Sotalol vs Flecainide

Hi Folks,

I was put on sotalol when I had an afib episode after a stress test. I converted after 12 hours. I was prescribed 40mg of sotalol twice daily. The first couple of weeks were okay but then hr went down to low 50s, and sometimes 40s, and I felt unable to function. I tapered off while waiting to see the cardio again.
He has stopped the Sotalol, and now wants me to take Flecainide 50 daily with Bisoprolol 1.25.
I am going to wait a few days as I still feel rough from the Sotalol, and want it to be totally out of my system before starting a new regime.
Echo and stress test were normal, the afib came on as I was cooling off from the test.
Normally I take a small amount of Metoprolol if the hr is high and start NOAC if I get an episode, and stay in bed until it converts (usually 12+ hours).
Any advice or experience of taking flec and bisoprolol as prophylaxis would be much appreciated. I am 71 and sometimes go for a year with no episodes, but then might get 2 or 3 in a row. I don't normally let my heart rate go as high as during the stress test, but was persuaded by the cardio. It's more like a medieval torture than a scientific test. Lets get him to run until he blows a fuse!
I seem to be wild sensitive to beta blockers, and had the same symptoms 25 years ago. Doc said, oh now you have low blood pressure, stop taking them.

Regards
John

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JohnBM
He has stopped the Sotalol, and now wants me to take Flecainide 50 daily with Bisoprolol 1.25.

Is this 25 mg flec 2x/day or 50 mg 1x/day? The Bisoprolol with the flec is likely to mitigate the possibility of the flec initiating 1:1 atrial flutter. A pretty low risk at 50 mg/day.

I'm a huge fan of minimum effective dose. You might ask the doc if you could do 25 mg/day flec without Bisoprolol (cut a 50 in half). The data suggest a dose this low doesn't do anything, but it does for me. Or maybe no meds and go back to your past plan since you've historically had very few episodes. Or the no meds approach till you go out of rhythm adding flecainide on demand when you do go out of rhythm for a quick conversion. This will likely be prescribed with a beta blocker, but only when you take the flec. Here is the original on demand flec paper from 2004 [pubmed.ncbi.nlm.nih.gov] (the pubmed site is down, as I type this, so you might try again later if you get this)



Edited 1 time(s). Last edit at 10/23/2022 04:45PM by GeorgeN.

Thanks George, those options sound sensible. I think the dose is bidaily, but cant decypher his prescription. I shall get it filled at the chemist tomorrow.
I thought i might start with half dose of the betablocker to see how i react, and then add the flec similarly.
If one takes flec daily, what happens if you get an afib episode?

Quote
JohnBM
He has stopped the Sotalol, and now wants me to take Flecainide 50 daily with Bisoprolol 1.25.
I am going to wait a few days as I still feel rough from the Sotalol, and want it to be totally out of my system before starting a new regime.
Echo and stress test were normal, the afib came on as I was cooling off from the test.
Normally I take a small amount of Metoprolol if the hr is high and start NOAC if I get an episode, and stay in bed until it converts (usually 12+ hours).

So you have metoprolol you use on an as-needed basis and now the doc has given you bisoprolol to take daily in addition to the metoprolol? Can you clarify if that's correct?

And you're only taking a NOAC when you have an episode? That's a pretty risky approach. Does your doctor approve of it?

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JohnBM
If one takes flec daily, what happens if you get an afib episode?

Max loading dose flec (meaning at one time, used to convert an episode) is 200 mg for someone up to 154 lbs (70 kg) and 300 mg over. So you'd subtract your daily dose from the maximum and use that as your max for the loading dose, of course depending on what your EP says.

