Heart rate control meds

I had Afib for 24 hours 3 days ago, and now have Afib again. Typically, it lasts for less than 24 hours and happens about every 2 weeks. Since having Afib a few days ago and now again I am feeling very fatigued. I take metoprolol when I get Afib, and I know the metoprolol can cause fatigue. My question is does anyone know of an anti-arrthymic that is well tolerated? I had problems with flecinide.

I have taken dofeteilide (no longer helping really) and I take cartizem for rate control when in afib. I tolerate them both well (except I had to lower the dose of dofetildie because of QT interval.). I have problems with metoprolol. I take an extended release cardizem when in longer term but I have tablets I can add if it goes higher (not sustained release). Or when not on the sustained release and if I go into afib. Dofetilide requires a trip to the hospital to get on it... 6 dose monitoring.

Multaq (dronedarone) is worth trying first. It has very few, if any, side effects for most people, doesn't usually cause fatigue, and doesn't have to be started in the hospital. Its only downside is it's fairly mild and it might not prevent your afib. But it's at least worth trying. If it doesn't work for you, you can step up to Tikosyn (dofetilide, mentioned by Bettylou above). If your doctor suggests amiodarone, I recommend refusing it until you've tried everything else, and then I would seriously consider ablation instead. Ablation is considered first line treatment these days.

Carey- which is safer? Tikosyn or Sotolol?

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susan.d
Carey- which is safer? Tikosyn or Sotolol?

I know you didn't ask me but I was just talking to one of my EPs about this. She treats Sotolol as a "lesser" drug. She does not start it in the hospital but my regular EP doctor does. (I saw 3 in the last 6 months for opinions.). Sotolol also has a bit of beta blocker which can be good for afib.. and yet can be bad if you don't tolerate. A friend moves her Sotolol dose around on advice of doctor without going in the hosptial. Mine said no going-- and would want me in the hosptial for anything other than going down on it. (to monitor QT interval.). If I am wrong here I am sure Carey can fill ya in .. but since I just had this conversation I thought I would chime in.

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susan.d
Carey- which is safer? Tikosyn or Sotolol?

I'd say they're roughly comparable, but since Dini experiences fatigue with metoprolol, she'll probably experience the same with sotalol since they're both beta blockers. If I were her I wouldn't bother trying sotalol.

I asked because I was afib free while on 80mg/24 hrs dosing of sotolol. I had a three day admission to the hospital. I switched to multaq after my ablation. One EP prefers sotolol but that means weaning off of multaq and having no protection. I contacted multaq pharmaceutical and they recommended 5 half life’s (around 13-17 hrs) off multaq completely before switching.

On the other hand my local ep prefers Tikosyn but with covid, the hospitals are not admitting non urgent cases now. I read Tikosyn has a up to 10% chance of v-fib/ sudden death/ etc while sotolol is milder like Multaq. It seems more deadly than flecainide.

I was curious. Thanks

Thank you all so much for your input. It sounds like I should talk to my ep about multaq. The BB are ok for occasional use, but as everyone has mentioned the fatigue is a huge issue. EP also wants to put me on hctz for bp, I hope that doesn’t make me feel dizzy and lightheaded and tired like the BB does.

I doubt the HCTZ will have an side effects for you at all except making you pee more. It's pretty benign.

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susan.d

On the other hand my local ep prefers Tikosyn but with covid, the hospitals are not admitting non urgent cases now. I read Tikosyn has a up to 10% chance of v-fib/ sudden death/ etc while sotolol is milder like Multaq. It seems more deadly than flecainide.

I was curious. Thanks

]]

I would love to know where that 10% came from. I think if you are monitored and your QT is lower than 500 then you would be ok. I started on 500 mcg in the hospital. I ended dup going to 250 and then 125. I think 10% is really high and I know I asked the risks question. If it was 10% I wouldn't have done it. But if you saw that I would love to know where so I can discuss with docs. thanks

Susan, I don't know where you got the 10% figure but that cannot be correct. No drug with a 10% chance of death would ever obtain FDA approval unless it was a life-saving drug of last resort with no alternatives available, and that certainly doesn't describe Tikosyn.

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Carey
Susan, I don't know where you got the 10% figure but that cannot be correct. No drug with a 10% chance of death would ever obtain FDA approval unless it was a life-saving drug of last resort with no alternatives available, and that certainly doesn't describe Tikosyn.

I’m sharing the info from drugs.com
BEFORE you discredit drugs.com (see your prior posts), I would like to say it’s an insult to pharmacists who religiously use drugs.com as their site and tool in obtaining new information about drug interactions and side effects.

My husband is a retired chain store pharmacist and he traveled from store to store as part of his duties. I know his major drug chain uses drugs.com.

