Amiodarone

JM Marraffa, Upstate Medical University, Syracuse, NY, USA

Ó 2014 Elsevier Inc. All rights reserved.
This article is a revision of the previous edition article by Elizabeth J. Scharman, volume 1, pp 98–99, Ó 2005, Elsevier Inc.

l Name: Amiodarone arrhythmias. It is one of the most commonly used and

l Chemical Abstracts Service Registry Numbers: 1951-25-3; prescribed antiarrhythmic drugs. Amiodarone is indicated in
19774-82-4 (hydrochloride) life-threatening, recurrent, ventricular tachycardia or fibrilla-
l Synonyms: Amiodarone hydrochloride; CordaroneÒ; tion when other interventions, such as epinephrine, have
NexteroneÒ; (2-(4-[2-Butyl-1-benzofuran-3-yl)carbonyl]- failed. It is also used in the management of supraventricular
2,6-diiodopheoxy)ethyl)diethylamine tachyarrhythmias, including atrial fibrillation, atrial flutter, and
l Chemical/Pharmaceutical/Other Class: Class III antiar- paroxysmal reentrant supraventricular tachycardia. Amiodar-
rhythmic agent, an iodinated benzofuran derivative one serves a prominent place in advanced cardiac life support
antiarrhythmic algorithms for numerous unstable rhythms. For unstable
l Molecular Formula: C25H29I2NO3 rhythms, amiodarone is used in the parenteral (intravenous)
l Chemical Structure: form. Oral amiodarone is used for chronic therapy once
a patient is stabilized.
O
CH3
Environmental Fate and Behavior
O
Exposure Routes and Pathways
Accidental and intentional overdoses of amiodarone are not
prevalent, and only a few cases are reported in the literature. If
overdose does occur, however, ingestion is the most common
route of exposure. Amiodarone is available in oral form as well
I I as for parenteral administration, and toxicity can occur by
either route.
O

Physicochemical Properties
Appearance of amiodarone is as a crystalline powder or in
H3C N
solution; it is a clear to pale-yellow micellar solution. Its pH is
3–4 for a 5% aqueous solution.
H3C Its molar mass is 645.311 6 g.

Human Exposure
Amiodarone and its metabolites are distributed into milk in
Background concentrations much higher than maternal plasma concentra-
tions. Data indicate that amiodarone and the major metabolite
Amiodarone was synthesized by chemists working with N-desethylamiodarone milk-to-plasma ratios range from 2.3 to
the plant extract of Khella (Ammi visnaga), which is a common 9.1 and from 0.8 to 3.8, respectively.
plant in North Africa. Scientists had noted that extracts of this
plant called khellin were effective in attenuating angina in
individuals taking it for other reasons and attempted to extract Toxicokinetics
an active component from the plant. Amiodarone was ulti-
mately synthesized in 1961 by Belgian chemists working on Following oral administration, amiodarone is slowly and var-
preparations derived from khellin. Amiodarone gained wide- iably absorbed from the gastrointestinal tract. The oral
spread use in Europe by 1980 and was approved in the United bioavailability varies greatly, with a range of 22–86% (average
States by the Food and Drug Administration in 1985 for the of 50%). The reason for the variable bioavailability is not
treatment of arrhythmias. known but postulated to be due to metabolism of drug in the
gut lumen, first-pass metabolism in the liver, and poor disso-
lution characteristics of the drug. If amiodarone is ingested
Uses with foods, in particular those high in fat content, the rate and
extent of absorption are increased.
Amiodarone has a major place in the management of The peak plasma concentration of amiodarone occurs
both acute and chronic ventricular and supraventricular within 3–7 h (range: 2–12 h) after oral administration. The

Encyclopedia of Toxicology, Volume 1 http://dx.doi.org/10.1016/B978-0-12-386454-3.00691-6 197

198 Amiodarone

onset of action, however, is delayed for 2–3 days and up to mechanisms, including a cytotoxic effect on pneumocytes; an
1–3 weeks post drug initiation. Although not clearly estab- immune mediated mechanism in genetically predisposed
lished, the maximal antiarrhythmic effect occurs within patients; and possibly an effect on the angiotensin enzyme
1–5 months after initiation of oral therapy. The antiarrhythmic system. This results in a disruption of lysosomal membranes by
effect generally persists for 10–150 days after withdrawal of amiodarone and a release of toxic oxygen radicals leading to
therapy. apoptosis of lung epithelial cells.
Amiodarone is extensively metabolized to an active
metabolite, N-desethylamiodarone. The apparent volume of
distribution is 65.8l kg 1 (range: 18.3–147.7 l kg 1). After Acute and Short-Term Toxicity
chronic administration, amiodarone and its metabolite are Animal
extensively distributed to adipose tissue and many other
organs, including the liver, lung, spleen, and skeletal muscle. The oral LD50 dose of amiodarone hydrochloride is
Amiodarone is extensively bound to plasma proteins, mainly >3000 mg kg 1 in rats and dogs. The intravenous LD50 dose of
albumin. The drug and its metabolite cross the placenta and are amiodarone hydrochloride is 170 mg kg 1 in rats and
distributed into breast milk. 5000 mg kg 1 in dogs.
The metabolism of amiodarone is not fully elucidated but
appears to be at least biphasic. After a single i.v. dose of Human
amiodarone, the terminal elimination half-life is on average,
There is no published/established oral toxic dose of amiodar-
25 days (range: 9–47 days). The elimination half-life of
one. The determination of toxicity is based on observation and
N-desethylamiodarone is equal to or longer than the parent
clinical effects. Symptoms include nausea; vomiting; brady-
drug. The half-life appears to be much more prolonged
cardia; hypotension; heart block; QT prolongation with torsade
following multiple doses rather single doses. After chronic
de Pointes being a rare effect; and tremor and ataxia.
oral administration, the drug appears to be eliminated in
a biphasic manner with an initial elimination half-life of
about 2.5–10 days, which is followed by a terminal elimina- Chronic Toxicity (or Exposure)
tion half-life averaging 53 days (range: 26–107 days).
The exact metabolism of amiodarone has not been fully Animal
described, but the drug appears to be extensively metabolized Chronic studies in rats demonstrate an increase in carcinoge-
in the liver by N-deethylation to N-desethylamiodarone. The nicity risk for thyroid tumors. The effects are dose related and
excretion of amiodarone and its metabolite is not fully have been described at doses as low as 5 mg kg 1. Daily doses
described, though it appears that it is nearly completely of 90 mg kg 1 in pregnant rats showed reduced fertility. Daily
excreted in the feces as unchanged drug and N-desethylamio- doses in rabbits of 25 mg kg 1 showed no change in fertility or
darone presumably via biliary elimination. effects on the fetus. However, higher daily doses of 75 mg kg 1
Amiodarone and its major metabolite are not amenable to resulted in an increased rate of spontaneous abortion in these
hemodialysis for drug removal. rabbits.

Human
Mechanism of Action
Acute administration of amiodarone is generally well-tolerated
Amiodarone displays electrophysiologic characteristics of all by patients; however, chronic administration can result in
four classes within the Vaughan-Williams classification scheme. severe and devastating adverse effects. The exact mechanisms of
It is a sodium channel blocker with relatively fast on–off these adverse effects remain postulated and not clearly eluci-
kinetics; it has nonselective beta-adrenergic antagonist activity, dated. Severe bradycardia has been reported to occur. Hypo-
blocks potassium channels, and has a small degree of calcium and hyperthyroid have been reported with an unclear
channel antagonist activity. Its most prominent activity is mechanism of toxicity.
potassium channel blockade and, therefore, is classified as Pulmonary toxicity has been reported to occur in up to 5%
a Class III antiarrhythmic agent. It delays repolarization via of treated patients. The development of lung toxicity appears to
prolongation of the action potential duration and effective be associated with older age, duration of treatment, cumulative
refractory period; decreases AV conduction; depresses sinus dose, high levels of the metabolite, history of cardiothoracic
node and junctional automaticity; acts as a noncompetitive surgery, use of iodinated contract media, and probably preex-
alpha- and beta-receptor inhibitor; and slows automaticity of isting lung disease. The devastating pulmonary toxicity may
Purkinje fibers. Despite its popularity and frequency of use, develop as early as the first few days of treatment to several
amiodarone is a complex drug and displays unusual pharma- years later. The onset of this toxicity can be either insidious or
cologic effects and pharmacokinetics. Even more peculiar is the rapidly progressive. Pulmonary fibrosis has resulted in death.
multisystem organ adverse events attributed to amiodarone. Other side effects include elevated liver function tests;
The exact mechanisms of these adverse events remain unclear. uncommonly fulminant hepatitis; fatigue; tremor; dizziness;
Fatal complications of amiodarone include acute respiratory ataxia; corneal micro deposits (which usually do not affect
distress syndrome (ARDS), pulmonary fibrosis, cirrhosis, and vision); optic neuropathy/neuritis, which can lead to blindness;
bradycardia leading to cardiac arrest. Amiodarone pulmonary blue-gray skin discoloration, especially in areas exposed to the
toxicity is probably related to a combination of different sun; and skin necrosis, which rarely has occurred.
 Amiodarone 199

Immunotoxicity function tests, thyroid function tests, eye exams, chest radio-
graphs, and pulmonary function tests. In patients demon-
Reproductive Toxicity
strating adverse effects, a risk versus benefit assessment should
Amiodarone hydrochloride had reproductive effects in rats be performed to determine whether amiodarone therapy
when given at a dosage of 90 mg kg 1 day 1 to male and should be continued. In patients that develop pulmonary
female rats at 9 weeks prior to mating. In rabbits, at doses of 5, toxicity, discontinuation of therapy should be strongly
10, and 25 mg kg 1 day 1 maternal deaths occurred in all considered. In patients with severe pulmonary toxicity and
groups. Embryotoxicity occurred at doses of 10 mg kg 1 and ARDS, discontinuation of therapy is necessary and consider-
above. No teratogenicity occurred at any doses. In rats, amio- ation of corticosteroids should be employed.
darone has been found to be teratogenic at doses of
100 mg kg 1 day 1 given intravenously.
Amiodarone is pregnancy category D. Amiodarone and its Exposure Standards and Guidelines
major metabolite desethylamiodarone are distributed into
maternal plasma, cord plasma, infant plasma, placental tissue, The exposure limits for amiodarone hydrochloride include an
and breast milk. There have been case reports of neonatal 8 h time-weighted average of 70 mg m–3 (Hospira EEL).
hypothyroidism in infants whose mothers were taking amio-
darone during pregnancy.
See also: Iodine.
Genotoxicity
Amiodarone HCl has not been shown to be mutagenic in
Ames, micronucleus, and lysogenic induction tests. Further Reading

Carcinogenicity Bogazzi, F., Tomisti, L., Bartalena, L., Aghini-Lombardi, F., Martino, E., 2012.
Amiodarone and the thyroid: a 2012 update. J. Endocrinol. Invest. 35 (3),
Thyroid tumors have occurred after oral administration in rats, 340–348.
including follicular adenoma and carcinoma. The incidence of Erdogan, H.I., Gul, E.E., Gok, H., Nikus, K.C., 2012. Therapy-resistant ventricular
tachycardia caused by amiodarone-induced thyrotoxicosis: a case report of elec-
thyroid tumors in rats was higher than the incidence in controls trical storm. Am. J. Emerg. Med. 30 (9), 2092.e5–2092.e7.
with doses as low as 5 mg kg 1 day 1. Martin, C.M., 2012. Thyroid dysfunction and the elderly patient: a primer for phar-
macists. Consult. Pharm. 27 (10), 682–688.
Papiris, S.A., Triantafillidou, C., Kolilekas, L., Markoulaki, D., Manali, E.D., 2010.
Amiodarone: review of pulmonary effects and toxicity. Drug Saf. 33 (7),
Clinical Management
539–568.
Van Cott, T.E., Yehle, K.S., Decrane, S.K., Thorlton, J.R., 2013. Amiodarone-induced
In patients with intentional overdose of amiodarone, treatment pulmonary toxicity: case study with syndrome analysis. Heart Lung 42 (4),
is mainly supportive. Amiodarone is adsorbed to activated 262–266.
charcoal and it should be considered in patients with large,
intentional ingestions. There is little experience in managing
patients with intentional overdoses of amiodarone because this Relevant Websites
is not commonly reported. In such cases, treatment is largely
http://www.aafp.org/afp/2003/1201/p2189.html – Amiodarone: Guidelines for Use
based on symptoms. Vasopressors should be considered for
and Monitoring.
blood pressure support. Atropine should be considered if http://heartdisease.about.com/od/drugsforheartdisease/a/amiodarone_lung.htm –
symptomatic bradycardia occurs. Hemodialysis to remove Amiodarone Lung Toxicity.
amiodarone has little benefit. http://heartdisease.about.com/library/weekly/mcurrent.htm – Detailed History of
Patients with toxicity secondary to therapeutic, chronic use Amiodarone in Particular the Development and FDA Approval in 1985.
http://emedicine.medscape.com/article/129033-overview – Thyroid Dysfunction
of amiodarone should be managed supportively as well. Induced by Amiodarone Therapy an eMedicine (Medscape) Reference Article.
Patients on chronic amiodarone therapy should be routinely http://www.uptodate.com/contents/amiodarone-pulmonary-toxicity – UpToDate Article
followed and have continued monitoring, including liver on Amiodarone Pulmonary Toxicity.
 International Journal of Cardiology 221 (2016) 780–788

Contents lists available at ScienceDirect

International Journal of Cardiology

journal homepage: www.elsevier.com/locate/ijcard

Review

Amiodarone and cardiac arrest: Systematic review and meta-analysis

Ageliki Laina a,b, George Karlis c,d, Aris Liakos e, Georgios Georgiopoulos f, Dimitrios Oikonomou b,
Evangelia Kouskouni a, Athanasios Chalkias a,d,⁎, Theodoros Xanthos d,g
a
National and Kapodistrian University of Athens, Medical School, M.Sc. “Cardiopulmonary Resuscitation, Athens, Greece
b
A. Fleming General Hospital, Department of Internal Medicine, Athens, Greece
c
National and Kapodistrian University of Athens, Medical School, Evaggelismos Hospital, 1st Department of Intensive Care Medicine, Athens, Greece
d
Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
e
Aristotle University of Thessaloniki, Hippokratio General Hospital, Clinical Research and Evidence-Based Medicine Unit, Thessaloniki, Greece
f
National and Kapodistrian University of Athens, Medical School, Department of Clinical Therapeutics, Vascular Laboratory, Athens, Greece
g
European University Cyprus, School of Medicine, Nicosia, Cyprus

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The 2015 Guidelines for Resuscitation recommend amiodarone as the antiarrhythmic drug of choice
Received 21 May 2016 in the treatment of resistant ventricular fibrillation or pulseless ventricular tachycardia. We reviewed the effects
Accepted 8 July 2016 of amiodarone on survival and neurological outcome after cardiac arrest.
Available online 9 July 2016 Methods: We systematically searched MEDLINE and Cochrane Library from 1940 to March 2016 without
language restrictions. Randomized control trials (RCTs) and observational studies were selected.
Keywords:
Results: Our search initially identified 1663 studies, 1458 from MEDLINE and 205 from Cochrane Library. Of them,
Cardiac arrest
Cardiopulmonary resuscitation
4 randomized controlled studies and 6 observational studies met the inclusion criteria and were selected for
Amiodarone further review. Three randomized studies were included in the meta-analysis. Amiodarone significantly
Systematic review improves survival to hospital admission (OR = 1.402, 95% CI: 1.068–1.840, Z = 2.43, P = 0.015), but neither
Meta-analysis survival to hospital discharge (RR = 0.850, 95% CI: 0.631–1.144, Z = 1.07, P = 0.284) nor neurological outcome
compared to placebo or nifekalant (OR = 1.114, 95% CI: 0.923–1.345, Z = 1.12, P = 0.475).
Conclusions: Amiodarone significantly improves survival to hospital admission. However there is no benefit of
amiodarone in survival to discharge or neurological outcomes compared to placebo or other antiarrhythmics.
© 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction line drug for refractory VF/VT [12,13]. It has a complex mechanism
of action with mechanistic properties that include action at a- and
In Europe, the incidence of sudden cardiac arrest (SCA) is estimated b-adrenergic receptors, as well as on potassium, sodium and calcium
0.4–1 per 1000 inhabitants per year, thus involving between 350,000 channels. It markedly prolongs action potential and repolarization
and 700,000 people [1–3]. In North America, the annual incidence of while decreasing atrioventricular (AV) conduction and sinus node
out-of-hospital cardiac arrest (OHCA) is 50–55 per 100,000 people function [14].
and that of in-hospital cardiac arrest (IHCA) ranges from 3 to 6 per Amiodarone's effectiveness in refractory VF/VT was established by
1000 admissions [4]. Out-of-hospital cardiac arrest is the third leading two randomized double-blind studies, the ARREST and ALIVE trials,
cause of death in the USA. Unfortunately, resuscitation attempts are with both of these concluding that amiodarone had significantly higher
unsuccessful in most cases, while less than 10% of cardiac arrest victims rates of survival to admission to hospital [15,16]. Amiodarone also ap-
survive to hospital discharge [5,6]. pears to improve the response to defibrillation when given to humans
Although early defibrillation is highly effective for terminating or animals with VF/VT. However, there is no evidence regarding the
ventricular fibrillation/pulseless ventricular tachycardia (VF/VT), it optimal time at which amiodarone should be given when using a
cannot prevent recurrences of VT/VF and antiarrhythmic drugs are single-shock strategy. In all clinical studies until now, amiodarone was
commonly used [7–11]. Amiodarone is a Vaughan Williams class III given if VF/VT persisted after at least three shocks and in the absence
antiarrhythmic drug which is currently recommended as the first- of any other data, amiodarone is currently recommended at an initial
dose of 300 mg followed by intravenous infusion.
Despite the advances in resuscitation drug research, there are limit-
⁎ Corresponding author at: National and Kapodistrian University of Athens, Medical
School, M.Sc. “Cardiopulmonary Resuscitation”, 3 Ir. Politechniou Av., 18532 Piraeus,
ed data regarding the beneficial effects of amiodarone as far as hospital
Greece. to discharge and neurological outcome are concerned in both OHCA and
E-mail address: [email protected] (A. Chalkias). IHCA. This lack of evidence is reflected in the 2015 guidelines which

http://dx.doi.org/10.1016/j.ijcard.2016.07.138
0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
 A. Laina et al. / International Journal of Cardiology 221 (2016) 780–788 781

