Amiodarone: Uses, Dosage & Side Effects
Antiarrhythmic medication for serious heart rhythm disorders
📊 Quick Facts About Amiodarone
💡 Key Takeaways About Amiodarone
- Reserved for serious arrhythmias: Amiodarone is used when other antiarrhythmic drugs have failed or cannot be used, including life-threatening ventricular arrhythmias
- Extremely long half-life: With a half-life of 40–55 days, amiodarone remains in the body for months after discontinuation, meaning side effects and drug interactions can persist long after stopping
- Regular monitoring essential: Thyroid, liver, lung, and eye function must be monitored before starting treatment and at regular intervals during therapy
- Numerous drug interactions: Amiodarone interacts with many medications including warfarin, digoxin, statins, and other cardiac drugs — dose adjustments are often necessary
- Avoid sun exposure: Amiodarone causes photosensitivity; patients should use high-factor sunscreen and protective clothing
What Is Amiodarone and What Is It Used For?
Amiodarone is a class III antiarrhythmic drug that reduces the electrical excitability of the heart, counteracting rapid and irregular heart rhythms (arrhythmias). It is used to treat serious cardiac rhythm disturbances when other medications have proven ineffective or cannot be used.
Amiodarone is one of the most widely used antiarrhythmic medications worldwide and is included on the World Health Organization (WHO) Model List of Essential Medicines. It was first developed in the 1960s as an anti-anginal agent, but its powerful antiarrhythmic properties were soon recognized, and it became a cornerstone of arrhythmia management. Unlike most antiarrhythmic drugs that target a single ion channel, amiodarone has a broad spectrum of electrophysiological actions.
The drug works by prolonging the cardiac action potential duration and refractory period, primarily through potassium channel blockade (class III effect). However, it also exhibits sodium channel blocking (class I), beta-adrenergic blocking (class II), and calcium channel blocking (class IV) properties. This multi-channel mechanism makes amiodarone effective against a wide range of arrhythmias but also contributes to its complex side effect profile.
Amiodarone is primarily prescribed for the following conditions:
- Ventricular tachycardia (VT) — abnormally fast heart rhythm originating in the ventricles
- Ventricular fibrillation (VF) — a chaotic, life-threatening heart rhythm used in advanced cardiac life support (ACLS)
- Atrial fibrillation (AF) — the most common sustained cardiac arrhythmia, particularly when rate or rhythm control with other agents has failed
- Supraventricular tachycardia (SVT) — rapid heart rhythms originating above the ventricles
- Wolff-Parkinson-White (WPW) syndrome — a condition involving an accessory electrical pathway in the heart
Amiodarone is typically reserved as a second-line or third-line treatment due to its potential for serious side effects. It is used when other, safer antiarrhythmic drugs have been tried and found to be ineffective, poorly tolerated, or contraindicated. In emergency situations, however, it may be used as a first-line agent for life-threatening ventricular arrhythmias.
Amiodarone in cardiac arrest
Amiodarone plays a critical role in advanced cardiac life support (ACLS). During cardiac arrest caused by ventricular fibrillation or pulseless ventricular tachycardia that does not respond to defibrillation, amiodarone is administered intravenously. International resuscitation guidelines (European Resuscitation Council, American Heart Association) recommend an initial dose of 300 mg (or 5 mg/kg) given as a rapid bolus, with an additional 150 mg (or 2.5 mg/kg) if the arrhythmia persists.
In these acute situations, the contraindications that normally apply (such as low blood pressure or severe respiratory insufficiency) may not apply, as the immediate goal is to restore a viable heart rhythm and save the patient's life.
What Should You Know Before Taking Amiodarone?
Amiodarone should not be used if you are allergic to amiodarone or iodine, have untreated thyroid disorders, have a slow heart rate without a pacemaker, or are breastfeeding. Several serious drug interactions require dose adjustments or avoidance of concurrent use.
Before starting amiodarone therapy, your physician will conduct a thorough medical evaluation and baseline investigations. This is essential because amiodarone has a complex pharmacological profile and can affect multiple organ systems. Understanding the contraindications, warnings, and precautions helps ensure safe use of this powerful medication.
