Establishing Standards of Care for Amiodarone Monitoring In an Outpatient Setting

Abstract

Introduction: Amiodarone is a life-saving medication that is becoming more frequently utilized, but the rates of recommended monitoring for serious toxicities continue to be lacking. By implementing a quality improvement project that allows for education and interdisciplinary collaboration among pharmacists, cardiologists and primary care providers, we expect improved rates of amiodarone monitoring.

Objectives: To assess rates of monitoring of liver, thyroid and pulmonary function in the six months before and after initiation of a quality improvement project and to evaluate the effect of a pharmacist-managed dual warfarin and amiodarone monitoring on maintaining target INR.

Study Design: Retrospective electronic chart review

Methods: We evaluated rates of monitoring according to an established Veterans Affairs (VA) protocol. Patients who filled a prescription for amiodarone and warfarin or direct oral anticoagulants (DOACs), apixaban, rivaroxaban, dabigatran between May 1, 2014 to April 30, 2015 were reviewed. Percent time spent in target INR (% TTR) was used as an outcome parameter to evaluate effect on maintaining target INR.

Results: Seventy-three subjects were in the pre-intervention group and sixty-nine patients were in the post-intervention group. Rates of six week monitoring were noted to be low (6-19%). All rates of six month monitoring, except CXR, increased in the post-intervention group as compared to the pre-intervention group.  Both the rates of monitoring of ALT (p = 0.034) and free T4 (p = <0.001) were found to be significantly higher in the post-intervention group, as compared to the pre-intervention group. The % TTR was 64% in pre-intervention group and 58% in post-intervention group.

Conclusions: Collaboration with pharmacists in an outpatient setting leads to improved rates on monitoring on recommended laboratory tests. This study allowed us to remove unnecessary laboratory testing and imaging within our facility and demonstrate the effectiveness of an established anticoagulation clinic in maintaining target INR.