usual oral amiodarone loading dose of 400 to 1200 mg/day (typically in two divided doses). This should be continued until a total loading dose of 10 grams has been received, then the dose should be reduced to the usual maintenance dose of 200 to 400 mg/day. Both oral and IV therapy can be given concurrently for a few days if there is a concern about gastrointestinal tract function. Dose adjustment Amiodarone is metabolized in the liver. The major metabolite is desethylamiodarone, which is active and has a longer elimination half-life than amiodarone [1]. Dose reduction is probably necessary in patients with significant hepatic disease. By comparison, there is minimal elimination of both amiodarone and desethylamiodarone by the kidneys due both to the large volume of distribution and extensive protein binding; the latter effect also minimizes drug removal by dialysis. As a result, the dose of amiodarone does not have to be reduced in patients with renal disease or in patients undergoing dialysis. https://www.uptodate.com/contents/amiodarone-clinical-uses/print 12/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate Drug interactions Amiodarone is highly bound to plasma proteins (>96 percent) and can alter the plasma concentration of other highly bound drugs. Interactions with other drugs, such as digoxin and warfarin, must be considered. A few key drug interactions are discussed separately in UpToDate. Additionally, specific interactions of amiodarone with other medications may be determined using the Lexicomp drug interactions tool. (See "Amiodarone: Adverse effects, potential toxicities, and approach to monitoring", section on 'Adverse drug interactions'.) Use in children The overall safety and efficacy of amiodarone in children have not been fully established. Use of amiodarone in the treatment of tachyarrhythmias in children has been reported in several small series and one small clinical trial [36]. Although amiodarone is effective for number of arrhythmias, its use in children is often limited by toxicities. Adverse events are common with IV amiodarone use in children and may be severe. Consultation with a pediatric cardiologist is advised. Severe adverse effects may include cardiovascular collapse, hypotension, bradycardia, and AV block. Nausea and vomiting are also common. ECG and blood pressure monitoring should be performed during administration of IV amiodarone. Amiodarone appears to be effective in the following circumstances: Supraventricular tachycardia (SVT) In children with refractory SVT, IV amiodarone is an option as second-line therapy for conversion to sinus rhythm. Use of IV amiodarone in this setting is generally limited to treatment of SVT that is refractory to other agents (adenosine, procainamide), and oral amiodarone is a second-line therapy for the prevention of recurrent arrhythmia. In children with frequent or symptomatic SVT episodes, oral amiodarone is sometimes used for chronic management if there is a poor response to first- and second-line agents (eg, beta blockers, digoxin, and sotalol). (See "Management of supraventricular tachycardia (SVT) in children".) Wide QRS complex tachycardia IV amiodarone has also been used, alone or in combination with other antiarrhythmic drugs, in infants and children with resistant, life- threatening ventricular tachyarrhythmias [37,38]. (See "Management and evaluation of wide QRS complex tachycardia in children", section on 'Shock-resistant tachyarrhythmia'.) Optimal dosing of amiodarone in children is not well established. For oral therapy, dosing is based upon body weight or, in children less than one year of age, upon body surface area. The loading dose, which can be given in one or two divided 2 doses per day, is 10 to 15 mg/kg per day or 600 to 800 mg/1.73 m per day for 4 to 14 days or until adequate control of the arrhythmia is attained or prominent adverse effects occur. 