Amiodarone instructions for administration

Because of the unique pharmacokinetic properties, difficult dosing schedule, and severity of the side effects if patients are improperly monitored, amiodarone should be administered only by physicians who are experienced in the treatment of life-threatening arrhythmias who are thoroughly familiar with the risks and benefits of amiodarone therapy, and who have access to laboratory facilities capable of adequately monitoring the effectiveness and side effects of treatment.

In order to insure that an antiarrhythmic effect will be observed without waiting several months, loading doses are required. A uniform, optimal dosage schedule for administration of Amiodarone has not been determined. Because of the food effect on absorption, Amiodarone should be administered consistently with regard to meals. Individual patient titration is suggested according to the following guidelines:

For life-threatening ventricular arrhythmias, such as ventricular fibrillation or hemodynamically unstable ventricular tachycardia
Close monitoring of the patients is indicated during the loading phase, particularly until risk of recurrent ventricular tachycardia or fibrillation has abated. Because of the serious nature of the arrhythmia and the lack of predictable time course of effect, loading should be performed in a hospital setting. Loading doses of 800 to 1,600 mg/day are required for 1 to 3 weeks (occasionally longer) until initial therapeutic response occurs. (Administration of Amiodarone in divided doses with meals is suggested for total daily doses of 1,000 mg or higher, or when gastrointestinal intolerance occurs.) If side effects become excessive, the dose should be reduced. Elimination of recurrence of ventricular fibrillation and tachycardia usually occurs within 1 to 3 weeks, along with reduction in complex and total ventricular ectopic beats.

Since grapefruit juice is known to inhibit CYP3A4-mediated metabolism of oral Amiodarone in the intestinal mucosa, resulting in increased plasma levels of Amiodarone; grapefruit juice should not be taken during treatment with oral Amiodarone.

Upon starting Amiodarone therapy, an attempt should be made to gradually discontinue prior antiarrhythmic drugs. When adequate arrhythmia control is achieved, or if side effects become prominent, Amiodarone dose should be reduced to 600 to 800 mg/day for one month and then to the maintenance dose, usually 400 mg/day. Some patients may require larger maintenance doses, up to 600 mg/day, and some can be controlled on lower doses. Amiodarone may be administered as a single daily dose, or in patients with severe gastrointestinal intolerance, as a b.i.d. dose. In each patient, the chronic maintenance dose should be determined according to antiarrhythmic effect as assessed by symptoms, Holter recordings, and/or programmed electrical stimulation, and by patient tolerance. Plasma concentrations may be helpful in evaluating nonresponsiveness or unexpectedly severe toxicity.

The lowest effective dose should be used to prevent the occurrence of side effects. In all instances, the physician must be guided by the severity of the individual patient's arrhythmia and response to therapy.

When dosage adjustments are necessary, the patient should be closely monitored for an extended period of time because of the long and variable half-life of Amiodarone and the difficulty in predicting the time required to attain a new steady-state level of drug.