state that during cardiac arrest uninterrupted, high-quality chest com- studies. The rest of the studies as observational ones were assessed with high risk of bias as
they lack randomization, allocation concealment and blinding [24–29].
pressions and early defibrillation for VF/VT are of primary importance,
while drug administration is of secondary importance [12,13]. The aim
2.4. Statistical analysis
of this systematic review and meta-analysis is to assess the available
evidence regarding the effects of amiodarone on survival and neurolog- The risk estimates of each study were treated as ORs. In order to provide a more
ical outcome after cardiac arrest. meaningful effect size, we compared amiodarone vs. all other alternative treatments
(i.e. nifekalant or lidocaine or placebo). Neurological outcomes were grouped into
two categories of good recovery and severe disability and measured as ORs with
2. Methods
95% CIs as well adapted for meta-analysis.
We performed a meta-analysis of studies investigating the effect of administering
2.1. Eligibility criteria and search strategy
amiodarone in terms of cardiac arrest to obtain the pooled estimate separately for:
1) ROSC, 2) survival to hospital admission, 3) 24 h survival, 4) survival to hospital
We identified eligible studies by searching MEDLINE via PUBMED and the Cochrane
discharge, and 5) neurological outcome. Heterogeneity was tested by using the I2 statisti-
Library from 1940 to March 2016 without language restrictions (MEDLINE and Cochrane
cal method (I2 b 20% low, 20% b I2 b 60% moderate, and I2 N 60% high) [30]. Moderate to
search terms in Appendices A and B, respectively). As no human subjects or medical
significant heterogeneity (P b 0.1) existed among studies and a random effects model
records were reviewed in this study, institutional review board approval was not required.
was subsequently implemented using the DerSimonian & Laird method with the estimate
Our search strategy included relevant substance names, Medical Subject Heading and
of heterogeneity being taken from the inverse-variance. To test whether the true effect in
Entree terms. Keywords used included “cardiac arrest”, “heart arrest”, “sudden death”,
all studies is the same (i.e. heterogeneity), we used the I-squared measure I2 that permits
“cardiopulmonary resuscitation”, “cardio-pulmonary resuscitation”, “CPR”, “ventricular
quantification of discrepancy among studies. We conducted a between-study subgroup
fibrillation”, “pulseless ventricular tachycardia”, “pulseless electrical activity”, “death,
analysis to evaluate whether the estimates of the effect of amiodarone on study main
sudden”, “heart arrest, induced”, “amiodarone”, “cordarone”, “pacerone”, “nexterone”
endpoints differ within certain populations (OHCA vs. IHCA, short vs. long duration CPR,
and “angoron”. In addition, we searched the following databases for unpublished or
initial shockable rhythm, short duration (b10 min) vs. long (N10 min) duration of ALS,
ongoing studies: http://www.controlled-trials.com and http://wwwclinicaltrials.gov. We
early (b24 min) vs. delayed (N24 min administration of amiodarone after cardiac arrest)).
also searched the reference lists of eligible articles and relevant reviews [17–19].
A gender subgroup analysis was not feasible since all but one study [25] reported that the
percentage of males among subjects with cardiac arrest exceeded 65%. Differences in
2.2. Study selection pooled effect sizes between subgroups were compared with a test of interaction
(Cochran's Q test). The mean effect size and confidence intervals (CIs) of individual studies
Two independent reviewers (AL and AL) screened all potentially relevant titles and were illustrated with forest plots. To estimate the contribution of continuous study
abstracts for eligibility. The remaining articles underwent full-text review; again, studies moderators to the overall heterogeneity, random-effects meta-regression was performed.
that that did not fit inclusion criteria were excluded. We identified studies according to The presence of publication bias was investigated graphically by funnel plots of preci-
the following criteria: randomized control designed or observational; children or adult sion and statistically by regression tests for asymmetry. The Egger test as well as the Begg
human studies with either OHCA or IHCA; and the included studies should have been & Mazumdar test were implemented and performed a linear regression of the interven-
conducted according to the international resuscitation guidelines. In addition, the includ- tion effect estimates on their standard errors weighting by 1/(variance of the intervention
ed studies should have reported one of the following outcomes: return of spontaneous effect estimate).
circulation (ROSC); short-term survival: survival to hospital intensive care unit admission Statistical analysis was performed with STATA package, version 11.1 (StataCorp,
for out-of-hospital patients and 24 h survival for in-hospital patients; survival to hospital College Station, Texas, USA). The module “metan” was used for meta-analysis. We deemed
discharge; and neurologic outcome at hospital discharge. Neurological outcome was statistical significance at P b 0.05.
assessed using the Glasgow Outcome Scale (GOS) which classifies physical functioning
capacity into 5 stages: grade 5 — good recovery (returns to normal life), grade 4 —
moderate disability (independent), grade 3 — severe disability (depends on care), 3. Results
grade 2 — vegetative stage, and grade 1 — death [20].
The authors completed the literature search and selected by consensus the studies Our search in literature initially identified 1663 studies, 1458 from
based on inclusion criteria as judged by title, abstract, and complete manuscript. Intrarater
MEDLINE and 205 from Cochrane Library. Of them, 4 randomized con-
reliability was measured with a 10% sample of citations, resulting in a kappa of 0.91. Each
article with conflicting opinion from the two initial reviewers was discussed with another trolled studies and 6 observational studies met the inclusion criteria
reviewer (DO) for a final resolution. The selected studies compared amiodarone to placebo and were selected for further review (Fig. 1).
or other antiarrhythmic drugs (lidocaine and nifekalant).
We included four randomized controlled trials that compared amiodarone to placebo,
lidocaine or nifekalant in adults with OHCA and shock-resistant VF. We also included 3.1. Study characteristics
retrospective observational studies comparing amiodarone either with placebo or other
antiarrhythmic drugs (lidocaine and nifekalant). Publications retrieved from electronic Table 2 presents the characteristics of the included studies. Seven
databases were imported into reference management software (EndNoteX6, Thomson studies reported interventions after adult OHCA, while 3 studies report
Reuters, New York, USA).
interventions after adult IHCA. Only one study included children as
participants. Three categories were identified: amiodarone vs. placebo,
2.3. Data extraction and quality assessment
amiodarone vs. lidocaine, and amiodarone vs. nifekalant and were
Data extraction was performed independently by two reviewers (AL and AL). For grouped as amiodarone vs. alternative treatment in order to derive
each eligible trial we extracted data on study characteristics, participants' baseline more reliably the effect size of amiodarone towards cardiac arrest in
characteristics, and outcomes regarding ROSC, short-term survival, survival to discharge the current meta-analysis.
and neurological function. Missing data were requested via e-mails to corresponding
The meta-analysis included 10 studies and a total of 5326 patients
authors.
For each eligible study, we recorded odds ratios (ORs) and hazard ratios (HRs) (2162 subjects received amiodarone, 1422 received placebo, 1666
and corresponding 95% confidence intervals as indexes of the effect size of amiodarone. received lidocaine, and 76 received nifekalant) (Table 2). Studies that
Numeric data for effect size or the ratio of the number of patients that experienced the were incorporated in the meta-analysis were published since 1999.
endpoint among cases and controls were used from the selected articles. Corresponding sample sizes ranged from 25 to 3026 individuals. For
Two reviewers independently assessed risk of bias of each study using the Cochrane
individuals that were treated with amiodarone, median age was
Collaboration risk-of-bias tool (Table 1) [21]. We assessed each trial across the following
quality domains: a) random-sequence generation; b) allocation concealment; c) blinding; 64.7 years and 75.8% of the population was male, while 78.4% of the
d) incomplete outcome data; and e) selective outcome reporting or other potential threats patients in the amiodarone arm and 73.9% in the alternative treatment
to validity. Disagreements were discussed with another reviewer (DO) and resolved by arm presented previous history of cardiac disease.
consensus.
In the randomized trials conducted by Kudenchuk et al. in 1999 and 2016 complete
randomization and adequate blinding were performed and the rescuers were blinded as 3.2. Return of spontaneous circulation
well throughout the trials, so low risk of bias was considered across the studies [16,22].
In the study of Dorian et al. although sequence generation was not reported in the text, Seven out of 10 studies reported ROSC. Administration of amioda-
randomization was used and allocation concealment as well as blinding were considered
to be adequately performed [15]. As a result, low risk of bias was considered. In the study
rone tended to decrease the odds for ROSC by 22% (OR = 0.780, 95%
by Amino et al. unclear risk of allocation bias was considered [23]. Also, performance and CI: 0.574–1.059, Z = 1.59, P = 0.112) (Fig. 2A). Moderate to signifi-
detection bias was considered as well regarding the high risk of selection in observational cant heterogeneity was observed across the studies (I2 = 51.4%,
782 A. Laina et al. / International Journal of Cardiology 221 (2016) 780–788

Fig. 1. Flow chart.

P = 0.054) and pooled effects were derived under random-effects Z = 0.03, P = 0.977) [22,23]. Sensitivity analysis for ROSC as well as
models meta-analysis. for the other endpoints (i.e. survival to hospital admission, 24 h survival,
Only two randomized studies (Amino et al. in 2010 and Kudenchuk survival to hospital discharge and neurological outcome) on the basis of
et al. in 2016) reported the effect size of amiodarone for ROSC and the age was not performed since all studies reported trivial differences
pooled effect was not significant (OR = 1.006, 95% CI: 0.658–1.539, (around a mean of 65 years) in this variable. On the other hand, we
 A. Laina et al. / International Journal of Cardiology 221 (2016) 780–788 783

Table 1
Risk-of-bias in the included studies.

Study Random-sequence generation Allocation concealment Blinding Incomplete Free of selective Assessment
(reference) outcome data reporting/other of risk of bias
addressed? bias across study

Kudenchuck et al. [16] Complete randomization was Lack of details reported Adequate Yes Yes Low risk of bias
used according to the text
Dorian et al. [15] Complete randomization was Adequately performed Adequate Yes Yes Low risk of bias
used according to the text
Amino et al. [23] Randomized controlled design, Unclear risk of allocation Blinding was performed, Yes Yes Unclear risk
lack of detailed information bias was considered lack of details of bias
Kudenchuck et al. [22] Complete randomization was Adequate Yes
used according to the text
Rea et al. [26] High risk of allocation bias according to the retrospective design No blinding was performed Yes Yes High risk of bias
Skrifvars et al. [24] High risk of allocation bias according to the retrospective design No blinding was performed Yes Yes High risk of bias
Pollak et al. [29] High risk of allocation bias according to the retrospective design No blinding was performed Yes Yes High risk of bias
Valdes et al. [27] High risk of allocation bias according to the retrospective design No blinding was performed Yes Yes High risk of bias
Harayama et al. [28] High risk of allocation bias according to the retrospective design No blinding was performed Yes Yes High risk of bias
Amino et al. [23] High risk of allocation bias according to the retrospective design No blinding was performed Yes Yes High risk of bias

performed a sensitivity analysis by excluding studies with less than 150 (P = 0.769 and P = 0.716, respectively). Finally, amiodarone was not
patients in total and the pooled (n = 4 studies) OR for amiodarone associated with survival to hospital admission in both subgroups of
treatment did not substantially indicate a significant decrease of ROSC ALS duration (short or long) (P N 0.05 for all).
rates (RR = 0.784; 95% CI: 0.563–1.092, Z = 1.44, P = 0.150).
Taking into account the moderate to significant observed heteroge- 3.4. Survival at 24 h
neity (I2 = 51.4%) between the included studies, we conducted
between-study subgroup analyses on the basis of criteria with potential Only 3 out of 10 studies reported survival at 24 h post-ROSC. Admin-
clinical interest and biological plausibility. When pooled estimates were istration of amiodarone was not associated with improved survival
derived independently for IHCA and OHCA subjects, amiodarone at 24 h post-ROSC (OR = 0.797, 95% CI: 0.402–1.582, Z = 0.65, P =
administration significantly decreased the odds for ROSC only for IHCA 0.517) (Fig. 2C). Significant heterogeneity was observed across the
(OR = 0.434, 95% CI: 0.278–0.676, Z = 3.44, P b 0.001). However, studies (I2 = 76.8%, P = 0.013). Due to the limited number of studies
this pooled effect was derived only from two studies with a total of available for this endpoint, no further sensitivity and subgroup analyses
207 subjects receiving amiodarone. In contrast, amiodarone administra- were performed.
tion was not associated with ROSC in OHCA individuals (n = 5 studies)
(OR = 0.949, 95% CI: 0.823–1.094, Z = 0.72, P = 0.469). A relevant 3.5. Survival to hospital discharge
test for interaction was significant (P = 0.001) (Fig. 3A). Under the
same prism, amiodarone was not associated with ROSC (P N 0.05 for Nine out of 10 studies reported survival to hospital discharge. Ad-
all) in CPR subgroups (short vs. long duration), initial shockable rhythm, ministration of amiodarone was not associated with survival to hospital
duration of ALS, and time of drug administration (P for interaction discharge (RR = 0.850, 95% CI: 0.631–1.144, Z = 1.07, P = 0.284)
test N 0.1 for all). (Fig. 2D). Moderate heterogeneity was observed across the studies
(I2 = 45.9%, P = 0.064).
3.3. Survival to hospital admission When the meta-analysis was restrained to randomized studies
(n = 4), amiodarone tended to improve survival to hospital dis-
Six out of 10 studies reported survival to hospital admission. Admin- charge (OR = 1.139; 95% CI: 0.963–1.347, Z = 1.52, P = 0.129). In
istration of amiodarone was associated with improved survival to hos- contrast, a relevant sensitivity analysis for studies with more than
pital admission after cardiac arrest (OR = 1.402, 95% CI: 1.068–1.840, 150 patients in total (n = 6) indicated that amiodarone deteriorated –
Z = 2.43, P = 0.015) (Fig. 2B). Moderate to significant heterogeneity albeit not significantly – survival to hospital discharge (OR = 0.889;
was observed across the studies (I2 = 57.8%, P = 0.036). 95% CI: 0.661–1.196, Z = 0.22, P = 0.824).
When we restrained our meta-analysis on randomized studies When pooled estimates were calculated for IHCA and OHCA sub-
(n = 4), amiodarone treatment significantly improved survival to jects, amiodarone administration was not associated with survival
hospital admission (RR = 1.575; 95% CI: 1.379–1.798, Z = 6.71, to hospital discharge after OHCA (OR = 1.021, 95% CI: 0.756–1.379,
P b 0.001). Along this line, a relevant sensitivity analysis for studies Z = 0.14, P = 0.891), while it significantly decreased survival rates
with more than 150 patients in total (n = 5) indicated that amiodarone after IHCA (OR = 0.612, 95% CI: 0.411–0.912, Z = 2.41, P = 0.016).
was associated with survival rates to hospital admission (OR = 1.379; A relevant test for interaction was significant (P = 0.01). In contrast,
95% CI: 1.036–1.837, Z = 2.2, P = 0.028). amiodarone was not associated with survival to hospital discharge
All studies that reported effect estimates of amiodarone on hospital (P N 0.05 for all) in CPR subgroups, initial shockable rhythm, duration
admission recruited as expected only patients with OHCA. Therefore, of ALS, and time of drug administration (early vs. late) (P for interaction
no subgroup analysis was performed for this outcome on the basis of test N 0.1 for all).
IHCA and OHCA. In contrast, amiodarone administration was associated
with improved survival selectively in individuals who received CPR 3.6. Neurological outcome
of short duration (OR = 1.655, 95% CI: 1.062–2.578, Z = 2.23, P =
0.026) or early intravenous drug administration (OR = 1.676, 95% CI: Administration of amiodarone was not associated with improved
1.203–2.336, Z = 3.05, P = 0.002) or had a shockable rhythm (OR = neurological outcome (OR = 1.114, 95% CI: 0.923–1.345, Z = 1.12,
1.676, 95% CI: 1.203–2.336, Z = 3.05, P = 0.002). A relevant test for P = 0.475) (Fig. 2E), while no heterogeneity was observed across
interaction was significant only for subgroup analysis of early vs. the studies (I2 = 0%, P = 0.496). Due to the limited number of studies
delayed administration of amiodarone (P = 0.019), while a difference available for this endpoint, no further sensitivity and subgroup analyses
was not established for CPR or rhythm (shockable or non-shockable) were performed.
 784
Table 2
Characteristics of the included studies.

Study Study design Setting and sample size Study population Intervention Control Reported outcomes

Kudenchuk Randomized Conducted in Seattle and suburban King County, Adults with non-traumatic OHCA were 300 mg of amiodarone The diluent, Survival to hospital; survival to hospital
et al. [16] double-blind, Washington by EMS; CPR protocols in accordance with eligible if VF or Pulseless VT was present after diluted with dextrose polysorbate 80, as discharge; adverse events; neurologic
placebo AHA guidelines for ACLS in 1982; 504 participants three or more precordial shocks intravenously (Cordarone, placebo function
controlled Wyeth-Ayerst Laboratories,
study Philadelphia)
Dorian et al. Randomized The study was conducted under the auspices of the Adults with non-traumatic out-of-hospital VF Amiodarone (5 mg/kg of Lidocaine (1.5 mg/kg Survival to hospital; survival to hospital
[15] double-blind Toronto EMS system, a multitiered out-of-hospital resistant to three shocks, at least one dose of estimated body weight at a concentration of discharge; adverse events
study emergency-response system; treatment protocols IV epinephrine, and a fourth defibrillator diluted with dextrose) 10 mg/ml)
were in accordance with AHA guidelines for ACLS in shock or with recurrent VF after successful (Cordarone, Wyeth-Ayerst (Sanofi-Synthelabo,
2000; 347 participants were enrolled initial defibrillation Laboratories, Philadelphia) Paris)

A. Laina et al. / International Journal of Cardiology 221 (2016) 780–788

Skrifvars Retrospective Conducted by Helsinki EMS systems; CPR was Adult OHCA patients with VF/Pulseless VT A bolus of 300 mg No amiodarone was ROSC; survival to hospital admission;
et al. [24] designed performed according to 2000 guidelines; 180 patients resistant to three shocks amiodarone without dilution administered survival to hospital discharge
study were enrolled after three ineffective shocks,
an additional 150 mg dose
might be administered
Pollak et al. Retrospective Undertaken by specifically tutored medical trainees at In-hospital cardiac arrest patients with Amiodarone Lidocaine ROSC; survival to hospital discharge
[29] observational two tertiary care centers. Resuscitation efforts VF/Pulseless VT
cohort study performed by ACLS-certified physicians. 95 patients
enrolled
Rea et al. Retrospective Undertaken in three academic medical centers in the Adult in-hospital cardiac arrest secondary to Amiodarone Lidocaine/amiodarone Survival at 24 h; survival to hospital
[26] observational US. Caregivers are ACLS certified and each institution VF/Pulseless VT patients plus lidocaine discharge
study follows ACLS guidelines published by AHA. 194
patients enrolled
Amino et al. Randomized Conducted by EMS of Tokai University between August Adult OHCA patients with first defibrillation Amiodarone (initial dose 125 Nifekalant ROSC; survival to hospital admission;
[23] controlled 2007 and April 2009. The CPR protocol was modified failure or VF recurrence were included mg repeated up to three times discharge survival rate ; neurological
study from the 2005 guidelines of AHA. 30 patients were if defibrillation failed) function
enrolled in the study.
Harayama Retrospective 283 OHCA were transported from December 2005 to OHCA patients with shock-resistant VF Amiodarone Nifekalant ROSC; survival to hospital discharge;
et al. [28] observational January 2011 to a Japanese hospital by ambulance, CPR treated with tracheal intubation and IV mean time from the initiation of the
study was performed according to the 2005 International epinephrine (1 mg every 3–5 min) before drug administration to ROSC; number of
Consensus on CPR, with a protocol of one shock antiarrhythmic drug administration DC shocks after drug administration;
followed by 2 min of chest compressions; 25 patients neurological outcome
were enrolled
Valdes et al. Retrospective 242 hospitals provided data for at least 6 months Patients younger than 18 years of age with Amiodarone Lidocaine, ROSC; 24 h survival; survival to hospital
[27] cohort during study period from January 2000 to February in-hospital cardiac arrest due to pulseless VT amiodarone and discharge
designed 2008 to Get With the Guidelines-Resuscitation or VF lidocaine
study database; 889 patients were included
Amino et al. Retrospective “SOS-KANTO study”: conducted in the Kanto area by Adult OHCA with shock-resistant VT/VF 125 mg amiodarone over 10 Nifekalant, lidocaine ROSC; survival to hospital admission; 24
[25] observational the Kanto Regional Society of Japanese Association for (requiring more than two shocks) min, 150 mg amiodarone IV h survival
study Acute Medicine; 500 patients were enrolled bolus, 300 mg amiodarone IV
bolus
Kudenchuk Randomized The study (ALPS) was performed by EMS at 10 North Patients ≥18 years old with non-traumatic Amiodarone Lidocaine, placebo ROSC; survival to hospital admission;
et al. [22] double blind American sites participating in the Resuscitation Out- OHCA with documented persistent or survival to hospital discharge;
study comes Consortium (ROC). Patients with OHCA were recurrent VF/VT after 1 ≥ shock neurologic function
treated in accordance with AHA guidelines for ad-
vanced life support; 3026 participants
 A. Laina et al. / International Journal of Cardiology 221 (2016) 780–788 785

Fig. 2. Odds ratio (OR) and 95% CI for main endpoints: (A) ROSC; (B) survival to hospital admission; (C) 24 h survival; (D) survival to hospital discharge; and (E) good neurological
outcome. Studies are listed by date of publication. Boxes represent the OR and lines represent the 95% CI for individual studies. The diamonds and their width represent the pooled
ORs and the 95% CI, respectively. ROSC indicates recovery of spontaneous circulation and CI indicates confidence intervals.

3.7. Meta-regression 3.8. Publication bias

Gender was not a predictor of the magnitude of the OR for all main The funnel plot for the association between amiodarone admin-
outcomes in our study (P N 0.1 for all). The percentage of patients istration and hospital discharge was asymmetrical at its left middle
with history of cardiac disease, duration of BLS and ALS, time to intuba- portion (Fig. 5) either because of publication bias or because of a
tion, amiodarone administration, and total number of shocks were not true inexistence of negative studies (absence of publication bias).
associated with the predictive value of amiodarone for ROSC or survival However, regression tests for funnel plot asymmetry did not indi-
outcomes (P N 0.1 for all). In contrast, age tended to predict the magni- cate significant small-study effects (Egger's test: P = 0.244 and
tude of the log OR for survival to hospital admission (P = 0.080) in Begg&Mazdumar test: P = 0.917) that could affect our results in a
6 studies, indicating a positive association (Fig. 4). meaningful way.
786 A. Laina et al. / International Journal of Cardiology 221 (2016) 780–788

Fig. 3. Odds ratio (OR) and 95% CI after amiodarone administration according to setting of cardiac arrest (IHCA vs. OHCA) for: (A) ROSC and (B) survival to hospital discharge. Boxes
represent the ORs and lines represent the 95% CI for individual studies. The diamonds and their width represent the pooled ORs and the 95% CI, respectively. ROSC indicates recovery
of spontaneous circulation and CI indicates confidence intervals.

4. Discussion no other randomized double blind large study was conducted until
only recently when Kudenchuck et al. [22] compared amiodarone to
This systematic review and meta-analysis showed that administra- placebo or lidocaine in a population of 3026 patients and reported
tion of amiodarone significantly increases survival to hospital admis- that neither amiodarone nor lidocaine resulted in a significantly higher
sion. However, amiodarone did not result in a significantly higher rate rate of survival or favorable neurologic outcome than the rate with pla-
of survival to hospital discharge or favorable neurological outcome at cebo among patients with OHCA due to initial shock-refractory VF/VT.
discharge when compared with placebo or other antiarrhythmic drugs. Our results regarding ROSC rates do not comply with the aforemen-
Amiodarone was established as the antiarrhythmic drug of choice tioned effect of amiodarone on short-term survival; in our study, we re-
for shock refractory VF/VT in cardiac arrest when two previous random- port that amiodarone decreases the odds for ROSC. Two randomized
ized trials in 1999 [16] and 2002 [15] showed significantly higher rates studies which concluded that amiodarone is superior to placebo or lido-
of ROSC and hospital admission in cardiac arrest patients treated with caine in survival to hospital admission did not report ROSC as outcome
amiodarone than those treated with placebo or lidocaine. Since then [15,16]. When pooled estimates were derived independently for IHCA
 A. Laina et al. / International Journal of Cardiology 221 (2016) 780–788 787

study reported no difference in the number of shocks after nifekalant

or amiodarone administration needed to terminate shock-resistant
VF [28]. Regarding neurologic outcome, both Amino et al. [23] and
Harayama et al. [28] reported a slight dominance in favor of nifekalant.
As a pure potassium channel blocker, nifekalant might have the po-
tential to be used during CPR as it does not exert the hemodynamic
effects of amiodarone while decreasing the defibrillation threshold.
Nevertheless, large randomized double blind trials are needed in order
to examine the potential benefits of this agent in cardiac arrest [31].

