Generic flec & breath hold conversion

These two are related in the same episode for me.

Since around 2008, I’ve purchased my flecainide from Europe and was initially prescribed Tambocor in the US before that. The flec is from Meda AB, a specialty pharmaceutical company and is branded Apocard or Tambocor, depending on the country they are sold in. The pills are individually wrapped on a blister pack card which keeps them from oxidizing. Because of my good afib control and few episodes, I end up disposing of the meds after about 5 years (a number that I pulled out of the air, but seems to work). Though I still have some of these, got some generic flec from a US pharmacy. Used the generic for the first time for an episode yesterday. Normally flec (as Apocard or Tambocor) converts me in an hour or two, with 4 or 4.5 hours being the outlier except for my first two flec conversions in 2004 (one converting a 2.5 month episode). Yesterday took 9 hours and was aided by a breath hold conversion. See below. Listening to these to Peter Attia podcasts has sensitized me to issues with generics (and branded meds, too) [peterattiamd.com] [peterattiamd.com] (Susan has also previously commented about this) From the beginning, after taking the generic flec, this episode seemed to respond differently than my other flec conversion episodes. Kind of like the med didn’t have as much potency. Of course, I don’t know this to be the issue, it could have just been this particular episode. I don’t plan to repeat the experiment, and will continue to use the Meda branded meds from Europe for future episodes.

In January, I posted [www.afibbers.org] (images come through on my phone, but not on my Mac browser) about a breath hold conversion and that the mechanism was low SpO2 vs. high CO2 as I’d originally thought here in 2018 [www.afibbers.org] and also here in 2018 [www.afibbers.org] . Yesterday, I’d tried a few breath holds, without success, as it is hard to hold them long with your heart flopping around. As time wore on, I thought I’d need get anticoagulation and organize a cardioversion. The afib had converted to flutter at about 115 BPM, which is actually pretty comfortable. This time I did 50 or 60 hyperventilation breaths followed by an exhaled breath hold. I was wearing a recording heart rate monitor as well as an SpO2 device, without recording turned on. When the urge to breathe got strong (caused by high CO2), I gave up and started breathing, I converted 15 or 20 seconds or more after I’d started breathing. The CO2 urge to breathe goes away immediately after starting to breathe. The SpO2 dropped into the 80’s, but did not drop till quite a bit after I'd started breathing. Low, but not for me as I routinely drop to 70% or lower on these holds. I’m now much more convinced it is the low SpO2, not the high CO2 that caused the conversion. This may be good news, as with a lot of hyperventilation breaths, it is easier to get a low SpO2 as opposed to high CO2.

Warning, these breathing techniques are powerful. They may have risk for some people. I have done them repeatedly when not in afib, so know what to expect. I’ve also studied the physiology and biochemistry. I have recorded PAC’s on these long exhaled breath holds, when not in afib. Perhaps, this is a mechanism for the reset? These could kick someone into afib. If you try this, do it sitting, reclining or prone. The hyperventilation gets rid of the signal or urge to breath from CO2. If you drop O2 too low, you could pass out. Hence don’t want to be standing, operating machinery or near water. If you pass while on the floor, prone, you should just start breathing again. You don’t want to fall & hit your head. If you are prone to anxiety attacks, you may want to avoid breath holds that increase CO2 to an uncomfortable level.

Here are some heart rate vs. time graphs of the conversion:

[drive.google.com]

[drive.google.com]

Image from January with SpO2 & heart rate.

[drive.google.com]



Edited 2 time(s). Last edit at 06/01/2021 06:00PM by GeorgeN.

George - just to clarify - are these Valsalva or modified Valsalva maneuvers or something else?

Is there a video on YouTube demonstrating the technique?

Thanks

George- I too got my brand name flecainide (Tambocor) from Germany or the U.K. I have a carryon worth of brand in blister paks left (some expiration is 8-23) since I no longer can take flecainide. I’m waiting to make a trip to dispose of them to a drop off pharmacy bin.

I feel brand works better than generic flecainide. At least for me.

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NotLyingAboutMyAfib
George - just to clarify - are these Valsalva or modified Valsalva maneuvers or something else?

