Among these, amiodaroneinduced pulmonary toxicity apt occurs in 417%. Amiodarone toxicity and the acute respiratory distress syndrome. In about 6% of patients, amiodarone induced pneumotoxicity aipt can be seen and is dose and duration dependent. Pulmonary fibrosis lawsuit amiodarone, pacerone, or cordarone. Although the biochemical and morphologic characteristics associated with amiodarone induced pulmonary toxicity aipt are welldefined, the mechanisms underlying this disorder remain unknown. The clinical features of the pulmonary involvement are mild dyspnea, leukocytosis, hypoxemia, elevation in the erythrocyte sedimentation rate, and restrictive changes on pulmonary function testing. Amiodaroneinduced pulmonary toxicity is a diagnosis of exclusion. Amiodarone is a highly effective treatment for supraventricular and ventricular tachyarrhythmia. Dailymed amiodarone hydrochloride injection, solution. Previously published experience suggests that pulmonary injury may resolve when drug treatment is stopped and treatment with corticosteroids is started 26.
Amiodarone toxicity pulmonary, thyroid and hepatic. Fatal toxicities may be caused by pulmonary toxicity, hepatotoxicity, and proarrhythmic effect. The patient was successfully managed with pulse high dose steroid therapy. Pulmonary toxicity usually manifests as an acute or subacute pneumonitis. Pdf download for hrct findings of amiodarone pulmonary toxicity. Clinical features of amiodaroneinduced pulmonary toxicity. Recent reports have shown that pmxdhp improves oxygenation in patients with acute exacerbation of. Polymyxin bimmobilized fiber column direct hemoperfusion pmxdhp is a medical device that reduces blood endotoxin levels in sepsis. The mechanism of amiodarone induced pulmonary toxicity is not entirely clear but is thought to be caused by direct cytotoxic damage and an indirect immune reaction. Pulmonary toxicity is a wellknown adverse effect of amiodarone which necessitates close monitoring a 74yearold male was prescribed amiodarone and acenocoumarol for af. Both under and overactivity of the thyroid may occur.
Amiodarone is an antiarrhythmic drug that can cause interstitial pneumonitis leading to. Amiodarone is an antiarrhythmic agent commonly used to treat supraventricular and ventricular arrhythmias. Several forms of pulmonary disease occur among patients treated with amiodarone, including interstitial pneumonitis, organizing pneumonia, acute respiratory distress syndrome ards, diffuse alveolar hemorrhage dah, pulmonary nodules and solitary masses, and also. Pdf amiodarone is an antiarrhythmic agent commonly used to treat supraventricular and ventricular arrhythmias. Successful treatment of severe amiodarone pulmonary. Editorin their editorial on amiodarone pulmonary toxicity gillian a j jessurun and harry j g m crijns made several misleading statements about the diagnosis of this dangerous condition.
Amiodarone is associated with a wide range of adverse effects, including pulmonary toxicity. One hundred ninety cardiac patients were prospectively enrolled in an amiodarone protocol. Several features of this adverse effect make it difficult to diagnosis and treat. The diagnosis is difficult due to the nonspecificity of sympto. Ct findings indicative of significant amiodarone exposure included a highattenuation parenchymalpleural lesions in eight of the 11 patients 73%, and b increased liver andor spleen attenuation in 10 of the 11 patients 91%. Amiodaroneinduced pulmonary toxicity a frequently missed.
The most specific test of pulmonary toxicity due to amiodarone is a dramatically decreased dl co noted on pulmonary function testing. Among its various adverse effects, amiodaroneinduced pulmonary toxicity apt is the most life threatening complication, which has been described mostly in patients who have been in treatment with high accumulative doses for a long duration of time. We read with great interest the recent article by marchlinski and associates on the pulmonary toxicity of amiodarone 1. Amiodarone pulmonary toxicity annals of internal medicine. Amiodaroneinduced interstitial pneumonitis bmj case reports. Chest xray showing diffuse bilateral infiltrates, usually imaging can be sufficient in the appropriate clinical setting to establish diagnosis of amiodarone toxicity.
Twelve 6% of the 207 patients with pulmonary disease had amiodarone stopped due to amiodaroneinduced toxicity compared to 35 3% of the 1,066 without pulmonary disease p. Amiodarone is structurally similar to thyroxine and also contains iodine. The onset of pulmonary toxicity may be either insidious or rapidly progressive. The incidence of pulmonary toxicity from amiodarone is not precisely known. Amiodaroneinduced interstitial pneumonitis is characterised by insidious onset of nonproductive cough andor dyspnoea after 612 months of amiodarone therapy dose.