5. Conclusion

Amiodarone significantly improves survival to hospital admission.

However, amiodarone does not improve survival to discharge or neuro-
logical outcomes compared to placebo or other antiarrhythmics.

Fig. 4. Odds ratio (OR) of survival to hospital admission with regard to age (n = 6). Each Funding sources
study is represented by a circle showing the actual coordinates (observed effect size) for
that study. The size of each circle is proportional to the weight of the respective study in None.
the analysis i.e. the inverse of the within-study variance for each study. The center line
shows the predicted values by fixed-effects meta-regression. The vertical axis is on a log
scale. Disclosures

None.
and OHCA subjects, amiodarone administration significantly decreased
the odds for ROSC only for the IHCA victims. Indeed, in the pediatric Conflict of interest
study by Valdes et al., lidocaine independently improved ROSC and
24 h survival [27], while similar results were derived from the study The authors report no relationships that could be construed as a
of Pollak et al. [29]. Of note, in both studies, only a small amount of conflict of interest.
patients finally received amiodarone as an antiarrhythmic drug despite
the existing recommendations. Acknowledgments
Regarding the 24 h survival, amiodarone was found to have no ben-
efit when compared to placebo or other antiarrhythmics. However, only Nothing to acknowledge.
3 out of 10 studies included this outcome and due to significant hetero-
geneity across the studies we did not proceed to further analysis. Also, Appendix A. MEDLINE search terms
we found that amiodarone associates to neither survival to hospital dis-
charge nor good neurological outcome. Interestingly, when the meta- #19, “Search ((((((amiodarone) OR cordarone) OR nexterone)
analysis was restrained to randomized studies, amiodarone tended OR angoron) OR pacerone)) AND (((((((((((““cardiac arrest””) OR
to improve survival to hospital discharge. Furthermore, when we calcu- ““heart arrest””) OR ““sudden death””) OR ““CPR””) OR ““cardiopul-
lated pooled results for IHCA and OHCA subjects, amiodarone adminis- monary resuscitation””) OR ““cardio-pulmonary resuscitation””)
tration was not associated with survival to hospital discharge after OR ““ventricular fibrillation””) OR ““pulseless ventricular tachycardia””)
OHCA, but significantly decreased survival rates of IHCA patients. OR ““pulseless electrical activity””) OR ““death, sudden””) OR ““heart
It is worth mentioning that a small randomized trial by Amino et al. arrest, induced””)”,1450
reported that amiodarone may be slightly superior than nifekalant in #18, “Search ((((((((((““cardiac arrest””) OR ““heart arrest””) OR
improving defibrillation success, but without significant differences in ““sudden death””) OR ““CPR””) OR ““cardiopulmonary resuscitation””)
survival and neurological outcomes [23]. However, a retrospective OR ““cardio-pulmonary resuscitation””) OR ““ventricular fibrillation””)
OR ““pulseless ventricular tachycardia””) OR ““pulseless electrical
activity””) OR ““death, sudden””) OR ““heart arrest, induced”””,98906

Appendix B. Cochrane Library queries

#17, “Search ““heart arrest, induced”””,6790

#16, “Search ““death, sudden”””,22842
#15, “Search ““pulseless electrical activity”””,565
#14, “Search ““pulseless ventricular tachycardia”””,220
#13, “Search ““ventricular fibrillation”””,22872
#12, “Search ““cardio-pulmonary resuscitation”””,248
#11, “Search ““cardiopulmonary resuscitation”””,16886
#10, “Search ““CPR”””,8775
#9, “Search ““sudden death”””,33309
#8, “Search ““heart arrest”””,30507
#7, “Search ““cardiac arrest”””,23698
#6, “Search ((((amiodarone) OR cordarone) OR nexterone) OR
angoron) OR pacerone”,9513
Fig. 5. Publication bias for survival to hospital discharge. Circles represent individual
#5, “Search angoron”,2
studies of the meta-analysis and the vertical line the pooled estimate of the OR for #4, “Search nexterone”,1
survival to hospital discharge. #3, “Search pacerone”,4
788 A. Laina et al. / International Journal of Cardiology 221 (2016) 780–788

#2, “Search cordarone”,9511 [9] M. Holmberg, S. Holmberg, J. Herlitz, Factors modifying the effect of bystander
cardiopulmonary resuscitation on survival in out-of-hospital cardiac arrest patients
#1, “Search amiodarone”,9481 in Sweden, Eur. Heart J. 22 (2001) 511–519.
#1: amiodarone: ti,ab,kw (Word variations have been searched) [10] R.A. Waalewijn, J.G. Tijssen, R.W. Koster, Bystander initiated actions in out-of-
1075 hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation
Study (ARRESUST), Resuscitation 50 (2001) 273–279.
#2: pacerone: ti,ab,kw (Word variations have been searched) 0 [11] T. Iwami, G. Nichol, A. Hiraide, et al., Continuous improvements in “chain of survival”
#3: cordarone:ti,ab,kw (Word variations have been searched) 8 increased survival after out-of-hospital cardiac arrests: a large-scale population-
#4: nexterone:ti,ab,kw (Word variations have been searched) 0 based study, Circulation 119 (2009) 728–734.
[12] J. Soar, J.P. Nolan, B.W. Böttiger, et al., European Resuscitation Council guidelines for
#5: angoron:ti,ab,kw (Word variations have been searched) 0 resuscitation 2015: section 3. Adult advanced life support, Resuscitation 95 (2015)
#6: #1 or #2 or #3 or #4 or #5 1077 100–147.
#7: “cardiac arrest”:ti,ab,kw (Word variations have been searched) [13] M.S. Link, L.C. Berkow, P.J. Kudenchuk, et al., Part 7: adult advanced cardiovascular
life support: 2015 American Heart Association guidelines update for cardiopulmo-
1440
nary resuscitation and emergency cardiovascular care, Circulation 132 (2015)
#8: “heart arrest”:ti,ab,kw (Word variations have been searched) S444–S464.
1684 [14] P.T. Pollak, Oral amiodarone: historical overview and development, Pharmacotherapy
#9: “sudden death”:ti,ab,kw (Word variations have been searched) 18 (1998) 121S–126S.
[15] P. Dorian, D. Cass, B. Schwartz, R. Cooper, R. Gelaznikas, A. Barr, Amiodarone as
848 compared with lidocaine for shock-resistant ventricular fibrillation, N. Engl. J.
#10: “CPR”:ti,ab,kw (Word variations have been searched) 852 Med. 346 (2002) 884–890.
#11: “cardiopulmonary resuscitation”:ti,ab,kw (Word variations [16] P.J. Kudenchuk, L.A. Cobb, M.K. Copass, et al., Amiodarone for resuscitation after out-
of-hospital cardiac arrest due to ventricular fibrillation, N. Engl. J. Med. 341 (1999)
have been searched) 1022 871–878.
#12: “cardio-pulmonary resuscitation”:ti,ab,kw (Word variations [17] Y. Huang, Q. He, M. Yang, L. Zhan, Antiarrhythmia drugs for cardiac arrest: a systemic
have been searched) 16 review and meta-analysis, Crit. Care 17 (2013) R173.
[18] T. Boyd, W. Brady, The “Code Drugs in Cardiac Arrest”—the use of cardioactive med-
#13: “ventricular fibrillation”:ti,ab,kw (Word variations have been ications in cardiac arrest resuscitation, Am. J. Emerg. Med. 30 (2012) 811–818.
searched) 1008 [19] M.E. Ong, T. Pellis, M.S. Link, The use of antiarrhythmic drugs for adult cardiac arrest:
#14: “pulseless ventricular fibrillation”:ti,ab,kw (Word variations a systematic review, Resuscitation 82 (2011) 665–670.
[20] J. Horn, T. Cronberg, F.S. Taccone, Prognostication after cardiac arrest, Curr. Opin.
have been searched) 1 Crit. Care 20 (2014) 280–286.
#15: “pulseless electrical activity”:ti,ab,kw (Word variations have [21] J.P. Higgins, D.G. Altman, P.C. Gøtzsche, et al., Cochrane Bias Methods Group,
been searched) 36 Cochrane Statistical Methods Group, The Cochrane Collaboration's tool for assessing
risk of bias in randomised trials, BMJ 343 (2011) d5928.
#16: “heart arrest, induced”:ti,ab,kw (Word variations have been
[22] P.J. Kudenchuk, S.P. Brown, M. Daya, et al., R.O.C. Investigators, Amiodarone, lido-
searched) 448 caine, or placebo in out-of-hospital cardiac arrest, N. Engl. J. Med. 374 (2016)
#17: #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or 1711–1722.
#16 or #17 4396 [23] M. Amino, K. Yoshioka, T. Opthof, et al., Comparative study of nifekalant versus
amiodarone for shock-resistant ventricular fibrillation in out-of-hospital cardiopul-
#18: #6 and #17 161 monary arrest patients, J. Cardiovasc. Pharmacol. 55 (2010) 391–398.
[24] M.B. Skrifvars, M. Kuisma, J. Boyd, et al., The use of undiluted amiodarone in the
References management of out-of-hospital cardiac arrest, Acta Anaesthesiol. Scand. 48 (2004)
582–587.
[1] J. Berdowski, R.A. Berg, J.G. Tijssen, R.W. Koster, Global incidences of out-of-hospital [25] M. Amino, S. Inokuchi, K. Nagao, et al., SOS-KANTO 2012 Study Group, Nifekalant
cardiac arrest and survival rates: systematic review of 67 prospective studies, Resus- hydrochloride and amiodarone hydrochloride result in similar improvements for
citation 81 (2010) 1479–1487. 24-hour survival in cardiopulmonary arrest patients: the SOS-KANTO 2012 study,
[2] J.T. Grasner, J. Herlitz, R.W. Koster, F. Rosell-Ortiz, L. Stamatakis, L. Bossaert, Quality J. Cardiovasc. Pharmacol. 66 (2015) 600–609.
management in resuscitation—towards a European cardiac arrest registry (EuReCa), [26] R.S. Rea, S.L. Kane-Gill, M.I. Rudis, et al., Comparing intravenous amiodarone or
Resuscitation 82 (2011) 989–994. lidocaine, or both, outcomes for inpatients with pulseless ventricular arrhythmias,
[3] J.T. Grasner, L. Bossaert, Epidemiology and management of cardiac arrest: what Crit. Care Med. 34 (2006) 1617–1623.
registries are revealing, Best Pract. Res. Clin. Anaesthesiol. 27 (2013) 293–306. [27] S.O. Valdes, A.J. Donoghue, D.B. Hoyme, et al., American Heart Association Get
[4] A.S. Go, D. Mozaffarian, V.L. Roger, et al., American Heart Association Statistics Com- With The Guidelines-Resuscitation Investigators, Outcomes associated with
mittee and Stroke Statistics Subcommittee, Heart disease and stroke statistics—2014 amiodarone and lidocaine in the treatment of in-hospital pediatric cardiac arrest
update: a report from the American Heart Association, Circulation 129 (2014) with pulseless ventricular tachycardia or ventricular fibrillation, Resuscitation 85
e28–e292. (2014) 381–386.
[5] G.D. Perkins, A.S. Lockey, M.A. de Belder, F. Moore, P. Weissberg, H. Gray, National [28] N. Harayama, S. Nihei, K. Nagata, et al., Comparison of nifekalant and amiodarone for
initiatives to improve outcomes from out-of-hospital cardiac arrest in England, resuscitation of out-of-hospital cardiopulmonary arrest resulting from shock-
Emerg Med J. 33 (2016 Jul) 448–451. resistant ventricular fibrillation, J. Anesth. 28 (2014) 587–592.
[6] M.E. Kleinman, E.E. Brennan, Z.D. Goldberger, et al., Part 5: adult basic life support [29] P.T. Pollak, V. Wee, A. Al-Hazmi, J. Martin, K.B. Zarnke, The use of amiodarone for
and cardiopulmonary resuscitation quality: 2015 American Heart Association in-hospital cardiac arrest at two tertiary care centres, Can. J. Cardiol. 22 (2006)
guidelines update for cardiopulmonary resuscitation and emergency cardiovascular 199–202.
care, Circulation 132 (2015) S414–S435. [30] G.H. Guyatt, A.D. Oxman, R. Kunz, et al., GRADE Working Group, GRADE guidelines:
[7] C. Sasson, M.A. Rogers, J. Dahl, A.L. Kellermann, Predictors of survival from out-of- 7. Rating the quality of evidence—inconsistency, J. Clin. Epidemiol. 64 (2011)
hospital cardiac arrest: a systematic review and meta-analysis, Circ. Cardiovasc. 1294–1302.
Qual. Outcomes 3 (2010) 63–81. [31] I.N. Pantazopoulos, G.T. Troupis, C.N. Pantazopoulos, T.T. Xanthos, Nifekalant in the
[8] M. Wissenberg, F.K. Lippert, F. Folke, et al., Association of national initiatives to treatment of life-threatening ventricular tachyarrhythmias, World J. Cardiol. 3
improve cardiac arrest management with rates of bystander intervention and (2011) 169–176.
patient survival after out-of-hospital cardiac arrest, JAMA 310 (2013) 1377–1384.
Transplantation
Presented at the Academic Surgical Congress 2016

To use or not to use? Amiodarone

before heart transplantation
Entela B. Lushaj, MD, PhD,a Ravi Dhingra, MD,b Shahzad Chindhy, MD,a Shahab Akhter, MD,a
Takushi Kohmoto, MD, PhD,a Susan Ulschmid, BS,a Satoru Osaki, MD, PhD,a Abbasali Badami, MD,a
and Lucian Lozonschi, MD,a Madison, WI

Background. Amiodarone frequently is used in patients with heart failure. Concerns still exist about
possible complications related to its lingering effect during and after heart transplantation.
Methods. We selected all consecutive patients who received a heart transplant at our institution between
January 2004 and December 2015 (n = 220) and compared the peri- and postoperative outcomes of
patients who were taking amiodarone for at least 120 days before heart transplant (n = 127) with
patients who did not take amiodarone prior to heart transplant (n = 93).
Results. Compared with patients with no amiodarone use prior to transplant, those who had used
amiodarone were similar in age, body mass index, sex, cause of cardiomyopathy, prevalence of diabetes,
hypertension, presence of defibrillator, and had similar donor ischemic times during transplant (all
P > .05). Median operative time, aortic cross clamp time, mechanical ventilation and median hospital
duration of stay did not differ between the 2 groups (P > .05). Patients exposed to amiodarone had fewer
cellular rejections (5% vs 20%; P = .001) but more primary graft dysfunction (4% vs 0%; P = .025)
and post-transplant pneumonia (P = .047) compared with patients not taking amiodarone prior to
transplant. Both groups had similar rate of atrial fibrillation, 30-day readmission, and 30-day mortality
(P > .05). Even though 1-year survival was not affected by amiodarone use (P = .51), long-term (5-year)
survival was significantly less in patients exposed to amiodarone (P = .03).
Conclusion. Amiodarone use did not affect the incidence of atrial fibrillation nor 30-day and 1-year
survival post-transplantation. Nevertheless, post-transplant pulmonary complications were significantly
greater and 5-year survival was less among patients treated with amiodarone prior to transplant.
(Surgery 2017;161:1273-8.)

From Cardiothoracic Surgerya and Cardiovascular Medicine,b University of Wisconsin School of Medicine
and Public Health, Madison, WI

CONGESTIVE HEART FAILURE remains a major source of

morbidity and mortality worldwide. Heart trans-
This study was supported by the University of Wisconsin,
Department of Surgery. plantation is the gold standard of care of patients
This study was presented as a quick shot presentation at the
with advanced heart failure considered to be suit-
11th Annual Academic Surgical Congress, Session: Basic able candidates. However, patients awaiting heart
Science + Outcomes/Clinical: Cardiothoracic on February 4, transplant (HTx) often have life-threatening atrial
2016. It was presented under the title: Does Preoperative and ventricular arrhythmias, for which antiar-
Amiodarone Exposure Impact Outcomes in Cardiac Transplant rhythmic drug therapy is needed. Amiodarone is
Recipients.
one of the most commonly prescribed antiar-
Accepted for publication September 24, 2016.
rhythmic medications in North America1 and one
Reprint requests: Lucian Lozonschi, MD, Division of Cardiotho-
of the preferred antiarrhythmic medications for
racic Surgery, University of Wisconsin School of Medicine and
Public Health, 600 Highland Avenue, Madison, WI 53792. patients with advanced heart failure. A nearly 6%
E-mail: [email protected]. increase in amiodarone prescription before HTx
0039-6060/$ - see front matter was observed from 2005–2013.2 Amiodarone is
Ó 2016 Elsevier Inc. All rights reserved. effective and it has been shown to maintain normal
http://dx.doi.org/10.1016/j.surg.2016.09.034 sinus rhythm in patients with atrial fibrillation and

SURGERY 1273
1274 Lushaj et al Surgery
May 2017

to decrease the rate of recurrence of ventricular Registry for Mechanically Assisted Circulatory Sup-
tachycardia.3,4 However, amiodarone has been port classification.23
found to be associated with a variety of adverse ef- Continuous variables are measured as
fects including, pulmonary toxicity,5-7 sinus brady- mean ± standard deviation and compared using
cardia, atrioventricular nodal block or ventricular the t test. When the distribution appeared to be
arrhythmias,8-10 and hepatotoxicity.11,12 Amiodar- skewed, we used median and interquartile ranges
one has a long half-life, ranging from 60 days in pa- and compared using the Mann-Whitney U-test. Cat-
tients receiving short-term therapy, up to 120 days egorical variables are reported as numbers and
in patients with long-term use of amiodarone, and percentages and compared using the v2 test.
a large volume of distribution.13-15 Given Kaplan-Meier survival curves were examined for
these adverse effects and conflicting published 1- and 5-year survival post-HTx and compared
data,16-21 concerns still remain regarding the effect using log-rank tests. Cox proportional hazard
of preoperative amiodarone use on heart trans- regression models were used to compare the risk
plant patients and their outcomes. The goal of of death in patients who were taking amiodarone
our study was to assess the effects of long-term prior with transplant with those who were not
use of amiodarone before HTx on perioperative taking amiodarone prior to transplant. All analyses
complications and patient survival. were performed using the IBM SPSS statistical
software program (IBM Corp, SPSS Statistics for
METHODS Windows, version 22.0, Armonk, NY).
We retrospectively reviewed institutional Society
of Thoracic Surgeons data of all consecutive RESULTS
patients (n = 220) who received HTx at our institu- Mean age of the patients at the time of trans-
tion from January 2004 to December 2015. This plant, body mass index, sex, cause of ischemia, and
study was approved by our Institutional Review comorbidities such as diabetes, hypertension, and
Board of the University of Wisconsin School of chronic obstructive pulmonary disease, did not
Medicine and Public Health. Patient demo- differ between the group who were on amiodarone
graphics, clinical risk factors, and peri- and postop- prior to transplant when compared with those who
erative characteristics were obtained prospectively were not on amiodarone (all P > .05; Table I).
and recorded in our database. Follow-up data Similar number of patients had implantable defi-
were collected retrospectively from each patient’s brillators (48% vs 44%; P = .55) and left ventricular
electronic medical record. This was censored by assist devices (69% vs 62%; P = .28) prior to trans-
patient death or the final follow-up date (April plantation (Table I). Operative variables at heart
2016). A waiver of the need to obtain consent transplant including donor ischemic time, total
from patients was approved. operative time, cardiopulmonary bypass time,
For the purpose of this study, patients were aortic cross clamp, and intubation time were not
divided into 2 groups: patients who were taking different between AMIO and non-AMIO group
amiodarone (AMIO group) 120 days before HTx (Table II). Similar number of patients had pro-
(n = 93) and patients who did not receive amiodar- longed (>24 hours) mechanical ventilation in
one (non-AMIO) 120 days before HTx (n = 127). the 2 groups (Table II).
Four patients from the non- AMIO group had Cellular rejection rates were significantly less in
taken AMIO well before 120 days prior to HTx. the patients exposed to amiodarone within
Five patients from the non-AMIO group received 120 days pre-heart transplant (5% vs 20%; P =
AMIO after HTx for a few days until discharge. .001). However, more patients had primary graft
The primary study outcomes were adverse postop- failure (4% vs 0%; P = .025) and pneumonia (8%
erative (30-day) events such as atrial fibrillation, vs 2%; P = .04; Table III) in the immediate postop-
rejection rate (determined by weekly biopsies), erative period, in the patients exposed to amiodar-
pulmonary complications, primary graft failure one before heart transplant. One patient in each
(as previously defined),22 cardiac arrest, renal fail- group had a temporary pacemaker placed, while
ure, and patient survival (30-day, 1- and 5-year). none of these patients was implanted with a perma-
Atrial fibrillation was assessed on a 3-lead electro- nent pacemaker. Similar number of patients devel-
cardiogram (ECG) used for monitoring during oped atrial fibrillation (6% vs 7%; P = .76). Both
each myocardial biopsy visit. A 12-lead ECG was ob- groups had similar rate of renal failure requiring
tained whenever atrial fibrillation was suspected. dialysis, cardiac arrest, need for prolonged ino-
All definitions for postoperative complications tropes, and intensive care unit and hospital dura-
and adverse events were based on Interagency tion of stay (all P > .05). Comparable number of
Surgery Lushaj et al 1275
Volume 161, Number 5

Table I. Patient characteristics

Amiodarone use before heart transplant
Yes (group 1) No (group 2)
Demographics (n = 93) (n = 127) P value
Mean age (y) 53 ± 10 55 ± 10 .14
Male 75 (81%) 105 (83%) .70
BMI (kg/m2) 27 ± 5 27 ± 5 .99
Ischemic cause 7 (8%) 9 (7%) .78
Diabetes 31 (33%) 43 (34%) .87
Hypertension 45 (48%) 69 (54%) .38
LVEF <45% 80 (86%) 105 (83%) .54
COPD 43 (46%) 50 (39%) .30
Implantable defibrillator 45 (48%) 56 (44%) .55
IABP 3 (3%) 6 (5%) .46
Previous LVAD 64 (69%) 79 (62%) .28
Donor ischemic time (min) 209 ± 60 209 ± 62 .91
Statistically significant associations (P < .05).
Values are n (%) or mean ± SD.
BMI, Body mass index; LVEF, left ventricular ejection fraction; COPD, chronic obstructive pulmonary disease; IABP, intra-aortic balloon pump; LVAD, left
ventricular assist device.