Is there a video on YouTube demonstrating the technique?

NLAMA, it is not Valsalva, which is holding the breath on an inhale and bearing down. This is a bunch of hyperventilation breaths followed by a breath hold after an EXHALE. No bearing down. This is similar to what Wim Hof does. Wim usually recommends 30 or 40 hyperventilation breaths. For my purpose here, I did more (50, 60 or more - didn't count - the more you do the easier it is to hold an exhale), I inhaled starting with the belly & diaphragm, then filled the chest, then exhaled as fully as I could to get rid of as much CO2 as possible. Then, on an exhale, I held my breath out. At the beginning of the breath hold, the only discomfort is from the lack of air in the lungs. As time goes on, the CO2 starts to build and you get the signal to breathe. The breathing muscles can also start to spasm. These are the signals to breathe. The free divers will tell you that you actually have a lot more time before you pass out. Not with afib, but just fooling around, I've dropped my SpO2 into the 40's (not that I'm suggesting anybody else do this). When SpO2 gets low, CO2 is also high. Because of the Bohr Effect, your body actually gets to use more of the oxygen as hemoglobin will bind less tightly to the O2 as the blood pH lowers with more CO2/carbonic acid. This causes a right shift in the oxyhemoglobin dissociation curve. You want an exhaled breath hold, as your O2 will lower much more quickly than on an inhaled breath hold.

A search on Wim's videos on his technique. This will explain the basic concept. A search on hypoxia and arrhythmia conversions turns up nothing. There are papers on hypoxia causing arrhythmia in emergency/ICU settings. But no YouTube videos showing a guy converting an afib episode with a low SpO2 breath hold

Again, as mentioned, these techniques can have side effects. Some people have even had emotions or past traumas come up during these techniques (though I've never experienced this).



Edited 2 time(s). Last edit at 05/28/2021 03:53PM by GeorgeN.

Some people have even had emotions or past traumas come up during these techniques (though I've never experienced this)

I'd love to find a technique that brings up past youth even at the cost of experiencing those traumas again.

Congradulations on your pioneering Conversion!

Backing up, why did you even go into AFIB in the first place?
I assume your new CO2 machine was not up and available?

Whether we are measuring CO2 or SPO2, are we still assuming a combined effect of Flecainide/Breath Holds on the lengthening of the ERP thus facilitating Arrhythmia termination?

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NotLyingAboutMyAfib
I'd love to find a technique that brings up past youth even at the cost of experiencing those traumas again.

The techniques that are known for emotional stuff include Stan Grof's Holotropic Breathing as well as what is called Rebirthing.

Both involve long periods of hyperventilation and are best done with a coach under supervision. I've not done this.

For more there are descriptions in James Nestor's book Breath and Scott Carney describes Hof's work in detail in What Doesn't Kill Us and goes beyond in The Wedge.

Hof has classes online which I've taken - goes beyond breathing into hypothermia and other things.

One of the best breathing instructors is Patrick McKeown Site: [oxygenadvantage.com] His last two books are excellent, The Breathing Cure (right now only available off his website in Ireland. Will be in the US in July? I think. I have a copy from Ireland. Also The Oxygen Advantage. These are great for helping breathing overall, not so much the psych part.

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The Anti-Fib
Backing up, why did you even go into AFIB in the first place?

