Can a patient be on oral amiodarone (Amio) and intravenous amiodarone (Amio) if they are still in atrial fibrillation with rapid ventricular response (Afib RVR)?

From the Guidelines

Yes, a patient can be on both oral amiodarone (amio po) and intravenous amiodarone infusion (amio gtt) simultaneously if they are in atrial fibrillation with rapid ventricular response (Afib RVR). This approach is sometimes used in the acute management of persistent Afib RVR when transitioning from IV to oral therapy.

Key Considerations

• The IV amiodarone is typically initiated first at a loading dose of 150 mg over 10 minutes, followed by an infusion of 1 mg/min for 6 hours, then 0.5 mg/min thereafter.
• Oral amiodarone can be started concurrently at 400-600 mg daily in divided doses.
• The overlap allows for maintaining therapeutic levels while transitioning to oral therapy, as oral amiodarone has a delayed onset of action due to its long half-life and large volume of distribution.
• Careful monitoring is essential during this overlap period, including continuous cardiac monitoring, regular assessment of vital signs, and monitoring for QT prolongation on ECG.
• The combined therapy increases the risk of adverse effects such as hypotension, bradycardia, and QT prolongation, so the total daily dose and duration of overlap should be carefully managed by the healthcare team, as supported by guidelines such as those outlined in 1 and 1.

Monitoring and Management

• Regular assessment of the patient's condition and adjustment of the treatment plan as necessary is crucial.
• The patient should be closely monitored for signs of adverse effects, and the healthcare team should be prepared to intervene promptly if any issues arise.
• The use of amiodarone, whether IV or oral, should be guided by the most recent and highest quality evidence, such as the recommendations provided in 1 and 1, to ensure the best possible outcomes for the patient.

From the FDA Drug Label

The optimal dose for changing from intravenous to oral administration of amiodarone will depend on the dose of intravenous amiodarone already administered, as well as the bioavailability of oral amiodarone. Patients whose arrhythmias have been suppressed by amiodarone may be switched to oral amiodarone.

The FDA drug label does not explicitly state whether a patient can be on both amiodarone PO and amiodarone IV (gtt) if they are still in Afib RVR. However, it does provide guidance on transitioning from IV to oral amiodarone therapy.

• Key consideration: The decision to use both IV and oral amiodarone simultaneously should be based on clinical judgment and careful monitoring of the patient's condition.
• Clinical monitoring: is recommended, particularly for elderly patients, when changing to oral amiodarone therapy 2 3. The label does not provide direct information on the use of both formulations in patients with Afib RVR.

From the Research

Atrial Fibrillation with Rapid Ventricular Response Management

• The management of atrial fibrillation (AF) with rapid ventricular response (RVR) involves controlling the heart rate and preventing complications such as stroke, heart failure, and death 4.
• Pharmacological agents used to control heart rate in AF with RVR include beta blockers, calcium channel blockers, amiodarone, and digoxin 5, 6, 7, 8.

Amiodarone Use in AF with RVR

• Amiodarone is a commonly used medication for AF with RVR, particularly in critically ill patients 6, 8.
• Studies have shown that amiodarone can be effective in controlling heart rate in AF with RVR, but its effectiveness may vary compared to other medications such as beta blockers and calcium channel blockers 6, 8.

Concomitant Use of Amiodarone PO and GTT

• There is limited evidence specifically addressing the concomitant use of amiodarone PO and GTT in patients with AF with RVR.
• However, studies have shown that concomitant use of multiple medications, such as beta blockers and calcium channel blockers, can be effective in controlling heart rate in AF with RVR 7.
• The decision to use concomitant amiodarone PO and GTT should be based on individual patient factors, such as hemodynamic stability and response to treatment, and should be guided by clinical judgment and evidence-based guidelines 4.