If you don’t believe drugs.com is reliable because of the necessity to add every symptom ANYONE gets, check out the following. It lists v-tach and v-fib as very common and common from 0-10% with 14.5% for ventricular arrhythmias. I agree to ignore “rare” reports but “very common” and “common” should not be discounted.

[ibb.co]

I’m sure there are a lot of folks who experimenting with black box drugs, inexperience cardiologists, and plain bad dumb luck that contributes to up to 10%. Since you don’t know each lurker or person who reads this site, you have to prepare to expect there are those who drug experiment, take many cyp450 drugs at once causing enzymes inhibitor reactions, have kidney or liver enzymes overload from supplements which increases their score from 0-10.

[www.ncbi.nlm.nih.gov]

Perhaps if you don’t like drugs.com, don’t ask a pharmacist (who uses drugs.com) for a new drug consultation. I just find it insulting to discount pharmacists. Their education is long and like doctors, they are required to take 30 hours (last I heard) of continuous education before each time they renew their license. Their job is more than counting pills and transferring from a big bottle on the shelf to a vial. Doctors rely on them for drug advice.

I mentioned Tikosyn side effects in comparison to others.

Flecainide
Cardiovascular

Cardiovascular side effects including arrhythmias are the most serious side effects. Flecainide may cause or exacerbate arrhythmias in 1% of patients with preexisting paroxysmal supraventricular tachycardia and in 7% of patients with paroxysmal atrial fibrillation. Flecainide may also exacerbate arrhythmias in 7% to 13% of patients with preexisting sustained or nonsustained ventricular arrhythmias.

Flecainide-induced arrhythmias include sinus bradycardia or arrest in 2%, bundle branch blocks in 1%, increased premature ventricular depolarizations in 1%, ventricular tachycardia or fibrillation in 0.5%, and sudden death in 0.2% of patients. New ventricular arrhythmias have been reported in 3.4% of patients.

Flecainide may cause prolongation of the PR, QRS, and corrected QT intervals. Most of the QT interval prolongation is attributable to widening of the QRS complex rather than prolongation of the JT interval. Rare cases of torsades de pointes have been reported.

Exacerbation of congestive heart failure is rare and only occurs in about 0.5% and 9% of patients with preexisting supraventricular arrhythmias and ventricular arrhythmias, respectively. Hypotension is almost exclusively associated with intravenous administration of flecainide.[Ref]

Risk factors for a proarrhythmic effect include underlying congenital or structural heart disease.

A case of "pseudoinfarction" has been reported in which flecainide induced a transient right bundle branch block with a focal block in the septal fibers of the left bundle branch system. An electrocardiogram (ECG) also revealed ST segment elevations and a Q-wave pattern, consistent with septal infarction. The patient did not have a myocardial infarction by enzyme studies, and the ECG abnormalities resolved after discontinuation of flecainide.

One patient with a history of ischemic congestive heart failure, myocardial infarction (MI), and ventricular arrhythmias developed profound cardiogenic shock without evidence of MI or a new or worsened ventricular arrhythmia. The associated serum flecainide concentration was 1.8 mcg/mL.[Ref]

Multaq:
Cardiovascular

Very common (10% or more): QT prolongation (28%)

Common (1% to 10%): Bradycardia

Very rare (less than 0.01%): New or worsening heart failure, atrial flutter with 1:1 atrioventricular conduction[Ref]

Sotolol:
Cardiovascular

Very common (10% or more): Bradycardia (up to 16%), chest pain (up to 16%), palpitation (up to 14%)

Common (1% to 10%): Edema, abnormal ECG, hypotension, proarrhythmia (including Torsade de Pointes), syncope, heart failure, presyncope, vasodilation, Automatic Implantable Cardioverter-Defibrillator (AICD) discharge, hypertension, stroke[Ref]

Tikosyn:
Cardiovascular

Very common (10% or more): Ventricular arrhythmias (up to 14.5%), ventricular tachycardia (up to 12.4%)

Common (1% to 10%): Torsade de pointes, ventricular fibrillation, atrioventricular block, heart block

Uncommon (0.1% to 1%): Bundle branch block

Frequency not reported: Angina pectoris, atrial fibrillation, hypertension, palpitation, supraventricular tachycardia, bradycardia, heart arrest, myocardial infarct[Ref]

Source: drugs.com
side effects professional
I ignore the uncommon, rare and frequency not reported. Very common and common gets my attention

I don't know where you got the idea that I don't think drugs.com is a reliable site and I don't know what prior posts of mine you're referring to. I use drugs.com all the time. In fact, it's my go-to site for drug research. But what you find there (or on any other drug site) can be misleading because it's been simplified for public consumption. This is a good example of that.

