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Amiodarone is one of the most effective medicines for heart rhythm disorders and is often used when other antiarrhythmics are not an option. It builds up in the tissues over weeks, contains a lot of iodine and keeps acting for months after it has been stopped. That is why regular check-ups of the thyroid, lungs, liver, eyes and heart, together with consistent sun protection, are an integral part of treatment.
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Amiodarone and its breakdown product inhibit several liver enzymes (CYP3A4, CYP2C9, CYP2D6) and the transport protein P-glycoprotein. As a result, the levels of many other medicines rise. Because amiodarone stays in the body for so long, according to the SmPC such interactions can still occur several months after stopping.¹
| Combination | Consequence | What to do |
|---|---|---|
| Medicines that can trigger torsade de pointes: class I and III antiarrhythmics such as sotalol or quinidine, some antipsychotics (e.g. sulpiride), erythromycin or pentamidine given as an infusion | Excessive QT prolongation, dangerous ventricular tachycardia | Contraindicated according to the SmPC |
| Other QT-prolonging medicines, for example some antidepressants, antibiotics or anti-sickness medicines | Increased risk of torsade de pointes | Only after careful consideration and with ECG monitoring |
| Fluoroquinolones such as levofloxacin or ciprofloxacin | QT prolongation | Avoid, according to the SmPC |
| MAO inhibitors | Dangerous interactions | Contraindicated |
| Beta blockers such as bisoprolol, verapamil, diltiazem | Very slow pulse, conduction disorders | Not recommended according to the SmPC; if the combination is used deliberately, then with ECG checks |
| Cardiac glycosides: digoxin, digitoxin | Levels rise, pulse and conduction slowed | Watch for signs of toxicity, check levels, adjust the dose |
| Vitamin K antagonists such as phenprocoumon | Stronger anticoagulation, risk of bleeding | Measure the INR more often during and after treatment |
| Dabigatran | Higher levels, more bleeding | With caution, adjust the dose if necessary |
| Statins broken down via CYP3A4: simvastatin, atorvastatin, lovastatin | Increased risk of muscle damage up to and including rhabdomyolysis | According to the SmPC, choose a statin that is not broken down via CYP3A4, e.g. rosuvastatin |
| Potassium-lowering medicines: laxatives that cause potassium loss, diuretics such as furosemide or hydrochlorothiazide, corticosteroids | Low potassium promotes torsade de pointes | Avoid and correct potassium deficiency; check potassium |
| Hepatitis C medicines containing sofosbuvir | Life-threatening slow pulse and heart block | Not recommended; if unavoidable, monitoring in hospital at the start — even if amiodarone was stopped months ago |
| Ciclosporin, tacrolimus, sirolimus, fentanyl, phenytoin, flecainide, sildenafil, colchicine, midazolam | Levels and side effects of these medicines rise | Dose adjustment and checks as instructed by your doctor |
| Grapefruit juice and other CYP3A4 inhibitors | Amiodarone levels rise | Avoid, according to the SmPC |
The combination with beta blockers is worth a closer look: the SmPC advises against it because of the risk of an overly slow pulse, but at the same time stresses that in ventricular rhythm disorders a beta blocker should not be dropped in favour of amiodarone.¹ In cardiology practice, the two are therefore deliberately combined in certain heart conditions — with close ECG and pulse checks. That is a decision for the practice, not a reason to leave out one of the medicines yourself.
In 2015 there was a Rote-Hand-Brief (red hand letter) on the combination with sofosbuvir, after severe slowing of the pulse had occurred.³ The warning explicitly also applies to people who stopped amiodarone in the preceding months. Alcohol puts additional strain on the liver and increases impairments in your ability to react; restraint makes sense. With every new prescription — especially antibiotics, psychiatric medicines and anti-sickness medicines — amiodarone needs to be put on the table. This is exactly what the interaction check is for; the basics are in the guide drug interactions.
To put it honestly: amiodarone is rarely the first medicine, but often the one that is left. The European guidelines use it mainly where other antiarrhythmics are ruled out because of heart failure or structural heart disease, and, because of the side effects on organs, they recommend regular check-ups and a critical review of long-term use.²,⁴
| Option | Strength | Typical limitation |
|---|---|---|
| Amiodarone | Very effective, can also be used in heart failure | Side effects on the thyroid, lungs, liver, eyes, skin; many interactions |
| Flecainide, propafenone | Effective in atrial fibrillation without structural heart disease | Not in heart failure or after a heart attack |
| Dronedarone | Related to amiodarone, without iodine | Less effective; not in heart failure and not in permanent atrial fibrillation |
| Sotalol | Beta blocker with class III effect | QT prolongation, kidney function needs to be considered |
| Beta blockers, digitalis (rate control) | Slow the pulse in atrial fibrillation without changing the rhythm | Do not maintain the rhythm |
| Catheter ablation | Can treat the cause of rhythm disorders | A procedure; not suitable for every rhythm disorder or every person |
It is legitimate to ask the practice whether amiodarone is still needed or whether there is an alternative — for example after a successful ablation or if the rhythm disorder for which it was started was a long time ago. In atrial fibrillation, it is also not just about the rhythm: protection against strokes with anticoagulants such as apixaban remains independent of it. How to initiate such a review is described in the guide reviewing long-term medication.
Usually yes, but slowly. The discolouration is caused by deposits in the skin, intensified by sunlight, and mainly occurs with longer treatment at higher doses. According to the SmPC, it fades over one to four years after stopping. Consistent sun protection slows its progression. Raise the change — it is also a reason to check whether the dose is still right or whether there is an alternative. It needs to be distinguished from a genuine blue colouring due to lack of oxygen, which comes with breathlessness.
These are very probably the typical corneal deposits. They are usually harmless and do not damage the eye. Still have it looked at by an ophthalmologist, mentioning amiodarone, because very rarely the optic nerve can also be affected — and then every week counts. Suddenly worse vision, a shadow in your field of vision or pain when moving your eyes need checking the same day. Until it has been checked, it makes sense to be cautious about driving at night.
Not automatically. A slightly changed T4 with a normal TSH is common on amiodarone and not a reason to stop. A genuinely underactive thyroid is often corrected with thyroid hormone while amiodarone continues. An overactive thyroid is more serious and, according to the SmPC, usually leads to stopping — but not by you alone; it is planned, because the rhythm disorder still needs treatment. Have the values assessed jointly by cardiology and your GP or endocrinology practice.
Because amiodarone stays in the body for a long time. According to the SmPC, thyroid disorders can still occur months after stopping, thyroid values should be checked until about a year afterwards, and interactions also remain possible for months. Sun protection is still needed for some time. So record in your medication plan when you stopped amiodarone — this information is important for every new prescription.
The interaction check reviews your list, even if amiodarone was stopped only recently.
