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1 High Alert Contraindications/Precautions

Contraindicated in: Patients with cardiogenic shock; Severe sinus node dysfunc- PDF Page #1
amiodarone (am-ee-oh-da-rone) tion; 2nd- and 3rd-degree AV block; Bradycardia (has caused syncope unless a pace-
Cordarone, Nexterone, Pacerone maker is in place); Hypersensitivity to amiodarone or iodine; OB: Can cause fetal
Classification hypo- or hyperthyroidism; Lactation: Enters breast milk and can cause harm to the
Therapeutic: antiarrhythmics (class III) neonate; use an alternative to breast milk; Pedi: Safety not established; products con-
taining benzyl alcohol should not be used in neonates.
Pregnancy Category D
Use Cautiously in: History of HF; Thyroid disorders; Corneal refractive laser sur-
gery; Severe pulmonary or liver disease; Geri: Initiate therapy at the low end of the
Indications dosing range due tophepatic, renal, or cardiac function; comorbid disease; or other
Life-threatening ventricular arrhythmias unresponsive to less toxic agents. Unla- drug therapy.
beled Use: PO: Management of supraventricular tachyarrhythmias. IV: As part of
the Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support Adverse Reactions/Side Effects
(PALS) guidelines for the management of ventricular fibrillation (VF)/pulseless ven- CNS: confusional states, disorientation, hallucinations, dizziness, fatigue, malaise,
tricular tachycardia (VT) after cardiopulmonary resuscitation and defibrillation have headache, insomnia. EENT: corneal microdeposits, abnormal sense of smell, dry
failed; also for other life-threatening tachyarrhythmias. eyes, optic neuritis, optic neuropathy, photophobia. Resp: ADULT RESPIRATORY DIS-
TRESS SYNDROME (ARDS), PULMONARY FIBROSIS, PULMONARY TOXICITY. CV: CHF, WORS-
Action ENING OF ARRHYTHMIAS, bradycardia, hypotension. GI: anorexia, constipation, nau-
Prolongs action potential and refractory period. Inhibits adrenergic stimulation. sea, vomiting, abdominal pain, abnormal sense of taste,qliver enzymes. GU: p
Slows the sinus rate, increases PR and QT intervals, and decreases peripheral vascu-
libido, epididymitis. Derm: TOXIC EPIDERMAL NECROLYSIS (rare), photosensitivity,
lar resistance (vasodilation). Therapeutic Effects: Suppression of arrhythmias.
blue discoloration. Endo: hypothyroidism, hyperthyroidism. Neuro: ataxia, invol-
Pharmacokinetics untary movement, paresthesia, peripheral neuropathy, poor coordination, tremor.
Absorption: Slowly and variably absorbed from the GI tract (35– 65%). IV admin-
istration results in complete bioavailability. Interactions
Distribution: Distributed to and accumulates slowly in body tissues. Reaches high Drug-Drug:qrisk of QT prolongation with fluoroquinolones, macrolides, and
levels in fat, muscle, liver, lungs, and spleen. Crosses the placenta and enters breast azole antifungals (undertake concurrent use with caution).qlevels of digoxin
milk. (pdose of digoxin by 50%).qlevels of class I antiarrhythmics (quinidine, mex-
Protein Binding: 96% bound to plasma proteins. iletine, lidocaine, or flecainide—pdoses of other drugs by 30– 50%).qlevels of
Metabolism and Excretion: Metabolized by the liver, excreted into bile. Mini- cyclosporine, dextromethorphan, methotrexate, phenytoin, carvedilol, and
mal renal excretion. One metabolite has antiarrhythmic activity. theophylline. Phenytoinpamiodarone levels.qactivity of warfarin (pdose of
Half-life: 13– 107 days. warfarin by 33– 50%).qrisk of bradyarrhythmias, sinus arrest, or AV heart block
with beta blockers or calcium channel blockers. Cholestyramine maypamio-
TIME/ACTION PROFILE (suppression of ventricular arrhythmias)
darone levels. Cimetidine and ritonavirqamiodarone levels. Risk of myocardial
ROUTE ONSET PEAK DURATION depression isqby volatile anesthetics.qrisk of myopathy with lovastatin and
PO 2–3 days (up to 2–3 3–7 hr wk–mos simvastatin (do not exceed 40 mg/day of lovastatin or 20 mg/day of simvastatin).
mo) Drug-Natural Products: St. John’s wort induces enzymes that metabolize ami-
IV 2 hr 3–7 hr unknown odarone; mayplevels and effectiveness. Avoid concurrent use.
