12/18 7/6/23, 3:09 PM Pharmacologic therapy in survivors of sudden cardiac arrest - UpToDate GRAPHICS Amiodarone dosing in adults by indication Indications Loading dose Maintenance dose Atrial arrhythmias Prevention of recurrent PAF Total loading dose: 6 to 10 grams Lowest effective dose, usually 100 to 200 mg orally once per day Pharmacologic cardioversion of PAF Outpatient: Given as 400 to 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 elective cardioversion or Total loading dose: 6 to 10 grams orally over 2 to 6 Lowest effective dose, usually 100 to 200 mg orally catheter ablation of AF weeks once per day Given as 400 to 1200 mg Maximum 400 mg orally per orally per day in divided doses day in most circumstances Restoration and maintenance of NSR in critically ill patients with AF Total IV loading dose: 1050 mg Given as 150 mg IV bolus over 10 to 30 minutes, followed by continuous IV infusion at 1 mg per minute for 6 hours, then 0.5 mg per Ventricular rate control in critically ill patients with AF and rapid ventricular response 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 https://www.uptodate.com/contents/pharmacologic-therapy-in-survivors-of-sudden-cardiac-arrest/print 13/18 7/6/23, 3:09 PM Pharmacologic therapy in survivors of sudden cardiac arrest - UpToDate Ventricular arrhythmias Primary and secondary prevention of SCD in patients with LV dysfunction who are not candidates for or refuse ICD implantation Total oral loading dose: 6 to 10 grams Maximum 400 mg orally per day in most circumstances Outpatient: 400 to 600 mg orally per day in divided doses with meal Lowest effective dose, ideally 200 mg or less orally once per day or in divided doses 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 of shocks Outpatient: Given as 400 to 600 mg orally per day in Lowest effective dose, ideally 200 mg or less orally per day 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 with VF or pulseless VT 300 mg IV or IO rapid bolus 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 hemodynamically stable Total IV loading dose: 1050 mg If amiodarone is used chronically: Lowest effective dose, ideally 200 mg or less 150 mg IV bolus over 10 minutes, followed by continuous IV infusion at 1 mg per minute for 6 hours, patients orally per day; maximum 400 mg orally per day in most 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 https://www.uptodate.com/contents/pharmacologic-therapy-in-survivors-of-sudden-cardiac-arrest/print 14/18 7/6/23, 3:09 PM Pharmacologic therapy in survivors of sudden cardiac arrest - UpToDate Additional 150 mg boluses may be given if VT storm recurs 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/pharmacologic-therapy-in-survivors-of-sudden-cardiac-arrest/print 15/18 7/6/23, 3:09 PM Pharmacologic therapy in survivors of sudden cardiac arrest - UpToDate 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): Ambasilide, amiodarone, dronedarone, dofetilide, ibutilide, sotalol, vernakalant Class IIIb (metabolically dependent K+ channel openers): https://www.uptodate.com/contents/pharmacologic-therapy-in-survivors-of-sudden-cardiac-arrest/print 16/18 7/6/23, 3:09 PM Pharmacologic therapy in survivors of sudden cardiac arrest - UpToDate 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/pharmacologic-therapy-in-survivors-of-sudden-cardiac-arrest/print 17/18 7/6/23, 3:09 PM Pharmacologic therapy in survivors of sudden cardiac arrest - UpToDate Contributor Disclosures Philip J Podrid, MD, FACC No relevant financial relationship(s) with ineligible companies to disclose. Scott Manaker, MD, PhD Other Financial Interest: Expert witness in workers' compensation and in medical negligence matters [General pulmonary and critical care medicine]; National Board for Respiratory Care [Director]. All of the relevant financial relationships listed have been mitigated. Samuel L vy, MD No relevant financial relationship(s) with ineligible companies to disclose. 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/pharmacologic-therapy-in-survivors-of-sudden-cardiac-arrest/print 18/18