2 The dose should then be reduced to 5 mg/kg per day or 200 to 400 mg/1.73 m per day https://www.uptodate.com/contents/amiodarone-clinical-uses/print 13/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate once daily for several weeks. If the arrhythmia does not recur, the lowest effective dose should be used for maintenance. The usual minimal dose is 2.5 mg/kg per day. For IV therapy in critically ill children with tachyarrhythmias who have not responded to standard therapy, a variety of regimens have been used. We typically give a slow bolus infusion of 5 mg/kg (maximum dose 300 mg) IV over 20 to 60 minutes. If the patient does not convert to sinus rhythm, additional bolus doses of 1 to 5 mg/kg (up to a total of 15 mg/kg) can be given if there are no signs of toxicity (eg, hypotension, prolonged QT interval). This can be followed, if necessary, by a continuous infusion at a rate of 5 to 10 mcg/kg per minute. Use in pregnancy Amiodarone has unique characteristics that mandate cautious use in pregnancy. The complications that can occur with the use of amiodarone during pregnancy are: Hypothyroidism or hyperthyroidism in the mother or fetus because of the iodine in amiodarone Fetal bradycardia Fetal QT interval prolongation Premature labor Low birth weight In addition, amiodarone is found in fetal tissue and breast milk. For these reasons, the use of amiodarone in pregnancy should be reserved for maternal and fetal arrhythmias not responding to agents with known safety. Concomitant beta-blocker therapy should be avoided. Breast feeding is not recommended when the mother is taking amiodarone. (See "Supraventricular arrhythmias during pregnancy" and "Maternal conduction disorders and bradycardia during pregnancy".) Neonates of mothers taking amiodarone should have complete thyroid function tests and developmental follow-up. (See "Clinical features and detection of congenital hypothyroidism".) SIDE EFFECTS While amiodarone does have many potential benefits, side effects are a serious concern. Of greatest concern are potential toxicities involving the lungs, thyroid, liver, eyes, and skin ( table 3). The potential side effects related to amiodarone use are discussed in detail separately. (See "Amiodarone: Adverse effects, potential toxicities, and approach to monitoring".) https://www.uptodate.com/contents/amiodarone-clinical-uses/print 14/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Atrial fibrillation" and "Society guideline links: Ventricular arrhythmias" and "Society guideline links: Supraventricular arrhythmias".) SUMMARY AND RECOMMENDATIONS Electrocardiographic actions Amiodarone has various electrophysiologic properties that are favorable in the treatment of tachyarrhythmias. There are important differences in these properties between the oral and intravenous (IV) preparations. (See 'Electrophysiologic properties' above.) Amiodarone can slow the sinus heart rate, prolong the PR interval, widen the QRS complex, and prolong the QT interval on surface electrocardiogram. (See 'Effects on the ECG' above.) Treatment of atrial arrythmias Oral amiodarone This can be used to treat most types of atrial arrhythmias but is used primarily to maintain normal sinus rhythm in patients with atrial fibrillation (AF). However, oral amiodarone is not FDA approved in the United States for rhythm control in AF, despite common usage for this indication. While there is no universally accepted dosing regimen ( table 4), oral loading doses of 400 to 1200 mg/day in divided doses (up to a total loading dose of 6 to 10 grams) can be used. The usual maintenance dose should be the lowest effective dose, which for AF is usually 200 mg daily but can sometimes be as low as 100 mg daily. (See 'Oral amiodarone for the treatment of atrial arrhythmias' above.) IV amiodarone This is primarily used for the treatment of atrial arrhythmias in two settings: restoration and maintenance of sinus rhythm in critically ill patients with hemodynamically unstable AF, and rate control in critically ill patients with AF with rapid ventricular response in whom the tachycardia is contributing to hemodynamic compromise. An initial IV loading dose of 150 mg is given over a minimum of 10 minutes ( table 4). More rapid infusion increases the risk of hypotension. The loading dose should be followed by a continuous infusion of 1 mg/minute for six hours and 0.5 mg/minute thereafter. (See 'Intravenous amiodarone for the treatment of atrial arrhythmias' above.) https://www.uptodate.com/contents/amiodarone-clinical-uses/print 15/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate Treatment of ventricular arrythmias Amiodarone is useful in a variety of ventricular arrhythmias but is most commonly used for the