Flecanaide for Pill in a Pocket

After 8 months of heavenly blissful NSR, (from having an ablation), Afib has returned about every other day now lasting more hours each day. Today was 14 hours, then I always convert back to NSR on my own. I asked the NP of the EP if I could try Flecanaide as a pill in the pocket since I've read about it on this website to tide me over until I can get another ablation. (They are booked up at least a month)

She RX'd 150 mg 2 hours after Afib starts along with 25 mg Metoprolol. I get the RX in two days, pharm had to order it. I'm 67 Year old , 130 lb. 2 years ago when Afib started, the first doc I saw RX'd Flec 50 mg (I think) 2X per day every day. I took it two and a half days. That amount did stop one episode, but it came roaring back--- worse--- six hours later(seemed to shake my chest more) than before, so I never wanted to take another one of those pills. No doctor ever explained the higher dose Pill in a Pocket.

Does anyone have any advice for me on what to look out for when I do take it? What if my AF breaks through again in the middle of the night? Is it dangerous for someone like me? I have never been converted in hospital before and sure don't want to if i can ride it out at home.

There was no discussion about pros and cons of the Pill in a Pocket Flec. I just asked if I could try it, and the NP Rx'd it.

My opinion - every other day seems frequent for PIP. A daily dose might make more sense. Why endure an episode every other day if a daily dose could prevent it? I don't know where the frequency cutoff is.

I believe the max dose is 200 mg for those under 154 pounds. Ratioing 130/154 would give a max dose of 168, so that is OK.

The contraindication for flec is heart failure. Assume you are otherwise in good health. They likely would not have prescribed flec otherwise.



Edited 1 time(s). Last edit at 02/20/2021 06:51PM by GeorgeN.

George is right. You don’t weigh enough for 300mg in a 24 hour period. I had a flecainide overdose from reading about the PIP method without knowing if you weigh less than 154 you can overdose. Trust me it’s dangerous. I was in the cardiac icu for 3 days and was told by the charge nurse I was lucky I didn’t die.

Thanks George for posting the weight/dose disclaimer!

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LaniB

There was no discussion about pros and cons of the Pill in a Pocket Flec. I just asked if I could try it, and the NP Rx'd it.

[www.afibbers.org]

The time to go to the Hospital for Electrocardioversion, is if you can't convert on your own, or it looks that way. Also by the time you went to the Hospital ER Room, even if they agreed to convert you, it would probably take 4-5 hours.

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The Anti-Fib
The time to go to the Hospital for Electrocardioversion, is if you can't convert on your own, or it looks that way. Also by the time you went to the Hospital ER Room, even if they agreed to convert you, it would probably take 4-5 hours.

I never waited that long. Before my first ablation I was a frequent ecv’er at the ER. I would be wheeled from the front to the triage and on the way I was greeted by all the nurses who saw me the previous week or two. Then a doctor or two would greet me and say out loud “get the crash cart ready because we are doing an ecv!!” It ran smoothly and I was in and out. After my second ablation i chose an ER further away because I really like my NP. Now each flutter/AF/SVT can reach up to 244 hr. In December my heart couldn’t catch up with the tachycardia and I got a type 2 MI.

I do try to wait a bit to try to self convert but I am so darn symptomatic and flutter is harder to go away on its own. Last week’s flutter was my absolute worst. Heart rate was 170s, BP dropped to 80/50 and I had angina (same as my MI), dripping sweat and nausea that I was concerned I could possible aspirate once sedated for the ECV and I was very dizzy. That was my fastest record to get ecv. They rushed to put on the pads and I don’t remember being knocked out with a sedative or even waiting for the anesthesiologist. I just woke up in surprise with a 49 pulse.

I blame my flecainide overdose for all of this. Before the PIP experience with 16 year history of afib, I never had this high tachycardia during an afib episode and I waited it out and mostly self converted within an hour tops. Everyone is different but I wanted to share my perspective.



Edited 2 time(s). Last edit at 02/21/2021 01:11PM by susan.d.