Table II. Operative variables

Amiodarone use before heart transplant
Yes (n = 93) No (n = 127) P value
Operative time, min 463 (381, 542) 456 (362, 549) .72
CPB time, min 201 (177, 233) 197 (171, 231) .43
Aortic cross clamp time, min 118 (100, 147) 120 (100, 139) .85
Intubation time, min 613 (438, 1,220) 715 (441, 1,150) .47
Prolonged ventilation, >24 h 20 (22%) 28 (22%) .99
Statistically significant associations (P < .05).
Values are n (%) or mean ± SD or median (interquartile range).
CPB, Cardio-pulmonary bypass; U, units.

patients had unplanned hospital readmissions with pretransplant (hazard ratio = 2.12; confidence in-
30-day postdischarge in each group (P = .36; Table terval, 1.05–4.27; P = .034; Fig, B). In the AMIO
III). group, the reasons for death beyond 1 year after
A total of 8 patients died within 30 days post- HTx included cardiovascular complications (car-
transplant. Of those 8 deaths, 4 patients were from diac arrest [n = 2], arrhythmias [n = 2]), pulmo-
the AMIO group and 4 patients were from the non- nary (n = 3; pneumonia, pulmonary
AMIO group (P = .99). Reasons for death included adenocarcinoma, respiratory failure), malignancy
primary graft failure (AMIO group n = 2; non- (n = 2), noncompliance (n = 1), and unknown
AMIO group n = 1), multiple organ failure (non- (n = 4). In the non-AMIO group reasons for death
AMIO group n = 1), respiratory failure (AMIO included cardiovascular complications (cardiac ar-
group n = 1), brain anoxia (AMIO group n = 1), rest, myocardial infarction [n = 2]), malignancy
and unknown (non-AMIO group n = 2). Patient (n = 4), unknown (n = 2), and gastrointestinal
survival at 1 year was not affected by use of amio- bleeding (n = 1).
darone (P = .51; Fig, A). However, 5-year survival
was significantly less in the amiodarone exposed DISCUSSION
group (P = .030; Fig, B). Patients taking amiodar- Life-threatening arrhythmias are the most
one prior to transplant had >2-fold greater risk common cause of sudden cardiac death and
of death within 5 years post-HTx compared with present a great risk for patients with end-stage
patients who did not use amiodarone heart failure, including patients undergoing
1276 Lushaj et al Surgery
May 2017

Table III. Outcomes

Amiodarone use before heart
transplant
Yes (n = 93) No (n = 127) P value
ICU LOS, h 99 (58, 144) 85 (54, 129) .32
Hospital LOS, d 10 (8, 13) 10 (8, 14) .69
Atrial fibrillation 6 (6%) 9 (7%) .76
Cellular rejection 5 (5%) 26 (20%) .001*
Prolonged 1 (1%) 1 (0.8%) .87
inotropes
Acute renal 30 (32%) 32 (26%) .33
failure
Pneumonia 7 (8%) 3 (2%) .047*
Cardiac arrest 2 (2%) 7 (6%) .15
Primary graft 4 (4%) 0 .025*
failure
30-d readmission 21 (23%) 23 (18%) .36
30-d mortality 4 (4%) 5 (4%) .99
*Statistically significant associations (P < .05).
ICU, Intensive care unit; LOS, length of stay; cellular rejection, acute
cellular rejection 1R-3R.

heart transplantation.24 Several groups have

been assessing the impact of preoperative amio-
darone exposure in heart transplant recipients,
but there are still no definitive answers on the
safety of this drug in this group of patients. To
add to the body of evidence, we investigated
retrospectively the impact of amiodarone expo-
sure on perioperative outcomes and patient sur- Fig. Kaplan-Meier survival analysis of patients exposed
vival on 220 heart transplanted patients. The 2 and not exposed to amiodarone before heart transplan-
groups of patients with and without amiodarone tation. (A) One-year survival and (B) 5-year survival.
therapy did not show differences in demo-
graphic or operative data, providing 2 similar Conflicting results have been reported also on
groups principally varying only in terms of prior the effect of amiodarone exposure on cellular
amiodarone therapy. rejection. We found significantly lesser rejection
Rhythm disturbances including atrial fibrilla- rates (5% vs 20%) in patients taking amiodarone
tion are common after heart transplant.25,26 They before transplant. Others also have found similar
are thought to develop from the manipulation of protective effect against rejection or have seen no
the heart, pericardial inflammation, use of ino- difference in rejection rates in patients exposed to
tropes, autonomic changes after the operation, pre-transplant amiodarone.20,31-33 Amiodarone
and organ rejection.25,27 Some studies have could play a protective role due to its immune-
demonstrated a lesser incidence (about 11%) of altering properties as observed by lesser cellular
atrial fibrillation after long-term amiodarone ther- rejection rates.31,34-36
apy,28,29 while others have found a greater inci- In addition, amiodarone has a negative chrono-
dence shortly after transplant.30 Our study tropic and inotropic effect and could be one of the
showed that preoperative amiodarone exposure causes of primary graft failure/dysfunction after
did not have a significant effect on the rate of heart transplantation. Similar to our study, pre-
post-transplant atrial fibrillation when compared liminary results from Yerebakan et al17 showed an
with the control group. It is not surprising that increased incidence of acute primary graft dysfunc-
we did not see an effect on atrial fibrillation after tion in patients exposed to pre-transplant
transplantation in our study population as the inci- amiodarone.
dence of atrial fibrillation in our patient popula- The effect of amiodarone exposure on patient
tion was low in both groups (6% vs 7%). survival has been the most controversial outcome.
Surgery Lushaj et al 1277
Volume 161, Number 5

Our results are in concordance with previously 5. Abuzaid A, Saad M, Ayan M, Kabach A, Haddad TM,
published data that amiodarone has no effect on Smer A, et al. Acute amiodarone pulmonary toxicity after
drug holiday: a case report and review of the literature.
short-term patient survival. We observed a low and Case Rep Cardiol 2015;2015:927438.
similar 30-day mortality rate of 4% in patients 6. Fadahunsi O, Krol R. Acute amiodarone pulmonary toxicity
exposed and not exposed to amiodarone. Several following lung resection. Int J Biomed Sci 2014;10:217-20.
studies have found a similar result on short-term 7. Wolkove N, Baltzan M. Amiodarone pulmonary toxicity.
survival.17,20,32,33 However, a recent meta-analysis Can Respir J 2009;16:43-8.
8. Essebag V, Reynolds MR, Hadjis T, Lemery R, Olshansky B,
that included 6 studies with a total of 869 partici- Buxton AE, et al. Sex differences in the relationship be-
pants concluded that exposure to amiodarone tween amiodarone use and the need for permanent pacing
prior to cardiac transplantation is associated with in patients with atrial fibrillation. Arch Internal Med 2007;
a greater rate of postoperative mortality.37 A large 167:1648-53.
cohort study of 14,944 patients undergoing HTx 9. Hauser TH, Pinto DS, Josephson ME, Zimetbaum P.
Safety and feasibility of a clinical pathway for the outpa-
showed that 1-year survival was lesser in the amio- tient initiation of antiarrhythmic medications in patients
darone treated patients.2 Their findings showed with atrial fibrillation or atrial flutter. Am J Cardiol 2003;
also that the duration of AMIO treatment could 91:1437-41.
relate to postoperative mortality. 10. Hauser TH, Pinto DS, Josephson ME, Zimetbaum P. Early
Despite a similar 1-year survival, we found a recurrence of arrhythmia in patients taking amiodarone
or class 1C agents for treatment of atrial fibrillation or atrial
lesser 5-year survival in patients who received long- flutter. Am J Cardiol 2004;93:1173-6.
term preoperative amiodarone. There were more 11. Hussain N, Bhattacharyya A, Prueksaritanond S. Amiodar-
deaths due to pulmonary complications in the one-induced cirrhosis of liver: what predicts mortality?
AMIO treated group. However, cardiac related ISRN Cardiology 2013;2013:617943.
deaths were similar, 29% and 22% in the AMIO 12. Gluck N, Fried M, Porat R. Acute amiodarone liver toxicity
likely due to ischemic hepatitis. Isr Med Assoc J 2011;13:
and non-AMIO group, respectively. 748-52.
Study limitations. Our study has limitations, 13. Latini R, Tognoni G, Kates RE. Clinical pharmacokinetics of
including its retrospective, nonrandomized design, amiodarone. Clin Pharmacokinet 1984;9:136-56.
data collection restricted to the variables that were 14. Zipes DP, Prystowsky EN, Heger JJ. Amiodarone: electro-
available in electronic medical records, and anal- physiologic actions, pharmacokinetics and clinical effects.
J Am Coll Cardiol 1984;3:1059-71.
ysis of a limited number of patients from a single 15. Somani P. Basic and clinical pharmacology of amiodarone:
institution. We only assessed the ECGs available in relationship of antiarrhythmic effects, dose and drug con-
our electronic medical records, thereby creating a centrations to intracellular inclusion bodies. J Clin Pharma-
potential to miss atrial fibrillation episodes occur- col 1989;29:405-12.
ring outside the hospital. 16. Jennings DL, Martinez B, Montalvo S, Lanfear DE.
Impact of pre-implant amiodarone exposure on out-
Lower rejection rates were found in patients comes in cardiac transplant recipients. Heart Fail Rev
exposed to pretransplant amiodarone. Amiodarone 2015;20:573-8.
use did not affect the incidence of post-transplant 17. Yerebakan H, Naka Y, Sorabella R, Hill SC, Takeda K,
atrial fibrillation, the need for prolonged inotropes, Schulze P, et al. Amiodarone treatment prior to heart trans-
or 1-year post-transplant survival. However, post- plantation is associated with acute graft dysfunction and
early mortality: a propensity-matched comparison. J Heart
transplant pulmonary complications were signifi- Lung Transplant 2014;33:S105.
cantly greater and 5-year survival was lower among 18. Blomberg PJ, Denofrio D, Chen G, Homoud M, Wang PJ,
patients treated with amiodarone prior to transplant. Estes NA, et al. Preoperative amiodarone increases risk of
bleeding complications following cardiac transplantation.
J Heart Lung Transplant 2001;20:237-8.
REFERENCES 19. Chin C, Feindel C, Cheng D. Duration of preoperative
1. Vassallo P, Trohman RG. Prescribing amiodarone. JAMA amiodarone treatment may be associated with postoperative
2007;298:1312-22. hospital mortality in patients undergoing heart transplanta-
2. Cooper LB, Mentz RJ, Edwards LB, Wilk A, Rogers JG, tion. J Cardiothorac Vasc Anesth 1999;13:562-6.
Patel CB, et al. Implications of amiodarone use before heart 20. Chelimsky-Fallick C, Middlekauff HR, Stevenson WG,
transplantation. J Heart Lung Transplant 2016;35:S63. Kobashigawa J, Saxon LA, Moriguchi J, et al. Amiodarone
3. Pedersen CT, Kay GN, Kalman J, Borggrefe M, Della-Bella P, therapy does not compromise subsequent heart transplan-
Dickfeld T, et al. EHRA/HRS/APHRS expert consensus on tation. J Am Coll Cardiol 1992;20:1556-61.
ventricular arrhythmias. Heart Rhythm 2014;11:166-96. 21. Blomberg PJ, Feingold D, Denofrio D, Rand W,
4. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Konstam MA, Estes M, et al. Comparison of survival and
Cleveland JC, et al. AHA/ACC/HRS guideline for the man- other complications after heart transplantation in patients
agement of patients with atrial fibrillation: a report of the taking amiodarone before surgery versus those not taking
American College of Cardiology/American Heart Associa- amiodarone. Am J Cardiol 2004;93:379-81.
tion TaskForce on Practice Guidelines and the Heart 22. Kobashigawa J, Zuckermann A, Macdonald P, Leprince P,
Rhythm Society. J Am Coll Cardiol 2014;64:e1-76. Esmailian F, Luu M, et al. Report from a consensus
1278 Lushaj et al Surgery
May 2017

conference on primary graft dysfunction after cardiac trans- 30. Isiadinso I, Meshkov AB, Gaughan J, Sandhu P, Lim S,
plantation. J Heart Lung Transplant 2014;33:327-40. Cordova F, et al. Atrial arrhythmias after lung and heart–
23. Kirklin JK, Naftel DC, Pagani FD, Kormos RL, lung transplant: effects on short-term mortality and the in-
Stevenson LW, Blume ED, et al. Seventh INTERMACS fluence of amiodarone. J Heart Lung Transplant 2011;30:
annual report: 15,000 patients and counting. J Heart 37-44.
Lung Transplant 2014;34:1495-504. 31. Goldstein DR, Coffey CS, Benza RL, Nanda NC, Bourge RC.
24. Saravanan P, Davidson NC. Risk assessment for sudden car- Relative perioperative bradycardia does not lead to adverse
diac death in dialysis patients. Circ Arrhythm Electrophysiol outcomes after cardiac transplantation. Am J Transplant
2010;3:553-9. 2003;3:484-91.
25. Pavri BB, O’Nunain SS, Newell JB, Ruskin JN, William G. 32. S
anchez-L
azaro IJ, Almenar L, Martinez-Dolz L,
Prevalence and prognostic significance of atrial arrhythmias Chamorro C, Moro J, Ag€ uero J, et al. Does amiodarone in-
after orthotopic cardiac transplantation. J Am Coll Cardiol fluence early mortality in hearttransplantation? Transplan-
1995;25:1673-80. tation 2006;38:2537-8.
26. Schwarz ER, Czer LS, Simsir SA, Kass RM, Trento A. Amio- 33. Macdonald P, Hackworthy R, Keogh A, Sivathasan C,
darone-induced QT prolongation in a newly transplanted Chang V, Spratt P. The effect of chronic amiodarone ther-
heart associated with recurrent ventricular fibrillation. Car- apy before transplantation on early cardiac allograft func-
diovasc J Afr 2010;21-2:109-12. tion. J Heart Lung Transplant 1991;10(5pt1):743-9.
27. Cohn WE, Gregoric ID, Radovancevic B, Wolf RK, 34. Wilson BD, Clarkson CE, Lippmann ML. Amiodarone
Frazier OH. Atrial fibrillation after cardiac transplantation: causes decreased cell-mediated immune responses and in-
experience in 498 consecutive cases. Ann Thorac Surg hibits the phospholipase C signaling pathway. Lung 1993;
2008;85:56-8. 171:137-48.
28. Rivinius R, Helmschrott M, Ruhparwar A, Schmack B, 35. Akoun GM, Cadranel JL, Blanchette G, Milleron BJ,
Erbel C, Gleissner CA, et al. Long-term use of amiodarone Mayaud CM. Bronchoalveolar lavage cell data in
before heart transplantation significantly reduces early post- amiodarone-associated pneumonitis. Evaluation in 22 pa-
transplant atrial fibrillation and is not associated with tients. Chest 1991;99:1177-82.
increased mortality after heart transplantation. Drug Des 36. Akoun GM, Gauthier-Rahman S, Millerone BJ, Perrot JY,
Devel Ther 2016;10:677-86. Maynaud CM. Amiodarone-induced hypersensitivity pneu-
29. Dasari TW, Pavlovic-Surjancev B, Patel N, et al. Incidence, monitis. Chest 1984;85:133-5.
risk factors, and clinical outcomes of atrial fibrillation and 37. Jennings DL, Baker WL. Pre-transplant amiodarone expo-
atrial flutter after heart transplantation. Am J Cardiol sure increases mortality in cardiac transplant recipients: a
2010;106:737-41. meta-analysis. J Heart Lung Transplant 2016;35:S420.
 Materials Science and Engineering C 78 (2017) 780–786

Contents lists available at ScienceDirect

Materials Science and Engineering C

journal homepage: www.elsevier.com/locate/msec

Improved oral bioavailability of probucol by dry media-milling

LiJia a, YangYan a,c, ZhaoMeihui a, XuHui a,⁎, MaJunyuan b, WangShaoning b,⁎
a
School of Pharmacy, Shenyang Pharmaceutical University, Shenyang 110016, PR China
b
School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, PR China
c
Shanghai Institute of Pharmaceutical Industry, Shanghai 201203, PR China

a r t i c l e i n f o a b s t r a c t

Article history: The polymer/probucol co-milled mixtures were prepared to improve drug dissolution rate and oral bioavailabil-
Received 6 December 2016 ity. Probucol, a BCS II drug, was co-milled together with Copovidone (Kollidon VA64, VA64), Soluplus, or MCC
Received in revised form 20 April 2017 using the dry media-milling process with planetary ball-milling equipment. The properties of the milled mixtures
Accepted 22 April 2017
including morphology, crystal form, vitro drug dissolution and in vivo oral bioavailability in rats were evaluated.
Available online 23 April 2017
Probucol existed as an amorphous in the matrix of the co-milled mixtures containing VA64, which helped to en-
Keywords:
hance drug dissolution. The ternary mixture composed of VA64, RH40, and probucol showed increased dissolu-
Probucol tion rates in both sink and non-sink conditions. It also had a higher oral bioavailability compared to the reference
Dissolution formulation. Dry-media milling of binary or ternary mixtures composed of drug, polymer and surfactant possibly
Bioavailability have wide applications to improve dissolution rate and oral bioavailability of water-insoluble drugs.
Bioavailability © 2017 Elsevier B.V. All rights reserved.
Co-milling
Planetary mill