Contraindications
Amiodarone must not be used in the following situations (except during cardiac arrest resuscitation):
- Allergy to amiodarone or iodine — amiodarone contains approximately 37% iodine by weight
- Sinus bradycardia (slow heart rate) — unless a pacemaker is in place
- Sinoatrial block or high-degree AV block — unless a pacemaker is in place
- Untreated thyroid disorders — both hypothyroidism and hyperthyroidism must be corrected before treatment
- Severe circulatory insufficiency or very low blood pressure
- Breastfeeding — amiodarone is excreted in breast milk and can harm the nursing infant
- Concurrent use with certain QT-prolonging drugs — including sotalol, quinidine, procainamide, and certain antipsychotics
For the intravenous formulation specifically, additional contraindications include severe respiratory insufficiency, cardiomyopathy, and heart failure, as intravenous administration can worsen these conditions. However, these restrictions do not apply when amiodarone is used during advanced cardiac life support for cardiac arrest.
Warnings and Precautions
Speak to your doctor before taking amiodarone if you have any of the following conditions:
- Low blood pressure, severe heart failure, or respiratory insufficiency
- Hepatitis C being treated with sofosbuvir — the combination can cause life-threatening bradycardia. Your doctor may consider alternative treatments. If concurrent use is necessary, extra cardiac monitoring will be required
- Awaiting heart transplantation — amiodarone use before transplant has been associated with an increased risk of primary graft dysfunction, where the transplanted heart fails within the first 24 hours
- Dry cough and shortness of breath — may indicate pulmonary toxicity, a serious adverse effect
- Worsening vision — may indicate optic neuropathy, which can lead to blindness
- Severe skin reactions — widespread rash, blistering, or mucosal involvement
- Slow or irregular heartbeat, dizziness, or fainting — particularly if taking sofosbuvir concurrently
Pregnancy and Breastfeeding
Amiodarone poses significant risks during pregnancy. The drug crosses the placenta and its high iodine content can affect fetal thyroid development, potentially causing neonatal hypothyroidism or goiter. There is also a risk of fetal growth restriction and other adverse developmental effects.
Amiodarone should not be used during pregnancy unless the potential benefit to the mother justifies the serious risk to the fetus and no safer alternative is available. If amiodarone is deemed absolutely necessary during pregnancy, close fetal and neonatal monitoring of thyroid function is essential.
Breastfeeding is contraindicated during amiodarone therapy. The drug and its active metabolite (desethylamiodarone) are excreted in breast milk in significant concentrations, and the high iodine content can adversely affect the infant's thyroid function.
Children
There is limited data on the safety and efficacy of amiodarone in children. Pediatric use should be carefully evaluated by a specialist, and the intravenous formulation containing benzyl alcohol should be used with extreme caution in children under 3 years of age due to the risk of a serious condition called metabolic acidosis.
How Does Amiodarone Interact with Other Drugs?
Amiodarone has numerous significant drug interactions due to its effects on cardiac electrophysiology and its inhibition of cytochrome P450 enzymes (CYP3A4, CYP2C9, CYP2D6). Many common medications require dose reductions or should be avoided entirely when used with amiodarone.
Drug interactions with amiodarone are a major clinical concern for several reasons. First, amiodarone inhibits multiple cytochrome P450 enzymes involved in drug metabolism, leading to increased blood levels of many co-administered medications. Second, its extremely long half-life means that interactions can persist for weeks or months after amiodarone is discontinued. Third, many interactions carry the risk of serious cardiac complications, including potentially fatal arrhythmias.
It is critically important to inform your doctor about all medications you are taking, including over-the-counter drugs, herbal supplements, and grapefruit juice, before starting amiodarone.
