From the FDA Drug Label
Amiodarone hydrochloride injection is indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy.
Elevations of blood hepatic enzyme values [alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT)] are commonly seen in patients with immediately life-threatening VT/VF
Acute, centrolobular confluent hepatocellular necrosis leading to hepatic coma, acute renal failure, and death has been associated with the administration of intravenous amiodarone
Nonsustained VT with liver injury:
- Amiodarone may be used to treat nonsustained VT, but it can cause liver injury.
- The decision to use amiodarone should be made with caution, weighing the potential benefits against the risks of liver injury.
- Lidocaine is not mentioned in the provided drug labels as a treatment for nonsustained VT with liver injury.
- No direct comparison between amiodarone and lidocaine can be made based on the provided information. 1, 1, 1
From the Research
For nonsustained ventricular tachycardia (VT) in a patient with liver injury, lidocaine is generally preferred over amiodarone. Lidocaine is recommended at a loading dose of 1-1.5 mg/kg IV followed by an infusion of 1-4 mg/min, with dose reduction in liver disease. Amiodarone should be avoided or used with extreme caution in patients with significant liver dysfunction because it undergoes extensive hepatic metabolism and can cause further hepatotoxicity, as noted in various studies 2, 3.
The most recent and highest quality study, a Bayesian network meta-analysis from 2017 4, demonstrated that lidocaine had superior effects on survival to hospital discharge compared to amiodarone, magnesium, and placebo in patients with pulseless VT or VF. This study supports the preference for lidocaine over amiodarone in the context of liver injury, where minimizing hepatic stress is crucial.
Some key points to consider when using lidocaine in liver injury include:
- Close monitoring for signs of toxicity such as confusion, seizures, and bradycardia
- Dose reduction by 50% or more depending on the severity of liver dysfunction
- Addressing underlying causes such as electrolyte abnormalities, hypoxia, or ischemia, which are common in patients with liver disease
Overall, the choice between lidocaine and amiodarone for nonsustained VT in patients with liver injury should prioritize lidocaine due to its safer profile in liver disease, as supported by the most recent evidence 4.