Amiodarone-induced acute hepatotoxicity

Abstract

Dear Editor, We present the case of a 44-year-old man admitted with central chest pain associated with breathlessness that was not relieved by taking sublingual glyceryl nitrate. He presented with a background of old inferior infarct, dilated cardiomyopathy and poor left-ventricular (LV) function and hypertension. There was history of continued alcohol and cocaine abuse. Electrocardiogram on admission confirmed atrial flutter, ventricular rate of 160 bpm with evidence of heart failure, and systolic blood pressure 90 mmHg. All biochemical and hematological parameters were within normal limits. Intravenous (IV) amiodarone 300 mg was administered intravenous (i.v) over 30 min and a maintenance dose of 900 mg over 24 h to attempt pharmacological cardioversion. His heart rate slowed down and later reverted to sinus rhythm. However, over night, he became transiently hypotensive with reduced urine output that subsequently improved. Repeat blood tests the following day revealed an acute increase in alanine aminotransferase (ALT) to 4,428 (see Table 1) and bilirubin to 45. Amiodarone was discontinued. ALT peaked at 4,578 on day 3 but returned to normal at day10. Hepatic ultrasound revealed no abnormality. In particular, there was no evidence of hepatic congestion. The patient was started on digoxin, anti-heart-failure medication optimized his condition, and once he was stable. He was discharged with a further cardiology follow-up.

Predictors of intravenous amiodarone induced liver injury

“…This was in accordance with several case studies in which LV dysfunction was observed. 4 , 7 , 12 , 18 , 19 The same was also found with oral amiodarone. 22 If direct drug toxicity is assumed, LV dysfunction delays amiodarone elimination by prolonging the half life of its metabolites, and therefore might predispose to liver injury.…”

“…Similarly, heart failure, congestive liver disease, high dose of IV amiodarone, and hypotension from ventricular arrhythmias were observed in patients with AILI among case reports. 4 , 18 , 19 …”

“…However, the available data regarding acute hepatotoxicity form intravenous (IV) amiodarone are not far beyond case reports. 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 The mechanisms of liver injury with IV amiodarone are controversial. Ischemic injury due to compromised hemodynamic conditions may have a role.…”

“…Underlying liver injury from heart failure, high dose of IV amiodarone, hypotension from ventricular arrhythmias (VAs), and postoperative therapy following coronary artery bypass grafting (CABG) were observed in case reports. 4 , 8 , 18 , 19 Up to our knowledge, there are no prospective clinical studies that addressed the predictors of AILI.…”

Acute Hepatotoxicity of Intravenous Amiodarone

“…Finally, 8 cases were collected (Table 2). 8,[10][11][12][13][14] According to the currently available documentation, hepatotoxicity usually occurs within 24 hours after starting IV amiodarone administration, but sometimes after more than 3 days. 8 It usually recovers gradually after discontinuing IV amiodarone.…”