Can amiodarone be initiated in a patient with elevated Liver Function Tests (LFTs)?

From the Guidelines

Amiodarone should not be started in patients with significantly elevated LFTs, as the risk of liver toxicity is a concern, and alternative options should be considered first. The decision to initiate amiodarone in patients with elevated liver function tests (LFTs) requires careful consideration of the severity of the elevation, the clinical necessity of the medication, and a thorough risk-benefit assessment 1.

Key Considerations

• For mild to moderate LFT elevations (less than 3 times the upper limit of normal), amiodarone may be initiated with close monitoring of liver enzymes at baseline, then every 3-6 months.
• For severe elevations (greater than 3 times normal), alternative antiarrhythmic options should be considered first, due to the increased risk of liver toxicity 1.
• If amiodarone is deemed necessary despite significant LFT elevations, it is recommended to start with a lower loading dose and transition to the lowest effective maintenance dose, with liver function monitored more frequently 1.

Monitoring and Dose Adjustment

• Liver function should be monitored closely, with transaminases checked at baseline, then every 3-6 months for mild to moderate elevations, and every 1-2 months for severe elevations or if amiodarone is initiated despite significant LFT elevations.
• If transaminases rise to more than 3 times baseline during treatment or jaundice develops, amiodarone should be discontinued, as indicated by guidelines for use and monitoring 1.

From the FDA Drug Label

Baseline abnormalities in hepatic enzymes are not a contraindication to treatment

• Elevated LFTs are not a contraindication to starting amiodarone.
• However, patients with elevated LFTs should be monitored carefully for evidence of progressive hepatic injury.
• Consideration should be given to reducing the rate of administration or withdrawing amiodarone if there is evidence of hepatic injury 2.

From the Research

Amiodarone and Elevated LFTs

• Amiodarone is known to cause hepatotoxicity, as reported in several studies 3, 4.
• The drug can cause liver attenuation on CT scans, which may not correlate with the total exposure to amiodarone over time 3.
• Elevated liver function tests (LFTs) are a common problem in patients, and can be caused by various factors, including drug-induced liver injury (DILI) 5, 6, 7.
• In patients with elevated LFTs, a detailed medical history and thorough clinical examination should be performed to narrow down possible causes 6.
• Laboratory diagnostics, including screening tests for differential liver diseases, and non-invasive methods such as elastography, MRI, MRCP, and CT, can be used to evaluate elevated LFTs 6, 7.

Initiating Amiodarone in Patients with Elevated LFTs

• There is no direct evidence to suggest that amiodarone should not be started in patients with elevated LFTs.
• However, given the potential for amiodarone to cause hepatotoxicity, clinicians should carefully adjust the dosage to the lowest effective level and regularly monitor liver function tests in patients 3.
• It is essential to weigh the benefits of amiodarone therapy against the potential risks of hepatotoxicity in patients with elevated LFTs.
• A comprehensive diagnostic evaluation is necessary to identify the underlying etiology of abnormal liver function tests and to initiate appropriate therapeutic strategies 7.