THURSDAY POTD, ALL TREMOR BEFORE ITS MIGHT

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AMIODARONE: THROW IT IN THE TRASH!  

 

At least, that's what I'm going to try to convince you of today.

Recently there was a patient in stable VTach, awake alert normotensive.

Get 150/300 mg bolus of amio right? That's what everyone goes for. It's familiar, it's comfortable, it's oh so sexy (ok maybe not that one). But they probably shouldn't.

 

 

THE BASICS

Amio is typically used in 3 indications in the ED.

  1. Afib for cardioversion
  2. VTach for cardioversion
  3. Refractory VF or pulseless VT

 

WHY I WON'T BE USING IT IN ANY OF THESE THINGS

 

  1. AFIB
    1.  shown to be no more effective than flecainide/propafenone at 24 hours("pill-in-pocket"), and no more effective than placebo in first 1-2 hours. (https://www.ncbi.nlm.nih.gov/pubmed/12535819)
    2. Procainamide had a better conversion rate with mean time of 55 minutes, with lower incidence of SE (https://www.ncbi.nlm.nih.gov/pubmed/18045891)
    3. Electrical Cardioversion has a conversion rate of >90% with 1 shock, approaching 100% if 2 shocks delivered.
  2. VTach (Stable)
    1. PROCAMIO TRIAL: read it, love it, admire it. Use it over and over and over again. (https://www.ncbi.nlm.nih.gov/pubmed/27354046). Basically it says that procainamide is safer and more effective than amio.
  3. Refractory VF/Pulseless VT
    1. Multiple studies showing increase of ROSC, but no increase in neurological outcomes. Does it really do anything?

 

NOTES: Procainamide dosing for VT is 10 mg/kg run over 20 minutes. Dosing for AF is 1 gm over 60 minutes. The AF dosing is in the computer under COMMON MED DRIPS. The major side effect of procainamide is HYPOTENSION, so be care with already hypotensive patients, and have them on a monitor. (but amio also causes hypotension so who really cares???)

 

SO. I don't know if this changes your practice or not. Definitely read the studies, do your own due diligence. We often reach for amio because it's familiar, but often it can cause more harm than good. I know Jason and the Argonauts, sorry, Pharmacists, support using PROCAINAMIDE in most situations.

 

Disclaimer: I wish I was getting paid by the makers of procainamide.

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