Go here and scroll down to tables 6 and 7. In table 6 you can see that the risk of v-fib is dose-dependent and ranged from 0% to 0.4% (and placebo had a 0.1% risk). And if you look at table 7, you see that another study found a 4.8% risk, which would be alarming except that placebo showed a 3.1% risk, placing that 4.8% number in serious doubt.

But all of this is largely beside the point. These risks are why they require you to start Tikosyn in the hospital. Once you've gone through that process successfully, you don't face those risk levels. If you did, this drug wouldn't be on the market. Those were risk levels observed in people in the hospital, and I virtually guarantee that every patient who experienced an episode of ventricular arrhythmia was sent home without a Tikosyn prescription.

As for people experimenting with drugs they don't understand thoroughly, my advice would be that antiarrhythmics are the absolute last drugs anyone should do that with. Each and every one of them is dangerous when misused.

Safety of Oral Dofetilide for Rhythm Control
of Atrial Fibrillation and Atrial Flutter

Methods and Results—We conducted a retrospective chart review of a cohort of 1404 patients initially loaded on dofetilide
for atrial fibrillation suppression at the Cleveland Clinic from 2008 to 2012 to evaluate the incidence and risk factors for
in-hospital adverse events and the long-term safety of continued use. Of the 17 patients with TdP during loading (1.2%),
10 had a cardiac arrest requiring resuscitation (1 death), 5 had syncope/presyncope, and 2 were asymptomatic. Dofetilide
loading was stopped for 105 patients (7.5%) because of QTc prolongation or TdP. Variables correlated with TdP were
(1) female sex, 2) 500-μg dose, (3) reduced ejection fraction, and (4) increase in QTc from baseline. One-year all-cause
mortality was higher in patients who continued dofetilide compared with those who discontinued use (hazard ratio,
2.48; 95% confidence interval, 1.08–5.71; P=0.03). Those patients who had a TdP event had higher one-year all-cause
mortality than those who did not (17.6% versus 3% at 1 year; P<0.001).
Conclusions—Dofetilide loading has a low but finite risk of TdP and other adverse events that warrant the current Food
and Drug Administration–mandated practice of inpatient monitoring during drug loading. In this cohort, all-cause
mortality was higher at 1 year in those patients continued on dofetilide and in those patients who experienced TdP while
loading.

That’s why I originally posted which is milder and safer— Sotolol or Tikosyn? Both require 3 days in hospital.

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susan.d
That’s why I originally posted which is milder and safer— Sotolol or Tikosyn? Both require 3 days in hospital.

For what it is worth, as I mentioned, I know 2 docs that give out Sotolol w/o a hosptial stay. Mine doesn't. But I am on the Tikosyn. IDK. I'd be concerned taking Sotolol w/o at least one or two ECGs after being on it..

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Carey


But all of this is largely beside the point. These risks are why they require you to start Tikosyn in the hospital. Once you've gone through that process successfully, you don't face those risk levels. If you did, this drug wouldn't be on the market. Those were risk levels observed in people in the hospital, and I virtually guarantee that every patient who experienced an episode of ventricular arrhythmia was sent home without a Tikosyn prescription.

.

I woke up thinking about this thread... because I am on TIkoysn so it was in my head and I thought exactly that.. that the 10% maybe is right but that is why you start it in the hosptial. I am still on it .. while in afib... so doc doesn't have to re-admit me to restart but I gotta tell you- I'm thinking of stopping. But that's a whole other thing. They did have me stop 3+ days prior to the ablation. When that didn't happen b/c of the blood clot, they restarted me. But it was 3 days later. (Before they said if I stopped it for a day I'd have to come in.. later they recanted. IDK. ). Anyway- I woke up thinking it HAS to be because there are risks.. they start you in the hosptial but once it is homestasis the risks are much lower. That said I left hospital several years ago with QT right around 500. 3 months later they lowered me to 250.. 3 months later lowered me to 125. I'm like.. you guys are just making this stuff up right? (And the 125 worked for a couple years. I just think.. if I get the ablation at some point will it still be helping me out.. idk.)

It's not 10% or anywhere near that, but it is surprising they would discharge you on 500 mcg of Tikosyn with a QT of 500. Do you have a particularly low resting heart rate? Lower heart rates have wider QTs.

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Carey
It's not 10% or anywhere near that, but it is surprising they would discharge you on 500 mcg of Tikosyn with a QT of 500. Do you have a particularly low resting heart rate? Lower heart rates have wider QTs.

it was below 500..but barely. And when I went for the 3 month it was over. (like 510). it is hard, as I am sure you know, to get a proper QT while in Afib. My heart rate is a little lower (I can't even rememeber for sure but at last congenital heart doc I had him look and I think he said it was 70 w/o any meds.). So now I am on cartizem CD to lower it plus the dofetilide. But no not a super low rate..