Letters to the Editor

Thrombophlebitis: A Common Complication of Amiodarone

to the editor: I read with interest the excellent article1 by Dr. Siddoway on the clinical use
of the antiarrhythmic drug amiodarone (Cordarone) that appeared in the December 1,
2003, issue of American Family Physician. The author clearly presented the effectiveness
and adverse effects related to this therapy that has been used intravenously or orally to
convert and prevent recurrences of cardiac arrhythmias. However, there was no mention
in the article1 of thrombophlebitis, a common complication associated with intravenous
amiodarone.2
Recent studies3 have reported rates of phlebitis as high as 16 percent with the intravenous
administration of amiodarone. A meta-analysis4 of 18 randomized controlled trials
studying intravenous amiodarone to convert atrial fibrillation reported an 8 percent rate of
phlebitis among the 550 patients who received amiodarone. In this systematic review,4
phlebitis was the most common adverse effect of the drug, followed by bradycardia (4
percent of patients) and hypotension (2 percent of patients).
Thrombophlebitis usually occurs when high doses of amiodarone are infused over a long
period in peripheral veins. Thus, to avoid this side effect, the drug should be administered
in a peripheral vein for a maximum of 24 hours. Afterwards, the drug must be used orally
or a central vein access should be considered.5 By following these precautions, this
minor but frequent complication can be avoided.
HENRIQUE HORTA VELOSO, M.D.
ANGELO AMATO VINCENZO DE PAOLA, M.D.
VOTCOR-Hospital da Venervel Ordem Terceira da Penitncia
Rua Conde de Bonfim 1033, Tijuca
Rio de Janeiro, Brazil 20530-001
REFERENCES
1. Siddoway LA. Amiodarone: guidelines for use and monitoring. Am Fam Physician
2003;68:2189-96.
2. Aravanis C. Acute thrombophlebitis due to IV use of amiodarone. Chest 1982;82:5156.
3. Vardas PE, Kochiadakis GE, Igoumenidis NE, Tsatsakis AM, Simantirakis EN,
Chlouverakis GI. Amiodarone as a first-choice drug for restoring sinus rhythm in patients
with atrial fibrillation: a randomized, controlled study. Chest 2000;117:1538-45.
4. Hilleman DE, Spinler SA. Conversion of recent-onset atrial fibrillation with
intravenous amiodarone: a meta-analysis of randomized controlled trials.
Pharmacotherapy 2002;22:66-74.
5. Faniel R, Schoenfeld P. Efficacy of i.v. amiodarone in converting rapid atrial
fibrillation and flutter to sinus rhythm in intensive care patients. Eur Heart J 1983;4:1805.

Plebitis And Varicose Veins

This is an inflammation of the veins. The signs are pain and tenderness in the course of
the vessel, which soon becomes cord-like and knotted, by which it may be distinguished
from arteritis. There are swelling and redness of the adjacent parts, the redness being in
streaks. The limb below the part is swollen, from obstruction of the circulation and
effusion of serum. Pus is a frequent production of phlebitis, in which case perfect
occlusion of the vein above occurs, with the formation of an abscess, or the pus passes
into the heart and produces excessive prostration. Varicose veins are the sequel generally
to phlebitis.
TREATMENT. -- The treatment consists in fomentations, leeching, and occasional
purging. The alteratives should also be given. The topical application of tincture of
lobelia and arnica are also useful. Rest is enjoined. The abscesses and consequent
ulceration should be treated upon general principles. If the veins become varicosed,
astringent applications, and careful bandaging, should be resorted to.
The best method of curing varicose veins, however, is by elastic stockings. These give an
equable pressure, which can be so regulated as to afford any compression desired, on
every part of the leg where the varicose veins exist. If the veins are varicosed throughout
the whole length of the limb, the full-length stocking should be worn. If confined only to
the leg, the stocking represented on the right-hand side of the cut is alone necessary, and
in some cases the knee-caps and anklets are only required, depending upon the situation
of the varicose veins. These elastic contrivances are not only radical cures, but patients
suffering from varicose veins have no idea what ease and comfort they afford. They give
a very agreeable support to the limb, prevent varicose ulcers, besides quickly reducing
the enlarged veins to natural size. They are made of the best silk, are very durable, and
not so expensive as not to be afforded by the poorest sufferer. All those desiring these
admirable contrivances are requested to correspond with the author; -- preliminary
correspondence as to size, measurement, etc., is in all cases essential to secure that
perfect adaptation which is indispensably necessary in order to afford relief and cure.
Great harm is done if the elastic appliance is not eligible in every respect, and therefore
patients should hesitate before purchasing those inferior, half cotton articles, which are
purchasable everywhere; they do not fulfil the conditions required of them, and are
capable of doing great injury, owing to the unequal compression they afford. Prices as
above.

If you would like to learn about the causes, symptoms and diagnosis of Phlebitis, and
Plebitis treatment, you will find the following information of help.

Phlebitis
Superficial thrombophlebitis is an inflammation of a vein just under the skin, usually in a
leg. A small blood clot commonly forms in the vein, but is usually not serious. The
condition usually settles and goes within 2-6 weeks. Treatments can ease pain or
discomfort. Complications occur in a small number of cases. Superficial thrombophlebitis
is different to, and much less serious than, deep vein thrombosis.

What is thrombophlebitis?

Phlebitis means inflammation of a vein.

Thrombo(sis) means a blood clot in a vein.