1. Introduction drugs. Several pharmaceutical products based on micronized or nano-

crystal/nanosuspension techniques via milling method, have been suc-
The number of active pharmaceutical ingredients (API) of cessfully marketed [10]. While the wet-milling technique needs post-
biopharmaceutics classification system II (BCS II) is increasing. Howev- processing in production of nanosuspensions, the most important ad-
er, their oral availability is generally limited due to the low aqueous sol- vantages of dry media-milling method are no solidification, good chem-
ubility. Improving the solubility/dissolution of poorly water-soluble ical stability, and easy processing of API into suitable dosage forms
compounds is a challenging task in the development of pharmaceutical although agglomeration and temperature increase may occur.
preparations containing BCS II drug for oral delivery [1]. Various strate- Probucol is a potent anti-oxidative drug for the prevention and treat-
gies have been introduced to improve the dissolution of poorly water- ment of atherosclerotic cardiovascular diseases and xanthoma. It has
soluble drugs, such as particle size reduction (e.g. dry or wet milling), also been used as a lipid-lowering drug before. Although Western coun-
pro-drugs, cyclodextrin inclusion, self-emulsification, etc. [2–5]. Al- tries withdraw it because of the reduction in serum high density lipo-
though several methods have been reported to improve dissolution protein cholesterol (HDL-C), recent animal and clinical studies
and oral bioavailability of probucol [6–9], it is valuable to develop a sim- reported favorable effects of probucol on atherosclerotic cardiovascular
ple, easily scale-up, solvent-free technology with low heat. diseases. Its mechanisms of action have been explained at the molecular
Milling is an important process to reduce particle size mechanically level. Although probucol is known to prolong QT interval on an electro-
in chemistry, mineral processing, materials and pharmaceutical indus- cardiogram, no fatal ventricular arrhythmias have been reported even
tries. The co-milling approach is more versatile in contrast to melting in positive studies. Potent anti-oxidative effect of probucol and en-
or solvent-evaporation methods. Melting is a temperature-dependent hanced reverse cholesterol transport (RCT) may explain its strong
process. Many substances undergo thermal decomposition and impuri- anti-atherosclerotic effects despite serum HDL-C reduction. Probucol
ties are increased at high temperature. For solvent-evaporation has pleiotropic and beneficial therapeutic effects on cardiovascular sys-
methods, residual solvents remaining in final product may create po- tem. Especially, it was one of the few drugs to prevent restenosis after
tential toxicity issues. Therefore, embedding a poorly water-soluble percutaneous transluminal coronary (PTCA). Although statins are effec-
drug as a solid dispersion in a hydrophilic carrier by mild co-milling is tive for lowering low density lipoprotein cholesterol (LDL-C) and reduc-
a promising strategy for enhancing the dissolution of water-insoluble ing coronary heart disease risk, probucol should be considered as an
option in case statins are not effective [11]. Currently, probucol is still
⁎ Corresponding authors.
widely used in some Asian countries, including China, Japan and
E-mail addresses: [email protected], [email protected] (H. Xu), Korea. The use of probucol, with its long history of safe use and
[email protected] (S. Wang). established effectiveness, needs to be re-evaluated for its ability to

http://dx.doi.org/10.1016/j.msec.2017.04.141
0928-4931/© 2017 Elsevier B.V. All rights reserved.
 J. Li et al. / Materials Science and Engineering C 78 (2017) 780–786 781

reduce coronary heart disease risk and other lipid-lowering therapy. rate of 10 °C/min in a dynamic nitrogen atmosphere. Approximately
Western countries might have abandoned probucol too soon [11,12]. 5 mg of sample was sealed in an aluminum pan and an empty sealed
As a typical BCS II drug, the effectiveness of probucol (oral bioavail- pan was used as the reference.
ability b 10%) is greatly limited due to its extremely low water solubility
(5 ng/mL) [13]. Therefore, effective methods are needed in order to im- 2.5. In vitro drug release
prove its dissolution and oral bioavailability. In this study, polymer/
probucol co-milled mixture with improved dissolution was successfully The in vitro release test was performed using the paddle method as
prepared by dry-media co-milling of probucol and pharmaceutical poly- described in Chinese Pharmacopoeia (2015) using a ZRS-8G Dissolution
mer(s) (MCC, VA64 or Soluplus). The physicochemical properties and Apparatus (Tianda Tianfa Technology Co. Ltd., China). In this study,
oral adsorption of the co-milled mixture were evaluated as well. 900 mL SDS (2% w/w) solutions (sink condition) or purified water
(non-sink condition) at 37.0 ± 0.5 °C were used as the dissolution
2. Materials and methods media respectively, and the rotation speed was set at 50 r/min. The
milled samples equivalent to 3 mg or 15 mg probucol were added to
2.1. Materials the dissolution medium respectively, at pre-determined time intervals.
The dissolution sample (5.0 mL) was withdrawn from the beakers and
Probucol was purchased from Wuyi Cihang Pharmaceutical Co. Ltd. replaced with the equal volume of fresh medium. The dissolution sam-
(Hebei, China). Kollidon® VA64 (Vinylpyrrolidone/vinyl acetate = ples were filtered through a membrane filter of 0.45 μm pore size
60/40, VA64), Soluplus® (Polyvinylcaprolactam-polyvinyl acetate- (Millipore, USA) and the content of probucol was then assayed by LC-
polyethylene glycol graft copolymer), and Cremophor®RH40 (RH40) 10AD high performance liquid chromatography (HPLC) (SHIMADZU,
were kindly donated by BASF Company Ltd. (Germany). Microcrystal- Tokyo, Japan) equipped with a Dikma® ODS C18 chromatography col-
line cellulose (MCC) was purchased from Changwei Pharmaceutical umn (200 mm × 4.6 mm, 5 μm) and a UV–vis detector (242 nm). The
Company Ltd. (Shanghai, China). All other reagents used were of analyt- mobile phase consisted of methanol and distilled water (100:3, v/v)
ical or chromatographic grade. and was pumped at a flow rate of 1.0 mL/min. Validation of the assay
method showed good linearity in the concentration range of 0.2 μg/mL
2.2. Dry media-milling to 10.0 μg/mL (A = 139911C + 5165.65, R2 = 0.9995) and precision
(RSD b 2.0%).
Ball milling was performed with a PM0.4L high energy planetary mill
(Chishun, China) equipped with 200 cm3 zirconium oxide milling bowl 2.6. In vivo pharmacodynamics study
containing 150 g beads (Ø = 0.5 mm) at room temperature and
1000 r/min. The mixtures of probucol and polymers were placed in Male Sprague-Dawley rats 190 g ± 20 g were obtained from the Lab-
the milling bowl at a beads/sample weight ratio of 30:1. To avoid tem- oratory Animal Center of Shenyang pharmaceutical University (Shen-
perature increase of the sample, pause periods of 10 min were set yang, China). The rats were fasted overnight before experiments. Rats
after every 30 min of milling. The resulted powders were sieved through were randomly divided into two groups, and orally administered with
a 100 mesh screen and stored at room temperature. The formulation VA64/RH40/Probucol ternary co-milled mixture (test formulation) or
and milling time of the sample were listed in Table 1 (F1–F3: unary mill- milled powder of commercially available probucol tablet (reference for-
ing formulations; F4–F6: binary co-milling formulations; F7–F9: ternary mulation) at a dose of 250 mg probucol/kg body weight separately.
co-milling formulations). Blood samples were collected into heparinized tubes from the suborbit-
al vein at the following time points: predose, 1 h, 2 h, 4 h, 6 h, 8 h, 10 h
2.3. Optical microscopic and scanning electron microscopy (SEM) 12 h, 24 h, and 36 h. Plasma was separated by centrifugation at
observation 5000 rpm for 10 min and then stored at − 20 °C until determination.
All procedures were performed according to the guidelines and approv-
The milled mixtures were observed with a BA300POL microscope al of the Institutional Animal Experimentation Ethics Committee of
(Motic, China). Morphology of Samples sputtered with gold, were ob- Shenyang Pharmaceutical University.
served using S-3400 SEM (Hitachi, Japan) at 5.0 KV electron acceleration For analysis, 200 μL internal standard (2.0 μg/mL amiodarone in
voltage from different random microscopic fields. The number of parti- methanol) was spiked to 200 μL of plasma sample, mixed vigorously
cle and particle size distribution was measured using the attached soft- for 1 min, and then 200 μL methanol was added and vortexed. 1 mL of
ware from at least five representative regions. n-hexane was added and vortexed for another 3 min. After centrifuga-
tion at 5000 r/min for 10 min, the organic phase was transferred to an-
2.4. Differential scanning calorimetry (DSC) analysis other tube and evaporated to dryness at 40 °C. The residue was
reconstituted in 100 μL mobile phase, 20 μL of the solution was injected
DSC analysis was carried out using DSC-1 system (Mettler Toledo, into the HPLC system. Probucol was assayed by LC-10AD HPLC
Switzerland) in the temperature range of 30 °C–200 °C at a heating (SHIMADZU, Tokyo, Japan) equipped with a Thermo C18 column
(250 mm × 4.6 mm, 5 μm) and a UV–vis detector (242 nm). The mobile
Table 1 phase consisted of acetonitrile, distilled water and triethylamine
Formulations of probucol and polymer/probucol mixtures. (93:7:0.01, v/v/v) was pumped at a flow rate of 1.0 mL/min.
Maximum concentration (Cmax) and maximum times (Tmax) were
Ingredients, g Effective milling time, h
obtained directly from the concentration versus time data. The other
Probucol MCC Soluplus VA64 RH40 pharmacokinetic parameters (AUC0–72 h and t1/2) were analyzed by
F1 5 – – – – 2 DAS 2.1.1 software (supplied by Chinese Pharmacological Society).
F2 5 – – – – 4
F3 5 – – – – 6
3. Results
F4 0.75 4.25 – – – 1
F5 0.75 – 4.25 – – 1
F6 0.75 – – 4.25 – 1 3.1. Morphology and physicochemical properties
F7 0.75 – – 3.6125 0.6375 1
F8 0.25 – – 4.0375 0.7125 1 The microscopic and SEM images of milled samples were shown in
F9 1.5 2.975 0.525 1
Fig. 1. With the increase of milling time, the particle size of probucol
782 J. Li et al. / Materials Science and Engineering C 78 (2017) 780–786

was significantly decreased. For the binary mixtures, the particle size of mixture. It seemed that probucol and VA64 agglomerated to larger par-
VA64/probucol co-milled mixture (F6) was about 20 μm while the sizes ticle during milling process.
of MCC/probucol co-milled mixture (F4) and Soluplus/probucol co- The DSC thermogram of probucol showed a typical sharp endother-
milled mixture (F5) were larger than 100 μm with broader size distribu- mic peak at 129.1 °C corresponded to melting point, which indicated the
tion compared to the VA64/probucol mixture. The SEM images indicat- crystalline state of probucol. The endothermic peak of probucol was still
ed that Soluplus and MCC still keep their original morphology with observed after milling for 6 h (Fig. 2, m and n). For the binary co-milled
probucol particle attached to the surface after milling in their binary mixtures, MCC/probucol or Soluplus/probucol had the endothermic
milling mixtures. It is interesting to notice that the surface of both peak in the DSC curves (Fig. 2, a and d) while the peak disappeared in
VA64/probucol binary co-milled mixture (F6) and VA64/RH40/ VA64/probucol binary co-milled mixture (Fig. 2, g). The DSC curve for
probucol co-milled mixture (F7) particles were smoother, with more the physical mixture of VA64 ternary mixture (Fig. 2, l) looks like the su-
uniform particle size but irregular shape than other binary co-mill perimposition of the thermal profiles of drug and milling additives. No

Fig. 1. The optical microscopic pictures and SEM images of probucol and polymer/probucol mixtures after dry milling.
 J. Li et al. / Materials Science and Engineering C 78 (2017) 780–786 783

significant changes were observed except a small shift of the endother-

mic peak to lower temperature. This indicated no obvious interactions
between the ingredients. On the contrary, the ternary mixture prepared
by co-milling (Fig. 2, k) showed no endothermic peak, which indicated
that probucol was transformed from crystalline to amorphous form
after dry media milling.

3.2. In vitro drug release

The drug release profiles of the milled mixtures (Table 1) conducted

under sink or non-sink conditions were shown in Fig. 3. There was no
difference in dissolution patterns between the pristine drug and milled
drug which failed to improve the dissolution rate. For binary co-milled
mixtures, the dissolution (sink condition) of MCC/probucol and Fig. 3. Dissolution profiles of binary co-milled mixture and ternary co-milled mixture
(n = 3). VA64/probucol binary co-milled mixture under sink condition (□), VA64/
Soluplus/probucol was not detected by HPLC method in this study RH40/probucol ternary co-milled mixture under sink condition (○), and VA64/
while about 10% of drug was released from the binary co-milled mixture RH40/probucol ternary co-milled mixture under non-sink condition (●).
of VA64/probucol at 2 h. The results implied that reducing the particle
size by dry-media milling method may not be the key factor to increase
probucol dissolution rate. The polymer used for co-milling with drug physical mixture was extremely low (only 0.36% at 2 h), whereas that of
could play an important role. Inspired by other reports [14–17], a ternary co-milled mixture was greatly improved to about 30% at 2 h.
third ingredient (RH40, a nonionic surfactant) was incorporated into Although probucol tablets (Chinese Pharmacopoeia, and Japanese
the binary mixture to form a ternary milled mixture of drug, a polymer, Pharmacopoeia) and probucol fine granules (Japanese Pharmacopoeia)
and a nonionic surfactant in order to further improve drug dissolution. are included in various Pharmacopoeia (no dissolution test was speci-
The dissolution of ternary co-milled mixture VA64/RH40/probucol in- fied), only probucol tablet was available in Chinese market. Besides
creased obviously under both sink condition (about 30% at 2 h) and the normally used diluents (such as cellulose derivative and lactose)
non-sink condition (about 20% at 2 h). and other inactive ingredients, considerable amount of surfactants
The ratios of drug to excipients had a significant influence on drug (Tween 80) was incorporated in the tablet formulations to improve
release as well. The dissolution rates of probucol from ternary formula- drug dissolution/absorption. The commercially available probucol tablet
tions were obviously decreased with an increase in the ratio of drug to (Qilu Pharmaceutical Co. Ltd., China) was grinded to coarse powders to
excipients (Fig. 4). The reason may be that high content of probucol perform dissolution test. The cumulative drug dissolution percentage of
was not completely embedded in polymer matrix and excess drug ag- the grinded tablets was only 0.68% at 2 h (Fig. 5) that was significantly
gregated or can't maintain amorphous state [18,19]. lower than that of the ternary co-milled formulations.
It is known that nonionic surfactant, such as RH40, is generally used
as solubilizer to increase the solubility of drugs. In order to understand 3.3. In vivo pharmacokinetics
the effect of RH40 on ternary co-milling mixture, the dissolution test
of VA64/RH40/probucol ternary co-milled mixture and its physical mix- The mean plasma concentration versus time curves of probucol after
ture were conducted. The results showed that the dissolution rate of its a single oral administration of grinded powder of probucol commercial
tablets or the ternary co-milled mixture to rats were shown in Fig. 6. The
plasma concentrations of probucol from ternary co-milled mixture
were considerably higher than that of commercial tablets at almost all
sampling time, which suggested significantly increased oral drug
absorption.
The main pharmacokinetic parameters of probucol were calculated
and summarized in Table 2. The mean maximum plasma drug concen-
tration (Cmax) of the ternary co-milled mixture prepared by dry
media-milling method was 6.0-folds higher than that of commercial
tablets (2.46 mg/L vs. 0.41 mg/L). And the Tmax values were 2.55 h and

Fig. 2. The DSC curves of probucol binary co-milled mixtures and ternary co-milled
mixture. (a) Soluplus/probucol co-milled mixture, (b) Soluplus/probucol physical
mixture, (c) Soluplus, (d) MCC/probucol co-milled mixture, (e) MCC/probucol physical
mixture, (f) MCC, (g) VA64/probucol co-milled mixture, (h) VA64/probucol physical Fig. 4. Dissolution profiles of different ratios of drug to excipient (n = 3). VA64/RH40/
mixture, (i) VA64, (j) RH40, (k) VA64/RH40/probucol co-milled mixture, (l) VA64/ probucol ternary co-milled mixtures containing 30% (◇), 15% (○), and 5% (△) of
RH40/probucol physical mixture, (m) probucol milled 6 h, and (n) untreated probucol. probucol, respectively.
784 J. Li et al. / Materials Science and Engineering C 78 (2017) 780–786

Table 2
Pharmacokinetic parameters of ternary co-milled mixture and commercial formulation of
probucol after a single-dose (100 mg/kg) oral administration to rats (n = 6).

Parameters Ternary co-milled mixture Commercial formulation

T1/2, h 2.03 ± 1.54 58.58 ± 34.67

Cmax, mg/L 2.46 ± 1.09 0.41 ± 0.29
Tmax, h 2.55 ± 0.76 2.26 ± 1.07
AUC(0–72), mg/L*h 21.47 ± 6.32 7.38 ± 3.33

and the grinded mixture was not uniformly dispersed according to the
SEM images. Soluplus, polyvinyl caprolactam-polyvinyl acetate-poly-
ethylene glycol graft copolymer, is a novel amorphous polymer specifi-
cally designed to produce amorphous solid dispersions by hot melt
Fig. 5. Dissolution profiles of VA64/RH40/probucol ternary co-milled mixtures (□), extrusion. The amphiphilic structure of Soluplus makes it a polymeric
physical mixture (▽), and commercial tablets of probucol (△), respectively (n = 3). surfactant, which form self-assemble micelles in aqueous media. Re-
cently, Soluplus was reported to be effective in increasing the solubility
and dissolution and improving the oral bioavailability of poorly water-
2.26 h for the ternary co-milled mixture and commercial tablets, respec- soluble drugs [23,24]. In the Soluplus/probucol co-milled mixture, the
tively, with no significant difference. The AUC0–72 h of probucol ternary hydrophilic domain (polyvinylcaprolactam and polyethylene glycol)
co-milled mixture was higher in comparison with commercial tablets of Soluplus served as a flexible outer shell of the core-shell structure
(21.47 mg/L*h vs. 7.38 mg/L*h). The relative bioavailability of ternary in aqueous solution, while the hydrophobic domain (polyvinyl acetate)
co-milled mixture (AUC0–72 h) to commercial tablet (AUC0–72 h) was formed a solid inner core that was believed to be able to entrap hydro-
291%. phobic drugs (e. g. probucol) inside [25]. However, the dissolution rate
was much lower than what was expected. The possible explanations
was that probucol did not transform crystalline state to amorphous
4. Discussions state after milling and Soluplus was not homogeneously mixed with
probucol, not preventing drug particle aggregation during the milling.
From microscopic and SEM images of milled samples, the gradual re- Compared to a crystalline drug, an amorphous drug should be easier
duction in size and associated morphological changes of probucol dur- to be solubilized by polymeric micelle. Due to the relatively lower Tg
ing the milling process were observed. As expected, the milling of Soluplus (70 °C), the heat will be generated due to the friction be-
process led to a smaller particle size. But the decrease of particle size tween the materials and milling beads, resulted in higher temperature.
and milling time was not linearly related. After certain time of milling, Therefore, Soluplus became softened and even sticky, and it is difficult
the particle size of probucol did not reduce anymore and aggregation to be crushed into finer powders or tend to agglomeration. MCC, one
occurred. This aggregation process occurs spontaneously in powders of the most popular excipients in oral solid dosage forms, is a tenacious
because of adhesion forces that always appeared among fine particles natural polymer.
obtained by milling method [20]. According to DSC patterns, the obvious Unlike the MCC/probucol or Soluplus/probucol binary co-milled
endothermic peak of the grinded probucol revealed that it still existed mixture, VA64/probucol binary co-milled mixture had a smooth surface
as crystal state even after long-period milling. The low dissolution rate on their irregular-shaped particles with no drug powder adhering to.
also demonstrated that particle size reduction has no clear effect on im- This is shown in the microscopic and SEM images of the sample. Because
proving the dissolution of probucol milled. the temperature of the grinded materials was far below the relatively
Table 3 listed the chemical structure, melting point (Tm), glass tran- higher Tg of VA64 (101 °C), VA64 was brittle and easily to be broken
sition temperature (Tg), and the critical micelle concentration (CMC) of during the milling. It was believed that under the intensive mechanical
the main excipients used in the co-milled mixtures. milling force, the particle sizes of both VA64 and probucol might de-
In the MCC/probucol and Soluplus/probucol binary system, MCC and creased gradually and extremely fine probucol and VA64 particles
Soluplus are difficult to be crushed into fine particles. They maintained were uniformly blended and agglomerate to larger particles as a result
original material morphology with drug powders adhered to the surface of adhesion forces of the fine powders. Although the form transition
due to the milling process is well known [26,27], the transition of
probucol from crystalline to amorphous state after milling at the pres-
ence of VA64 (Fig. 2, g) was not well understood yet. All the factors in-
cluding energy input, highly dispersed state of VA64 and probucol, and
the crystal inhibition effect of Copovidone VA64 (similar to the effect of
polyvinylpyrrolidone homopolymer), possibly had effect on form
transition.
The dissolution behavior of the co-milled mixture was greatly de-
pendent on the nature of the hydrophilic polymer used. VA64 is a ran-
dom copolymer of 6 parts of hydrophilic N-vinylpyrrolidone monomer
(VP) and 4 parts of lipophilic vinyl acetate monomer (VA). The polymer
is freely water soluble with the balanced ratio of monomers [28]. Due to
the homogenous blending of hydrophobic probucol and hydrophilic
matrix of VA64 (agglomerated particle), probucol can readily dissolve
along with the rapid dissolution of VA64. Besides the amorphous
probucol presented in the co-milled mixtures, which offers lower ther-
Fig. 6. Plasma probucol concentrations versus time profiles after a single-dose
modynamic barrier to dissolution, other factors, such as greater hydro-
(100 mg/kg) oral administration of ternary co-milled mixture (□) and commercial philicity, increased wettability and particle size reduction, may also
formulation (○) of probucol to rats (n = 6). contribute to the enhanced dissolution rate [29]. In addition, highly
 J. Li et al. / Materials Science and Engineering C 78 (2017) 780–786 785

Table 3
The characteristics of excipients used in co-milled mixtures.

