Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
Antiarrhythmics (class 3)Amiodarone100mg tablets: £1.64
200mg tablets: £2.00
Treatment should only be initiated by a hospital specialist and only for the treatment of severe rhythm disorders not responding to other therapies.
Prescribing at initial loading dose should be limited to 2 weeks and provided by specialist. Care should be taken to ensure that only the ongoing dose is used for prescribing by any other doctor.

Amiodarone therapy requires monitoring of:
• LFTs and TFTs at baseline and then every 6 months.
• Ophthalmic examination at baseline and then twelve-monthly
The long half-life of amiodarone (~50 days) means the therapeutic and adverse effects persist for long periods after discontinuation of therapy.
WARNING Do not exceed Simvastatin 20mg in patients taking amiodarone and monitor lipid levels to ensure lowest dose necessary of simvastatin is used.
Dronedarone400mg tablets: £67.50 (60)Although effective in treating atrial fibrillation and flutter, dronedarone is not as effective as amiodarone. However, the different side effect profile has led to its use in patients for whom amiodarone may be contraindicated or otherwise unsuitable.

Dronedarone is indicated for the maintenance of sinus rhythm after successful cardioversion in adult clinically stable patients with paroxysmal or persistent atrial fibrillation (AF). Due to its safety profile (see sections 4.3 and 4.4), dronedarone should only be prescribed after alternative treatment options have been considered.

Dronedarone must not be given to patients with left ventricular systolic dysfunction or to patients with current or previous episodes of heart failure.

Careful monitoring during dronedarone administration is recommended by regular assessment of cardiac, hepatic and pulmonary function (see below). If AF reoccurs discontinuation of dronedarone should be considered. Treatment with dronedarone should be stopped during the course of treatment, in case the patient develops any of the conditions which would lead to a contraindication as mentioned in section 4.3. Monitoring of co-administered medicinal products like digoxin and anti-coagulants is necessary. See the SPC for further information. Also MHRA Alert Dronedarone (10/2011)

See NICE guidance TA197 for more information: NICE TAG

What issues should be considered regarding drug induced QT prolongation?
Prolongation of the QT interval can lead to a life threatening ventricular arrhythmia known as torsades de pointes which can result in sudden cardiac death. Recently there have been warnings relating to drug-induced QT prolongation for four commonly used drugs – citalopram, domperidone, hydroxyzine and ondansetron. There are also a number of other widely used drugs which are known to cause QT prolongation and there are a number of drug interactions which can increase the risk of this adverse effect occurring.