Hi Carey
No the metoprolol is from previous script.
I wouldn't take the two. I did tell the cardio that i respond well to it, but he wrote bisoprolol anyway.
I read a few papers on the intermittent use of noacs, and discussed with him about it. After some thought he said he would read one, which i sent him. He doesn't have a protocol to recommend such use, which i accept.
My understanding is that afib induced stroke is most likely to occur within 10 days of afib, and that noacs act very quickly, thus the rationale that one starts as soon as episode occurs, and continue for a number of weeks.
Hey, thanks for your feedback. I always find this forum very helpful

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JohnBM
Hi Carey
No the metoprolol is from previous script.
I wouldn't take the two. I did tell the cardio that i respond well to it, but he wrote bisoprolol anyway.
I read a few papers on the intermittent use of noacs, and discussed with him about it. After some thought he said he would read one, which i sent him. He doesn't have a protocol to recommend such use, which i accept.
My understanding is that afib induced stroke is most likely to occur within 10 days of afib, and that noacs act very quickly, thus the rationale that one starts as soon as episode occurs, and continue for a number of weeks.Hey, thanks for your feedback. I always find this forum very helpful

Interesting John! I do similar - take Eliquis for a few days only after an AF episode lasting a few hours to 1 day. Of course my cardiologist advises strongly against doing that which i understand (would do the same in his position)
Please keep us updated!

John, do you know what your CHADS-Vasc score is? That's the number you need to know if taking NOACs on an as-needed basis is safe.

Yes Carey CHA2DS2-VASc score is 1. Like others in the forum i can feel every heartbeat so am aware of jumps and bumps, and especially afib.
I have always been concerned about taking flec as i live at least an hour and a half from hospital, and seem to be very sensitive to medication, hence the trouble with sotalol.
Cardio says that if the flec doesn't prevent more episodes he will send me for ablation. I would prefer not. We don't have a Natale here, and even the cardio said that you may need a touchup or two! Forgive my ignorance but burning the inside of the heart is not a minor procedure. Oh, the joys of afib!

I've had to take sotalol during eight months, but its BB properties were disabling.
Later, I switched to flecainide + bisoprolol, but it was disabling too, because of the BB. I then went for a PIP strategy, and felt really better while in NSR. Maybe something to try?

Thanks Pompon, sounds like you have similar reaction to my own. Do you have any problems taking flec as pip? What is your regime? Betablocker first then flec at what dosage?
P.s. is your shorthand BB meaning betablocker?

BB for betablocker, indeed.
It seems we're both very disabled by BB or rhythm drugs having BB properties, like sotalol.
But we're all different, and I think our similarities don't go further.
Unlike you, I have frequent AFib episodes (about 5/month) and they're short (AVG 1hr). Flec as PIP needs some time to act, at least 30min I think, and my episodes are always self-ending (to date), even without meds, so I don't take them any more.
I'm 64 and otherwise healthy, and have been 4x ablated.

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Pompon
Flec as PIP needs some time to act, at least 30min I think,

My experience is more like an hour minimum (and I chew the tablets to increase the absorption speed). Inhaled flec seems to act much faster, per this study referenced by Susan: [www.afibbers.org]

Thanks for the clarification, George. This explains why flec hadn't enough time to act for me.

I have been taking Flecainide PIP for about 10 years. Currently though, its been taking it about 10-24 hours to work. Had one ablation at Ceders sinai about9 years ago but now getting a fib about once a week or so. Now looking at another ablation or i wish pulse field ablation was approved.

It’s been awhile since you posted about this but I thought I would chime in on my experience in hopes it still might be useful. I took 80mg of Sotalol twice a day for 2 years. It was absolutely debilitating with severe fatigue and low heart rates and did nothing for the frequency of my episodes. I could barely function no matter how well I ate. My episodes took so much out of me it would take 3 days for me to recover from one. My resting heart rate would often go down to the 30’s. I have a new EP and I asked him about switching to Flecainide. I started on 50mg twice a day the same day. The transition was rough-I had episodes daily for the first 5 days but they lasted less than an hour as opposed to the 12-18 hour episodes I had on Sotalol.

I also started on a magnesium regimen and I haven’t felt this good in 3 years. I haven’t had an episode in several days so apparently the Flecainide has kicked in. I have high hopes!