Major Interactions (Avoid Combination)
Amiodarone should not be combined with the following medications due to the risk of life-threatening arrhythmias (torsades de pointes) or other serious adverse effects:
| Drug / Class | Risk | Recommendation |
|---|---|---|
| Quinidine, Procainamide, Sotalol | Additive QT prolongation, risk of torsades de pointes | Contraindicated — do not combine |
| Certain antipsychotics (haloperidol, droperidol, pimozide) | QT prolongation, risk of torsades de pointes | Contraindicated — do not combine |
| Macrolide antibiotics (erythromycin IV, moxifloxacin) | QT prolongation, risk of cardiac arrhythmias | Contraindicated — do not combine |
| Pentamidine (antiprotozoal) | QT prolongation, risk of torsades de pointes | Contraindicated — do not combine |
| Methadone | Additive QT prolongation | Avoid combination — use alternatives |
| Mefloquine (antimalarial) | QT prolongation, bradycardia | Avoid combination — use alternatives |
Interactions Requiring Dose Adjustment or Monitoring
The following medications may require dose reductions or increased monitoring when used with amiodarone:
| Drug / Class | Effect | Action Required |
|---|---|---|
| Warfarin | Amiodarone inhibits warfarin metabolism via CYP2C9; INR may increase 2–3 fold | Reduce warfarin dose by 30–50%; monitor INR closely |
| Digoxin | Amiodarone increases digoxin levels by 70–100% via P-glycoprotein inhibition | Reduce digoxin dose by 50%; monitor serum levels |
| Statins (simvastatin, atorvastatin, lovastatin) | Increased statin levels via CYP3A4 inhibition; risk of rhabdomyolysis | Limit simvastatin to 20 mg/day; consider alternative statin |
| Beta-blockers, Verapamil, Diltiazem | Additive bradycardia and AV block | Use with caution; monitor heart rate and ECG |
| Phenytoin | Amiodarone increases phenytoin levels via CYP2C9 inhibition | Monitor phenytoin levels; reduce dose as needed |
| Cyclosporine, Sirolimus | Increased immunosuppressant levels via CYP3A4 inhibition | Monitor drug levels; reduce dose as needed |
| Sofosbuvir (hepatitis C treatment) | Life-threatening bradycardia | Avoid if possible; cardiac monitoring if combined |
| Dabigatran | Increased dabigatran levels via P-glycoprotein inhibition | Consider dose reduction; monitor for bleeding |
| Fentanyl | Increased fentanyl levels via CYP3A4 inhibition | Monitor for respiratory depression; dose reduction may be needed |
| Grapefruit juice | Inhibits CYP3A4; increases amiodarone levels | Avoid grapefruit juice during treatment |
Because amiodarone is metabolized very slowly and remains in the body for a long time (weeks to months after discontinuation), drug interactions can persist long after amiodarone therapy has ended. This is particularly relevant for long-term oral therapy. Always inform your doctor or anesthesiologist that you have taken amiodarone, even if you stopped treatment months ago.
What Is the Correct Dosage of Amiodarone?
Amiodarone dosing is individualized. Oral treatment typically begins with a loading dose of 600–800 mg daily for 1–2 weeks, followed by a maintenance dose of 100–400 mg daily. Intravenous dosing in emergency settings is 5 mg/kg administered over 20 minutes to 2 hours.
Amiodarone dosing follows a unique pattern compared to most medications. Because of its very long half-life and extensive tissue distribution, a loading phase is required to achieve therapeutic tissue concentrations. This is followed by a lower maintenance dose. The exact doses and duration are determined individually by the prescribing physician based on the type and severity of the arrhythmia, the patient's weight, and their response to treatment.
Adults — Oral Administration
Loading Phase (1–3 weeks)
The typical oral loading dose is 600–800 mg per day, divided into 2–3 doses, taken with meals. This loading phase usually lasts 1–2 weeks, or until a total loading dose of approximately 10 grams has been administered. In some cases, physicians may use higher initial doses (up to 1,200 mg/day) for shorter periods, or lower doses (400 mg/day) for longer periods, depending on the clinical situation.
Maintenance Phase
After the loading phase, the dose is gradually reduced to the lowest effective maintenance dose, typically 100–400 mg per day (usually 200 mg daily). Some patients may require as little as 100 mg daily or every other day. The goal is to use the minimum dose that maintains control of the arrhythmia to minimize the risk of side effects.
Adults — Intravenous Administration
Intravenous Infusion (preferred method)
The recommended dose is 5 mg/kg body weight administered by intravenous infusion over 20 minutes to 2 hours, diluted in 250 ml of 5% dextrose solution. This may be followed by repeat infusions up to a maximum of 1,200 mg (approximately 15 mg/kg) per 24 hours, with the infusion rate adjusted based on clinical response.