⫽ Canadian drug name. ⫽ Genetic Implication. CAPITALS indicate life-threatening, underlines indicate most frequent. Strikethrough ⫽ Discontinued.
Name /bks_53161_deglins_md_disk/amiodarone 02/17/2014 01:51PM
2 tion, slight QRS widening, T-wave amplitude reduction with T-wave wid-
Drug-Food: Grapefruit juice inhibits enzymes in the GI tract that metabolize ami-
odarone resulting inqlevels and risk of toxicity; avoid concurrent use.
Route/Dosage
Ventricular Arrhythmias
PO (Adults): 800– 1600 mg/day in 1– 2 doses for 1– 3 wk, then 600– 800 mg/day
in 1– 2 doses for 1 mo, then 400 mg/day maintenance dose.
PO (Children): 10 mg/kg/day (800 mg/1.72 m2/day) for 10 days or until response
or adverse reaction occurs, then 5 mg/kg/day (400 mg/1.72 m2/day) for several
weeks, thenpto 2.5 mg/kg/day (200 mg/1.72 m2/day) or lowest effective mainte-
nance dose.
IV (Adults): 150 mg over 10 min, followed by 360 mg over the next 6 hr and then
540 mg over the next 18 hr. Continue infusion at 0.5 mg/min until oral therapy is initi-
ated. If arrhythmia recurs, a small loading infusion of 150 mg over 10 min should be
given; in addition, the rate of the maintenance infusion may beq. Conversion to ini-
tial oral therapy— If duration of IV infusion was ⬍1 wk, oral dose should be 800–
1600 mg/day; if IV infusion was 1– 3 wk, oral dose should be 600– 800 mg/day; if IV
infusion was ⬎3 wk, oral dose should be 400 mg/day. ACLS guidelines for pulseless
VF/VT— 300 mg IV push, may repeat once after 3– 5 min with 150 mg IV push (max-
imum cumulative dose 2.2 g/24 hr; unlabeled).
IVIntraosseous (Children and infants): PALS guidelines for pulseless VF/VT—
5 mg/kg as a bolus; Perfusion tachycardia— 5 mg/kg loading dose over 20– 60
min (maximum of 15 mg/kg/day; unlabeled).
Supraventricular Tachycardia
PO (Adults): 600– 800 mg/day for 1 wk or until desired response occurs or side
effects develop, thenpto 400 mg/day for 3 wk, then maintenance dose of 200– 400
mg/day.
PO (Children): 10 mg/kg/day (800 mg/1.72 m2/day) for 10 days or until response
or side effects occur, then 5 mg/kg/day (400 mg/1.72 m2/day) for several weeks,
thenpto 2.5 mg/kg/day (200 mg/1.72 m2/day) or lowest effective maintenance dose.
NURSING IMPLICATIONS
Assessment
● Monitor ECG continuously during IV therapy or initiation of oral ther-
apy. Monitor heart rate and rhythm throughout therapy; PR prolonga-
Plate # 0-Composite pg 2 # 2
ening and bifurcation, and U waves may occur. QT prolongation may be
associated with worsening of arrhythmias and should be monitored PDF Page #2
closely during IV therapy. Report bradycardia or increase in arrhyth-
mias promptly; patients receiving IV therapy may require slowing rate,
discontinuing infusion, or inserting a temporary pacemaker.
● Assess pacing and defibrillation threshold in patients with pacemakers and im-
planted defibrillators at beginning and periodically during therapy.
● Assess for signs of pulmonary toxicity (rales/crackles, decreased breath
sounds, pleuritic friction rub, fatigue, dyspnea, cough, wheezing, pleu-
ritic pain, fever, hemoptysis, hypoxia). Chest x-ray and pulmonary func-
tion tests are recommended before therapy. Monitor chest x-ray every
3– 6 mo during therapy to detect diffuse interstitial changes or alveolar
infiltrates. Bronchoscopy or gallium radionuclide scan may also be used
for diagnosis. Usually reversible after withdrawal, but fatalities have oc-
curred.