secondary prevention of recurrent ventricular arrhythmias in patients, including patients with an implantable cardioverter- defibrillator (ICD) to reduce the frequency of ICD shocks. The recommended loading dose ( table 4) for the prevention of ventricular arrhythmias is 400 to 1200 mg/day (usually in divided doses) for a total of 6 to 10 grams (except for secondary prevention of ICD shocks, when the loading dose is typically 8 to 10 grams). Maintenance doses range from 200 to 400 mg/day, with the lower doses carrying less risk of adverse side effects. (See 'Amiodarone for ventricular arrhythmias' above.) In the context of implantable cardioverter-defibrillators Despite its effectiveness in reducing ventricular tachyarrhythmias, amiodarone has been shown to be inferior to ICDs in reducing mortality in both primary and secondary prevention studies of patients at high risk for sudden cardiac death. Thus, the use of amiodarone in this setting should be reserved for patients who are candidates for an ICD but who cannot or refuse to have an ICD implanted. (See 'Primary prevention of sudden cardiac death' above and 'Secondary prevention of sudden cardiac death' above.) Transition from IV to oral dosing The dosing of amiodarone following conversion from IV to oral administration varies according to the duration of IV treatment prior to conversion. (See 'Transition from IV to oral therapy' above.) Drug interactions and side effects Amiodarone has the potential for numerous drug interactions and side effects ( table 3) that require monitoring. (See 'Drug interactions' above and "Amiodarone: Adverse effects, potential toxicities, and approach to monitoring".) Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Goldschlager N, Epstein AE, Naccarelli GV, et al. A practical guide for clinicians who treat patients with amiodarone: 2007. Heart Rhythm 2007; 4:1250. 2. Connolly SJ. Evidence-based analysis of amiodarone efficacy and safety. Circulation 1999; 100:2025. 3. Vassallo P, Trohman RG. Prescribing amiodarone: an evidence-based review of clinical indications. JAMA 2007; 298:1312. https://www.uptodate.com/contents/amiodarone-clinical-uses/print 16/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate 4. Desai AD, Chun S, Sung RJ. The role of intravenous amiodarone in the management of cardiac arrhythmias. Ann Intern Med 1997; 127:294. 5. Gomes JA, Kang PS, Hariman RJ, et al. Electrophysiologic effects and mechanisms of termination of supraventricular tachycardia by intravenous amiodarone. Am Heart J 1984; 107:214. 6. Scheinman MM, Levine JH, Cannom DS, et al. Dose-ranging study of intravenous amiodarone in patients with life-threatening ventricular tachyarrhythmias. The Intravenous Amiodarone Multicenter Investigators Group. Circulation 1995; 92:3264. 7. Clemo HF, Wood MA, Gilligan DM, Ellenbogen KA. Intravenous amiodarone for acute heart rate control in the critically ill patient with atrial tachyarrhythmias. Am J Cardiol 1998; 81:594. 8. Aiba T, Shimizu W, Inagaki M, et al. Excessive increase in QT interval and dispersion of repolarization predict recurrent ventricular tachyarrhythmia after amiodarone. Pacing Clin Electrophysiol 2004; 27:901. 9. Kamiya K, Nishiyama A, Yasui K, et al. Short- and long-term effects of amiodarone on the two components of cardiac delayed rectifier K(+) current. Circulation 2001; 103:1317. 10. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1. 11. Singh BN, Singh SN, Reda DJ, et al. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med 2005; 352:1861. 12. Lei LY, Chew DS, Lee W, et al. Pharmacological Cardioversion of Atrial Tachyarrhythmias Using Single High-Dose Oral Amiodarone: A Systematic Review and Meta-Analysis. Circ Arrhythm Electrophysiol 2021; 14:e010321. 13. Um KJ, McIntyre WF, Mendoza PA, et al. Pre-treatment with antiarrhythmic drugs for elective electrical cardioversion of atrial fibrillation: a systematic review and network meta-analysis. Europace 2022; 24:1548. 14. Darkner S, Chen X, Hansen J, et al. Recurrence of arrhythmia following short-term oral AMIOdarone after CATheter ablation for atrial fibrillation: a double-blind, randomized, placebo-controlled study (AMIO-CAT trial). Eur Heart J 2014; 35:3356. 