A vein is a blood vessel that takes blood towards the heart. If a vein becomes inflamed, a
blood clot commonly forms inside the inflamed portion. So, the term thrombophlebitis is
used to mean an inflamed vein, with or without a small blood clot inside the vein.
(However, thrombophlebitis is commonly just called phlebitis.)

What is superficial thrombophlebitis?

The superficial veins are the ones that you can often see or feel just under the skin. Most
bouts of thrombophlebitis occur in a leg vein, but any superficial vein can be affected. A
typical site is in a varicose vein in a leg. Varicose veins are common, particularly in
pregnant women. Superficial thrombophlebitis is not usually serious, but complications
sometimes occur (see below).
Note: this page does not deal with inflammation or thrombosis of deep veins. The deep
veins are larger, pass through the muscles in your arms and legs, and you cannot see or
feel them. Some people get confused between superficial thrombophlebitis and deep vein
thrombosis. They are quite different. A deep vein thrombosis (DVT) is more serious, and
is dealt with in another page.

What causes superficial thrombophlebitis?

Most cases
Many cases occur for no apparent reason. A slight injury to the vein may trigger the
inflammation in some cases. Many cases occur in people who already have varicose veins
of the legs. Varicose veins are probably more prone to minor injuries which can lead to
inflammation.

Risk factors
There are a number of 'risk factors' that make it more likely for inflammation or a blood
clot to develop in a vein which may lead to superficial thrombophlebitis.

Abnormality, damage or injury to a vein. Varicose veins are the most common
abnormality. A common cause of injury is by injecting drugs into a vein. This is

common in people who inject 'street drugs'. Sometimes it occurs after having
intravenous injections or intravenous infusions ('drips') in hospital. There are
other rare disorders that can damage veins such as Behcet's disease, Buerger's
disease, and Mondor's disease.

Abnormalities of blood clotting factors. Various conditions can alter certain

chemicals ('clotting factors') in the bloodstream which make the blood more easy
to clot. These include: using the oral contraceptive pill, cancer, smoking, and
pregnancy. One study found that an episode of thrombophlebitis in the leg
occurred in about 1 in 200 pregnant women, with most occurring in the first 48
hours after giving birth. There are also some rare hereditary blood disorders where
blood clots develop more readily than usual.

Stasis of blood (blood flowing more slowly than normal). For example, this
occurs in varicose veins, during long flights, in people who are immobile, and
following major surgery.

What are the symptoms of superficial thrombophlebitis?

Swelling, redness, and tenderness along a part of the vein are the usual symptoms.

You may develop a fever (high temperature).

If a blood clot develops inside the inflamed part of the vein, the vein may then
feel hard or 'knobbly'. The blood clot is usually of little concern as it is small.
There are many other veins which carry the blood, and bypass the blocked vein.

When the inflammation settles, a persistent darker area of skin

(hyperpigmentation) may remain over the affected vein. A persistent firm nodule
(small lump) may also remain below the skin at the site of the affected vein.

What is the treatment for superficial thrombophlebitis?

Most bouts of superficial thrombophlebitis settle within 2-6 weeks. No treatment may be
needed if the symptoms are mild. Treatment aims to ease symptoms.

Keep on with normal activities as much as possible.

A hot flannel (cloth) placed over the vein may ease the pain.

Anti-inflammatory painkillers such as ibuprofen may ease the pain (but are not
advised if you are pregnant). Paracetamol is an alternative.

When you rest (when watching TV, or reading a book, etc), if you raise an
affected leg so that your foot is higher than your hip, it helps to reduce swelling
and discomfort. You can do this by lying on a sofa and putting the leg up on some
cushions. When sleeping in bed, you can keep your leg raised by putting it on a
pillow.

Compression (support) stockings may be advised by your doctor if a vein in your

leg is affected. This may ease discomfort whilst the inflammation settles.

If varicose veins are the source of the problem, once the inflammation has settled, you
may wish to consider treatment to remove the varicose veins. See your doctor for advice.

Are there any complications from superficial thrombophlebitis?

The inflammation and pain usually settle within a few weeks. Most people make a full
recovery. The possible complications listed below are uncommon, but are listed to give a
guide as to 'what to look out for'. See a doctor as soon as possible if you suspect a
complication is developing.

Infection. Sometimes the affected vein becomes infected. The pain may then
become worse, and the redness spreads. You are likely to feel generally unwell.
You may need antibiotics if the vein becomes infected. Rarely, infection in a vein
becomes severe and may spread to other areas of the body.

Blood clot extending. In some cases, the blood clot extends further up the vein. It
may join with a deep, large vein, and the clot may extend to cause a 'deep vein
thrombosis' (DVT). This is more likely if the superficial thrombophlebitis is in the
upper thigh, near to where the superficial veins and the deep veins of the leg meet.
It is also more likely to occur if the superficial thrombophlebitis develops in a
previously normal vein (not a varicose vein). Another page deals with DVT. Very
briefly, see a doctor urgently if:
o inflammation, redness, or hardness spread up the inner thigh towards the
groin.
o your whole leg swells.
o pain becomes suddenly worse.
o you develop any new breathing problems, or get chest pains. (Sometimes a
clot from a DVT breaks off and travels to the lung.)

Rare conditions. If you have recurring bouts of superficial thrombophlebitis, it

may be the first indication of a more serious condition (listed above in 'risk
factors'). Tests may be advised if there is no explanation for recurring bouts of
superficial thrombophlebitis.

EMIS and PIP 2005 Updated: September 2005 PRODIGY Validated