If you searched for ACLS medication updates because you are afraid your old drug cards are now wrong, here is the reassuring part up front. The core cardiac arrest drugs you learned - epinephrine, amiodarone, lidocaine - are still the core cardiac arrest drugs. What has shifted is the emphasis: when to give them, which drugs to stop reaching for out of habit, and how much evidence sits behind each choice. The current reference point is the Part 9 Adult Advanced Life Support chapter of the 2025 American Heart Association guidelines, and this article walks through its medication content in plain language.
A quick note on scope. This is a medication-focused companion piece. If you want the full picture of what changed across compressions, defibrillation, airway, and algorithms, start with our broader roundup, AHA Guideline Changes for 2026: What ACLS Providers Need to Know Now. And if you want the actual doses, routes, and indications on one page you can print, keep our ACLS Medications Cheat Sheet: Dosages, Routes, and Indications open in another tab. This article explains what is current and what has been refined; the cheat sheet is the quick-lookup tool.
One ground rule before we start: we only describe changes that appear in the published guideline text. Where a drug's dosing has not changed, we say so rather than inventing a headline. Always confirm against the official algorithm and your facility protocols before you act at the bedside.
Guideline updates come in three flavors, and mixing them up causes most of the confusion on the unit. A new recommendation adds something that was not addressed before. A changed recommendation reverses or modifies earlier advice. A reaffirmed recommendation keeps the previous advice but strengthens or restates the evidence. Medication content in ACLS is mostly the third kind. Drugs rarely get dramatic dose changes, because large randomized trials in cardiac arrest are difficult to run and the existing evidence tends to be incremental.
The AHA's own executive summary of the 2025 guidelines notes that the adult advanced life support section added new recommendations on vector change and double sequential defibrillation, nonvasopressor medications, adjuncts to CPR, and the initial management of bradycardia. Notice that "nonvasopressor medications" is on that list. That is where most of the medication-related practice changes live, and it is why this article spends real time on drugs you might not think of as "core" ACLS medications.
Epinephrine remains the foundational vasopressor in adult cardiac arrest. The guideline language is that epinephrine administration is recommended, and that it is reasonable to give 1 mg every 3 to 5 minutes. If your muscle memory says "1 mg, every 3 to 5 minutes," nothing in the current text asks you to change that.
What the guideline does emphasize is the evidence behind alternatives. According to the AHA's adult advanced life support guideline page, studies comparing different dosing intervals, high-dose epinephrine, and low-dose epinephrine against standard-dose epinephrine have not demonstrated an advantage in survival outcomes. In other words, the question "should we try a bigger or smaller dose?" has been tested, and the standard dose has held its ground.
The practical teaching point is rhythm-specific timing:
The 2025 text explains the reasoning: epinephrine has been shown to increase return of spontaneous circulation and survival to hospital admission, but the evidence for improved survival to discharge or good neurologic outcome is limited. For patients in shockable rhythms, that literature supports prioritizing rapid defibrillation and giving epinephrine after initial CPR and shock attempts have not worked. The practical translation for a megacode: in VF, your first priority is the shock and high-quality compressions, not the drug. In asystole or PEA, there is no shock to wait for, so epinephrine goes in early.
For a deeper dive on dosing mistakes and timing habits, see our guide to epinephrine in ACLS: dosing, timing, and common mistakes.
If you trained in an earlier era, you may remember vasopressin appearing in the algorithm as an optional substitute for the first or second epinephrine dose. That option is not part of the current picture. The 2025 recommendation states that vasopressin, alone or in combination with epinephrine, should not be used in place of epinephrine, and it carries a Class 3 (No Benefit) designation. For the practical bottom line: when the algorithm says epinephrine, it means epinephrine.
For adults in cardiac arrest with VF or pulseless VT that is unresponsive to defibrillation, the guideline states that amiodarone or lidocaine may be considered. The wording matters: "may be considered" is a softer recommendation than "is recommended." These drugs have a role, but the foundation of VF/pVT care is still defibrillation and high-quality CPR.