15. Mohanty S, Di Biase L, Mohanty P, et al. Effect of periprocedural amiodarone on procedure outcome in patients with longstanding persistent atrial fibrillation undergoing extended pulmonary vein antrum isolation: results from a randomized study (SPECULATE). Heart Rhythm 2015; 12:477. https://www.uptodate.com/contents/amiodarone-clinical-uses/print 17/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate 16. Daoud EG, Strickberger SA, Man KC, et al. Preoperative amiodarone as prophylaxis against atrial fibrillation after heart surgery. N Engl J Med 1997; 337:1785. 17. Giri S, White CM, Dunn AB, et al. Oral amiodarone for prevention of atrial fibrillation after open heart surgery, the Atrial Fibrillation Suppression Trial (AFIST): a randomised placebo- controlled trial. Lancet 2001; 357:830. 18. Khan IA, Mehta NJ, Gowda RM. Amiodarone for pharmacological cardioversion of recent- onset atrial fibrillation. Int J Cardiol 2003; 89:239. 19. Hilleman DE, Spinler SA. Conversion of recent-onset atrial fibrillation with intravenous amiodarone: a meta-analysis of randomized controlled trials. Pharmacotherapy 2002; 22:66. 20. Chevalier P, Durand-Dubief A, Burri H, et al. Amiodarone versus placebo and class Ic drugs for cardioversion of recent-onset atrial fibrillation: a meta-analysis. J Am Coll Cardiol 2003; 41:255. 21. Cairns JA, Connolly SJ, Roberts R, Gent M. Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators. Lancet 1997; 349:675. 22. Singh SN, Fletcher RD, Fisher SG, et al. Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. N Engl J Med 1995; 333:77. 23. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2018; 72:e91. 24. Claro JC, Candia R, Rada G, et al. Amiodarone versus other pharmacological interventions for prevention of sudden cardiac death. Cochrane Database Syst Rev 2015; :CD008093. 25. Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med 1996; 335:1933. 26. Buxton AE, Lee KL, Fisher JD, et al. A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators. N Engl J Med 1999; 341:1882. 27. Passman R, Subacius H, Ruo B, et al. Implantable cardioverter defibrillators and quality of life: results from the defibrillators in nonischemic cardiomyopathy treatment evaluation study. Arch Intern Med 2007; 167:2226. https://www.uptodate.com/contents/amiodarone-clinical-uses/print 18/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate 28. Goldschlager N, Epstein AE, Naccarelli G, et al. Practical guidelines for clinicians who treat patients with amiodarone. Practice Guidelines Subcommittee, North American Society of Pacing and Electrophysiology. Arch Intern Med 2000; 160:1741. 29. Connolly SJ, Dorian P, Roberts RS, et al. Comparison of beta-blockers, amiodarone plus beta- blockers, or sotalol for prevention of shocks from implantable cardioverter defibrillators: the OPTIC Study: a randomized trial. JAMA 2006; 295:165. 30. Hohnloser SH, Dorian P, Roberts R, et al. Effect of amiodarone and sotalol on ventricular defibrillation threshold: the optimal pharmacological therapy in cardioverter defibrillator patients (OPTIC) trial. Circulation 2006; 114:104. 31. Podrid PJ. Amiodarone: reevaluation of an old drug. Ann Intern Med 1995; 122:689. 32. Gallik DM, Singer I, Meissner MD, et al. Hemodynamic and surface electrocardiographic effects of a new aqueous formulation of intravenous amiodarone. Am J Cardiol 2002; 90:964. 33. Boyce BA, Yee BH. Incidence and severity of phlebitis in patients receiving peripherally infused amiodarone. Crit Care Nurse 2012; 32:27. 34. Norton L, Ottoboni LK, Varady A, et al. Phlebitis in amiodarone administration: incidence, contributing factors, and clinical implications. Am J Crit Care 2013; 22:498. 35. Oragano CA, Patton D, Moore Z. Phlebitis in Intravenous Amiodarone Administration: Incidence and Contributing Factors. Crit Care Nurse 2019; 39:e1. 36. Saul JP, Scott WA, Brown S, et al. Intravenous amiodarone for incessant tachyarrhythmias in children: a randomized, double-blind, antiarrhythmic drug trial. Circulation 2005; 112:3470. 37. Perry JC, Fenrich AL, Hulse JE, et al. Pediatric use of intravenous amiodarone: efficacy and safety in critically ill patients from a multicenter protocol. J Am Coll Cardiol 1996; 27:1246. 