What is the maximum recommended dose of amiodarone (antiarrhythmic medication)?

Maximum Dose of Amiodarone

The maximum loading dose of amiodarone is 1,200 mg daily in an inpatient monitoring setting, while the maximum maintenance dose is 400 mg daily, though 200 mg daily is preferred to minimize long-term adverse effects. 1

Loading Dose Maximum

Oral Loading:

• Up to 1,200 mg daily may be considered in an inpatient monitoring setting during the loading phase, though this increases risk of adverse effects 1
• Standard loading regimens range from 400-600 mg daily (divided doses) for 2-4 weeks, or 800-1,600 mg daily until 10 grams total cumulative dose is achieved 1, 2, 3
• Higher loading doses (>2,100 mg/24 hours) are associated with increased risk of hypotension and should be avoided 4

Intravenous Loading:

• Maximum 24-hour IV dose is approximately 2,200 mg (2.2 grams) 2
• Initial 24-hour regimen: ~1,000 mg total (150 mg bolus over 10 minutes, then 1 mg/min for 6 hours, then 0.5 mg/min) 2, 4
• Supplemental 150 mg boluses (over 10 minutes) may be given for breakthrough arrhythmias, but total daily dose should not exceed 2.2 grams 2, 4

Maintenance Dose Maximum

The maximum recommended maintenance dose is 400 mg daily, though 200 mg daily is strongly preferred to minimize toxicity: 1, 3, 5

• Standard maintenance: 200-400 mg daily for ventricular arrhythmias 2, 3
• Preferred maintenance: 200 mg daily for atrial fibrillation 3, 5
• Use the lowest effective dose possible since adverse effects correlate directly with total amiodarone exposure (dose × duration) 2

Critical Dosing Caveats

Avoid exceeding these limits due to serious toxicity risks:

• Doses above 600 mg daily maintenance cause side effects in virtually all patients 6
• Mean daily doses >2,100 mg during loading are associated with increased hypotension risk 4
• IV loading infusions at concentrations and rates exceeding recommendations have resulted in hepatocellular necrosis, acute renal failure, and death 4

Common pitfall: Clinicians sometimes continue high loading doses (600-800 mg daily) as maintenance therapy, which dramatically increases toxicity risk. After loading is complete, reduce to 200-400 mg daily maximum 1, 3

Monitoring Requirements at Maximum Doses

When using higher doses, monitor closely for:

• Bradycardia, QT prolongation, and heart block 1, 3
• Hypotension (especially with IV therapy >2,100 mg/24 hours) 4
• Pulmonary toxicity (subacute cough, progressive dyspnea, interstitial infiltrates) 1, 2
• Hepatic toxicity, thyroid dysfunction, and neurologic effects 1, 7