Started Amiodarone...expect INR to rise?

[bvdr]

It is a rather long story how this came to be but the short version is that I have been having a lot of neurological type symptoms and since the whole array of them can be a side effect of flecainide I asked to be taken off of it. I am temporarily on amiodarone.....at least until I can determine if things get better when off flecainide. My choice was either being put in the hospital to start sotolol or another drug and that wasn't appealing to me either. I had PFTs prior to starting Amiodarone and they were good. I have elevated pulmonary pressures (which actually were a little better this time around) so this is not a long term deal but just for gathering information. If nothing changes than I'm back to the flecainide. I've been warned that my coumadin dose will probably have to be adjusted downward. What is the experience here on the forum?

 

[Adrienne]

I had A-Fib before I had my surgery and was put on Coumadin, Amiodarone and other things. The Amiodarone kept the INR high until they adjusted it. Then, after the surgery when I was finally off the Amiodarone, it took a while to readjust the amount of Coumadin (which I stayed on for a while) which had to be increased gradually because then, the INR was too low.

 

[MaryC]

My caridologist advised me I had a-flutter at my first post-surgery check up. He put me on flecanide and referred me to one of his peers that dealt with heart rhythm problems. Prior to being put on the flecanide I had no idea I had a heart rhythm problem. Afterward, my heart felt like it was pounding in my chest, my heart rate at rest was 120+ bpm. I also had 2 episodes of nearly passing out. Not my favorite drug to say the least!! Since being taken off of the drug I have had no problems. I am out of the a-flutter so I'm not on any of those drugs now. My brother has had good luck on the sotolol with no side affects and he's not had any more heart rhythm problems.

 

[Guest]

Anticipate having to reduce warfarin by 1/3 to 1/2.

If you started by taking 2 tablets it will need to be done fairly soon. If not it may happen gradually - maybe over several months.

 

[hensylee]

I am sorry to hear you are going through these ups and downs. I wish you well and hope 'they' will come up with a combination that will work to alleviate things. Blessins.........

 

[bvdr]

Thanks for the replies.

Mary, Flecanide is a powerful drug but there are side effects. I have been on it for over 4 1/2 years and except for these possible neurological and visual side effects it has gone quite well. I'm glad you are off of it and hopefully can stay in sinus rhythm for years to come.

Adrienne, thanks. I'll keep a close eye on it.

Ann, it is always nice to hear from you. I get more results this week. Everything is still in limbo about what course of action I will take. Maybe things will soon become clearer.

Al, your help is always appreciated. I started on 2 tabs 3xd for the first two days (1200mg/d) and now I'm on a week of 2 tabs twice a day (800mg) and then I go on 400mg/d. So I gather I should expect to adjust my warfarin fairly soon. Thanks again.

 

[Nancy]

Gosh Betty-

All this going on behind the scenes! Wouldn't it be a good thing of they discovered the reason for the neurological problems, and could resolve them for you.

Fix up one thing, and it affects something else, life can be such a balancing act sometimes. I saw 20+ years of that with Joe. All was well for much of those years by staying on a very narrow path.

Hope things go well with Amiodarone.

 

[JimL]

When I checked the PDR five years ago when I was prescribed amiodarone, it said that the effect on INR was a 100% increase; as Al said, the ultimate change would be a reduction to 1/2 the previous coumadin dosage.

 

[Bill Hall]

Hi Betty - I thought I would just add to the already said. I took amiodarone and coumadin after my surgery. My blood thinned quickly and they kept me a few extra days to make sure of the dose. But in the next two weeks I went from 2 pills to one pill to a half pill. Yes, I broke the pill in half every other day. I hope you are doing well and keeping good health.
Bill

 

[bvdr]

Nancy, you are so right about the balancing act. Sometimes it is so hard to tell if something is an independent new thing or a side effect of a medication.
I have had so many invasive procedures the last few months that it seems I'm always either getting off my coumading, bridging, or trying to get my level up again. It doesn't seem like it should be this complicated but when you get something involving PMD, cardio, neurologist, othopedic surgeon, and neuro surgeon all involved it becomes so very quickly.

Jim, thanks, it seconds what Al said so at least no conflicting advice to add to the muddle.

Bill, I started the amiodarone just as I was finishing a spell on Lovenox and just approaching range. I rather expect to yo-yo a bit. It is times like this that I am so happy to be a home tester.
How long were you on it?

 

[DrAllan]

Amiodarone is not the favorite drug in my formulary in spite of the fact that I have been on it three times for durations of 3-6 months. It is an interesting and extremely dangerous drug. When initially developed and undergoing human testing, mainly at the VA, the testing was stopped because it was so effective in controlling ventricular arrhythmias. It was then approved by the FDA for use. It took several years to discover it bad side effects. The most serious is pulmonary fibrosis, which is almost completely fatal. It can cause both hypothyroidism and hyperthyroidism, both of which are difficult to treat medically once they occur. A very disconcerting side effect is bluish discoloration of the skin, mainly of the nose.

Amiodarone today carries a ?Black Box? warning from the FDA. It is approved ONLY for life threatening ventricular arrhythmias not controlled by any other means. However, it is used extensively by cardiologists for atrial arrhythmias as an ?off label drug?. Why is such a dangerous drug used? Because it is so effective!! It gets the complaining patient and difficult medical problem off of the doctor?s back.

Ordinary PFTs (pulmonary function tests) do not detect the onset of pulmonary fibrosis. The only test that does is a carbon monoxide diffusion test, which is not a routine part of PFTs. An abnormality of change in the baseline is an indicator of fibrosis, but the disease may be irreversible by then.