Cardiac Arrest (ACLS Protocol)
For defibrillation-resistant ventricular fibrillation: 300 mg (or 5 mg/kg) diluted in 20 ml of 5% dextrose, given as a rapid intravenous bolus. An additional 150 mg (or 2.5 mg/kg) may be considered if ventricular fibrillation persists.
Children
There is limited safety and efficacy data for amiodarone use in children. When used, pediatric dosing is determined by a specialist cardiologist and is typically based on body weight. The intravenous formulation containing benzyl alcohol should be used with extreme caution in children under 3 years of age.
Elderly Patients
Elderly patients may be more susceptible to bradycardia and thyroid dysfunction. Lower maintenance doses may be appropriate, and more frequent monitoring is recommended. Dose adjustments should be made based on clinical response and tolerability.
Missed Dose
If you miss a dose of oral amiodarone, take it as soon as you remember. However, if it is nearly time for your next dose, skip the missed dose and continue with your regular schedule. Do not take a double dose to make up for a missed one. Because of amiodarone's very long half-life, missing a single dose is unlikely to significantly affect blood levels.
Overdose
In case of suspected overdose, seek immediate medical attention. Symptoms of amiodarone overdose may include severe bradycardia, heart block, hypotension, and cardiac arrest. There is no specific antidote. Treatment is supportive and may include atropine for bradycardia, vasopressors for hypotension, and temporary cardiac pacing if needed. Hemodialysis is not effective for removing amiodarone due to its high volume of distribution and protein binding.
What Are the Side Effects of Amiodarone?
Amiodarone can cause side effects affecting multiple organ systems, including thyroid dysfunction, pulmonary toxicity, liver damage, corneal microdeposits, photosensitivity, and neurological effects. Regular monitoring is essential to detect adverse effects early.
Like all medications, amiodarone can cause side effects, though not everyone experiences them. The side effect profile of amiodarone is particularly complex because the drug accumulates in virtually every tissue of the body and can affect multiple organ systems. Side effects are generally more common and more severe with higher doses and longer durations of treatment.
It is important to attend all scheduled monitoring appointments so that potential adverse effects can be detected early, when they are often reversible. Many of the serious side effects of amiodarone develop gradually over weeks to months, so regular screening is essential for safe long-term use.
- Skin rash, fever, difficulty breathing, and drop in blood pressure — signs of anaphylactic reaction (up to 1 in 10,000 patients)
- Swelling of face, tongue, or throat; hives and difficulty breathing — signs of angioedema
- Persistent dry cough and shortness of breath — may indicate pulmonary toxicity, which can be life-threatening
- Deteriorating vision — may indicate optic neuropathy, which can lead to permanent vision loss
- Severe skin reactions with widespread skin damage, blistering, or mucosal ulceration — may indicate Stevens-Johnson syndrome or toxic epidermal necrolysis
Common (up to 1 in 10 patients)
- Bradycardia (slow heart rate)
- Decreased libido
- Injection site reactions (pain, redness, swelling, inflammation, tissue necrosis)
- Low blood pressure (usually mild and transient)
- Itching, eczema-like rash
- Corneal microdeposits (reversible on discontinuation; rarely affect vision)
- Photosensitivity (increased sunburn risk)
- Nausea, vomiting, taste disturbances
- Elevated liver enzymes
- Tremor
Uncommon (up to 1 in 100 patients)
- Hypothyroidism (underactive thyroid)
- Hyperthyroidism (overactive thyroid)
- Peripheral neuropathy (numbness, tingling in hands/feet)
- Blue-grey skin discoloration (especially on sun-exposed areas)
- Sleep disturbances, vivid dreams
Very Rare (up to 1 in 10,000 patients)
- New or worsened cardiac arrhythmias
- Nausea, severe liver dysfunction
- Raised intracranial pressure, headache
- Pulmonary toxicity (pneumonitis, pulmonary fibrosis)
- Sweating, hot flushes
- SIADH (syndrome of inappropriate antidiuretic hormone secretion)
Frequency Not Known
- Neutropenia (decreased white blood cells), agranulocytosis
- Torsades de pointes (a specific form of ventricular tachycardia)
- Optic neuropathy (may lead to blindness)
- Delirium, hallucinations, confusion
- Acute pancreatitis
- Urticaria (hives)
- Back pain
- Primary graft dysfunction after heart transplantation
- Stevens-Johnson syndrome, toxic epidermal necrolysis, DRESS syndrome
Thyroid effects — a special concern
Thyroid dysfunction is one of the most clinically significant side effects of amiodarone, occurring in 15–20% of patients on long-term therapy. Amiodarone contains approximately 37% iodine by weight, and a 200 mg daily dose delivers roughly 75 mg of organic iodine — far exceeding the normal daily requirement of 0.15–0.3 mg.
