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Medications and doses for ventricular rate control in adult patients with atrial fibrillation

Medications and doses for ventricular rate control in adult patients with atrial fibrillation
Medication IV dosing Oral dosing* Notes
Diltiazem Bolus dosing:
  • First bolus: 0.25 mg/kg (average adult dose: 20 mg) administered over 2 minutes; if dose is tolerated but does not produce desired response (ie, 20% reduction in baseline heart rate or heart rate ≤100 beats/min) within 15 minutes, administer a second bolus.
  • Second bolus: 0.35 mg/kg (average adult dose: 25 mg) administered over 2 minutes.

In those who respond to the first or second bolus, initiate a continuous infusion at 5 to 10 mg/hour. May increase in 5 mg/hour increments as needed to a maximum of 15 mg/hour.

IR: 30 mg 4 times daily; increase as needed to achieve ventricular rate control; usual dose: 120 to 480 mg/day in 3 or 4 divided doses.

ER: 120 mg once daily or in 2 divided doses depending on formulation; increase as needed to achieve ventricular rate control; usual dose: 120 to 480 mg/day.
  • IV regimen usually controls the ventricular rate within 4 to 5 minutes.
  • Some experts use a lower bolus dose of 5 to 15 mg if there is concern for hypotension.
Esmolol Rapid titration with bolus doses:
  • 500 mcg/kg loading dose administered over 1 minute, followed by a continuous infusion of 50 mcg/kg/minute. Reassess after 4 minutes.
  • If response is inadequate, administer a second bolus of 500 mcg/kg and increase infusion to 100 mcg/kg/minute. Reassess after 4 minutes.
  • If response is inadequate, administer a third and final bolus of 500 mcg/kg and increase infusion to 150 mcg/kg/minute. Reassess after 4 minutes.
  • If response is inadequate, may increase infusion to a maximum of 300 mcg/kg/minute.

or

Slow titration without bolus doses:
  • Initiate continuous infusion at 50 mcg/kg/minute; if needed based on clinical response, may increase in 50 mcg/kg/minute increments at 30-minute intervals to a maximum of 300 mcg/kg/minute.
 Not available as oral preparation.
  • Due to short half-life, useful when uncertain if patient will become hypotensive with a beta blocker.
Verapamil

Bolus dosing: 5 to 10 mg administered over 2 to 3 minutes; may repeat every 15 to 30 minutes as needed and tolerated.

Once rate control is achieved with bolus doses, initiate a continuous infusion at 5 mg/hour; titrate based on clinical response to a maximum of 20 mg/hour.

IR: 40 mg 3 to 4 times daily; increase as needed to achieve ventricular rate control; maximum dose: 480 mg/day in 3 to 4 divided doses.

ERΔ: 120 or 180 mg once daily; increase as needed to achieve ventricular rate control; maximum dose: 480 mg/day in 1 to 2 divided doses.
  • Rate control is often achieved with 1 or 2 bolus doses.
  • With IV administration, onset of effect on AV node is within 2 minutes and peak effect is in 10 to 15 minutes.
  • Control of the ventricular response is lost in approximately 90 minutes if repeated boluses or a maintenance infusion are not given.
Metoprolol

Bolus dosing: 2.5 to 5 mg administered over 2 minutes; may repeat at 5-minute intervals up to a total dose of 15 mg.

While subsequent doses can be given intravenously, the optimal regimen is not well defined, and oral administration is preferable.

IR (metoprolol tartrate): 25 mg twice daily; increase dose gradually (eg, by 12.5 mg every 6 hours) as needed and tolerated to achieve ventricular rate control; maximum dose: 100 mg twice daily.

ER (metoprolol succinate): 50 mg once daily; increase dose gradually as tolerated to achieve ventricular rate control; maximum dose: 400 mg once daily.		  
Propranolol Bolus dosing: 1 mg administered over 1 minute; may repeat at 2-minute intervals for up to 3 doses.

IR: 10 mg 3 to 4 times daily; increase dose gradually as tolerated to achieve ventricular rate control; maximum dose: 40 mg 3 to 4 times daily.

ER: 60 mg once daily; increase as needed to achieve ventricular rate control up to 160 mg once daily.		  
Digoxin◊ TDD: 0.25 to 0.5 mg administered over several minutes, followed by 0.25 mg every 6 hours for a total loading dose of 0.75 to 1.5 mg.

TDD: 0.5 mg once, followed by 0.25 mg every 6 hours for a total loading dose of 0.75 to 1.5 mg.

Maintenance dose (for use after administration of IV or oral TDD): 0.125 to 0.25 mg once daily.
  • May use as add-on therapy in patients who do not adequately respond to a calcium channel blocker and/or beta blocker; not generally used as monotherapy.
Amiodarone§ Loading dose: 150 mg over ≥10 minutes followed by 1 mg/minute for 6 hours, then 0.5 mg/minute for 18 hours; may administer repeat boluses of 150 mg over ≥10 minutes as needed, not to exceed 6 to 8 additional bolus doses per 24 hours.

Following IV infusion, administer 400 to 1200 mg/day in divided doses to complete a total (IV plus oral) loading dose of approximately 10 grams. Consider overlapping IV and oral therapy for 24 to 48 hours.

Usual maintenance dose: 100 to 200 mg once daily.
  • May use in select patients requiring urgent therapy who are intolerant of other preferred agents (ie, calcium channel blockers, beta blockers, digoxin).
  • Due to small chance of cardioversion, careful attention to anticoagulation is necessary.
This table shows doses of drugs that can be used for ventricular rate control in adult patients with atrial fibrillation who do not have heart failure. It should be used in conjunction with UpToDate content on control of ventricular rate in patients with atrial fibrillation. When initiating or altering therapy, use of a drug interactions database, such as the drug interactions program, is advised.

AV: atrioventricular; ER: extended-release; IR: immediate-release; IV: intravenous; TDD: total digitalizing dose.

* Oral dosing in this table is initial dosing for patients requiring nonurgent therapy, unless otherwise noted. For patients transitioning from IV to oral therapy, UpToDate authors typically convert the total daily dose of the IV medication to an equivalent divided or long-acting oral dose of a medication in the same class. Refer to UpToDate topic on control of ventricular rate in patients with atrial fibrillation for discussion.

¶ Diltiazem extended-release is available in 12- and 24-hour formulations. Refer to a drug information reference, such as the drug interactions program or local product information, for dosing details.

Δ Verapamil ER delayed-onset capsules (ie, Verelan PM and generics) are not interchangeable with other ER formulations and are intended for management of hypertension.

◊ Digoxin has a narrow therapeutic window and can cause significant toxicity. Individual patient characteristics (eg, kidney function, body habitus, concomitant medications) should be carefully considered when determining loading and maintenance dosing regimens. Dosing in this table does not account for dose adjustments. For discussion of dosing and monitoring, refer to UpToDate content on treatment with digoxin.

§ Amiodarone use is associated with a relatively high incidence of adverse effects. Refer to related UpToDate content for discussion, including monitoring.
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