Excipients Chemical structure Tm/Tg, °C CMC, mM

MCC Tm: 260–270 ___

(carbonization)

VA64 Tg: 101 ___

Vinylpyrrolidone/vinyl acetate = 60/40

Soluplus Tg: 70 0.0003 [21]

PEG 6000/vinylcaprolactam/vinyl acetate = 13/57/30

RH40 Hydrophobic part: glycerol polyethylene glycol hydroxystearate and fatty acid glycerol polyglycol esters Tm: 30 0.1 [22]
Hydrophilic part: polyethylene glycols and glycerol ethoxylate

dispersing of drug in the grinded mixture can help to enhanced dissolu- 5. Conclusions
tion due to the reduced agglomeration tendency of hydrophobic drug
[30]. Co-milled mixture containing BCS II drug, probucol, was produced
In the ternary mixture, RH40, a nonionic surfactant, could increase using dry media milling method. With the help of hydrophilic polymer
the solubility and wettability of water insoluble drug. It also decreased (VA64), and homogeneously distribution of amorphous form of
the Tg of matrix polymer as a plasticizer (The melting point of RH40 is probucol in the milled mixture was obtained. The co-milled mixture
only about 30 °C). Fortunately, SEM pictures showed that particle size showed enhanced in vitro dissolution and significantly improved in
and morphology were fundamentally unchanged. The addition of prop- vivo bioavailability in rats. The addition of surfactant RH40 to prepare
er amount of RH40 not only had no unfavorable effect like Soluplus/ the ternary co-milled mixture obviously increased the dissolution rate
probucol system during the grinding process, but also mixed uniformly of probucol at both sink and non-sink conditions. These results sug-
with fine probucol and VA64 powders, which agglomerate to large ter- gested that the binary or ternary mixtures composed of drug, polymer
nary particle. The significant improvement in probucol dissolution from and surfactant prepared by dry media-milling technique have great po-
the ternary co-milled mixture may be attributed to the local solubiliza- tential to improve in vitro drug dissolution rate and oral bioavailability
tion effect of RH40 in the microenvironment after the agglomerated of water-insoluble drugs in pharmaceutical applications.
particles were dispersed to aqueous medium [31]. The greatly increased
dissolution of VA64/RH40/probucol co-milled mixture than that of the
corresponded binary mixture (VA64/probucol) indicated that surfac-
References
tant added is the key factor to improve probucol dissolution. Further-
more, drug-to-polymer ratio is also critical to the development of [1] M. Maniruzzaman, M.M. Rana, J.S. Boateng, J.S. Mitchell, D. Douroumis, Dissolution
amorphous solid dispersions. Adequate amount of polymer is essential enhancement of poorly water-soluble APIs processed by hot-melt extrusion using
hydrophilic polymers, Drug Dev. Ind. Pharm. 39 (2) (2013) 218–227.
for inhibiting crystal transition and favoring physical stability during [2] C. Muehlenfeld, B. Kann, M. Windbergs, M. Thommes, Solid dispersions prepared by
storage. Otherwise, the probucol dissolution will decrease at high drug continuous comilling in an air jet mill, Int. J. Pharm. 102 (11) (2013) 4132–4139.
loading (Fig. 4). [3] M.E. Brewster, T. Loftsson, Cyclodextrins as pharmaceutical solubilizers, Adv. Drug
Deliv. Rev. 59 (7) (2007) 645–666.
However, based on the dissolution results of the ternary co-milled [4] J.W. Yoo, N. Doshi, S. Mitragotri, Adaptive micro and nanoparticles: temporal control
mixture and the physical mixture (Fig. 5), the increase in dissolution over carrier properties to facilitate drug delivery, Adv. Drug Deliv. Rev. 63 (14)
rate can't only be attributed to the solubilization by RH40. According (2011) 1247–1256.
[5] B.K. Kang, J.S. Lee, S.K. Chon, S.Y. Jeong, S.H. Yuk, G. Khang, H.B. Lee, S.H. Cho, Devel-
to the research of Paul Harmon et al. [32], the role of a surfactant in opment of self-microemulsifying drug delivery systems (SMEDDS) for oral bioavail-
the ternary amorphous solid dispersion particle is to prevent a rapid, ability enhancement of simvastatin in beagle dogs, Int. J. Pharm. 274 (1) (2004)
local drug domain aggregation, which is defined as “hydrophobic cap- 65–73.
[6] A. Mooranian, R. Negrulj, N. Chen-Tan, H.S. Al-Sallami, Z.X. Fang, T.K. Mukkur, et al.,
ture”. The main mechanism is that surfactant molecule rapidly absorbed
Microencapsulation as a novel delivery method for the potential antidiabetic drug
on the surface of amorphous drug, which allow the water-insoluble Probucol, Drug Des. Devel. Ther. 8 (2014) 1221–1230.
drug to escape hydrophobic capture and diffuse to bulk solution to in- [7] Z.W. Zhang, S.J. Jiang, Directed self-assembled nanoparticles of probucol improve
oral delivery: fabrication, performance and correlation, Pharm. Res. 31 (2014)
hibit crystal growth. Furthermore, the amphiphilic nature of surfactant
2266–2275.
also provides a high affinity for amorphous water-insoluble drug parti- [8] A. Pongpeerapat, C. Wanawongthai, Y. Tozuka, Formation mechanism of colloidal
cles. For the ternary co-milled mixture prepared by dry-media milling, nanoparticles obtained from probucol/PVP/SDS ternary ground mixture, Int. J.
the stable high disperse state of hydrophilic polymer VA64 and the Pharm. 352 (2008) 309–316.
[9] A. Zaghloul, I. Khattab, A. Nada, S. Al-Saidan, Preparation, characterization and opti-
above effect of RH40 significantly enhanced its dissolution, and neither mization of probucol self-emulsified drug delivery system to enhance solubility and
is dispensable. dissolution, Pharmazie 63 (9) (2008) 654–660.
786 J. Li et al. / Materials Science and Engineering C 78 (2017) 780–786

[10] M. Pautler, S. Brenner, Nanomedicine: promises and challenges for the future of [22] A. Christiansen, T. Backensfeld, K. Denner, W. Weitschies, Effects of non-ionic surfac-
public health, Int. J. Nanomedicine 5 (2010) 803–809. tants on cytochrome P450-mediated metabolism in vitro, Eur. J. Pharm. Biopharm.
[11] S. Yamashita, D. Masuda, Y. Matsuzawa, Did we abandon probucol too soon? Curr. 78 (1) (2011) 166–172.
Opin. Lipidol. 26 (4) (2015) 304–316. [23] S.O. Kyeremateng, M. Pudlas, G.H. Woehrle, A fast and reliable empirical approach
[12] P. He, H. Kawamura, M. Takemoto, Y. Maezawa, T. Ishikawa, R. Ishibashi, et al., Com- for estimating solubility of crystalline drugs in polymers for hot melt extrusion for-
bination of cilostazol and probucol protected podocytes from lipopolysaccharide-in- mulations, J. Pharm. Sci. 103 (9) (2014) 2847–2858.
duced injury by both anti-inflammatory and anti-oxidative mechanisms, J. [24] J. Djuris, I. Nikolakakis, S. Ibric, Z. Djuric, K. Kachrimanis, Preparation of carbamaze-
Nephrology (2016) 1–11. pine–Soluplus® solid dispersions by hot-melt extrusion, and prediction of drug–
[13] A. Pongpeerapat, C. Wanawongthai, Y. Tozuka, K. Moribe, K. Yamamoto, Formation polymer miscibility by thermodynamic model fitting, Eur. J. Pharm. Biopharm. 84
mechanism of colloidal nanoparticles obtained from probucol/PVP/SDS ternary (1) (2013) 228–237.
ground mixture, Int. J. Pharm. 352 (1) (2008) 309–316. [25] J.R. Hughey, J.M. Keen, D.A. Miller, K. Kolter, N. Langley, The use of inorganic salts to
[14] S. Mandal, C. Banerjee, S. Ghosh, J. Kuchlyan, N. Sarkar, Modulation of the improve the dissolution characteristics of tablets containing Soluplus®-based solid
photophysical properties of curcumin in nonionic surfactant (Tween-20) forming dispersions, Eur. J. Pharm. Sci. 48 (4) (2013) 758–766.
micelles and niosomes: a comparative study of different microenvironments, J. [26] J.E. Patterson, M.B. James, A.H. Forster, R.W. Lancaster, J.M. Butler, T. Rades, The in-
Phys. Chem. B 117 (23) (2013) 6957–6968. fluence of thermal and mechanical preparative techniques on the amorphous
[15] S.G. Gumaste, S.S. Gupta, A.T.M. Serajuddin, Investigation of polymer-surfactant and state of four poorly soluble compounds, J. Pharm. Sci. 94 (9) (2005) 1998–2012.
polymer-drug-surfactant miscibility for solid dispersion, AAPS J. 18 (5) (2016) [27] N. Chieng, J. Aaltonen, D. Saville, T. Rades, Physical characterization and stability of
1131–1143. amorphous indomethacin and ranitidine hydrochloride binary systems prepared
[16] T. Thongnopkoon, S. Puttipipatkhachorn, Stabilizing ability of surfactant on physico- by mechanical activation, Eur. J. Pharm. Sci. 71 (1) (2009) 47–54.
chemical properties of drug nanoparticles generated from solid dispersions, Drug [28] L. Widanapathirana, S. Tale, T.M. Reineke, Dissolution and solubility enhancement of
Dev. Ind. Pharm. (2017) (1080/03639045.2017.1291670). the highly lipophilic drug phenytoin via interaction with poly (N-
[17] A.N. Ghebremeskel, C. Vemavarapu, M. Lodaya, Use of surfactants as plasticizers in isopropylacrylamide-co-vinylpyrrolidone) excipients, Mol. Pharm. 12 (7) (2015)
preparing solid dispersions of poorly soluble API: selection of polymer–surfactant 2537–2543.
combinations using solubility parameters and testing the processability, Int. J. [29] M. Sugimoto, T. Okagaki, S. Narisawa, Y. Koida, K. Nakajima, Improvement of disso-
Pharm. 328 (2) (2007) 119–129. lution characteristics and bioavailability of poorly water-soluble drugs by novel
[18] J. Huang, R.J. Wigent, C.M. Bentzley, J.B. Schwartz, Nifedipine solid dispersion in mi- comilling method using water-soluble polymer, Int. J. Pharm. 160 (1) (1998) 11–19.
croparticles of ammonio methacrylate copolymer and ethylcellulose binary blend [30] A.L. Sarode, H. Sandhu, N. Shah, W. Malick, H. Zia, Hot melt extrusion (HME) for
for controlled drug delivery: effect of drug loading on release kinetics, Int. J. amorphous solid dispersions: predictive tools for processing and impact of drug–
Pharm. 319 (1) (2006) 44–54. polymer interactions on supersaturation, Eur. J. Pharm. Sci. 48 (3) (2013) 371–384.
[19] F. Qian, J. Huang, M.A. Hussain, Drug–polymer solubility and miscibility: stability [31] F. Yun, A. Kang, J. Shan, X. Zhao, X. Bi, J. Li, L. Di, Preparation of osthole-polymer solid
consideration and practical challenges in amorphous solid dispersion development, dispersions by hot-melt extrusion for dissolution and bioavailability enhancement,
J. Pharm. Sci. 99 (7) (2010) 2941–2947. Int. J. Pharm. 465 (1) (2014) 436–443.
[20] M.J. Arias, J.R. Moyano, J.M. Gines, Investigation of the triamterene–β-cyclodextrin [32] P. Harmon, K. Galipeau, W. Xu, C. Brown, W.P. Wuelfing, Mechanism of dissolution-
system prepared by co-milling, Int. J. Pharm. 153 (2) (1997) 181–189. induced nanoparticle formation from a copovidone-based amorphous solid disper-
[21] E. Bernabeu, L. Gonzalez, M. Cagel, E.P. Gergic, M.A. Moretton, D.A. Chiappetta, Novel sion, Mol. Pharm. 13 (5) (2016) 1467–1481.
Soluplus®—TPGS mixed micelles for encapsulation of paclitaxel with enhanced in
vitro cytotoxicity on breast and ovarian cancer cell lines, Colloids Surf. B. 140
(2016) 403–411.
 Fluid Phase Equilibria 450 (2017) 149e159

Contents lists available at ScienceDirect

Fluid Phase Equilibria

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / fl u i d

Solubility of an antiarrhythmic drug (amiodarone hydrochloride) in

supercritical carbon dioxide: Experimental and modeling
Gholamhossein Sodeifian a, b, *, Seyed Ali Sajadian a, Fariba Razmimanesh a
a
Department of Chemical Engineering, Faculty of Engineering, University of Kashan, 87317-53153, Kashan, Iran
b
Laboratory of Supercritical Fluids and Nanotechnology, University of Kashan, 87317-53153, Kashan, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Solubility measurement of solid solute components in supercritical carbon dioxide (SC-CO2) provides
Received 31 May 2017 essential information for forming pharmaceutical particles of smaller size with a desired size distribu-
Received in revised form tion, so as to achieve a better dissolution rate. In this study, for the first time, solubility of amiodarone
18 July 2017
hydrochloride (AMH) in SC-CO2 was determined using a static method at pressures and temperatures
Accepted 25 July 2017
Available online 28 July 2017
ranging within 12e30 MPa and 313.2e343.2 K, respectively. Under the applied conditions, molar solu-
bilities were obtained in the range of 2.510
105 to 1.012
103. For correlating the drug solubility in
SC-CO2, three of the most widely applied groups of models, namely semi-empirical density-based ap-
Keywords:
Amiodarone hydrochloride (AMH)
proaches, equations of state (EoSs), and regular solution models, were used. Statistical analysis of the
Solubility results showed the superiority of the Peng-Robinson's model over other models for estimating the
Modeling solubility of AMH based on experimental data.
Antiarrhythmic drug © 2017 Elsevier B.V. All rights reserved.
Equation of state (EoS)

1. Introduction system. This classification is based on drug absorption through

intestinal membrane at a rate that is proportional to its concen-
Nowadays, amiodarone hydrochloride (AMH) is being applied to tration at membrane surface, with “in vivo” dissolution being a
remedy ventricular and supraventricular arrhythmias, especially critical factor in this process [4,5]. The classification of AMH in the
when they are resistant to another common antiarrhythmic drugs. category II means that this drug has its absorption limited by its
It is also useful in treating less severe ventricular arrhythmias and solubility. A review on related literature shows that only few
many supra ventricular arrhythmias including atrial fibrillation and studies have been performed on the improvement of AMH solu-
re-entrant tachyarrhythmia involving accessory pathways. In fact, bility and absorption. Martín-Algarra et al. [6] described the effect
according to VaughanWilliams classification, it belongs to the of polyssorbate 80 on AMH intestinal absorption in rats, concluding
class III anti-arrhythmic drugs which prolong the duration of action that apparent absorption rate constants of AMH decrease as the
potential and effective refractory period in both atria and ventricles surfactant concentration increases. Elhasi et al. [7] verified that
[1e3]. Additionally, chemically known as (2-butylbenzofuran- 3-yl) micelles formed from block co-polymers by a co-solvent evapora-
[4-[2-(diethylamino)ethoxy]-3,5-diiodophenyl] methanone hy- tion method can effectively increase the water solubility of AMH,
drochloride, AMH is a benzofuranic derivate used for the treatment limit AMH precipitation upon dilution in physiological media, and
of both supraventricular and ventricular arrhythmias. Physically, reduce its hemolytic activity. With no doubt, development of oral
AMH is a white or almost white crystalline powder exhibiting very formulations for slightly soluble compounds can pose significant
slight solubility in water (0.2e0.5 mg/mL), free solubility in challenges at all stages of drug development. Basically, drug
methylene chloride, solubility in methanol, and sparing solubility aqueous solubility is one of the most critical physicochemical
in ethanol [2]. properties contributing into the drug absorption and bioavailability
Due to its reduced solubility and high intestinal permeability, features. It should be emphasized that, poor aqueous solubility of a
AMH belongs to category II of the biopharmaceutics classification drug might have inappropriate pharmacokinetic effects, i.e.
increasing a drug solubility improves the chance of achieving a
successful formulation later in development process [8].
* Corresponding author. Department of Chemical Engineering, Faculty of Engi- One of alternative ways for improving the solubility and disso-
neering, University of Kashan, 87317-53153, Kashan, Iran.
lution rate of poorly water-soluble drugs is supercritical fluid (SCF)
E-mail address: sodeifi[email protected] (G. Sodeifian).

http://dx.doi.org/10.1016/j.fluid.2017.07.015
0378-3812/© 2017 Elsevier B.V. All rights reserved.
150 G. Sodeifian et al. / Fluid Phase Equilibria 450 (2017) 149e159

technology. Carbon dioxide has been widely applied as a super- common groups of models including semi-empirical density-based
critical solvent because of its unique properties, namely non- models, EoSs, and regular solution. Finally, capabilities of various
flammability, non-polarity, non-explosiveness, inexpensiveness, models were examined.
easily removed from the extract, and low surface tension [9e11].
Furthermore, supercritical carbon dioxide (SC-CO2) is an 2. Experimental
environment-friendly solvent which provides such advantages as
nontoxicity, chemical stability, low viscosity, and high diffusivity 2.1. Materials
[12e15].
Various experimental methods have been employed to deter- Carbon dioxide (CO2) (CAS Number 124-38-9) was supplied by
mine solubility of drugs in SCF. In general, they can be classified Fadak Company (Kashan, Iran), at a minimum purity of 99.99%.
under two classes. The first class of the experimental methods is Amiodarone hydrochloride (CAS Number 19774-82-4) was pur-
based on a saturated solution whose solubility can be measured by chased from Amin Pharmaceutical Company (Isfahan, Iran), at a
static or dynamic methods. The second class relies on how the minimum purity of 99%. These compounds were used without
obtained saturated solution is analyzed. In this case, the applied further purification. Also, methanol (CAS Number 67-56-1) with
methods can be divided into four categories: gravimetric [16e19], purity (GC)  99.9% was obtained from Merck (German). More
spectrometric [20e22], chromatographic [23,24] and miscella- detailed information about the materials used in this paper is given
neous [25]. in Table 1.
The static methods utilize equilibrium cells of constant or var-
iable volume; these include recirculation of the solvent, agitation 2.2. Supercritical carbon dioxide apparatus and procedure
by magnetic stirrer, movable piston, or simply trap the solvent in
the equilibrium cell for a period of time [5]. Static methods involve Equipped with a UV e vis spectrophotometer, the apparatus
a closed cell containing the solute and a fixed amount of fluid. Here, used for stationary measurements of the equilibrium solubility is
there is no gross movement of any phase; however, often there is a illustrated in Fig. 1. First, by unlocking the valve on a stainless steel
stirrer that may be turned on and off in order to promote the container, CO2 gas was passed via the filter before being introduced
achievement of equilibrium, especially for liquid solutes. They are into the fridge. Thereupon, by lowering the temperature to 20  C,
equipped with a heating system and a pressure sensor to not only the gas was liquefied, so as to be prepared for pumping function.
control temperature and pressure conditions, but also maintain the Pressure quantities were recorded to an uncertainty of ±0.1 MPa by
system at equilibrium. Determination of phase compositions can be both pressure transporter and pressure meter (WIKA, Germany). To
performed by either an analytic or a synthetic method. A dynamic keep the experimental temperature, the equilibrium cell was
system employs supercritical flow which is continuously moved placed inside a meticulous oven (Froilabo Model, AE-60, France)
through a bed of solute, making it a simpler and faster approach which can maintain the temperature fluctuations within ±0.1 K. It
than the static method. However, in this method, failure to reach was armed with Pt 100 poly-modulus sensors with a digital depict
equilibrium solute concentration is always a possibility which showing regulated and real temperatures. Some 500 mg of AMH
should be taken into account [6,7]. To resolve this problem, together with glass balls of 2 mm in diameter were inserted into the
different workarounds have been proposed such as varying the static cell, having a capacity of 10 mL. To avoid physical entrainment
flow rate, using more than one extraction cell, varying the distri- of the undissolved AMP, both ends of the high-pressure equilibrium
bution of the solute in the extraction cell, and its recycling [25]. cell were installed with the stainless steel sintered disks. Supple-
The equations of state (EoS) and empirical density-based cor- mentary information can be found in our previous work [27].
relations are two major groups of approaches to solubility At operational conditions, SC-CO2 was pressurized up to the
modeling in SCFs. EoS modeling usually needs the selection of the desired pressure before being passed into the equilibrium cell. In
most appropriate equation and mixing rules and also a knowledge this study, the time to reach the equilibrium state was put to 60 min
of the solute properties. EoSs are usually applied to engineering (it was indicated to be enough via elementary experiments). At the
practices as they can be used to predict thermodynamic properties end of the static time, 600 mL of the saturated SC-CO2 was intro-
of fluids and to describe phase behavior of mixtures over large duced into an injection circuit (loop) by a six-port, two-status valve.
temperature and pressure ranges [26,27]. Thus, solubility modeling By changing direction of the injection tap, the circuit was depres-
by EoS is a challenging task. On the other hand, the use of empirical surized into the accumulation (collection) vial containing a speci-
models does not require any knowledge of additional solute fied volume of solvent (methanol). At the finish of the process, the
properties and is therefore quite popular in chemical engineering micrometer tap was used to modulate the depressurizing process,
applications where such models have often been found to be suc- so as to inhibit solvent scattering. In the last step, the circuit was
cessful in correlating existing solubility data. cleaned with the solvent which was stored in the accumulation vial.
Although many solubility studies have been carried out on Final volume of the solution was 5 mL. Experiments was carried out
different drugs, but a report on solubility of AMH as a poorly water- in triplicate.
soluble drug is yet to be released. As such, the main objective of this Obtained in different conditions, solubility values of AMH were
work was set to measure and investigate the solubility of AMH in recorded by absorbency mensurations at lmax employing a model
SC-CO2. Moreover, experimental data were correlated using three 2100 Shimadzu UV-Vis spectrophotometer with 1-cm pass length

Table 1
The sources and mass fraction purity of the materials used in this paper.