Both hypothyroidism (more common in iodine-sufficient populations) and hyperthyroidism (more common in iodine-deficient areas) can occur. Amiodarone-induced thyrotoxicosis (AIT) is divided into two types: Type 1 occurs in patients with underlying thyroid disease, while Type 2 is a destructive thyroiditis caused by direct toxic effects of amiodarone on thyroid tissue. Mixed forms also occur and can be challenging to diagnose and manage.
Thyroid function tests (TSH, free T4, free T3) should be performed before starting amiodarone and every 6 months during treatment, and for several months after discontinuation.
Pulmonary toxicity
Pulmonary toxicity is the most serious non-cardiac adverse effect of amiodarone, occurring in 2–17% of patients depending on the dose. It can present as pneumonitis (inflammation of lung tissue) or, less commonly, as pulmonary fibrosis (scarring). Symptoms include progressive dyspnea (shortness of breath), non-productive cough, weight loss, and malaise.
Annual chest X-rays and pulmonary function tests are recommended during long-term therapy. If pulmonary toxicity is suspected, amiodarone should be discontinued and corticosteroid therapy may be initiated. Early detection is critical, as pulmonary toxicity can be fatal if not recognized promptly.
Required monitoring schedule
| Test | Baseline | During Treatment |
|---|---|---|
| Thyroid function (TSH, free T4) | Before starting | Every 6 months |
| Liver function tests | Before starting | Every 6 months |
| Chest X-ray | Before starting | Annually, or if symptoms develop |
| Pulmonary function tests | Before starting | Annually, or if symptoms develop |
| Eye examination | Before starting | Annually, or if visual symptoms |
| ECG | Before starting | Regularly, especially during loading |
How Should You Store Amiodarone?
Store amiodarone tablets below 25°C (77°F) in the original packaging, protected from light. Keep out of the reach and sight of children. Do not use after the expiry date.
Proper storage of amiodarone is important to maintain the medication's effectiveness and safety. The following guidelines apply:
- Temperature: Store at or below 25°C (77°F). Do not refrigerate or freeze.
- Light protection: Amiodarone is light-sensitive. Keep tablets in their original packaging until use.
- Moisture: Protect from moisture. Store in a dry place.
- Children: Keep out of the sight and reach of children.
- Expiry date: Do not use after the expiration date printed on the packaging. The expiry date refers to the last day of the stated month.
For the injectable formulation, the solution should be used immediately after dilution. Concentrations below 600 mg/L should not be used. Only 5% dextrose (glucose) solution should be used for dilution — do not mix with other drugs in the infusion solution. Unused portions should be discarded by healthcare personnel.
When using medical equipment containing DEHP (di-2-ethylhexyl phthalate) plasticizers, DEHP may leach into the solution in the presence of amiodarone. DEHP-free infusion sets are recommended to minimize patient exposure.
What Does Amiodarone Contain?
Amiodarone tablets contain amiodarone hydrochloride as the active ingredient. The injectable formulation also contains benzyl alcohol and polysorbate 80 as excipients.
Active ingredient
The active substance is amiodarone hydrochloride. Amiodarone is an iodinated benzofuran derivative, and approximately 37% of its molecular weight is iodine. This high iodine content is relevant to its effects on thyroid function and its iodine-related contraindications.
Tablets
Available in 100 mg and 200 mg strengths. Excipients vary by manufacturer but typically include lactose monohydrate, corn starch, povidone, colloidal silicon dioxide, and magnesium stearate.
