What is the protocol for Amiodarone (amiodarone hydrochloride) bolus and infusion for atrial fibrillation (afib) with rapid ventricular response (RVR)?

From the Guidelines

For atrial fibrillation with rapid ventricular response (AFib with RVR), amiodarone can be administered as a 150 mg IV bolus over 10 minutes, followed by a continuous infusion of 1 mg/min for 6 hours, then 0.5 mg/min for the remaining 18 hours, with a total 24-hour dose not exceeding 2.2 grams, as recommended by the most recent guidelines 1.

Administration and Monitoring

The administration of amiodarone for AFib with RVR should be done with caution, considering its potential side effects such as QT prolongation, hypotension, and bradycardia 1. Continuous cardiac monitoring is essential during the administration of amiodarone. Blood pressure should be monitored frequently, especially during the bolus and early infusion. Amiodarone should be administered through a central line when possible, or through a large peripheral vein to avoid phlebitis.

Considerations and Precautions

Patients should also be monitored for potential adverse effects including thyroid dysfunction, pulmonary toxicity, and liver function abnormalities if continued on oral therapy after the initial IV treatment 1. The potential benefit of amiodarone must be carefully weighed against its considerable potential toxicity, and it is considered a suitable alternative agent for heart rate control when conventional measures are ineffective.

Key Points

• Amiodarone can be used for AFib with RVR as a 150 mg IV bolus over 10 minutes, followed by a continuous infusion of 1 mg/min for 6 hours, then 0.5 mg/min for the remaining 18 hours.
• Total 24-hour dose should not exceed 2.2 grams.
• Continuous cardiac monitoring and frequent blood pressure monitoring are essential during administration.
• Patients should be monitored for potential adverse effects, including thyroid dysfunction, pulmonary toxicity, and liver function abnormalities.

From the FDA Drug Label

The recommended starting dose of amiodarone is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen: After the first 24 hours, continue the maintenance infusion rate of 0.5 mg/min (720 mg per 24 hours) In the event of breakthrough episodes of VF or hemodynamically unstable VT, use 150 mg supplemental infusions of amiodarone (mixed in 100 mL of D5W and infused over 10 minutes to minimize the potential for hypotension)

For Atrial Fibrillation with Rapid Ventricular Response (AFib RVR), the recommended dose of amiodarone is a bolus of about 1000 mg over the first 24 hours of therapy, followed by a maintenance infusion of 0.5 mg/min. In cases of breakthrough episodes, a supplemental infusion of 150 mg can be used. 2

From the Research

Amiodarone Bolus and Drip for AFib RVR

• Amiodarone is one of the options for acute ventricular rate control in atrial fibrillation, although it is not typically the first choice 3, 4.
• The effectiveness of amiodarone in controlling ventricular rate in AFib RVR has been studied, with one study finding that metoprolol had a lower failure rate than amiodarone in achieving rate control 5.
• Amiodarone may be used in certain clinical situations, such as when other agents are contraindicated or ineffective 3, 4.
• The use of amiodarone in AFib RVR is not without risks, and its use should be carefully considered based on the individual patient's clinical situation 6.
• In terms of specific dosing, a bolus and drip of amiodarone may be used to achieve rapid control of ventricular rate, although the exact dosing regimen may vary depending on the patient's response and clinical situation 5.

Comparison to Other Agents

• Amiodarone has been compared to other agents, such as metoprolol and diltiazem, in terms of its effectiveness in achieving rate control in AFib RVR 5.
• One study found that metoprolol was superior to amiodarone in achieving rate control at 4 hours, although amiodarone may still be a useful option in certain clinical situations 5.
• The use of concomitant parenteral calcium channel blockers and beta blockers, such as diltiazem and metoprolol, may also be effective in achieving rate control in AFib RVR, although the risk of bradycardia should be carefully considered 7.

Clinical Considerations

• The choice of agent for AFib RVR should be individualized based on the patient's clinical situation, including their underlying cardiac disease, comorbidities, and hemodynamic stability 3, 4, 6.
• The use of amiodarone or other agents should be carefully considered in patients with certain comorbidities, such as bronchial asthma or chronic obstructive pulmonary disease 3, 4.
• The risk of adverse outcomes, including stroke, heart failure, and death, should be carefully considered when managing AFib RVR, and anticoagulation therapy may be necessary in certain patients 6.