38. Figa FH, Gow RM, Hamilton RM, Freedom RM. Clinical efficacy and safety of intravenous Amiodarone in infants and children. Am J Cardiol 1994; 74:573. Topic 926 Version 43.0 https://www.uptodate.com/contents/amiodarone-clinical-uses/print 19/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate GRAPHICS Revised (2018) Vaughan Williams classification of antiarrhythmic drugs abridged table Class 0 (HCN channel blockers) Ivabradine Class I (voltage-gated Na+ channel blockers) Class Ia (intermediate dissociation): Quinidine, ajmaline, disopyramide, procainamide Class Ib (rapid dissociation): Lidocaine, mexilitine Class Ic (slow dissociation): Propafenone, flecainide Class Id (late current): Ranolazine Class II (autonomic inhibitors and activators) Class IIa (beta blockers): Nonselective: carvedilol, propranolol, nadolol Selective: atenolol, bisoprolol, betaxolol, celiprolol, esmolol, metoprolol Class IIb (nonselective beta agonists): Isoproterenol Class IIc (muscarinic M2 receptor inhibitors): Atropine, anisodamine, hyoscine, scopolamine Class IId (muscarinic M2 receptor activators): Carbachol, pilocarpine, methacholine, digoxin Class IIe (adenosine A1 receptor activators): Adenosine Class III (K+ channel blockers and openers) Class IIIa (voltage dependent K+ channel blockers): https://www.uptodate.com/contents/amiodarone-clinical-uses/print 20/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate Ambasilide, amiodarone, dronedarone, dofetilide, ibutilide, sotalol, vernakalant Class IIIb (metabolically dependent K+ channel openers): Nicorandil, pinacidil Class IV (Ca++ handling modulators) Class IVa (surface membrane Ca++ channel blockers): Bepridil, diltiazem, verapamil Class IVb (intracellular Ca++ channel blockers): Flecainide, propafenone Class V (mechanosensitive channel blockers): No approved medications Class VI (gap junction channel blockers) No approved medications Class VII (upstream target modulators) Angiotensin converting enzyme inhibitors Angiotensin receptor blockers Omega-3 fatty acids Statins HCN: hyperpolarization-activated cyclic nucleotide-gated; Na: sodium; K: potassium; Ca: calcium. Graphic 120433 Version 3.0 https://www.uptodate.com/contents/amiodarone-clinical-uses/print 21/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate Oral versus intravenous amiodarone Effect Variable Oral Intravenous amiodarone amiodarone Prolongation of action potential duration in atrial and ventricular myocardium +++ + Blockage of inactivated sodium channels +++ ++ Slowing of phase 4 depolarization in the sinus node +++ + Calcium channel blockade +++ +++ Noncompetetive blockade of alpha and beta adrenoreceptors + + (faster) AV node effective refractory period Ventricular effective refractory period / Heart rate QRS interval / QTc duration A-H interval H-V interval Block conversion of thyroxine to trilodothyronine +++ AV: atrioventricular; A-H interval: time from initial rapid deflection of the atrial wave to the initial rapid deflection of the His bundle potential; H-V interval: time from initial deflection of the His bundle potential to the onset of ventricular activity; +: yes or present; -: no or absent; : increase; : decrease. Comparison of the electropharmacologic effects of oral and intravenous amiodarone. Compared with oral amiodarone, the intravenous preparation produces a much lesser increase in the action potential duration in atrial and ventricular myocardium and a minimal increase in the atrial and ventricular refractory periods. As a result, there is little or no increase in QRS duration and the QT interval, respectively. Intravenous amiodarone also has little effect on sinus cycle length and has vasodilator activity that triggers an increase in sympathetic activity; both of these effects result in little or no slowing of the sinus rate. Lastly, the intravenous preparation may have more potent and more rapid antiadrenergic activity. Data from: Desai AD, Chun S, Sung RJ. Ann Intern Med 1997; 127:294. Graphic 79689 Version 4.0 https://www.uptodate.com/contents/amiodarone-clinical-uses/print 22/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate Relationship between fast sodium-mediated myocardial action potential and surface electrocardiogram Each phase of the myocardial action potential (numbers, upper panel) corresponds to a deflection or interval on the surface ECG (lower panel). Phase 4, the resting membrane potential, is responsible for the TQ segment; this segment has a prominent role in the ECG manifestations of ischemia during