method of administration is via peripheral infusion. Our study suggests following conversion to normal sinus rhythm; cardiothoracic surgery patients can effectively and safely be transitioned from IV to oral amiodarone without the need for specific overlap duration or transition strategy. IV to PO amiodarone