The dosing most providers learned continues to appear in the current materials:
The takeaway for exam prep is that the two drugs sit side by side as acceptable choices, not as a ranked pair. If your hospital stocks one over the other, either is consistent with the guideline. For the clinical comparison, read Lidocaine vs Amiodarone in ACLS, and for a pure dosing refresher see the amiodarone sections of the medications cheat sheet linked above.
The most meaningful shift in day-to-day practice is not a new drug. It is a cluster of drugs that the guideline asks you not to give routinely. The AHA's recommendations in the nonvasopressor section are consistent: these agents may help in specific situations, but they should not be part of the reflexive code-blue routine.
Routine calcium administration during cardiac arrest is rated Class 3 (No Benefit). The earlier focused update on this topic found that giving calcium routinely, including in refractory asystole and PEA, did not improve survival. This does not mean calcium has no place. It means calcium belongs where there is a reason for it, such as suspected hyperkalemia or certain toxicologic arrests. Our article on calcium administration during ACLS covers those specific indications.
Routine sodium bicarbonate is likewise rated Class 3 (No Benefit). Bicarbonate remains a reasonable consideration when there is a specific indication such as hyperkalemia or certain overdoses. A systematic literature review of sodium bicarbonate in in-hospital and out-of-hospital cardiac arrest gives the research background if you want to see how the evidence has been weighed. For clinical myth-busting, see Sodium Bicarbonate in Cardiac Arrest: Debunking Myths.
Steroid use during arrest is characterized as being of uncertain benefit (Class 2b), and routine magnesium, like calcium and bicarbonate, is not recommended during undifferentiated arrest unless there is a specific indication such as known hypomagnesemia. The combination of vasopressin, steroids, and epinephrine has been studied in in-hospital cardiac arrest; a recent review of vasopressin, steroids, and epinephrine triple therapy discusses the mechanisms and clinical evidence, and the AHA, ERC, and ILCOR guidance does not endorse routine use during in-hospital arrest.
The pattern across all four drugs is the same, and it is a useful way to organize your thinking: give them when you can name the reason, not because the clock is running. If you are the code leader and someone asks "should we give bicarb?", the guideline-aligned answer is "what is the specific indication?"
The executive summary lists the initial management of bradycardia among the areas where new recommendations were added. For medications, the part most learners care about is the familiar sequence: atropine as the first-line drug for symptomatic bradycardia, then transcutaneous pacing or an infusion of dopamine or epinephrine if atropine is not effective. As with every drug in this article, check the current algorithm graphic and your facility's protocol for the exact dosing and sequencing, because the algorithm is the document you will be tested against.
If you want to rehearse the sequence, our ACLS algorithms hub collects the algorithms in one place, and the pacing article on this site explains when pacing becomes the right next step.
One of the more visible additions in the 2025 update is on the opioid side. The guideline summary describes recommendations supporting public access to naloxone alongside AEDs, and take-home naloxone programs with training. For ACLS providers, the clinical lesson is that opioid-related arrest has its own pathway and that airway and ventilation support come first. In many of these patients the underlying problem is respiratory, not primary cardiac, so the order of operations differs from a classic VF arrest. Consider reviewing the opioid pathway as its own topic when you study.
Many providers over-study "what's new" and under-study "what's stable." Here is the stable core that your online ACLS exam and your megacode still revolve around:
If you can recite those four points and explain the reasoning, you are in good shape for medication questions on a current exam, regardless of which month you test.
Medication questions on certification exams tend to test three things: the right drug for the rhythm, the right dose and route, and the right timing in the algorithm. Here is a simple approach that respects how little actually changes between guideline cycles.
Medication practice in resuscitation moves slowly and deliberately. The best habit is to read the primary source periodically instead of relying on secondhand summaries, including summaries from training companies that may oversimplify. The AHA's Part 9 chapter is the document that defines the adult ALS medication recommendations, and the executive summary gives the highlights.
Our courses are developed by practicing Board Certified Emergency Medicine physicians and are based on current AHA and ILCOR guidelines, so you can complete your coursework online at your own pace and print your card as soon as you pass. If your card is coming due, you can renew with the ACLS recertification course and get the guideline-aligned medication content in one sitting. Unlimited retakes and a money-back guarantee if your employer does not accept the certification are part of how we make that low-risk.
This article is educational and does not replace your facility protocols, medical direction, or the official AHA materials.
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