JT is a 61 year old male. He has recently been diagnosed with atrial fibrillation and placed on amiodarone. He is also on warfarin with a history of DVT/PE. The amiodarone and warfarin interaction can be a little more challenging than other drug interactions. What really makes this unique is the long duration of action and half life of amiodarone.
Here’s some stats on amiodarone from Lexicomp:
- Onset: 2 days to 3 weeks
- Peak effect: 1 week to 5 months
- Half-life: average 58 days
So here’s some things to consider when identifying a patient on amiodarone and warfarin.
- How long have they been on these agents? This can help you determine if an interaction remains relevant or is already accounted for in INR monitoring.
- How often is reasonable to check INR when first initiating the amiodarone. Patient factors are going to play a role in this question. Due to the unique pharmacokinetics of amiodarone, this interaction can take up to weeks to ramp up. Checking a couple of times per week or once a week would potentially be reasonable until we feel the patient has stabilized.
- Is the patient a candidate for a newer oral anticoagulant that might not have this concern? One way to manage an interaction is to avoid a medication. This isn’t always possible, but should always be thought about.
- How long are we going to more closely monitor the amiodarone and warfarin interaction? If we’ve done weekly checks for 2, 3, 4 weeks with no change in an at goal INR, most clinicians will go back to routine monthly monitoring.
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Another really important concept is DID AMIODARONE WORK? If JT remains in AF, why would amiodarone be continued? Beacuse JT has AF does not mean amiodarone will be effective. in the AFFIRM study, the rhythm control arm success at ONE year was 82%, so at least 18% of patients should have had a less complicated and toxic therapy. The rate of staying in NSR declined over time and was 63% at 5 years.
Thanks Bill!
What are your thoughts on a patient who needs to be treated for a UTI with Levaquin and is also on Aricept. Prolonged QT really that much of a factor in short term use ?
Agree, amiodarone is a dirty drug, can be toxic to lungs and throws off thyroid with the iodine component. Some guidelines suggest rate control over rhythm control but I don’t like to question cardiologists too much. Seems like they taper the amiodarone over time in my experience. Drug interactions with warfarin tend to work themselves out with frequent INR monitoring, just be careful on initiation and discontinue
Warfarin is becoming old news for many patients who require lifelong anticoagulation with Afib or recurrent VTE. I say switch them to Xarelto (I like QD dosing), monitor adherence by checking refill history monthly, and follow up face-to-face or by phone quarterly to assess s/s of clots and bleeds.