exercise testing. ECG: electrocardiogram. Graphic 64133 Version 4.0 https://www.uptodate.com/contents/amiodarone-clinical-uses/print 23/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate Action potential currents Major cardiac ion currents and channels responsible for a ventricular action potential are shown with their common name, abbreviation, and the gene and protein for the alpha subunit that forms the pore or transporter. The diagram on the left shows the time course of amplitude of each current during the action potential, but does not accurately reflect amplitudes relative to each of the other currents. This summary represents a ventricular myocyte, and lists only the major ion channels. The currents and their molecular nature vary within regions of the ventricles, and in atria, and other specialized cells such as nodal and Purkinje. Ion channels exist as part of multi-molecular complexes including beta subunits and other associated regulatory proteins which are also not shown. Courtesy of Jonathan C Makielski, MD, FACC. Graphic 70771 Version 4.0 https://www.uptodate.com/contents/amiodarone-clinical-uses/print 24/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate Amiodarone baseline testing and monitoring for side effects Monitoring Area of interest for monitoring Possible adverse effect Baseline testing Follow-up testing Cardiac ECG (at baseline and during loading dose) Yearly QT prolongation; torsades de pointes After adding medications that Symptomatic sinoatrial interact with amiodarone or prolong or conduction system impairment the QT interval Implantable Defibrillation threshold As needed for Increased defibrillation cardioverter- testing (if clinically signs/symptoms threshold defibrillators indicated) Dermatologic Physical examination As needed for Photosensitivity to UV signs/symptoms light Blue-gray skin discoloration Endocrine TSH (with reflex testing if abnormal) 3 to 4 months after starting drug, then Hyperthyroidism, hypothyroidism yearly As needed for signs/symptoms Hepatic AST and ALT 6 months after starting AST or ALT elevation 2 upper limit of reference range drug, then yearly Ophthalmologic Eye examination Yearly Corneal microdeposits Optic neuropathy Pulmonary Chest radiograph, Yearly for surveillance Pulmonary toxicity PFTs* (cough, fever, dyspnea) Along with PFTs (including DLCO) and chest computed tomography for signs/symptoms Refer to UpToDate topics on pulmonary toxicity, thyroid toxicity, and clinical uses of amiodarone for additional information. https://www.uptodate.com/contents/amiodarone-clinical-uses/print 25/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate ECG: electrocardiogram; UV: ultraviolet; TSH: thyroid-stimulating hormone; AST: aspartate aminotransferase; ALT: alanine transaminase; PFTs: pulmonary function tests; DLCO: diffusing capacity of the lungs for carbon monoxide. There are differing opinions, and no concensus, of obtaining formal PFTs with assessment of diffusion capacity (ie, DLCO) as baseline testing in all patients. Some experts obtain baseline PFTs with DLCO prior to starting amiodarone, particularly among patients with underlying lung disease, while other experts rarely or never obtain baseline PFTs. Graphic 126072 Version 4.0 https://www.uptodate.com/contents/amiodarone-clinical-uses/print 26/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate Amiodarone dosing in adults by indication Indications Loading dose Maintenance dose Atrial arrhythmias Prevention of recurrent Total loading dose: 6 to 10 Lowest effective dose, PAF grams usually 100 to 200 mg orally once per day Pharmacologic Outpatient: Given as 400 to cardioversion of PAF 600 mg orally per day in divided doses with meals Maximum 200 mg orally per day Inpatient: Given as 400 to 1200 mg orally per day in divided doses with meals Pretreatment before Total loading dose: 6 to 10 Lowest effective dose, elective cardioversion or catheter ablation of AF grams orally over 2 to 6 weeks usually 100 to 200 mg orally once per day Given as 400 to 1200 mg orally per day in divided Maximum 400 mg orally per day in most circumstances doses Restoration and maintenance of NSR in Total IV loading dose: 1050 mg critically ill patients with AF Given as 150 mg IV bolus over 10 to 30 minutes, Ventricular rate control in critically ill