Solution for injection
Each milliliter contains 50 mg amiodarone hydrochloride. The solution also contains:
- Benzyl alcohol (20 mg/ml) — may cause allergic reactions and is associated with serious side effects in young children
- Polysorbate 80
- Water for injections
The injection solution is a clear, slightly yellowish liquid supplied in 3 ml ampoules (150 mg per ampoule).
The injectable formulation contains benzyl alcohol, which is associated with the risk of serious breathing difficulties in young children. This medication should not be given to neonates (up to 4 weeks of age) unless prescribed by a physician, and should not be used for more than 1 week in young children (under 3 years) without medical advice. If you have impaired liver or kidney function, consult your doctor before receiving this formulation.
Frequently Asked Questions About Amiodarone
Amiodarone is used to treat serious heart rhythm disorders (arrhythmias), including ventricular tachycardia, ventricular fibrillation, and atrial fibrillation. It is typically reserved for cases where other antiarrhythmic medications have been ineffective or cannot be used. During cardiac arrest, it is used as part of advanced cardiac life support (ACLS) protocols for defibrillation-resistant ventricular fibrillation.
The most common side effects include thyroid dysfunction (both hypothyroidism and hyperthyroidism), corneal microdeposits (usually asymptomatic), photosensitivity, nausea, tremor, and elevated liver enzymes. More serious but less frequent side effects include pulmonary toxicity, hepatotoxicity, optic neuropathy, peripheral neuropathy, and blue-grey skin discoloration. Regular monitoring of thyroid, liver, and lung function is essential during treatment.
Amiodarone has one of the longest half-lives of any commonly used medication, ranging from 40 to 55 days. After long-term oral therapy, the drug may remain in the body for several months after discontinuation. This is because amiodarone is highly fat-soluble and accumulates extensively in adipose tissue, liver, lungs, and other organs. Consequently, drug interactions and side effects can persist for weeks to months after stopping the medication. Always inform healthcare providers of prior amiodarone use.
Yes, amiodarone significantly affects thyroid function because it contains approximately 37% iodine by weight. A standard 200 mg daily dose delivers roughly 75 mg of organic iodine, far exceeding normal dietary intake. It can cause both hypothyroidism (underactive thyroid, more common in iodine-sufficient areas) and hyperthyroidism (overactive thyroid, more common in iodine-deficient areas). Thyroid function tests should be performed before starting treatment and every 6 months during therapy.
Regular monitoring is essential during amiodarone therapy. This includes thyroid function tests (every 6 months), liver function tests (every 6 months), pulmonary function tests and chest X-ray (annually or if respiratory symptoms develop), ophthalmological examination (annually or if visual symptoms occur), ECG monitoring, and assessment for peripheral neuropathy. Baseline assessments of all these parameters should be obtained before starting treatment.
Amiodarone should generally not be used during pregnancy due to the risk of fetal thyroid dysfunction, growth restriction, and other adverse effects. The drug crosses the placenta and its high iodine content can affect fetal thyroid development. It should only be used during pregnancy when the potential benefit justifies the serious risks to the fetus and no safer alternative is available. Breastfeeding is contraindicated during amiodarone therapy, as the drug is excreted in breast milk in significant concentrations.
References and Sources
This article is based on the following evidence-based sources. All medical information has been reviewed according to international guidelines and the GRADE evidence framework.
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- World Health Organization (WHO). WHO Model List of Essential Medicines – 23rd List, 2023. Geneva: World Health Organization.
- Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation. European Heart Journal. 2021;42(5):373–498. doi:10.1093/eurheartj/ehaa612
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- Vorperian VR, Havighurst TC, Miller S, et al. Adverse effects of low dose amiodarone: a meta-analysis. Journal of the American College of Cardiology. 1997;30(3):791–798.
- British National Formulary (BNF). Amiodarone Hydrochloride. NICE Evidence Services. bnf.nice.org.uk
- UpToDate. Amiodarone: Clinical uses, adverse effects, and toxicity. Wolters Kluwer, last updated 2025.
- Bogazzi F, Bartalena L, Martino E. Approach to the patient with amiodarone-induced thyrotoxicosis. Journal of Clinical Endocrinology & Metabolism. 2010;95(6):2529–2535. doi:10.1210/jc.2010-0180
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