Should I hold Multaq (dronedarone) before a procedure?

Should You Hold Multaq (Dronedarone) Before a Procedure?

Yes, you should hold Multaq (dronedarone) before most procedures, with the timing dependent on the bleeding risk of the procedure and the patient's renal function.

Timing of Discontinuation

For Low Bleeding Risk Procedures

• Hold dronedarone for 1 day (2 doses) before the procedure if the patient has normal renal function 1
• The last dose should be taken on the morning of the day before the procedure 1
• This approach is generally sufficient for procedures with minimal bleeding risk 1

For High Bleeding Risk Procedures

• Hold dronedarone for at least 48 hours (approximately 2 days) before the procedure when complete hemostasis is essential 1
• This longer interruption period is necessary for procedures such as:
  • Spinal puncture or neuraxial anesthesia 1
  • Major surgery 1
  • Any procedure where bleeding complications could be catastrophic 1

Key Pharmacologic Considerations

Dronedarone has a half-life of 27-31 hours and is primarily metabolized through the hepatic CYP3A4 enzyme system 2. Unlike warfarin or other anticoagulants, dronedarone is an antiarrhythmic medication with multi-channel blocking properties affecting sodium, potassium, and calcium channels 3, 4. While it is not primarily an anticoagulant, its discontinuation timing follows similar principles to other cardiovascular medications requiring procedural interruption.

Resumption After the Procedure

• Resume dronedarone at least 6 hours after low bleeding risk procedures once adequate hemostasis is achieved 1
• For high bleeding risk procedures, delay resumption for 24-48 hours or until surgical hemostasis is confirmed 1
• If there is ongoing bleeding or surgical contraindication, further delay resumption and consider the patient's underlying arrhythmia risk 1

Critical Pitfalls to Avoid

• Do not use bridging anticoagulation when holding dronedarone, as it is an antiarrhythmic agent, not an anticoagulant requiring bridging therapy 1
• Adjust timing for renal dysfunction: Although dronedarone is primarily hepatically cleared, patients with significant renal impairment may require extended discontinuation periods 2
• Avoid using dronedarone in patients with decompensated heart failure (NYHA class IV or class II-III with recent decompensation), as this increases mortality risk 3, 5, 6
• Do not restart dronedarone if the patient has developed permanent atrial fibrillation, as this is associated with increased mortality 5, 6

Special Populations

For patients with impaired renal function, consider extending the discontinuation window, though dronedarone's primary clearance is hepatic 2. Gender, weight, and age have minimal effect on dronedarone pharmacokinetics and do not require dose adjustment 2.