My hypothesis. In January, had a meeting with my doc, Steven Gundry. He'd had us take a food sensitivity panel. Turns out I spiked big time on some foods that I ate a lot of. I think in retooling my diet, some extra calcium got in from non dairy items (I don't eat dairy). Hence my normal very stable afib situation degraded. For me, when I have the electrolytes well in balance, the only trigger I have is from violating my own rules about excessive exercise. When they aren't in balance, then I'm like all the folks here who say they can't figure out their triggers because anything can be a trigger. My heart "feels" less stable in this situation and I can see it on my beat to beat heart rate monitor recordings overnight. I had some "unprovoked" episodes from January to early April. Now, compared to many folks, I still had a very low afib burden (it was like 0.2% for the first part of the year, before yesterday), but it was much more than my normal vanishingly small burden. In April, I tried a hair mineral analysis. I was skeptical, but decided to try it. Reviewing my data the consultant made a number of suggestions, including getting some of their mineral products. The idea was to follow the suggestions for 3 months and then retest, with likely changed suggestions. I ordered their products, but I also implemented her other suggestions and I could tell an immediate improvement (I'd also looked for and removed excess calcium in my diet). This continued. My magnesium tolerance dropped by about 1/3 and I forgot one day, May 4, and that caused digestive upset leading to an episode. I did this again on Wednesday the 26th. I also got a J&J vaccine after I tested for no antibodies 6 weeks after my 2nd Pfizer shot. I speculate this might be due to the Wim Hof breathing I do daily as it has been shown to impact the immune system. In fact, I do the Hof breathing as it keeps my lifelong rhinitis under control (along with food changes). My nose is clearer than it has ever been. The episode occurred around 6A on Thursday. I was awake and a little achy, likely from the vaccine. I also had some digestive distress from overdoing my magnesium the day before. In any case a stretched my legs with hard isometric tension and the episode took off. Still, I"m much more stable than I was two months ago. Again, as I noted, my burden remains very small. I learned some useful things from the episode, so all is good!

I should also note, every time I finish a Hof breathing session, I do reduced breathing to recover the CO2 I've blown off in the hyperventilation. I think improving CO2 tolerance is a big deal and unless I'm doing something special, I'm always breathing through my nose diaphragmatically with as small a breathing volume as I can manage.

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I assume your new CO2 machine was not up and available?

Not ordered yet.

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Whether we are measuring CO2 or SPO2, are we still assuming a combined effect of Flecainide/Breath Holds on the lengthening of the ERP thus facilitating Arrhythmia termination?

It is a good question that I don't know the answer to. It seems to be like throwing a switch and, as I posted, the SpO2 isn't that low. The one I posted from January looked to be about 82%. In my world, that isn't that hard to come by. Though I didn't have the recording turned on this time, from looking at it, it seemed about 85% or so, and was a different device, so readings may differ.

Just about flecainide..

I've used generic as well as Tambocor and Apocard. I used Apocard in a "retard" form (long release), and it worked fine during a couple of months.
I think the long release form is better when taking flec on a daily basis.
I took Tambocor and generic as PIP, and both were useless for me, so I've no opinion about which is better. Here in Belgium, it's commonly said that the branded versions are better.

GeorgeN:

" I think in retooling my diet, some extra calcium got in from non dairy items (I don't eat dairy). Hence my normal very stable afib situation degraded"

Personally, I have added back in a little Ca+ and cannot detect any changes.

"I also got a J&J vaccine after I tested for no antibodies 6 weeks after my 2nd Pfizer shot."

What test was this? My limited research into this indicates unreliability and false positives due to previous non C-19 viral infections (common Cold).

"Still, I"m much more stable than I was two months ago."

You mean you had episodes several months ago, and converted with just Breath-Holds? Was the 50+ hyperventilated breaths a new procedure for you this last conversion?

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The Anti-Fib
"I also got a J&J vaccine after I tested for no antibodies 6 weeks after my 2nd Pfizer shot."

What test was this? My limited research into this indicates unreliability and false positives due to previous non C-19 viral infections (common Cold).

Test: [www.labcorp.com] It was prescribed as part of a UCSF study I'm in.

Interpretation:
Negative: Less than 0.80 (<0.80) U/mL
Positive: Greater than or equal to 0.80 (≥0.80) U/mL
My result: 53.7 U/mL
My wife on the same test about 4 weeks after her second Moderna shot ~2600 U/mL.

MY BAD!! I misread the test and the results the first time through! I initially read that either a vaccine or infection could trigger a positive result. I just got the J&J vaccine for nothing as this test only tests for antibodies from the illness, not the vaccine. Next question, my wife likely have had an asymptomatic infection (we've both had multiple PCR and other COVID tests, all negative) and I didn't catch it from her. She got her first vaccine dose about 3 weeks after my first dose and I got my second dose 2 days after her first. We were traveling for the 10 days prior to her first dose. This is very interesting. We also had two tests just prior to the LabCorp test, as a part of the study, that we haven't gotten results for.