Taking amiodarone significantly complicates the process of being placed on another anti-arrhythmic drug. It also affects the INR for long periods of time.

Why all of these problems? While we know the mechanism of its action, we have very little idea as to its distribution and metabolism in the body. Its half-life (the time it takes for half of the drug to be gone) is unknown. It is estimated to be between several months and a year. Thus when you stop the drug its effects persist, often fluctuating, for a long time. Thus when first getting on the drug it is difficult to predict the time it takes to raise the INR, and when getting off the drug it may take a long period of time to achieve a stable warfarin dosage. In my own case, I can be 3.0 one day, 4.6 the next day, and 2.2 the third day, all on the same dosage of warfarin.

My advice is that if choosing between amiodarone or flecanide with complications, I would elect for atrial ablation.

 

[hensylee]

Thank you, Allan, for your informative post. We have discussed this drug for years but yours is the first to give us detailed input from a medical professional's standpoint. Most in VR have come to know it's dangerous and should be used as a last resort; we just don't know much more about it except for the awful side effects and the half life is very, very long.

If you don't mind, as we have newbies with questions about amiodarone, I will refer to your post. Thank you for telling us. Blessins.........

 

[bvdr]

Dr. Allan,
Thanks for the post. Were you ever on amiodarone at a time you had to come off warfarin for any procedure? I'm just wondering since I'm going to have that situation come up. If I'm in range it never takes more than 4 days for my INR to be about 1.0. If so, did it affect how long it took you to drop down to baseline. I'm usually told to hold for 5 days but after the first few times I know that isn't necessary for me unless the amio changes that. Thanks again for your comments. I'll tuck the atrial ablation away in my mind and pull it out later to think that one out.

 

[catwoman]

Dr. Allan:

Ditto on the thanks for the info about amiodarone.
My dad has pulmonary fibrosis and my brother-in-law's mom died from it. I didn't know about the PF link when my husband's surgeon ordered amiodarone (IV & oral) last mohth for arrhythmia after his MV repair. Luckily, he only took it for about 3-4 days.
A search on the web found references to "Smurf Syndrome," the bluish cast to the skin, which isn't always reversible, from what I read.
I asked a friend who is a pharmacist about amiodarone. He said doesn't like it, but his mom is on & off it, because it's the only drug that controls her arrhytmia. Said that after her ophthalmologist examined her at one appointment, he said, "You're on amiodarone." She had not told him that she had taken it (may not have been currently taking it). Seems that amiodarone builds up in the eyes.

 

[tcopel]

Don't know is this will help or not, but I was put on a relatively new antiarrhythmic called Tikasyn. I had a aortic aneursym addressed surgically on 5/14/07. Since then I have had 3 episodes of atrial fib (which I assume you are having now). I was shocked out of the 2nd episode successfully but returned to a fib a week later. Consequently, this medication was intiated.
As I understand it, it is a "clean" medication with little liver or kidney issues. No evidence of pulmonary fibrosis nor problems with thyroid. It does have a fairly lenghthy list of potential drug to drug interactions (like coumadin does).
It does require a hospitalization for the first 5 doses as they do an EKG after each dosage. Not all general cardiologist (as I understand it) can prescribe it. Cardiologist trained in EPS (rhythm problems) who have undergone further training can implement it. It quickly stopped the a fib in my case and there have no apparent side effects to date.

 

[bvdr]

Don't know is this will help or not, but I was put on a relatively new antiarrhythmic called Tikasyn. I had a aortic aneursym addressed surgically on 5/14/07. Since then I have had 3 episodes of atrial fib (which I assume you are having now). I was shocked out of the 2nd episode successfully but returned to a fib a week later. Consequently, this medication was intiated.
As I understand it, it is a "clean" medication with little liver or kidney issues. No evidence of pulmonary fibrosis nor problems with thyroid. It does have a fairly lenghthy list of potential drug to drug interactions (like coumadin does).
It does require a hospitalization for the first 5 doses as they do an EKG after each dosage. Not all general cardiologist (as I understand it) can prescribe it. Cardiologist trained in EPS (rhythm problems) who have undergone further training can implement it. It quickly stopped the a fib in my case and there have no apparent side effects to date.

Thank-you, Tcopel. I have not heard of Tikasyn but I will research it further. If I don't go back onto Flecainide, and I probably won't since some of the suspected side effects that I have been having seem to be improving, then I will be looking for an alternative than being on Amiodarone.

 

[DrAllan]

Tikosyn is an excellent drug. It worked for me about 3 months and then the afib returned. The medical literature shows that by one year, 75% of patients are not responding. Remeber, that under certain circumstances afib my be a self limited disease itself.

The hospitalization is required becasue the drug itself can cause ventrivular fibrillation. Thus if VF occurs, the staff would be able to defibrillate you. The monitoring is that an EKG is done 10 hours after receiving a dose and the QT interval is measured. if it prolongs beyond a certain time limit then the drug is stopped.

Because the potential of killing a patient with this drug exists, the drug company protects itself from possibly being sued. The drug can only be prescribed by MD who has read a 75 page document, and maybe answered some questions about it. The drug can only be dispensed by a certified pharmacist, who also has read some documentation of shorter amount AND who calls the company to determine wheter the doctor is on the approved list. The drug also does not come from the usual wholesale chain of supply, but directly from the manufacturer by FedEx. So, nothing magic about the drug, just alot of hocus-pocus in the dispensing.