How do you up-titrate an amiodarone (antiarrhythmic medication) drip?

Amiodarone Drip Up-Titration Protocol

For an amiodarone drip, start with a 150 mg loading dose over 10 minutes, followed by 1 mg/min for 6 hours, then decrease to 0.5 mg/min maintenance infusion. 1, 2

Initial Loading and Maintenance Protocol

1. Loading Phase:

   • Give 150 mg IV over 10 minutes
   • May repeat loading dose in 10-30 minutes if necessary for persistent arrhythmia 1

2. Early Maintenance Phase:

   • Immediately after loading dose, start 1 mg/min infusion (60 mg/hour)
   • Continue this rate for 6 hours 1, 2

3. Later Maintenance Phase:

   • After 6 hours, reduce to 0.5 mg/min (30 mg/hour)
   • Continue at this rate for up to 18-24 hours 1, 2

Up-Titration Guidelines for Breakthrough Arrhythmias

If breakthrough episodes of ventricular fibrillation (VF) or hemodynamically unstable ventricular tachycardia (VT) occur:

• Administer supplemental 150 mg bolus over 10 minutes 2
• Mix in 100 mL D5W to minimize hypotension risk
• Consider increasing maintenance infusion rate if repeated breakthroughs occur

Maximum Dosing Considerations

• Total dose over 24 hours should not exceed 2.2 g 1
• Daily doses above 2.1 g are associated with increased hypotension risk 2
• Do not exceed initial infusion rate of 30 mg/min 2

Administration Pearls

• Use a volumetric infusion pump (not drip counting) 2
• Administer through a central venous catheter when possible, especially for:
  • Concentrations >2 mg/mL
  • Infusions longer than 1 hour 2
• Use an in-line filter during administration 2
• For infusions >2 hours, use glass or polyolefin bottles with D5W 2
• Maximum concentration for peripheral administration: 2 mg/mL 2

Monitoring During Up-Titration

• Continuous cardiac monitoring for:
  • Bradycardia
  • QT prolongation
  • Heart blocks
• Regular blood pressure checks (hypotension is common)
• Monitor for phlebitis at infusion site 1

Conversion to Oral Therapy

When arrhythmias are suppressed and patient is stable, transition to oral amiodarone:

• For IV therapy <1 week: Start 800-1600 mg oral daily
• For IV therapy 1-3 weeks: Start 600-800 mg oral daily
• For IV therapy >3 weeks: Start 400 mg oral daily 1

Cautions During Up-Titration

• Rapid infusion can cause hypotension, bradycardia, and AV block 1
• High concentrations (>3 mg/mL) and rapid infusion rates have been associated with hepatocellular necrosis and acute renal failure 2
• Concentrations >2 mg/mL increase risk of peripheral vein phlebitis 2

Amiodarone's antiarrhythmic effect begins within 30 minutes of IV administration, making it effective for acute management of life-threatening arrhythmias while allowing time for proper up-titration 1.