Thank you for questioning and getting me to reread the test and results. High speed scanning doesn't always result in great attention to detail!

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The Anti-Fib
"Still, I"m much more stable than I was two months ago."

You mean you had episodes several months ago, and converted with just Breath-Holds? Was the 50+ hyperventilated breaths a new procedure for you this last conversion?

I had an episode in January that I terminated in about 3 minutes, posted on it and the link is in my original post in this thread above. I did not do a bunch of hyperventilation breaths before. From my post at the time:

"This morning had an episode that started while I was sitting quietly. I happened to have a beat to beat recording heart rate monitor and a recording pulse oximeter on. After a moment, decided to try an exhaled breath hold (exhaling first to get to low O2, high CO2 quicker, then extending the breath hold). {edit What I'm describing is to a) fully exhale, then b) hold your breath out as long as possible, but without pressure.} The urge to breathe will get strong. This is due to increased CO2.} That did convert me. The total episode time was maybe 3 minutes 20 seconds (my normal episode times are 60 minutes and converted with flecainide - so the episode self-converting is an unlikely explanation)."

I've had some episodes since, including several where I was away from home & flec for a few hours before trying anything. I've always felt conversions are easier if done right after an episode starts. I've had some unsuccessful breath holds, but as noted above, it is more difficult for me to hold an exhaled breath hold when my heart is flopping around like a fish in my chest. Since I now have an idea of an SpO2 target, that may be easier to motivate myself to hold much longer though the uncomfortable high CO2 signal to breathe. So yes, the large number of hyperventilation breaths was new for me. As noted, this episode converted to 115 BPM flutter, which is must more comfortable and it is easier to do long breath holds in this state.

So.. the flecanide from another country is better? how does one procure that? I have tried it and it never worked. I am currently on dofetilide but I have been toying of going off for a few reasons. I haven an EP appointment next week and going to discuss other meds. (Seems like I have tried a lot of them to no avail...)

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bettylou4488
So.. the flecanide from another country is better? how does one procure that? I have tried it and it never worked. I am currently on dofetilide but I have been toying of going off for a few reasons. I haven an EP appointment next week and going to discuss other meds. (Seems like I have tried a lot of them to no avail...)

Bettylou, I thought through my flec history. My first episode was in 2004, the year Tambocor (brand) went off patent. I recall my EP prescribed Tambocor. Around 2008, I started buying flec from Europe, through a broker [goldpharma.cn] (you can pay a few $$ to them to get a script, if you don't have one). As noted above, it was always from Meda and branded as either Tambocor or Apocar, depending on the country. Always the same packaging. So last week was the first time I've ever used generic. Now, afib is fickle and random, so may have been the day. However it did feel different than all the other times I've used it.

Susan.d sent me a link to a pharmacy in Israel. You can use the link to order. You take a photo of your prescription and send to them.

Refer A Friend: Give $50 Get $50

Earn $50 for every friend you refer who becomes a new IsraelPharm customer. Your friends save $50 off their first order and you're rewarded with $50 toward your next order. Copy the referral link or use the social channels to share your link with friends. Unlimited referrals and rewards. Use one reward per order; offer cannot be combined with other offers.

Your Referral URL: [www.israelpharm.com]

Shipping is slow on Goldpharma because of COVID (4 or so weeks). Not sure from Israel, something to ask.

You may be able to get Tambocor in the US. The stuff I got in 2004 was not blister packed, but still worked.

I couldn’t get tambocor in America so I bought it in Israel. They got it from the UK or Germany.

If the link George has doesn’t work, then go to www.israelpharma.com and use coupon code ref6604998
You get $50 off with your first order.



Edited 1 time(s). Last edit at 06/01/2021 04:23AM by susan.d.