Amiodarone is increasingly being used for managing cardiac dysrhythmias. Although the biochemical and morphologic characteristics associated with amiodaroneinduced pulmonary toxicity aipt are welldefined, the mechanisms underlying this disorder remain unknown. With longterm use, the prevalence of such toxicity varies between 5% and 15%. Medline abstract for reference 20 of amiodarone pulmonary. We have studied 15 patients with amiodarone pulmonary toxicity and compared them with five amiodarone patients without evidence of toxic effect.
Amiodarone pulmonary toxicity is a serious adverse effect that can be fatal. Pdf amiodarone is an iodinecontaining antiarrhythmic drug commonly used for the treatment of ventricular and supraventricular arrhythmias. Six of 15 patients who had toxic reactions presented with an acute illness that resembled an infectious disease. The most serious side effect of amiodarone is pulmonary toxicity. Amiodarone, a biiodinated benzofuran derivative, is, because of its high effectiveness, one of the most widely used antiarrhythmic agents. Pulmonary toxicity of amiodarone jama jama network. Severe amiodarone induced pulmonary toxicity nacca journal of. Amiodarone was stopped, and an alternate antiarrythmic agent was used. However, we were surprised that there was no mention of pulmonary toxic effects, which are the most serious side effects, and.
Amiodarone is a benzofuran derivative antiarrhythmic drug that has been commonly used to treat atrial fibrillation as well as supra ventricular and ventricular. Full text amiodaroneinduced pulmonary toxicity apt. Amiodaroneinduced pulmonary toxicity aipt is characterized in part by oedema, phospholipidosis, inflammation and thickening of the alveolar septa, intraalveolar inflammation, and pulmonary fibrosis 35. Early changes in pulmonary function tests during amiodarone rechallenge enrico p. Amiodarone pulmonary toxicity apt is the most serious side effect of amiodarone.
The case of a 63yearold male with classic radiographic and histologic findings. Acute amiodarone pulmonary toxicity after drug holiday. A following eightyear retrospective singlecenter analysis of patients on amiodarone was conducted, finding amiodarone pulmonary toxicity in 2. Amiodaroneinduced pulmonary toxicity with an excellent response. In this report, we describe a case of amiodarone induced pulmonary toxicity after a short course of therapy for postoperative atrial fibrillation. Reid, md, facc baltimore, maryland amiodarone is an investigational antiarrhythmic agent known to cause pulmonary toxicity. Amiodarone inhibits phospholipase a, which can result in an accumulation of phospholipids within lysosomes in. Pulmonary drug toxicity in a 60yearold woman with nonsmall cell lung cancer treated with carboplatin and vinorelbine. He was diagnosed with ards secondary to acute amiodarone pulmonary toxicity apt. Presents as hypersensitivity pneumonitis or interstitialalveolar pneumonitis 1017% incidence with 400 mgday may present without symptoms as abnormal diffusion capacity in a much higher percentage of patients.
Successful treatment of severe amiodarone pulmonary toxicity. Amiodaroneinduced pulmonary toxicity rare regardless of. Acute pulmonary toxicity after lowdose amiodarone therapy. Among its various adverse effects, amiodarone induced pulmonary toxicity apt is the most life threatening complication, which has been described mostly in patients who have been in treatment with high accumulative doses for a long duration of time. Pulmonary evaluation with chest xray and pulmonary function testing, including diffusion capacity. Amiodaroneinduced reversible and irreversible hepatotoxicity. Amiodarone induced pulmonary toxicity is a diagnosis of exclusion. Amiodarone may cause pulmonary toxicity mimicking metastatic lung disease. In this report, we describe a case of amiodaroneinduced pulmonary toxicity after a. Amiodaroneinduced pulmonary toxicity apt is a serious adverse event that can lead to death. However, adverse effects, especially potentially fatal and nonreversible acute and chronic pulmonary toxicity, continue to be observed.
Of these events, the most serious is amiodarone pulmonary toxicity. Cureus a case of amiodarone pulmonary toxicity with short. Amiodarone pulmonary toxicity is usually dosedependent, however, our patient was taking safe doses which make this case unique. Pulmonary toxicity may occur in association with amiodarone hydrochloride therapy. During the course of the prospective study amiodarone pulmonary toxicity was diagnosed in four other patients. Patients are usually elderly and have been exposed to amiodarone, usually for at least. Amiodarone is classified pharmacologically as a cationic amphiphilic drug cad, because its molecular structure has both polar and nonpolar constituents fig 1. Similarly, the primary metabolite of amiodarone, desethylamiodarone, reveals the same molecular features fig 1. Pulmonary function, chest radiographic appearances, and the cellular composition of bronchoalveolar lavage fluid were assessed in patients who were receiving amiodarone treatment. The mechanism of amiodaroneinduced pulmonary toxicity is not entirely clear but is thought to be caused by direct cytotoxic damage and an indirect immune reaction. Serious adverse effects sometimes result in a poor prognosis because of the very long plasma halflife of.
