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      Amiodarone-Induced Liver Attenuation on CT Scan: Alarming Signal for Toxicity and Prompt Discontinuation


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          Amiodarone, a class III antiarrhythmic drug, is commonly used for the management of life-threatening ventricular arrhythmias, atrial fibrillation, and other refractory supra-ventricular arrhythmias. Factors like a large volume of distribution, lipophilic property, deposition in tissues in large amounts, etc. have led to the development of amiodarone-induced multisystem adverse events. We report a case of amiodarone-induced hepatic attenuation on computed tomography (CT) of the abdomen in an elderly female patient. Amiodarone with a composition of 40% iodine by weight deposits in the liver, leading to characteristically increased radiodensity reported as increased attenuation on CT scan. Surprisingly, the severity and extent of hepatic attenuation on CT scans do not necessarily correlate with the total exposure to amiodarone over time. Individual factors may influence the liver's response to the drug, leading to varying degrees of hepatic changes. To minimize the risk of adverse events associated with amiodarone, clinicians should carefully adjust the dosage to the lowest effective level and regularly monitor liver function tests in patients. This proactive approach enables early detection of liver dysfunction and facilitates timely adjustments or discontinuation of amiodarone, thereby reducing potential harm.

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          Prescribing amiodarone: an evidence-based review of clinical indications.

          Although amiodarone is approved by the US Food and Drug Administration only for refractory ventricular arrhythmias, it is one of the most frequently prescribed antiarrhythmic medications in the United States. To evaluate and synthesize evidence regarding optimal use of amiodarone for various arrhythmias. Systematic search of MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other studies with clinical pertinence. The search was limited to human-participant, English-language reports published between 1970 and 2007. Amiodarone was searched using the terms adverse effects, atrial fibrillation, atrial flutter, congestive heart failure, electrical storm, hypertrophic cardiomyopathy, implantable cardioverter-defibrillator, surgery, ventricular arrhythmia, ventricular fibrillation, and Wolff-Parkinson-White. Bibliographies of identified articles and guidelines from official societies were reviewed for additional references. Ninety-two identified studies met inclusion criteria and were included in the review. Amiodarone may have clinical value in patients with left ventricular dysfunction and heart failure as first-line treatment for atrial fibrillation, though other agents are available. Amiodarone is useful in acute management of sustained ventricular tachyarrythmias, regardless of hemodynamic stability. The only role for prophylactic amiodarone is in the perioperative period of cardiac surgery. Amiodarone may be effective as an adjunct to implantable cardioverter-defibrillator therapy to reduce number of shocks. However, amiodarone has a number of serious adverse effects, including corneal microdeposits (>90%), optic neuropathy/neuritis (< or =1%-2%), blue-gray skin discoloration (4%-9%), photosensitivity (25%-75%), hypothyroidism (6%), hyperthyroidism (0.9%-2%), pulmonary toxicity (1%-17%), peripheral neuropathy (0.3% annually), and hepatotoxicity (elevated enzyme levels, 15%-30%; hepatitis and cirrhosis, <3% [0.6% annually]). Amiodarone should be used with close follow-up in patients who are likely to derive the most benefit, namely those with atrial fibrillation and left ventricular dysfunction, those with acute sustained ventricular arrhythmias, those about to undergo cardiac surgery, and those with implantable cardioverter-defibrillators and symptomatic shocks.
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            Amiodarone hepatotoxicity: prevalence and clinicopathologic correlations among 104 patients.

            The prevalence of apparent amiodarone-related hepatic injury in 104 patients followed prospectively is compared to that reported in the literature. Asymptomatic elevation of serum aminotransferase levels was detected in approximately one-fourth of the patients, a figure similar to the average of reported cases. The frequency of extrahepatic organ toxicity was increased in patients with elevated levels. Symptomatic "hepatitis" developed in 3% of this series and in less than 1% of cases in the literature. Evidence of hepatic phospholipidosis and the development of pseudoalcoholic liver injury is most likely due to the biochemical effects of the drug and to possible metabolic idiosyncrasy, respectively. Serial blood enzyme measurements, as recommended by the manufacturer, may offer some protection against the development of more serious liver injury. However, levels of amiodarone may persist in various tissues for weeks to months following withdrawal, and stopping the drug does not guarantee the prompt reversal of any organ toxicity. Accordingly, the risks posed and benefits offered by amiodarone should be carefully weighed prior to discontinuing the drug, as the risk of sudden cardiac death may outweigh the hazards of ongoing hepatic, pulmonary or other toxicity.
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              Amiodarone: an effective antiarrhythmic drug with unusual side effects.


                Author and article information

                Cureus (Palo Alto (CA) )
                1 June 2023
                June 2023
                : 15
                : 6
                : e39844
                [1 ] Internal Medicine, One Brooklyn Health - Interfaith Medical Center, Brooklyn, USA
                [2 ] Internal Medicine, Nepal Medical College Teaching Hospital, Kathmandu, NPL
                Author notes
                Copyright © 2023, Tun et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                : 1 June 2023
                Internal Medicine

                hepatotoxicity,adverse effect,atrial fibrillation,hyperattenuation,amiodarone


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