I have been using Flecainide in combination with the Breath-Holds George introduced, dating back to the Summer of 2019. I held off from posting about this due to safety concerns involving Flecainide being used in this way. I had previously had an NDE (adverse reaction) using a 300mg Flecainide Bolus dose (Pill in the Pocket), and I am much more wary of this drug than many others who post on this site. I had wanted to vett this procedure though several EP's, including having it monitored in a Hospital. I failed to make much progress in this area for various reasons. Dr's are busy as we know, in addition it would have been doing an unauthorized experimental procedure in the Hospital. One Dr. being wary, said it would need to be done quietly, sort of secretly. Then Covid-19 hit, and everyone was caught up in that drama. I did manage to have an EP observe a conversion attempt in his office (failed attempt). The first time I tried the Breath-Hold/Flec combo, it worked. Later it didn't work, so I experimented with trying to boost my CO2 levels up, prior to the BH. I was operating under the presumption that increasing CO2 would lengthen the ERP, in concert with the action of Flecainide, thus facilitating Arrythmia termination. Now George thinks we should focus on SPO2 negative drops instead. We are both trying to prepare for future study of this, although I am stuck in NSR for a year now. Of the main concerns with increasing CO2, is the resulting alteration of Blood Gases, making the blood too acidic.

Since my previous negative experience with Flecainide, I proceeded with a lower Bolus (Oral) dose of 225mg. A dosage that I felt was safe for me based on experience. I did the trials at home, and did them in my office chair in a reclined position, so if I passed out, I would not hurt myself. In retrospect it would have been good to have someone else present.

Results: Of the 5 episodes I have had since starting this, I have been successful 3 times converting to NSR. It took multiple tries, and I had a 20% success rate per Flecainide (225mg) dose try. I was also able to get from AFIB to Flutter or FIB/Flutter about 10 times before eventually reverting back to AFIB. In addition, I could reliably lower my Flutter rate doing this, by altering the Flutter Ratio downward. Keep in mind I am 80-90% persistent (requiring ECV's) in my AFIB. I scheduled ECV's in a parallel treatment plan, and as they usually are scheduled 6-10 days out, I had time to attempt multiple times, while waiting for the ECV. It is obvious that when it worked, I converted within seconds after doing the Breath-Hold. I will not go into detail with what I did, as it might not be the safest and most effective way forward.

I am not sure about the safety of this, and I don't recommend trying the Flecainide/Breath-Hold combo, unless you are already experienced with using Flecainide "pill in the pocket" dosing. Remember Flecainide is for those with "Lone-AFIB" , or structurally sound hearts. My elder EP who observed this basically said the same, that since I had a structurely sound heart he was not overly alarmed. Alternatively the BH's could be tried by themselves.



Edited 2 time(s). Last edit at 06/03/2021 10:58PM by The Anti-Fib.

Bolus Flecainide dosing is IV or injected (Google) in case someone wants to risk an overdose. I can’t stress enough how dangerous it is to experiment with flecainide as anti-afib also has mentioned. I’m not saying this because I spent 3 days in icu with a flecainide overdose and all nurses said I’m lucky to be alive. I’m posting a warning because flecainide has a black box label. It can cause death. I speculate some deaths could be from overdoses or experiments at home.

IMHO, one should double check with their EP before experimenting with potentially dangerous non medical trained suggestions in a non hospital setting away from a defibrillator and a trained emergency responder. Otherwise IMHO it could potentially harm someone, especially a desperate newbie who stumbled onto this forum and is unaware to ask a professional AF specialist EP instead of their GP for afib related questions. I’m going in the limb here because of my experience. I have since became a watchdog and advocate when it comes to flecainide experiments. I messed up and read here non medical approved PIP (no weight to dosing was disclosed), and I wouldn’t had risked my heart and life if the PIP posts came with a warning of 300mg is the dosage if you weigh more than 154 pounds and 200mg in a 24 hour period if you weigh less.



Edited 2 time(s). Last edit at 06/03/2021 11:38PM by susan.d.

Susan:

Thanks for your concern. I have consistently warned to be wary of Flecainide at high doses, after my bad experience 8 years ago. There are many here who have taken 300mg as a single dose (aka "pill in the pocket", with their Dr's approval. I don't agree with it, especially for the 1st time. If your over 154lbs, then the acute Oral dose for conversion is 300mg, and 150mg if by IV.