● IV: Assess for signs and symptoms of ARDS throughout therapy. Report
dyspnea, tachypnea, or rales/crackles promptly. Bilateral, diffuse pul-
monary infiltrates are seen on chest x-ray.
● Monitor BP frequently. Hypotension usually occurs during first several hours of
therapy and is related to rate of infusion. If hypotension occurs, slow rate.
● PO: Assess for neurotoxicity (ataxia, proximal muscle weakness, tingling or
numbness in fingers or toes, uncontrolled movements, tremors); common during
initial therapy, but may occur within 1 wk to several mo of initiation of therapy and
may persist for more than 1 yr after withdrawal. Dose reduction is recommended.
Assist patient during ambulation to prevent falls.
● Ophthalmic exams should be performed before and regularly during therapy and
whenever visual changes (photophobia, halos around lights, decreased acuity)
occur. May cause permanent loss of vision.
● Assess for signs of thyroid dysfunction, especially during initial therapy. Lethargy;
weight gain; edema of the hands, feet, and periorbital region; and cool, pale skin
suggest hypothyroidism and may require decrease in dose or discontinuation of
therapy and thyroid supplementation. Tachycardia; weight loss; nervousness; sen-
sitivity to heat; insomnia; and warm, flushed, moist skin suggest hyperthyroidism
and may require discontinuation of therapy and treatment with antithyroid agents.
● Lab Test Considerations: Monitor liver and thyroid functions before
and every 6 mo during therapy. Drug effects persist long after discontinuation.
䉷 2015 F.A. Davis Company CONTINUED
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3 ● Infusions exceeding 2 hr must be administered in glass or polyolefin bottles to

prevent adsorption. However, polyvinyl chloride (PVC) tubing must be used dur-
PDF Page #3
ing administration because concentrations and infusion rate recommendations
CONTINUED have been based on PVC tubing.
amiodarone ● Direct IV: Diluent: Administer undiluted. May also be diluted in 20– 30 mL of
D5W or 0.9% NaCl. Concentration: 50 mg/mL. Rate: Administer IV push.
Thyroid function abnormalities are common, but clinical thyroid dysfunction is ● Intermittent Infusion: Diluent: Dilute 150 mg of amiodarone in 100 mL of
uncommon. D5W. Infusion stable for 2 hr in PVC bag, or use pre-mixed bags. Concentra-
● Monitor AST, ALT, and alkaline phosphatase at regular intervals during therapy, tion: 1.5 mg/mL. Rate: Infuse over 10 min. Do not administer IV push.
especially in patients receiving high maintenance dose. If liver function studies are ● Continuous Infusion: Diluent: Dilute 900 mg (18 mL) of amiodarone in 500
3 times normal or double in patients with elevated baseline levels or if hepatomeg- mL of D5W. Infusion stable for 24 hr in glass or polyolefin bottle. Concentra-
aly occurs, dose should be reduced. tion: 1.8 mg/mL. Concentration may range from 1– 6 mg/mL (concentrations ⬎2
● May cause asymptomaticqin ANA titer concentrations. mg/mL must be administered via central venous catheter). Rate: Infuse at a rate
of 1 mg/min for the first 6 hr, then decrease infusion rate to 0.5 mg/min and con-
Potential Nursing Diagnoses tinue until oral therapy initiated.