patients with followed by continuous IV infusion at 1 mg per minute AF and rapid ventricular response for 6 hours, then 0.5 mg per minute for 18 hours* IV infusion (0.5 mg per minute) may need to be extended past 24 hours if unable to transition to oral therapy If amiodarone will be used chronically: Following IV infusion, give 400 to 1200 mg orally per day in divided doses to complete a total (IV plus oral) loading dose of 10 grams; consider overlapping IV and oral amiodarone for 24 to 48 hours Ventricular arrhythmias https://www.uptodate.com/contents/amiodarone-clinical-uses/print 27/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate Primary and secondary Total oral loading dose: 6 to Maximum 400 mg orally per prevention of SCD in patients with LV 10 grams day in most circumstances Outpatient: 400 to 600 mg Lowest effective dose, ideally dysfunction who are not candidates for or refuse orally per day in divided doses with meal 200 mg or less orally once per day or in divided doses ICD implantation Inpatient: 400 to 1200 mg orally per day in divided doses with meals for 1 to 2 weeks Prevention of ventricular arrhythmias in patients Total loading dose: 6 to 10 grams Maximum 400 mg orally per day in most circumstances with ICDs to decrease risk Outpatient: Given as 400 to 600 mg orally per day in Lowest effective dose, ideally 200 mg or less orally per day of shocks divided doses with meals Inpatient: Given as 400 to 1200 mg orally per day in divided doses with meals until desired dose is achieved Cardiac arrest associated 300 mg IV or IO rapid bolus with VF or pulseless VT with a repeat dose of 150 mg as indicated Upon return of spontaneous circulation follow with an infusion of 1 mg per minute for 6 hours and then 0.5 mg per minute for 18 hours* Electrical (VT) storm and incessant VT in Total IV loading dose: 1050 mg If amiodarone is used chronically: Lowest effective hemodynamically stable patients dose, ideally 200 mg or less orally per day; maximum 400 150 mg IV bolus over 10 minutes, followed by mg orally per day in most continuous IV infusion at 1 mg per minute for 6 hours, circumstances then 0.5 mg per minute for 18 hours IV infusion (0.5 mg per minute) may need to be extended past 24 hours if unable to transition to oral therapy Additional 150 mg boluses may be given if VT storm recurs https://www.uptodate.com/contents/amiodarone-clinical-uses/print 28/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate If amiodarone will be used chronically: Following IV infusion 400 to 1200 mg orally per day in divided doses to complete a total (IV plus oral) loading dose of 10 grams. Consider overlapping IV and oral amiodarone for 24-48 hours PAF: paroxysmal atrial fibrillation; AF: atrial fibrillation; NSR: normal sinus rhythm; IV: intravenous; SCD: sudden cardiac death; LV: left ventricular; ICD: implantable cardioverter-defibrillator; VF: ventricular fibrillation; VT: ventricular tachycardia; IO: intraosseous. When administered to critically ill patients with atrial fibrillation and rapid ventricular response, repeated 150 mg boluses can be given over 10 to 30 minutes if needed, but no more than six to eight additional boluses should be administered in any 24-hour period. Typically, patients are given 1 or 2 doses of oral amiodarone prior to discontinuation of the IV infusion. Graphic 117524 Version 5.0 https://www.uptodate.com/contents/amiodarone-clinical-uses/print 29/30 7/5/23, 8:18 AM Amiodarone: Clinical uses - UpToDate Contributor Disclosures Elsa-Grace Giardina, MD, MS, FACC, FACP, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Rod Passman, MD, MSCE Grant/Research/Clinical Trial Support: Abbott [Ablation]; AHA [Ablation]; NIH [Stroke prevention]. Consultant/Advisory Boards: Abbott [Ablation]; iRhythm [Monitoring]; Janssen [Atrial fibrillation detection]; Medtronic [Implantable cardiac monitors]. Speaker's Bureau: iRhythm [Monitoring]. All of the relevant financial relationships listed have been mitigated. Samuel L vy, MD No relevant financial relationship(s) with ineligible companies to disclose. Peter J Zimetbaum, MD Consultant/Advisory Boards: Abbott Medical [Lead extraction]. All of the relevant financial relationships listed have been mitigated. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/amiodarone-clinical-uses/print 30/30