My suggestion is unless your EP. discourages you from it....go get your touch up follow up ablation ASAP to fix it hopefully not only for your PH. well being but mental also.
I went through hell for around 4 years before i dec. to get my ablation...it was Cryo and the EP. could only ablate around 65% of my PV's because i had 5 PV's with some irregular shapes that the balloon could not fit/freeze so i went back for a RF one 1 year later and for 2.5 years since not a peep. (- the 1st 2 weeks that were not great as in 6 ARR. in 9 days)
The 2nd carries a 90+ % success rate long term whatever that means so get that going is my advice.
On a side note i am 6,2 180# and i had very similar sym. and freq. of ARR. as you do both before my 1st ablation and in between my Cryo and RF ablations so about every 2-3 days and i made life a lot easier for myself before getting fixed by using the 2nd most popular PIP out there Propafenone but by not using it normally.
For about 3.5 years i swallowed 2x150 mg Propaf. pills and converted on ave. in 3 hours but after my 1st unsuc. ablation the times were getting longer and sometimes no conversion at all and if i did not convert by around 8-10 hours i went into a horrible flutter around 150-160 beats that would last maybe 2 days no matter how many more propaf. i took so i looked for a way to stop this insanity either by switching to flec. or hmm maybe i thought get the full load of propaf. up front in my blood stream by CHEWING IT not swallowing it and boy did that ever work like charm. I chewed 1x150mg pill and on ave i converted in 1 HOUR so i was dancing after that.....both less drug and quicker conv. what's not to like not to mention the mental relief knowing i will never have the long ARR. followed by horrible flutter after was amazing. I started chewing within 5 min. of the onset of ARR. so the sooner you tackle it the better...it was like a runaway train with me but if i could get to it quick enough i could stop it in its tracks and it seems to work a little better with something to eat with some fat content.
2 months before my 2nd ablation the godsend RF 1.....i met the EP. that was going to perf. the RF on me and i told him about my chewing of Propaf. and he blinked threw his head back and laughed saying he never heard that before but great if it works for you he said and i will remember that....saying in not so many words that he may suggest this to some of his patients which of course is not the norm but it works believe me but we all have to keep in mind that everyone is diff.
I had about 80 ARR. between april 2018 when i 1st started using this method and nov. 2018 and it converted me every single time anywhere from 1/2 hour to 2 hours at the rare most. I found that if i did not convert by the 75 min. mark after the 150mg orig. chew i chewed 1/4 more of another pill every 15 min. until i converted now i may have converted anyway after around 2 hours with only the orig. 150mg chew but i played it safe by adding on a little at a time until conv. but this only happened maybe 10 times out of 80 times as 70 times i converted between 45-75 min as when chewed you get the full effects up front in the 1st 2 maybe 3 hours compared to the normal 8 hours for a dose of swallowed propaf.
It's not an enjoyable exper. chewing this drug though as it tastes like your chewing a rusted tin can and both your lips and tongue have a slightly frozen feeling for about 5 min. after chewing but it goes away..... so chew fast....it goes to show how powerful this drug is as in only a few seconds in your mouth and just grazing you lips as you chew you get that much reaction in your mouth and lips.
Anyway i have gone on about this enough so GL whatever route you choose and PM me if you want any more advice about propaf.



Edited 2 time(s). Last edit at 02/21/2021 03:19PM by vanlith.

Quote
susan.d

The time to go to the Hospital for Electrocardioversion, is if you can't convert on your own, or it looks that way. Also by the time you went to the Hospital ER Room, even if they agreed to convert you, it would probably take 4-5 hours.

I never waited that long. Before my first ablation I was a frequent ecv’er at the ER. I would be wheeled from the front to the triage and on the way I was greeted by all the nurses who saw me the previous week or two. Then a doctor or two would greet me and say out loud “get the crash cart ready because we are doing an ecv!!” It ran smoothly and I was in and out. After my second ablation i chose an ER further away because I really like my NP. Now each flutter/AF/SVT can reach up to 244 hr. In December my heart couldn’t catch up with the tachycardia and I got a type 2 MI.

I do try to wait a bit to try to self convert but I am so darn symptomatic and flutter is harder to go away on its own. Last week’s flutter was my absolute worst. Heart rate was 170s, BP dropped to 80/50 and I had angina (same as my MI), dripping sweat and nausea that I was concerned I could possible aspirate once sedated for the ECV and I was very dizzy. That was my fastest record to get ecv. They rushed to put on the pads and I don’t remember being knocked out with a sedative or even waiting for the anesthesiologist. I just woke up in surprise with a 49 pulse.

I blame my flecainide overdose for all of this. Before the PIP experience with 16 year history of afib, I never had this high tachycardia during an afib episode and I waited it out and mostly self converted within an hour tops. Everyone is different but I wanted to share my perspective.

I was figuring from the time decision was made to go to the ER, then getting there and so on. Yes the more symptomatic you are, the faster they would probably try to get it done.

Quote
vanlith
For about 3.5 years i swallowed 2x150 mg Propaf. pills and converted on ave. in 3 hours but after my 1st unsuc. ablation the times were getting longer and sometimes no conversion at all and if i did not convert by around 8-10 hours i went into a horrible flutter around 150-160 beats that would last maybe 2 days no matter how many more propaf. i took.

No matter how many more you took? Within 24 hours? Or 10-12 hours after taking 300mg already? Dangerous. I’m sure Propaf. Has a death warning label like flecainide.

I hope nobody is desperate enough to try because the risks of an overdose or death. George-your opinion please?

Susan Flec. i suspect is much stronger than Propafenone as you can take as much as 300mg (2 pills) every 8 hours= 900 mg. in 24 hours

I always waited 8 hours before another dosing regiment when trying to stop my afib/flutter and never going over 900mg in 24 hours...before of course my chewing miracle was discovered.