Decreased cardiac output (Indications) ● Y-Site Compatibility: alemtuzumab, amikacin, amphotericin B colloidal, am-
Impaired gas exchange (Side Effects) photericin B lipid complex, anidulafungin, atracurium, atropine, bleomycin,
bumetanide, calcium chloride, calcium gluconate, carboplatin, caspofungin, cef-
Implementation taroline, ceftriaxone, cefuroxime, ciprofloxacin, cisatracurium, cisplatin, clinda-
● High Alert: IV vasoactive medications are inherently dangerous; fatalities have mycin, cyclophosphamide, dactinomycin, daptomycin, dexmedetomidine, dilti-
occurred from medication errors involving amiodarone. Before administering, azem, dobutamine, docetaxel, doripenem, dopamine, doripenem, doxacurium,
have second practitioner check original order, dose calculations, and infusion doxycycline, epinephrine, erythromycin lactobionate, esmolol, etoposide, etopo-
pump settings. Patients should be hospitalized and monitored closely during IV side phosphate, famotidine, fenoldopam, fentanyl, fluconazole, gemcitabine, gen-
therapy and initiation of oral therapy. IV therapy should be administered only by tamicin, granisetron, haloperidol, idarubicin, ifosfamide, irinotecan, isoprotere-
physicians experienced in treating life-threatening arrhythmias. nol, ketamine, labetalol, lidocaine, linezolid, lorazepam, meperidine,
● Do not confuse amiodarone with amantadine. metaraminol, methylprednisolone, metoprolol, metronidazole, midazolam, mil-
● Hypokalemia and hypomagnesemia may decrease effectiveness or cause addi- rinone, mitoxantrone, morphine, mycophenolate, nesiritide, nitroglycerin, nor-
tional arrhythmias; correct before therapy. epinephrine, octreotide, oxaliplatin, palonosetron, pemetrexed, penicillin G po-
● Monitor closely when converting from IV to oral therapy, especially in geriatric pa- tassium, phentolamine, phenylephrine, potassium chloride, procainamide,
tients. quinupristin/dalfopristin, rifampin, rocuronium, tacrolimus, teniposide, tirofi-
● PO: May be administered with meals and in divided doses if GI intolerance occurs ban, tobramycin, vancomycin, vasopressin, vecuronium, vincristine, vinorelbine,
or if daily dose exceeds 1000 mg. voriconazole, zoledronic acid.
● Y-Site Incompatibility: aminocaproic acid, aminophylline, ampicillin/sulbac-
IV Administration tam, bivalirudin, ceftazidime, cytarabine, digoxin, doxorubicin hydrochloride, er-
● pH: 4.1. tapenem, fludarabine, fluorouracil, heparin, imipenem-cilastatin, levofloxacin,
● IV: Administer via volumetric pump; drop size may be reduced, causing altered mechlorethamine, methotrexate, micafungin, paclitaxel, piperacillin/tazobactam,
dosing with drop counter infusion sets. potassium acetate, potassium phosphates, sodium acetate, sodium bicarbonate,
● Administer through an in-line filter. sodium phosphates, yhiopental, thiotepa, tigecycline.
⫽ Canadian drug name. ⫽ Genetic Implication. CAPITALS indicate life-threatening, underlines indicate most frequent. Strikethrough ⫽ Discontinued.
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4
Patient/Family Teaching PDF Page #4
● Instruct patient to take amiodarone as directed. Advise patient to read the Medica-
tion Guide prior to first dose and with each Rx refill. If a dose is missed, do not
take at all. Consult health care professional if more than two doses are missed.
● Advise patient to avoid drinking grapefruit juice during therapy.
● Inform patient that side effects may not appear until several days, weeks, or yr after
initiation of therapy and may persist for several mo after withdrawal.
● Teach patients to monitor pulse daily and report abnormalities.
● Advise patients that photosensitivity reactions may occur through window glass,
thin clothing, and sunscreens. Protective clothing and sunblock are recom-
mended during and for 4 mo after therapy. If photosensitivity occurs, dosage re-
duction may be useful.
● Inform patients that bluish discoloration of the face, neck, and arms is a possible
side effect of this drug after prolonged use. This is usually reversible and will fade
over several mo. Notify health care professional if this occurs.
● Instruct male patients to notify health care professional if signs of epididymitis
(pain and swelling in scrotum) occur. May require reduction in dose.
● Advise patient to notify health care professional of all Rx or OTC medications, vita-
mins, or herbal products being taken and to consult with health care professional
before taking other medications, especially St. John’s wort.
● Instruct patient to notify health care professional of medication regimen before
treatment or surgery.
● Advise patient to notify health care professional if signs and symptoms of thyroid
dysfunction occur.
● Caution female patients to avoid breast feeding during therapy.
● Emphasize the importance of follow-up exams, including chest x-ray and pulmo-
nary function tests every 3– 6 mo and ophthalmic exams after 6 mo of therapy, and
then annually.
Evaluation/Desired Outcomes
● Cessation of life-threatening ventricular arrhythmias. Adverse effects may take up
to 4 mo to resolve.
Why was this drug prescribed for your patient?

䉷 2015 F.A. Davis Company