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Amiodarone (Pacerone, Cordarone)

Class III antiarrhythmic (with class I, II, and IV activity)

Mechanism of action

Primarily prolongs the action potential by blocking potassium efflux (class III), but also blocks sodium and calcium channels and has beta-blocking activity — so it covers all four Vaughan-Williams classes. Used for life-threatening ventricular arrhythmias, atrial fibrillation rhythm/rate control, and pulseless VT/VF in ACLS.

Adverse effects

Life-threatening / NCLEX-tested

  • Pulmonary toxicity (interstitial pneumonitis, pulmonary fibrosis) — life-threatening, dose- and duration-dependent
  • Hepatotoxicity
  • Thyroid dysfunction (hyper- AND hypothyroidism — molecule is iodine-rich)
  • Bradycardia and AV block
  • Torsades de pointes (QT prolongation, though less than other class III)
  • Corneal microdeposits and optic neuropathy
  • Blue-gray skin discoloration (face) with chronic use
  • Severe phlebitis with peripheral IV

Side effects

Common — what to teach

  • Photosensitivity (sun exposure → severe sunburn)
  • Nausea, anorexia
  • Fatigue, malaise
  • Tremor, ataxia, peripheral neuropathy
  • Vivid dreams, sleep disturbance
  • Constipation

Food & drug interactions

Raises levels of digoxin (often halve the digoxin dose) and warfarin (INR rises markedly — recheck within days). CYP3A4 substrate — interacts with many drugs including statins (cap simvastatin at 20 mg). Combined with QT-prolongers (fluoroquinolones, ondansetron, methadone, certain antipsychotics) raises torsades risk. Grapefruit raises levels.

Nursing implications

Assessment, monitoring, patient teaching

  • Baseline and periodic chest X-ray, PFTs (diffusion capacity), LFTs, TSH/T4, ECG, ophthalmologic exam — pulmonary, liver, and thyroid are the three big monitoring fronts
  • IV: give through a central line when possible; if peripheral, use a large vein and switch to PO ASAP — phlebitis is severe
  • Always on cardiac monitor for IV loading
  • Adjust co-administered digoxin and warfarin doses proactively (digoxin halve, warfarin recheck INR)
  • Counsel on photosensitivity — daily sunscreen and protective clothing
  • Teach to report new dyspnea, dry cough, chest pain (pulmonary toxicity), jaundice (liver), or thyroid symptoms
  • Half-life is extremely long (weeks–months) — drug effects and interactions persist long after discontinuation

When to hold / contraindications

  • Severe sinus bradycardia, second- or third-degree AV block (without pacemaker)
  • Cardiogenic shock
  • QTc > 500 ms or torsades on rhythm strip
  • Suspected pulmonary or hepatic toxicity (new dyspnea, marked LFT rise)
  • Severe iodine hypersensitivity

Memory anchor

Amiodarone hits LIVER, LUNGS, THYROID, EYES, SKIN — "the all-organ antiarrhythmic." Halve dig, recheck INR, sunscreen daily. Half-life in weeks, not days.

Reminder: Drug cards are study aids, not clinical guidance. Always cross-check doses, holds, and contraindications with your facility's formulary and your clinical instructors before patient care.

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