This drug is an iodinecontaining compound that tends to accumulate in several organs, including the lungs. Pulmonary toxicity is among the most serious adverse effects of amiodarone. Amiodarone and pulmonary effects annals of internal. An evaluation of possible mechanisms underlying amiodarone. Very early onset of amiodaroneinduced pulmonary toxicity. Amiodarone induced pulmonary toxicity is usually seen in cardiac surgical patients who have received large doses of amiodarone for ventricular arrhythmias over prolonged periods. It has been associated with a variety of adverse events. Jessurun gaj, crijns hjgm amiodarone pulmonary toxicity dose and duration of treatment are not the only determinants of toxicity. Because amiodarone is widely used, all clinicians should be vigilant of this possibility. The effectiveness of amiodarone in the treatment of cardiac arrhythmias is limited due to the development of pulmonary toxicity. Lung tissue was examined in five of the seven patients with clinical toxicity and showed alveolar wall thickening, exudation and interstitial and intraalveolar fibrosis with prominent foamy macrophages. Over a 10year period, 16 patients developed new or progressive respiratory symptoms while taking amiodarone.
Oct 16, 2012 amiodarone is associated with a wide range of adverse effects, including pulmonary toxicity. Abstract amiodarone is a widely used antiarrhythmic agent. A role for the direct toxicity of the drug is likely because a toxicity in part is related to dosage and duration of therapy, b many patients with amiodarone pulmonary toxicity have no evidence of an inflammatory or immune response in the lung, c in vitro studies indicate that amiodarone can be directly toxic to cultured lung cells or. Amiodaroneinduced pulmonary toxicity is usually seen in cardiac surgical patients who have received large doses of amiodarone for ventricular arrhythmias over prolonged periods. Twelve 6% of the 207 patients with pulmonary disease had amiodarone stopped due to amiodarone induced toxicity compared to 35 3% of the 1,066 without pulmonary disease p. A known complication of amiodarone therapy is amiodarone induced pulmonary toxicity apt. Eight of the patients had developed clinical and radiological evidence of lung disease and five were symptom free. Amiodarone pulmonary toxicity was diagnosed in 33 of the 573 patients 5.
Nonspecific pulmonary infiltrates were identified in nine of the 11 patients 82%. Dec 01, 2003 in early studies, the frequency of pulmonary toxicity in amiodarone therapy was 2 to 17 percent. The editorial by estes1 on the role of amiodarone for the management of atrial fibrillation describes several amiodarone doserelated adverse effects. Although severe apt, such as ards, is rare, mortality of severe apt is high. Amiodarone is an antiarrhythmic drug widely used, but its administration can be associated with several adverse sideeffects. Amiodarone lung is an interstitial lung disease seen in patients being administered amiodarone and can manifest in a number of histopathologic patterns. In about 6% of patients, amiodaroneinduced pneumotoxicity aipt can. Initial characteristics and outcome of hospitalized patients with.
These symptoms included dyspnea associated with abnormal chest radiographs or new or worsening abnormalities on pulmonary function testing. Ocular toxicity and blue man syndrome are also discussed. Pulmonary toxicity is a wellrecognized complication of longterm amiodarone use see package insert for oral amiodarone. Amiodaroneinduced pulmonary toxicity mimicking metastatic lung. A mechanistic study on the amiodaroneinduced pulmonary toxicity. Induced abnormalities in thyroid function are common.
Cads, as a group of pharmacologic agents, share the tendency to induce an accumulation of phospholipids within certain. Mar 02, 2012 a known complication of amiodarone therapy is amiodarone induced pulmonary toxicity apt. This article is from korean circulation journal, volume 43. Pulmonary toxicity an overview sciencedirect topics. Patients taking the antiarrhythmic drug amiodarone brand names pacerone and cordarone may face an increased risk of devastating side effects, including pulmonary fibrosis, lung disease, blindness, other lung damage and a serious skin condition called toxic epidermal necrolysis ten. One month after starting amiodarone, the patient experienced hemoptysis and trepopnea dyspnea in the left hemithorax and a chest xray revealed an interstitial patter. The rate increases at higher doses of amiodarone, particularly longterm use of doses over 500 mg daily. Amiodarone is often used in the suppression of tachyarrhythmias. Amiodarone and its metabolite desethylamiodarone accumulate in high concentrations in the liver, lungs and skin, besides in fat and muscle. The reported prevalence of pulmonary toxicity in patients receiving amiodarone is 10% range 218% 8. The knowledge of different safe dosage patterns is important for every working physician due to widely usage of the drug. Cough, new chest infiltrates in imaging studies and reduced lung diffusing capacity in the appropriate clinical setting of amiodarone use, after the meticulous exclusion of infection, malignancy and pulmonary oedema, are the cardinal clinical and laboratory elements. Amiodarone inhibits phospholipase a, which can result in an accumulation of phospholipids within lysosomes in the lungs and other tissues.
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