Edited 1 time(s). Last edit at 02/22/2021 03:13PM by vanlith.

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vanlith
Susan Flec. i suspect is much stronger than Propafenone as you can take as much as 300mg (2 pills) every 8 hours= 900 mg. in 24 hours.

Yes, from the original PIP paper, "The dose of flecainide was 300 mg if the patient weighed 70 kg or more and was 200 mg otherwise; the dose of propafenone was 600 mg if the patient weighed 70 kg or more and was 450 mg otherwise."

Quote
vanlith
...before of course my chewing miracle was discovered.

I've chewed my flec since early in my 16+ years using it PIP. Someone here (back then) mentioned it, and I've been doing it ever since. I don't know if it made a huge difference, but my routine has always been to take and chew it absolutely as soon as I know I'm in afib (unless I'm doing a breath hold conversion or other experiment). I also load up with lots of powdered magnesium and potassium at the same time. My conversions are usually pretty quick (an hour ish).

Vanlith- are you taking instant or time released? Others may need to ramp up after 3-4 days to the maximum dose.

Drugs.com

Usual Adult Dose for Atrial Fibrillation
Immediate-release Tablets:
Initial dose: 150 mg orally every 8 hours; may increase dose after at least 3 to 4 days to 225 mg orally every 8 hours; if additional therapeutic effect is needed, may increase dose to 300 mg orally every 8 hours.
Maximum dose: 900 mg/day

Uses:
-To prolong time to recurrence of paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms in patients without structural heart disease.
-To prolong time to recurrence of paroxysmal supraventricular tachycardia (PSVT) associated with disabling symptoms in patients without structural heart disease.
-To treat documented ventricular arrhythmias, such as sustained ventricular tachycardia that, in the judgment of the physician, are life-threatening.

Extended-release Capsules:
Initial dose: 225 mg orally every 12 hours; may increase dose after at least 5 days to 325 mg orally every 12 hours; if additional therapeutic effect is needed, may increase dose to 425 mg orally every 12 hours.

Use: To prolong time to recurrence of symptomatic atrial fibrillation (AF) in patients with episodic (most likely paroxysmal or persistent) AF who do not have structural heart disease.

Usual Adult Dose for Atrial Flutter
Immediate-release Tablets:
Initial dose: 150 mg orally every 8 hours; may increase dose after at least 3 to 4 days to 225 mg orally every 8 hours; if additional therapeutic effect is needed, may increase dose to 300 mg orally every 8 hours.
Maximum dose: 900 mg/day

Uses:
-To prolong time to recurrence of paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms in patients without structural heart disease.
-To prolong time to recurrence of paroxysmal supraventricular tachycardia (PSVT) associated with disabling symptoms in patients without structural heart disease.
-To treat documented ventricular arrhythmias, such as sustained ventricular tachycardia that, in the judgment of the physician, are life-threatening.

Extended-release Capsules:
Initial dose: 225 mg orally every 12 hours; may increase dose after at least 5 days to 325 mg orally every 12 hours; if additional therapeutic effect is needed, may increase dose to 425 mg orally every 12 hours.

Yes.....good Q. Susan...it was just the reg. time released.

Immediate time release or extended release? The maximum dosage differs from instant release 900mg after a 3-4 day ramp to maximum strength —to 425 mg every 12 hours maximum (am I right George?) for extended release with a 5 day ramp to maximum dose.



Edited 2 time(s). Last edit at 02/22/2021 07:44PM by susan.d.

Quote
susan.d
Immediate time release or extended release? The maximum dosage differs from instant release 900mg after a 3-4 day ramp to maximum strength —to 425 mg every 12 hours maximum (am I right George?) for extended release with a 5 day ramp to maximum dose.

I've never dealt with timed release flec or propafenone (& never used propafenone). Not sure why the max daily dose would differ with timed release. Don't think you'd want timed release for PIP, you want immediate loading dose. I know for daily use of flec, you want to build up to a steady state serum level. This is a function of the 1/2 life of the drug (stated as 12 hours, but surely differs for the individual) and how much you are taking. I've only taken flec daily during about one month in 2012 and I was titrating down the whole time. I also only took it at night as my episodes occurred at night, so having a steady state level during the day didn't make sense. This is NOT standard dosing and I was self-directed.

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GeorgeN
I know for daily use of flec, you want to build up to a steady state serum level. This is a function of the 1/2 life of the drug (stated as 12 hours, but surely differs for the individual) and how much you are taking..

When I was starting flecainide I had the flecainide serum test help determine what dosage will work for me (and my liver enzymes function). One takes their flecainide dose every 12 hours and the serum test is done exactly 11 hours later —one hour before your next dose.

I got resistance from a cardiologist in getting the lab test repeated when I dropped 50 pounds. I think this lab an important tool.