Material Source Mass fraction purity Purification method Analysis method

Amiodarone. Hcl Amin Pharmaceutical Co. 0.99 None HPLCa

Methanol Merck Co. 0.999 None GCb
CO2 Fadak Co. 0.9999 None GCb
a
High performance liquid chromatography.
b
Gas chromatography.
 G. Sodeifian et al. / Fluid Phase Equilibria 450 (2017) 149e159 151

Fig. 1. Schematic diagram of experimental apparatus used for measuring solubility.

quartz chambers (cells). Stock solutions of AMH (100 mg mL1)


g
were present by dissolving appropriate quantities of solid instance
g  C s L
Vs ðLÞ
in methanol. A complex of standard solutions was provided by S ¼ (5)
L Vl ðLÞ
appropriately diluting the stock solutions. The calibration curves
obtained (through regression coefficients of about 0.996) were
used to constitute the concentration of the drug in the accumula-
tion vial. Quantitative analysis by UV absorption was done at
240 nm for AMH solute drug. The equilibrium mole fraction, y2, and 3. Results and discussion
equilibrium solubility, S (g/L) in SC-CO2 over the pressure and
temperature ranges are calculated as follows: 3.1. Solubility results

nsolute The reliability and validity of the equipment and the experi-
y2 ¼ (1)
nsolute þ nCO2 mental values was examined at different pressures and tempera-
ture by measuring the solubilities of alpha-tocopherol and
where: naphthalene in supercritical carbon dioxide and the results are

 reported in our pervious work [27]. The experimental values ach-
g
Cs L
Vs ðLÞ ieved for Alpha-tocopherol were compared with results of
nsolute ¼
 (2) Johannsen and Brunner (1993) [23] and Pereira et al. (1995) [28].
g
Ms mol Also, the values of were compared with Reverchon et al. [29], Iwai
et al. [30], and Yamini et al. [20], in various operating conditions.

 Detailed information about the physical properties of AMH is
Vl ðLÞ
r gL summarized in Table 2. Solubilities of AMH in SC-CO2 were deter-
nCO2 ¼
 (3) mined within the pressure range of 12e30 MPa and the tempera-
g
MCO2 mol ture range of 313.2e343 K. The results are tabulated in Table 3. It
should be mentioned that, each data point was the average of at
where nsolute and nCO2 are moles of solute and CO2 in sampling loop, least three experimental measurements. Further presented in
Cs is the concentration of solute (g/L) in the accumulation vial ob- Table 3 was the CO2 density calculated by SpaneWagner equation
tained from the calibration curve, Vs(L) and Vl(L) are volumes of the [31]. Details of solubility data measurement (including equilibrium
accumulation vial and sampling circuit, and Ms and MCO2 are the mole fraction, y2, and equilibrium solubility, S (g/L)), in SC-CO2 over
solute and CO2 molecular weights, respectively. Inserted Eqs. (2) the considered pressure and temperature ranges are described in
and (3) in Eq. (1) results in the following equation (Eq. (4)): our previous work [27].


 The values shown in Table 3 and Fig. 2 are averages of three
g g

Vs ðLÞ
MCO2 mol
Cs L
replicated measurements with relative standard deviations of
y2 ¼



 smaller than 4.3%. Also, combined uncertainty of mole fraction was
Cs gL
Vs ðLÞ
MCO2 mol
g
þ Vl ðLÞ
r gL
Ms mol
g
achieved ±6.041
105. As listed in Table 3, the magnitude order of
the AMH solubility in SC-CO2 is 104. The ranges of mole fraction (y)
(4)
and solubility, S (g/L), of the solute component were 2.510
105 to
The equilibrium solubility, S (g/L) of the solute in SC-CO2 can be 1.012
103 and 0.127 to 11.696, respectively. The minimum and
achieved from Eq. (4) as well. maximum of temperatures and pressures in which AMH solubility
152 G. Sodeifian et al. / Fluid Phase Equilibria 450 (2017) 149e159

Table 2
Structure of the solute used and their physicochemical properties.

Compound Formula Structure MW (g/mol) CAS number Tm (K) [50] l(nm)

Amiodarone. Hcl C25H29I2NO3. Hcl 681.77 19774-82-4 427-431 K 240

Table 3
Solubility of AMH in SC-CO2 at various temperatures and pressures.

Temperature (K)a Pressure (MPa)a Density (kg/m3) [31] y 2
104 (Mole Fraction) S (g/l)

313.2 12 718.64 1.184 ± 0.004 1.247 ± 0.005

15 781.11 2.941 ± 0.009 3.368 ± 0.011
18 820.18 3.911 ± 0.012 4.704 ± 0.015
21 849.30 4.200 ± 0.011 5.231 ± 0.015
24 872.80 4.469 ± 0.018 5.720 ± 0.024
27 892.66 4.756 ± 0.140 6.226 ± 0.193
30 909.94 5.247 ± 0.024 7.003 ± 0.034
323.2 12 585.36 0.986 ± 0.025 0.846 ± 0.023
15 700.53 2.592 ± 0.009 2.663 ± 0.009
18 757.70 3.792 ± 0.020 4.213 ± 0.024
21 796.33 4.489 ± 0.095 5.242 ± 0.172
24 825.87 4.640 ± 0.086 5.620 ± 0.011
27 849.97 5.055 ± 0.110 6.302 ± 0.145
30 870.44 5.957 ± 0.008 7.606 ± 0.011
333.2 12 437.31 0.511 ± 0.013 0.327 ± 0.009
15 605.22 2.202 ± 0.052 1.954 ± 0.049
18 687.86 3.621 ± 0.145 3.653 ± 0.155
21 739.07 5.285 ± 0.162 5.729 ± 0.185
24 776.16 5.926 ± 0.043 6.746 ± 0.052
27 805.38 6.844 ± 0.052 8.086 ± 0.065
30 829.58 7.882 ± 0.115 9.593 ± 0.148
343.2 12 347.04 0.251 ± 0.006 0.127 ± 0.003
15 508.11 1.817 ± 0.016 1.354 ± 0.013
18 613.29 3.360 ± 0.125 3.022 ± 0.118
21 678.55 5.463 ± 0.053 5.437 ± 0.056
24 724.26 6.631 ± 0.282 7.045 ± 0.316
27 759.26 7.951 ± 0.284 8.857 ± 0.334
30 787.64 10.120 ± 0.260 11.696 ± 0.317
a
Standard uncertainty u are u(T) ¼ ±0.1 K; u(p) ¼ ± 0.1 MPa.

Fig. 2. Amiodarone solubility vs a) pressure and b) supercritical CO2 density at various temperatures.

were measured were 343.15 K, 12 MPa and 343.15 K, 30 MPa, solubility in SC-CO2 increases with an increase in pressure. This
respectively. As demonstrated by the isotherms in Fig. 2, AMH happens due to the resulting increase in SC-CO2 density and hence
 G. Sodeifian et al. / Fluid Phase Equilibria 450 (2017) 149e159 153

dissolving power that tend to reduce mean intermolecular distance hand.

of the involved molecules, favoring the solute-solvent specific in- In another model proposed by Spark et al. [43], AdachieLu
teractions [27,32]. The experimental results at pressures lower than model [44] was combined with del Valle-Aguilera model [45] to
19 MPa exhibited some retrograding behavior (crossover-pressure create an equation with six adjustable parameters. Both the Adachi-
effect). At pressures lower than the crossover pressure, the density Lu (and its linear modification) and the del Valle-Aguilera models
effect, which is sensitive to the pressure, is dominant; the solute is provided an improvement over Chrastil's model. Spark's model
more soluble at low temperatures. However, the solute vapor improves the results obtained using Adachi-Lu and del Valle-
pressure effect becomes dominant at pressures higher than the Aguilera models.
crossover pressure, where the solvent density turns less sensitive to Furthermore, Garlapati and Madras [39] correlated solubilities
the pressure, hence the solubility increases as temperature rises. of a solute in SCFs. They proposed a model similar to that proposed
Commonly, temperature has a dual effect on the solubility of drugs by Jouyban et al. for solubility prediction of a solute in SCF.
in the SC-CO2 by regulating both the density of SC-CO2 and the In the last stage, the solubility data was correlated by Bian et al.
vapor pressure of the drug. Similar results (dual effect of temper- [40] model with five adjustable parameters. In this model, a linear
ature) have been reported by some other researchers for measuring relationship between ln (y2) and ln (r) along with a linear rela-
the solubilities of 1,5- naphthalediamine, and 4,40 -dia- tionship between ln (y2) and r/T and a linear relationship between
minodiphenylmethanenaproxen [33], 1-aminoanthraquinone and ln (y2) and r ln (r) in isothermal conditions were considered [40].
1 nitroanthraquinone [34], dialkylalkyl phosphonates [35], ferro- According to the number of adjustable parameters of the models
cene and acetylferrocene [36], and 2,6- and 2,7- and in order to provide a reliable accuracy criterion to compare the
dimethylnaphthalenes [37] which can be used for reliability and accuracy of the models possessing different numbers of curve-
validity checking of the measured solubilities in this work. fitting parameters, average absolute relative deviations (AARD)
were calculated by Ref. [42]:
3.2. Correlation of solubility data  !
1 Xn y 
 i;cal  yi;exp 
AARD% ¼  
100 % (6)
As previously mentioned, solubility of the AMH was correlated Nz  yi;exp 
i¼1
using three well-known and widely used methods, namely semi-
empirical models, equation of state and regular solution with As another criterion for comparing the models, Radj is defined as
FloryeHuggins equation. follows [39,42]:
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
    
3.2.1. Density-based models Radj ¼ R2  Q 1  R2 ðN  Q  1ÞÞ (7)
As semi-empirical density-based models, the Chrastil, Bartle
et al., Spark et al., Garlapati et al., Jouyban et al., and Bian et al., where N is the number of data points in each set, Q is the number of
models were applied to correlate the solubility data in this work. independent variables in each equation, and R2 is the correlation
Formulae of the mentioned models are listed in Table 4. These coefficient (Eq. (3)). As Radj accounts for the number of independent
semi-empirical models have been described in literature [38e40]. variables, it can be applied to compare models of different numbers
Briefly, the Christel's [41] model is based on the assumption that of independent variables.
each molecule of a solute associates with k molecules of the su-
percritical solvent to form a solvate complex which is in equilib- SSE
R2 ¼ 1  (8)
rium with the system. According to this approach, a relation with SST
three adjustable parameters would be achieved for the solid solu-
bility. Total heat can be obtained from a third adjustable parameter where SSE is the error sum of squares and SST is the total sum of
(a2 ¼ DHt/R). squares. Capability of the model to fit the solubility data can be
In the Bartle et al. [25] model, the parameter a2 is applied to evaluated by another important criterion, namely F-value which is
determine the heat of vaporization of the solute, DHvap. Based on defined as:
the values of DHt (obtained from Chrastil's model) and DHvap., the
heat of solvation, DHsol., can be approximated for each solute-CO2 SSR =Q MSR
F  value ¼ ¼ (9)
system. SSE =ðN  Q  1Þ MSE
Jouyban et al. [42] also introduced a semi-empirical model
based on the effect of pressure and temperature. The model was where SSR is the regression sum of squares, MSR is the mean square
expressed by a non-linear relationship between ln (y2), in one hand, regression and MSE is the mean square residual. F-value is distrib-
and pressure, temperature and the density of pure CO2, on the other uted as a F statistic with Q and NQ1 degrees of freedom [46].
The models results and the corresponding AARD, Radj and F-
values of the density-based models are presented in Table 5. The
Table 4 obtained adjustable parameters led to the correlation of the solu-
Summary of the density based model used in this work.
bility data at good accuracies (9.44, 11.48, 10.10, 10.04, 8.44 and 9.49
Model Formula for Chrastil, Bartle et al., Spark et al., Garlapati et al., Bian et al., and
Chrastil [41] ln S ¼ a0 ln r þ a1 þ a2 Jouyban et al. models, respectively).
! T
Bartle et al. [25] Results illustrate the ability of Bian et al. model to correctly
ln y2 P
Pref ¼ a0 þ a1 ðr  rref Þ þ a2
T describe the solubility data measured for AMH. With six adjustable
! parameters, this model produced AARD, Radj and F-values of 8.49,
Sparks et al. [43] ða0 þa1 rr;1 þa2 r2r;1 Þ
S*2 ¼ rr;1 exp a3 þ aT4r þ Ta52 0.9874, and 526.20, respectively, for solubility data, indicating the
r

r MWsolute y2 capability of the model to correlate the solubility data. The corre-
S*2 ¼ rS S ¼ MW SCF ð1y2 Þ
c;1
lation results for AMH by the six semi-empirical models are also
Garlapati et al. [39] ln y2 ¼ a0 þ ða1 þ a2 rÞ lnr þ aT3 þ a4 lnðrTÞ
presented in Fig. 3aef.
Bian et al. [40] ln y2 ¼ a0 þ aT1 þ a2T$r þ ða3 þ a4 rÞln r
As mentioned above, the Chrastil's and Bartle et al. models have
Jouyban et al. [42] ln y2 ¼ a0 þ a1 r þ a2 P 2 þ a3 PT þ aP4 T þ a5 ln r
an energy term within temperature coefficient. Using the regressed
154 G. Sodeifian et al. / Fluid Phase Equilibria 450 (2017) 149e159

energy parameters, total heat, heat of vaporization, and heat of  !

1X n y 
solvation could be easily estimated for the examined drug-CO2  i;cal  yi;exp 
AARD% ¼  
100 % (13)
systems. Table 6 shows the calculated enthalpies for AMH in the SC- n i¼1  yi;exp 
CO2. As can be seen in Table 6, the total mixing heat determined
from the Chrastil's model was 36.77 kJ mol1. The enthalpy of AMH Proposed by Kirkpatrick et al. [52], Simulated Annealing (SA) is a
vaporization (endothermic) was estimated by the Bartle's model, Monte Carlo simulation-based method widely utilized to solve
(54.44 kJ mol1). Since the vaporization is endothermic whereas several complex problems. SA is a probabilistic technique (specif-
the solvation is exothermic, the vaporization heat is supposed to be ically, a metaheuristic algorithm) for global optimization of a
higher than the total heat. Based on the difference between DHvap function (optimal) or discrete space in a wide range of problems.
and DHtotal, the solvation heat (DHsol.) was found to The SA algorithm is based on a practical approach in materials
be 17.67 kJ mol1. processing science. In fact, annealing is a physical process where a
solid is slowly cooled until its structure is eventually established at
3.2.2. EoS-based models a minimum energy configuration [9,53,54].
Thermodynamically speaking, solubility equilibrium between Fig. 4a shows a comparison between experimental data and PR
solid solute and SC-CO2 can be given by the equality of component model at temperatures of 313.2, 323.2, 333.2 and 343.2 K for the
fugacity of either phases. Assuming that no SC-CO2 dissolves in the CO2-AMH system. The isotherms in Fig. 4 are calculated using the
solid-phase, the solid solute is incompressible and its vapor pres- optimized values of kij and lij. By comparing binary interaction
sure is very low [34], we can explain the solubility of solute in SC- parameters (kij and lij) in Table 9, it can be concluded that there is a
CO2 as follows: linear relationship between temperature and other parameters.
The calculated mean AARD for PR EoS was 6.03%, which shows a
0 1
good agreement with experimental observations.
@v2 ðP  P2 ÞA
s sub
4sub
2 exp RT
In Fig. 4b and Table 9, the results obtained for the PAZ model
P2sub with the optimally fitted binary parameters kij and lij at each tem-
y2 ¼ $ (10) perature resulted in values of AARD lower than 8.9%. It can be also
P 4SCF
2
observed in Fig. 5 and Table 9 that the parameters of the PAZ model
where ns2 is the molar volume of the solid (drug), P2sub is the subli- are all positive and exhibit linear relationship with temperature. As
mation pressure of the solute, as estimated by the Ambrose-Walton mentioned above, the interaction parameters kij and lij have linear
corresponding states method [47], T and P are the temperature and relationships with temperature as follows:
pressure of the system, respectively, and 4SCF 2 is the fugacity of the
drug in SC-CO2. In this research, fugacity coefficient of solute in SC- kij ¼ AT þ B (14)
CO2 was calculated according to PengeRobinson (PR) [48], Pazuki
et al. [49], and EoS combined with vdW2 mixing rule (see Table 7). lij ¼ CT þ D (15)
In Table 8, Pc, Tc and u are critical pressure (MPa), critical temper-
ature (K) and acentric factor for each compound, respectively. The where A, B, C and D are adjustable parameters determined by linear
melting point of AMH was reported in literature 427e431 K [50]. As regression fitting. The results of data fitting to these equations are
shown in Table 8, critical pressure, critical temperature, and normal tabulated in Table 10 wherein AARD values between experimental
boiling point (Tb) of AMH were estimated by the Marrero-Gani and calculated solubilities are further reported. The goodness of the
first-order method [51]. Also, the acentric factor was estimated linear correlation is validated by regression coefficients. As can be
using AmbroseeWalton method [47]. The solute-CO2 system, observed, these linear relations are able to successfully correlate
attractive parameter (a) and covolumes (b) of PAZ and PR EoS can the interaction parameters for the prediction of AMH þ SC-CO2
be expressed in the form of classical van der Waals (vdW) mixing solubility data within the investigated temperature range. The
rule with two parameters, as shown below: interaction parameters kij and lij showed a linear relationship (at
negative slope) with temperature.
X pffiffiffiffiffiffiffiffi 
am ¼ yi yj ai aj 1  kij (11)
j
3.2.3. Regular solution model with FloryeHuggins equation
  In this method, SC-CO2 is considered as an expanded liquid and
X bi þ bj   the equilibrium solubility of solid compounds (y2) in SC-CO2 is
bm ¼ yi yj 1  lij (12)
2 obtained from the following equation [55]:
j

In addition, lij and kij parameters were optimized using a f2s

y2 ¼ (16)
Simulated Annealing (SA) technique where the objective function is g∞ l
2 f2
minimized through the statistical measure of average absolute
relative deviation (AARD) between the experimental solubility and where f2s and f2l are the fugacities of pure solute in solid phase and
those obtained from the EoS, as follows: supercritical phase, respectively, and g∞2 is activity coefficient of the

Table 5
Different parameters of the AMH e CO2 binary system achieved by the Chrastil, Bartle, Sparks, Garlapati e Madras, Bian and Jouyban models.

Model a0 a1 a2 a3 a4 a5 AARD% Radj F-value

Chrastil 5.3149 20.1583 4423.4773 e e e 9.49 0.9862 478.91

Bartle 17.0096 0.0096 6548.2452 e e e 11.48 0.9838 271.96
Spark 7.5266 2.9303 0.9014 4.8518 11.177 1.7904 10.10 0.986 476.97
Garlapati and Madras 38.8370 3.6618 0.0002 3621.3085 1.5215 e 10.04 0.9859 472.86
Bian 5.4611 0.0032 98083.6992 7.2056 14.849 e 8.49 0.9874 526.20
Jouyban et al. 5.849 13.6033 0.000014 0.000023 1.1072 8.8137 9.44 0.9752 176.19
 G. Sodeifian et al. / Fluid Phase Equilibria 450 (2017) 149e159 155

Fig. 3. Comparison of experimental (points) and calculated (line) solubility of AMH based on the a) Chrastil, b)Bartle et al., c) Garlapati and Madras, d) Spark et al., e) Jouyban et al.
and f) Bian et al. models at various temperatures.

solid solute at infinite dilution. The ratio of these fugacities is ob- Table 6
tained as follows [55]: Approximated total (DHtotal), vaporization (DHvap) and solvation (DHsol) enthalpies
for AMH.
!

f2s DH2f 1 1 Compound DHtotal (kJ mol1)a DHvap. (kJ mol1)b DHsol. (kJ mol1)c
ln ¼  (17) Amiodarone.Hcl 36.77 ± 0.66 54.44 ± 0.97 - 17.67 ± 0.32
f2l R T2;m T
a
Obtained from the Chrastil's model.
b
where T2,m is the melting temperature of the solid compound, DH2f Obtained from the Bartle's model.
c
Obtained from the difference between the DHvap and DHtotal.
is its molar heat of fusion and R is the gas constant. g∞
2 is calculated
by the modified regular solution model coupled with the Flor-
yeHuggins term: calculated by the following equation:

n 

!0:5
n n DUivap
ln g∞
2 ¼ 2 2
ðd1  d2 Þ þ 1  2 þ ln 2 (18) di ¼ (19)
RT n1 n1 ni
where n is the molar volume and d is the solubility parameter
156 G. Sodeifian et al. / Fluid Phase Equilibria 450 (2017) 149e159

Table 7
Summary of the cubic EoSs used in this work.

Name Equation of state a b

Modified-Pazuki [49] RT yþ2bðTÞ aðTÞ

R2 Tc2 RTc
P¼ ybðTÞ$ y  bðTÞ ¼ 0:058743
bðTr ; uÞ
yðyþbðTÞÞ 0:51301
aðTr ; uÞ Pc
Pc
a1=2 ðTr ; uÞ ¼ 1 þ m1 ð1  Tr0:5 Þ þ m2 ð1  Tr0:5 Þ2 þ m3 ð1  Tr0:5 Þ3 bðTr ; uÞ1:2 ¼ 1 þ nð1  Tr Þ
m1 ¼ 0:4690 þ 0:709u  0:2660u 2 n ¼ 0:1723  0:3858u  0:1683u2

m2 ¼ 0:6548  1:2625u  1:9727u 2

m3 ¼ 0:9553 þ 5:0064u þ 0:4159u2

Peng -Robinson [48] P ¼ RT  vðvþbÞaðTÞ 0:45724 R2 Tc2 b ¼ 0:07780 R Tc

vb þ bðvbÞ aðTÞ ¼
a ðTr;u Þ Pc
Pc
aðTr;u Þ ¼ ½1 þ k ð1  Tr0:5 Þ 2
k ¼ 0:37464 þ 1:54226 u  0:26992 u2

Table 8
Estimated critical and physicochemical properties of CO2-AMH.

