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Atrial fibrillation - Management
What adverse effects are associated with amiodarone?

  • Nausea, vomiting, and taste disturbance commonly occur with loading doses but resolve with dose reduction.
  • Pulmonary toxicity
    • Pulmonary toxicity may present as dyspnoea (which may be severe and unexplained by the current cardiac status), non-productive cough, and deterioration in general health (fatigue, weight loss, and fever). If pulmonary toxicity is suspected, seek immediate specialist advice; the person may require admission.
  • Thyroid dysfunction
    • Approximately 4% of people taking maintenance doses of amiodarone may develop hypothyroidism or hyperthyroidism. People taking amiodarone should have their thyroid function checked every 6 months. If thyroid function tests are abnormal, seek specialist advice.
  • Hepatotoxicity
    • An asymptomatic increase in liver function test values is common in people taking amiodarone. Persistent elevation of liver function test values greater than 2 to 3 times the upper limit of normal (or twice previously elevated levels) occurs in 1.2% of people taking maintenance doses of amiodarone. Hepatotoxicity is rare, and death caused by severe hepatotoxicity is rarer still. Liver function should be monitored evey 6 months, and treatment with amiodarone should be stopped if severe liver function abnormalities or clinical signs of liver disease (for example jaundice) develop.
  • Cardiac toxicity
    • Maintenance doses of amiodarone may cause dose-dependent sinus bradycardia and conduction disturbances.
  • Visual disturbances
    • Most people develop corneal microdeposits; these rarely interfere with vision, but drivers may be dazzled by headlights at night. If vision is impaired or if optic neuritis (very rare) or neuropathy occurs, amiodarone must be stopped, to prevent blindness, and expert opinion sought. The manufacturer recommends annual eye examinations; however, expert opinion suggests that these are only necessary for people with visual symptoms.
  • Neurological symptoms
    • Amiodarone has been associated with neurological symptoms, such as tremor, ataxia, and (rarely) peripheral neuropathy. These are usually seen with loading doses and improve when maintenance treatment is started. Peripheral neuropathy may occur in people who have been taking amiodarone for a long time.
  • Skin toxicity
    • A blue-grey skin discolouration has been reported in approximately 2% of people taking amiodarone. This discolouration occurs in unprotected light-exposed skin and is slowly (and occasionally incompletely) reversible after stopping amiodarone.
    • Advise the person to:
      • Shield their skin from light during treatment and for several months after stopping treatment.
      • Use a wide spectrum sunscreen with a sun protection factor of at least 30 (for example Uvistat® or Sunsense® Ultra).
Basis for recommendation

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