Monitoring Requirements Consultant responsibility GP responsibility Every. 6 months • Assess compliance, ask patient about adverse effects (breathlessness, non-productive cough) and review possible interactions • TFTs (and for up to 12 months after discontinuation), U&Es, LFTs Annually • History & examination, Heart rate & ECG Other monitoring if applicable • Digoxin level- assess serum digoxin levels if dose increased or toxicity is suspected • INR- more frequent monitoring of INR both during and after amiodarone treatment (initially weekly for first 7 weeks) • Chest X-ray or CT scan if clinically indicated (suspected pulmonary toxicity) • Eye exam- Assess if new or worsening visual symptoms occur. • Check for drug interactions if new agents added to patient’s usual prescription Baseline *Loading History & examination ♦ adverse effects ♦ ♦ Heart rate & 12 lead ECG ♦ ♦ TFTs ♦ U&Es ♦ LFTs ♦ ♦ Digoxin level (if applicable) ♦ ♦ INR (if applicable) ♦ ♦ CXR ♦ PFTs inc DLCO ♦ Actions to be taken Parameter Action Symptoms of pulmonary toxicity (new/worsened cough or shortness of breath) Perform prompt ECG and CXR to exclude alternative diagnoses. If pulmonary toxicity remains a possibility, contact cardiologist/specialist or a respiratory physician urgently for confirmation of diagnosis and consideration of alternative anti-arrhythmics. Acute admission may be required. Early investigation with HRCT chest scan is important. ECG If there are signs of the following discuss with the oncall cardiology specialist: • QTc interval ≥ 500 milliseconds • QRS duration>120 milliseconds • prolonged PR interval (>240 milliseconds) if previously normal • Morbitz Type II or complete heart block GPs can also contact cardiologist for advice on • Interpretation of ECG • Consideration for stopping treatment e.g. if patient develop permanent AF/ ventricular tachycardia. Thyroid function tests (see appendix 1) An increase of up to 40% above the baseline T4 is a normal effect of amiodarone. This occurs approximately 2 months after initiation and does not require discontinuation if there is no clinical or further biological evidence (TSH) of thyroid disease. If TFTs are borderline repeat test in 6 weeks. In the event of thyrotoxosis seek the urgent advice of an endocrinologist. Liver function tests (See appendix 2) Normal results - continue treatment and reassess in 6 months If ALT increase within three times the normal range and patient is not jaundiced, continue amiodarone and repeat LFTs in 2 weeks. If still raised, refer to initiating hospital specialist urgently. If ALT increase exceeds three times the normal range or jaundiced- Stop amiodarone & refer to initiating specialist urgently. U&E’s / potassium In cases of hypokalaemia, corrective action should be taken and QT interval monitored. (SPC) Visual disturbances or loss of sight (new onset/ worsening) Perform eye examination, make urgent ophthalmology referral to exclude optic neuropathy and discuss alternative anti-arrhythmics with initiating cardiologist/ specialist Proarrhythmia Stop amiodarone and arrange urgent specialist appointment. Acute admission may be required. Bradycardia (HR <50bpm or symptoms present) Check for symptoms and arrange an ECG urgently If the patient has syncope or second or third degree heart block, admission is advised. Mild sinus bradycardia is common but if the patient has symptoms such as increased breathlessness or presyncope which you feel may be due to this- discuss with the specialist or arrange review. Neurological symptoms (e.g. tremor, ataxia) A reduced dosage may be required Blue skin discolouration A reduced dosage may be required
Appears in 2 contracts
Sources: Shared Care Agreement, Shared Care Agreement
Monitoring Requirements Consultant responsibility GP responsibility Every. 6 months • Assess compliance, ask patient about adverse effects (breathlessness, non-productive cough) and review possible interactions • TFTs (and for up to 12 months after discontinuation), U&Es, LFTs Annually • History & examination, Heart rate & ECG Other monitoring if applicable • Digoxin level- assess serum digoxin levels if dose increased or toxicity is suspected • INR- more frequent monitoring of INR both during and after amiodarone treatment (initially weekly for first 7 weeks) • Chest X-ray or CT scan if clinically indicated (suspected pulmonary toxicity) • Eye exam- Assess if new or worsening visual symptoms occur. • Check for drug interactions if new agents added to patient’s usual prescription Baseline *Loading History & examination ♦ adverse effects ♦ ♦ Heart rate & 12 lead ECG ♦ ♦ TFTs ♦ U&Es ♦ LFTs ♦ ♦ Digoxin level (if applicable) ♦ ♦ INR (if applicable) ♦ ♦ CXR ♦ PFTs inc DLCO ♦ Actions to be taken Parameter Action Symptoms of pulmonary toxicity (new/worsened cough or shortness of breath) Perform prompt ECG and CXR to exclude alternative diagnoses. If pulmonary toxicity remains a possibility, contact cardiologist/specialist or a respiratory physician urgently for confirmation of diagnosis and consideration Baseline *Loading History & examination adverse effects Heart rate & 12 lead ECG TFTs U&Es LFTs Digoxin level (if applicable) INR (if applicable) CXR PFTs inc DLCO cough or shortness of breath) of alternative anti-arrhythmics. Acute admission may be required. Early investigation with HRCT chest scan is important. ECG If there are signs of the following discuss with the oncall cardiology specialist: • QTc interval ≥ 500 milliseconds • QRS duration>120 milliseconds • prolonged PR interval (>240 milliseconds) if previously normal • Morbitz Type II or complete heart block GPs can also contact cardiologist for advice on • Interpretation of ECG • Consideration for stopping treatment e.g. if patient develop permanent AF/ ventricular tachycardia. Thyroid function tests (see appendix 1) An increase of up to 40% above the baseline T4 is a normal effect of amiodarone. This occurs approximately 2 months after initiation and does not require discontinuation if there is no clinical or further biological evidence (TSH) of thyroid disease. If TFTs are borderline repeat test in 6 weeks. In the event of thyrotoxosis seek the urgent advice of an endocrinologist. Liver function tests (See appendix 2) Normal results - continue treatment and reassess in 6 months If ALT increase within three times the normal range and patient is not jaundiced, continue amiodarone and repeat LFTs in 2 weeks. If still raised, refer to initiating hospital specialist urgently. If ALT increase exceeds three times the normal range or jaundiced- Stop amiodarone & refer to initiating specialist urgently. U&E’s / potassium In cases of hypokalaemia, corrective action should be taken and QT interval monitored. (SPC) Visual disturbances or loss of sight (new onset/ worsening) Perform eye examination, make urgent ophthalmology referral to exclude optic neuropathy and discuss alternative anti-arrhythmics with initiating cardiologist/ cardiologist/specialist Proarrhythmia Stop amiodarone and arrange urgent specialist appointment. Acute admission may be required. Bradycardia (HR <50bpm or symptoms present) Check for symptoms and arrange an ECG urgently If the patient has syncope or second or third degree heart block, admission is advised. Mild sinus bradycardia is common but if the patient has symptoms such as increased breathlessness or presyncope which you feel may be due to this- discuss with the specialist or arrange review. Neurological symptoms (e.g. tremor, ataxia) A reduced dosage may be required Blue skin discolouration A reduced dosage may be required
Appears in 1 contract
Sources: Shared Care Agreement