Component Tb (K) Tc (K) Pc (bar) u Vs (m3/mol) T (K)

313.2 323.2 333.2 343.2

Psub

Amiodarone.Hcl 787.04a 1040.37a 11.75a 0.43b 379.2c 3.46*104 b

0.00108 0.00317 0.0086

CO2 e 304.18 73.8 0.274 e e e e e

a
Estimated by marreroeGani first-order method [51].
b
Estimated by the AmbroseeWalton corresponding states method [47].
c
Estimated by Fedors's method [59].

Fig. 4. Comparison of experimental (points) and calculated (line) solubility of amiodarone based on the a) PR-Model b) PAZ-Model at various temperatures.

DUivap is the molar internal energy of vaporization. The equilibrium Table 9

solubility of the solid in SC-CO2 is calculated using Eqs. (20)e(22): Correlation results for solubility of AMH in SC-CO2, by PR, PAZ combined with the
vdW2 mixing rule.



Model Parameter T ¼ 313.2 K T ¼ 323.2 K T ¼ 333.2 K T ¼ 343.2 K
DH2f 1 1 n n n
ln y2 ¼   2 ðd1  d2 Þ2  1 þ 2  ln 2 PAZ-vdW2 k12 0.2629 0.1999 0.1742 0.1165
R T2;m T RT n1 n1 0.3661 0.2920 0.2705 0.2091
l12
(20) AARD 7.59 5.56 11.20 11.19
F value 67.37 38.77 93.96 42.21
In Eq. (20), DH2f
is estimated according to Yalkowsky [56] and Radj 0.9781 0.9625 0.9842 0.9655
the value of d1 is calculated by W-H. Pang and E. McLaughlln PR- vdW2 k12 0.3492 0.3126 0.2921 0.2779
method [57]. Molar volume of SC-CO2 (n1) is estimated by the EoS l12 0.4095 0.3490 0.3173 0.2928
proposed by F-H Huang et al. with 27 constants [58]. Also, d2 is AARD 8.52 2.59 6.30 6.72
determined using Eq. (21) [59]: F value 40.53 76.69 91.27 61.07
Radj 0.9641 0.9808 0.9838 0.9759
!1:13
n2 0
d2 ¼ d02 (21) In this equation, d02 and v02 are estimated at 298 K using the group
n2
contribution method developed by Fedors [59]. The parameter n2 is
 G. Sodeifian et al. / Fluid Phase Equilibria 450 (2017) 149e159 157

Table 11
Correlation results for solubility of AMH in SC-CO2, by Regular solution Model.

Model a b AARD F-value Radj

Regular solution 0.4781 4.5705 21.94 178 93.16

that the solubility of AMH in the SC-CO2 could be better estimated

at higher temperatures rather than lower temperatures.

4. Conclusion

Solubility measurement of solid solute components is an

essential tool for forming particle in micro and nano scales. In the
present work, solubility of amiodarone hydrochloride (AMH), as an
antiarrhythmic drug, in SC-CO2 was measured. The solubility data
obtained from a static method coupled with spectrophotometric
analysis were in the range of 2.510
105 to 1.012
103 (based on
Fig. 5. Temperature dependence of the binary interaction parameters for the the mole fraction). The maximum value of solubility was achieved
AMHeCO2 system.
at a pressure of 30 MPa and a temperature of 343.2 K. After
measuring the solubility, the experimental data was correlated to
Table 10 three different approaches including semi-empirical density-based
Adjustable parameters determined by linear regression fitting. models (Chrastil, Bartle et al., Spark et al., Garlapati et al., Jouyban
et al. and Bian et al. models), equations of state (PR and modified-
Model Interaction parameters
Pazuki models coupled with van der Waals mixing rule with two
kij lij
adjustable parameters), and regular solution model with Flor-
A B C D yeHuggins equation. Precise statistical analysis showed that PR-
PR- Model 0.0023 1.0768 0.0038 1.5948 vdW2 model presents better results than Pazuki, regular solution,
R2 0.9547 0.9544 and density-based models when it comes to the prediction of the
PAZ-Model 0.0046 1.7132 0.0049 1.0768 solubility of this material of pharmaceutical value in supercritical
R2 0.9776 0.9628 carbon dioxide.

Acknowledgements
considered as the adjustable parameter. Previous studies have
shown that ln (n2) is linearly related to log-density for SC-CO2 (ln The authors would like to thank the research deputy of Uni-
(r1)) [55,60]. versity of Kashan for providing financial supports for this valuable
project. (Grant # Pajoohaneh-1396/2). Moreover, the authors
ln n2 ¼ a ln r1 þ b (22) herein express their thanks to the Laboratory of Supercritical Fluids
and Nanotechnology of University of Kashan for providing experi-
where a and b are two temperature independent parameters for mental facilities. Furthermore, our special thanks go to Mr. Mehdi
each solid compound. Sodeifian for his technical cooperation and supporting in experi-
Fig. 6 show that the model is not capable of providing good mental works and sections.
predictions of the solubility for the SC-CO2-AMH system. Based on
the statistical results presented in Table 11, compared to other Nomenclature
presented models, the regular solution model showed a poorer
agreement with experimental data. Finally, it should be expressed a0  a5 Adjustable parameters of model
AARD Average absolute relative deviation
aðTÞ Energy parameter of the cubic EoS (Nm4 mol2)
b Volume parameter for equations of state(m3 mol1)
Cs Concentration of solute
f l2 Fugacity in solid state of liquid
f s2 Fugacity in solid state of solid
H Enthalpy
kij Binary interaction parameters in the mixing rules
lij Binary interaction parameters in the mixing rules
m1-m3 Parameter in Pazuki model
MSR Mean square regression
MSR Mean square residual
MW Molar mass, kg mol1
n Parameter in Pazuki model
N Number of data points, dimensionless
P Pressure
Pc Critical pressure
PR Peng Robinson
Fig. 6. Comparison of experimental and calculated solubility of amiodarone based on Pr Reduced pressure
the regular solution at various temperatures. Pref Reference pressure
158 G. Sodeifian et al. / Fluid Phase Equilibria 450 (2017) 149e159

Psub Sublimation pressure (Pa) [8] W.-G. Dai, C. Pollock-Dove, L.C. Dong, S. Li, Advanced screening assays to
rapidly identify solubility-enhancing formulations: high-throughput, minia-
Q Number of independent variables in each equation
turization and automation, Adv. Drug Deliv. Rev. 60 (2008) 657e672.
R Gas constant, J.mol1.K1 [9] G. Sodeifian, S.A. Sajadian, N.S. Ardestani, Experimental optimization and
R2 Correlation coefficient mathematical modeling of the supercritical fluid extraction of essential oil
S Solubility of a solute (g L1) from Eryngium billardieri: application of simulated annealing (SA) algorithm,
J. Supercrit. Fluids 127 (2017) 146e157.
PAZ Pazuki [10] G. Sodeifian, N.S. Ardestani, S.A. Sajadian, S. Ghorbandoost, Application of
SSE Error sum of squares supercritical carbon dioxide to extract essential oil from Cleome coluteoides
SST Total sum of squares Boiss: experimental, response surface and grey wolf optimization methodol-
ogy, J. Supercrit. Fluids 114 (2016) 55e63.
SSR Regression sum of squares [11] G. Sodeifian, S.A. Sajadian, N.S. Ardestani, Evaluation of the response surface
T Temperature, K and hybrid artificial neural network-genetic algorithm methodologies to
Tb Boiling point determine extraction yield of Ferulago angulata through supercritical fluid,
J. Taiwan Inst. Chem. Eng. 60 (2016) 165e173.
Tc Critical temperature [12] G. Sodeifian, S.A. Sajadian, N.S. Ardestani, Optimization of essential oil
T2,m Melting temperature of the solute extraction from Launaea acanthodes Boiss: utilization of supercritical carbon
Tr Reduced temperature dioxide and cosolvent, J. Supercrit. Fluids 116 (2016) 46e56.
[13] G. Sodeifian, S.A. Sajadian, N.S. Ardestani, Supercritical fluid extraction of
DU vap
i
Internal energy change of vaporization of solute at 298 K omega-3 from Dracocephalum kotschyi seed oil: process optimization and oil
y2 Mole fraction solubility properties, J. Supercrit. Fluids 119 (2017) 139e149.
n Molar volume (m3 mol1) [14] G. Sodeifian, S.A. Sajadian, N.S. Ardestani, Extraction of Dracocephalum kot-
schyi Boiss using supercritical carbon dioxide: experimental and optimization,
vl Volumes of the collection vial
J. Supercrit. Fluids 107 (2016) 137e144.
vs Volumes of the collection sampling loop [15] G. Sodeifian, S. Ghorbandoost, S.A. Sajadian, N.S. Ardestani, Extraction of oil
vdW2 Van der Waals mixing rule with two adjustable parameter from Pistacia khinjuk using supercritical carbon dioxide: experimental and
modeling, J. Supercrit. Fluids 110 (2016) 265e274.
[16] W.J. Schmitt, R.C. Reid, Solubility of monofunctional organic solids in chemi-
Greek symbols cally diverse supercritical fluids, J. Chem. Eng. Data 31 (1986) 204e212.
a(Tr, u) Temperature-dependent function in the attractive [17] E. Kosal, G.D. Holder, Solubility of anthracene and phenanthrene mixtures in
supercritical carbon dioxide, J. Chem. Eng. Data 32 (1987) 148e150.
parameter of the EoS [18] J. Dobbs, J. Wong, R. Lahiere, K. Johnston, Modification of supercritical fluid
b Parameter in Pazuki Model phase behavior using polar cosolvents, Ind. Eng. Chem. Res. 26 (1987) 56e65.

[19] E. Aionicesei, M. Skerget,  Knez, Measurement of CO 2 solubility and diffu-
Z.
d1,d2 Solubility parameters of CO2 and solute
sivity in poly (l-lactide) and poly (d, l-lactide-co-glycolide) by magnetic sus-
g∞2 Infinite activity coefficient of solute
pension balance, J. Supercrit. Fluids 47 (2008) 296e301.
r Density, kg.m3 [20] Y. Yamini, M.R. Fat'hi, N. Alizadeh, M. Shamsipur, Solubility of dihydrox-
rc Critical density ybenzene isomers in supercritical carbon dioxide, Fluid Phase Equilibria 152
rr Reduced density (1998) 299e305.
[21] K. Keshmiri, A. Vatanara, Y. Yamini, Development and evaluation of a new
rref Reference density semi-empirical model for correlation of drug solubility in supercritical CO 2,
4 Fugacity coefficient Fluid Phase Equilibria 363 (2014) 18e26.
u Acentric factor [22] H. Asiabi, Y. Yamini, F. Latifeh, A. Vatanara, Solubilities of four macrolide an-
tibiotics in supercritical carbon dioxide and their correlations using semi-
empirical models, J. Supercrit. Fluids 104 (2015) 62e69.
Subscripts [23] M. Johannsen, G. Brunner, Solubilities of the fat-soluble vitamins A, D, E, and K
in supercritical carbon dioxide, J. Chem. Eng. Data 42 (1997) 106e111.
1 Solvent (SCF) [24] E. Stahl, W. Schilz, E. Schütz, E. Willing, A quick method for the microana-
2 Solute (Drug) lytical evaluation of the dissolving power of supercritical gases, Angewandte
c Critical property Chemie Int. Ed. Engl. 17 (1978) 731e738.
[25] K. Bartle, A. Clifford, S. Jafar, G. Shilstone, Solubilities of solids and liquids of
cal Calculated
low volatility in supercritical carbon dioxide, J. Phys. Chem. Ref. Data 20
exp Experimental (1991) 713e756.
i, j Component [26] A.Z. Hezave, H. Rajaei, M. Lashkarbolooki, F. Esmaeilzadeh, Analyzing the
solubility of fluoxetine hydrochloride in supercritical carbon dioxide,
Sol Solvation
J. Supercrit. Fluids 73 (2013) 57e62.
Sub Sublimation [27] G. Sodeifian, S.A. Sajadian, N.S. Ardestani, Determination of solubility of
Vap Vaporization Aprepitant (an antiemetic drug for chemotherapy) in supercritical carbon
dioxide: empirical and thermodynamic models, J. Supercrit. Fluids 128 (2017)
102e111.
References [28] P.J. Pereira, M. Goncalves, B. Coto, E.G. de Azevedo, M.N. da Ponte, Phase
equilibria of CO2þ dl-a-tocopherol at temperatures from 292 K to 333 K and
[1] A.A.H. Sathali, M. Suganya, Effect of different natural and synthetic super- pressures up to 26 MPa, Fluid Phase Equilibria 91 (1993) 133e143.
disintegrants used in developement of amiodarone hydrochloride fast dis- [29] E. Reverchon, P. Russo, A. Stassi, Solubilities of solid octacosane and tri-
solving tablets: a comparative study, J. Curr. Chem. Pharm. Sci. 6 (2016). acontane in supercritical carbon dioxide, J. Chem. Eng. Data 38 (1993)
[2] A.M. Rubim, J.B. Rubenick, E. Gregolin, L.V. Laporta, R. Leitenberg, C.M.B. Rolim, 458e460.
Amiodarone hydrochloride: enhancement of solubility and dissolution rate by [30] Y. Iwai, T. Fukuda, Y. Koga, Y. Arai, Solubilities of myristic acid, palmitic acid,
solid dispersion technique, Braz. J. Pharm. Sci. 51 (2015) 957e966. and cetyl alcohol in supercritical carbon dioxide at 35. degree. C, J. Chem. Eng.
[3] N. Rahman, S.M. Haque, S.N.H. Azmi, H. Rahman, Optimized and validated Data 36 (1991) 430e432.
spectrophotometric methods for the determination of amiodarone hydro- [31] R. Span, W. Wagner, A new equation of state for carbon dioxide covering the
chloride in commercial dosage forms using N-bromosuccinimide and bro- fluid region from the triple-point temperature to 1100 K at pressures up to
mothymol blue, J. Saudi Chem. Soc. 21 (2017) 25e34. 800 MPa, J. Phys. Chem. Ref. Data 25 (1996) 1509e1596.
[4] M.K. Riekes, M.P. Tagliari, A. Granada, G. Kuminek, M.A.S. Silva, H.K. Stulzer, [32] R. Chim, S. Marceneiro, M.E. Braga, A.M. Dias, H.C. de Sousa, Solubility of
Enhanced solubility and dissolution rate of amiodarone by complexation with norfloxacin and ofloxacin in supercritical carbon dioxide, Fluid Phase Equi-
b-cyclodextrin through different methods, Mater. Sci. Eng. C 30 (2010) libria 331 (2012) 6e11.
1008e1013. [33] K. Khimeche, P. Alessi, I. Kikic, A. Dahmani, Solubility of diamines in super-
[5] H.S. Yeoh, G.H. Chong, N. Mohd Azahan, R. Abdul Rahman, T.S.Y. Choong, critical carbon dioxide: experimental determination and correlation,
P. Praserthdam, E. Editor, E. Intakan, E. Office, Y. Zhao, Solubility measurement J. Supercrit. Fluids 41 (2007) 10e19.
method and mathematical modeling in supercritical fluids, Eng. J. 17 (2013). [34] K. Tamura, R.S. Alwi, T. Tanaka, K. Shimizu, Solubility of 1-
[6] R. Martin-Algarra, R. Pascual-Costa, M. Merino, V. Casabo, Effects of poly- aminoanthraquinone and 1-nitroanthraquinone in supercritical carbon diox-
sorbate 80 on amiodarone intestinal absorption in the rat, Int. J. Pharm. 122 ide, J. Chem. Thermodyn. 104 (2017) 162e168.
(1995) 1e8. [35] K. Pitchaiah, C.B. Rao, N. Sivaraman, M. Joseph, G. Madras, I. Brondz, Solubility
[7] S. Elhasi, R. Astaneh, A. Lavasanifar, Solubilization of an amphiphilic drug by of dialkylalkyl phosphonates in supercritical carbon dioxide: experimental
poly (ethylene oxide)-block-poly (ester) micelles, Eur. J. Pharm. Biopharm. 65 and modeling approach, Fluid Phase Equilibria 435 (2017) 88e97.
(2007) 406e413. [36] S. Kazemi, V. Belandria, N. Janssen, D. Richon, C.J. Peters, M.C. Kroon,
 G. Sodeifian et al. / Fluid Phase Equilibria 450 (2017) 149e159 159

Solubilities of ferrocene and acetylferrocene in supercritical carbon dioxide, Chem. Fundam. 15 (1976) 59e64.
J. Supercrit. Fluids 72 (2012) 320e325. [49] G.R. Pazuki, S. Mansouri, F. Feyzi, Modified cubic equation of state for pre-
[37] Y. Iwai, Y. Mori, N. Hosotani, H. Higashi, T. Furuya, Y. Arai, K. Yamamoto, diction VLE phase behavior of fluids: pure and mixture, Sep. Sci. Technol. 42
Y. Mito, Solubilities of 2, 6-and 2, 7-dimethylnaphthalenes in supercritical (2007) 1883e1899.
carbon dioxide, J. Chem. Eng. Data 38 (1993) 509e511. [50] A. Jouyban, S.H. Eghrary, R. Zarghami, Solubility of amiodarone HCl in pro-
[38] C. Si-Moussa, A. Belghait, L. Khaouane, S. Hanini, A. Halilali, Novel density- pylene glycolþ ethanol, propylene glycolþ water and their ternary solvent
based model for the correlation of solid drugs solubility in supercritical car- mixtures at 25 and 37 C, J. Mol. Liq. 186 (2013) 52e55.
bon dioxide, Comptes Rendus Chim. 20 (2017) 559e572. [51] J. Marrero, R. Gani, Group-contribution based estimation of pure component
[39] C. Garlapati, G. Madras, New empirical expressions to correlate solubilities of properties, Fluid Phase Equilibria 183 (2001) 183e208.
solids in supercritical carbon dioxide, Thermochim. Acta 500 (2010) 123e127. [52] S. Kirkpatrick, Optimization by simulated annealing: quantitative studies,
[40] X.-Q. Bian, Q. Zhang, Z.-M. Du, J. Chen, J.-N. Jaubert, A five-parameter empirical J. Stat. Phys. 34 (1984) 975e986.
model for correlating the solubility of solid compounds in supercritical carbon [53] N. Ryden, C.B. Park, Fast simulated annealing inversion of surface waves on
dioxide, Fluid Phase Equilibria 411 (2016) 74e80. pavement using phase-velocity spectra, Geophysics 71 (2006) R49eR58.
[41] J. Chrastil, Solubility of solids and liquids in supercritical gases, J. Phys. Chem. [54] K. Beaty, D. Schmitt, M. Sacchi, Simulated annealing inversion of multimode
86 (1982) 3016e3021. Rayleigh wave dispersion curves for geological structure, Geophys. J. Int. 151
[42] A. Jouyban, H. Chan, N. Foster, Mathematical representation of solute solu- (2002) 622e631.
bility in supercritical carbon dioxide using empirical expression, J. Supercrit. [55] C.-S. Su, Y.-P. Chen, Correlation for the solubilities of pharmaceutical com-
Fluids 24 (2002) 19e35. pounds in supercritical carbon dioxide, Fluid Phase Equilibria 254 (2007)
[43] D.L. Sparks, R. Hernandez, L.A. Este vez, Evaluation of density-based models for 167e173.
the solubility of solids in supercritical carbon dioxide and formulation of a [56] S.H. Yalkowsky, Estimation of entropies of fusion of organic compounds, Ind.
new model, Chem. Eng. Sci. 63 (2008) 4292e4301. Eng. Chem. Fundam. 18 (1979) 108e111.
[44] Y. Adachi, B.C.-Y. Lu, Supercritical fluid extraction with carbon dioxide and [57] T. Pang, E. McLaughlin, Supercritical extraction of aromatic hydrocarbon solids
ethylene, Fluid Phase Equilibria 14 (1983) 147e156. and tar sand bitumens, Ind. Eng. Chem. Process Des. Dev. 24 (1985)
[45] J.M. Del Valle, J.M. Aguilera, An improved equation for predicting the solubility 1027e1032.
of vegetable oils in supercritical carbon dioxide, Ind. Eng. Chem. Res. 27 [58] F.-H. Huang, M.-H. Li, L.L. Lee, K.E. Starling, F.T. Chung, An accurate equation of
(1988) 1551e1553. state for carbon dioxide, J. Chem. Eng. Jpn. 18 (1985) 490e496.
[46] D.C. Montgomery, Design and Analysis of Experiments, John Wiley & Sons, [59] R.F. Fedors, A method for estimating both the solubility parameters and molar
2008. volumes of liquids, Polym. Eng. Sci. 14 (1974) 147e154.
[47] B.E. Poling, J.M. Prausnitz, J.P. O'connell, The Properties of Gases and Liquids, [60] C.-S. Su, Y.-P. Chen, Measurement and correlation for the solid solubility of
Mcgraw-hill New York, 2001. non-steroidal anti-inflammatory drugs (NSAIDs) in supercritical carbon di-
[48] D.-Y. Peng, D.B. Robinson, A new two-constant equation of state, Ind. Eng. oxide, J. Supercrit. Fluids 43 (2008) 438e446.