For those reading this- investigate the cyp450 inhibitor drugs you may take along with your flecainide because an inhibitor could increase the potency. I used to faint after taking flecainide and Prilosec for example. A good test to see your current flecainide levels after being processed through your liver enzymes is the flecainide serum test. It’s a timed test. You get blood drawn exactly 11 hours after your last dose. I highly recommend you asking for the test.

[www.resourcepharm.com]
Example of drugs that could interact and either increase or decrease the potency of your meds.

More:
[www.d.umn.edu]

A current peer review:. This explains it in a nutshell:
[www.ncbi.nlm.nih.gov]



Edited 1 time(s). Last edit at 06/03/2021 11:40PM by susan.d.

Susan i don't think deleting The Ani-Fib post like 934 is a good idea at all. He and you (as you previously have and i'm thankful for that!) have pointed out the dangers.
Based on what i've learned from this site and experiences posted i've just the day before yesterday applied it.
Went into AF after dinner, took only 50mg Flec; woke up 4am still in AF so took another 50mg; 9:20 still in AF so took another 50mg and did some breathing and relaxing exercises and luckily 11:30 am converted back to NSR - still holding

Thank you all the contributors and especially the Shannon and Carey!

Joe- I have valued and appreciated all of Anti-AF past posts and contributions. Thank you Anti-AF! He is an asset to this forum and I meant no malice. I only posted in the attempt to do a good deed and point out the severity of a flecainide overdose in the purpose of potentially saving someone from the ICU or worst.



Edited 1 time(s). Last edit at 06/03/2021 11:41PM by susan.d.

Easy Susan, you already made the right points right off the bat. Fortunately Joe only needs to take 50mg at a time to covert!

Joe- I’m happy 50mg works! You are quite fortunate.

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The Anti-Fib
...I am stuck in NSR for a year now.

Aside from Anti-Fib's (AF) and Susan's cautions about flec and breath holds, this is something people should pay attention to.

See AF's post [www.afibbers.org] in Colindo's thread [www.afibbers.org] . Colindo mentions Steve Carr's approach [www.afibbers.org] (and there are more links in this post).

We are all different, but these are ideas to pay attention to. Most of AF's episodes have been persistent. This means they would not convert on their own and many required an electrocardioversion. So AF's being "stuck in NSR for a year" in very significant!e

On my original post, I've had some questions about how old my generic flec is and how it was stored. It was obtained from a US pharmacy on March 22, 2021, so fresh. It was stored in a cool dark place. It was make by ANI Generics [www.anigenerics.com] The alternative explanation for my experience is that my afib was just different this time, not that there was a problem with the generic flec. No way to tell.

I've been experimenting with many hyperventilation breaths preceding an exhaled breath hold and followed by a 15 second inhaled breath hold, while in NSR. I've observed that the lowest SpO2 occurs around 25 seconds after the exhaled breath hold is ended by the 15 second inhaled hold. This likely indicates that low SpO2 is the conversion agent and not CO2. AF and I have both done breath holds not preceded by hyperventilation. On these and the ones with hyperventilation before, the SpO2 will drop as time goes on and CO2 will rise. The CO2 concentration will drop once the inhale starts and dilutes it. I will put monitors on and mark the beginning and end of the breath hold, so the patterns can be observed.

George- is your breathing holds similar to what my icu RN told me to do?— I was to take in a breath, blow it out and strain push like I was trying to move my bowels. I was trying to get out of tachycardia. We were looking at the monitor and my hr did drop considerably but it returned. I remember once in the Er a doctor asking me to try as well. It didn’t work for me but as you mentioned, everyone is different.

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susan.d
George- is your breathing holds similar to what my icu RN told me to do?— I was to take in a breath, blow it out and strain push like I was trying to move my bowels. I was trying to get out of tachycardia. We were looking at the monitor and my hr did drop considerably but it returned. I remember once in the Er a doctor asking me to try as well. It didn’t work for me but as you mentioned, everyone is different.

No, you were doing a valsalva maneuver, which is a vagal maneuver (increasing vagal tone). What I'm doing is changing the body's biochemistry and does not involve bearing down. Vagal maneuvers (of which there are a number) work for some people. [www.webmd.com] (Don't try # 6 in the link, it can be dangerous).