Dofetilide vs Dronedarone

I had a 2nd ablation in Dec 22,2022 for AT/AF. Started on sotalol 40mg x2/day. Went into AT/AF on April 15 and was cardioverted on April 20. Dosage of Sotalol was increased to 80mg x 2/day. Reoccurance of AF/Flutter on May 6 and I currently remain in AF.
Dr has suggested stopping Sotalol and starting either 400mg Dofetilide {with 3 day hospital stay} or 400mg Dronedarone {Multaq}.until another ablation late this year.
Does anyone have an opinion on effectiveness of these drugs.

I took Multaq for about a year. It has the reputation for being safe but not very effective and that was my experience—it totally failed in the end. I have not taken dofetilide but it has the reputation for being much more effective, though has the potential side effect of long QT syndrome, hence the 3 day hospital stay.

I've been on both. I tried Multaq (dronedarone) when my afib was in full swing and found it completely ineffective. I then went to Tikosyn (dofetilide) and that worked very well. When I started it people told me the longer you take it, the more effective it becomes, and I found them to be correct. Not much in the way of side effects for me for either drug, but as Daisy pointed out Tikosyn can cause widening of the QT, and if it widens too much you won't be able to take it. That's why they require the 3-day hospital stay. That's more likely if you're a woman because women have a naturally wider QT.

The second time I took Multaq was in the 30 days following my ablation with Natale. He likes to use it after ablations precisely because it is mild, largely free of side effects, and his ablation patients usually don't need a heavy hitting drug just to keep their hearts calm after the procedure. In that role it worked very well for me.

If I were you, I would try the Multaq first. It may not work for you, but if it does that saves you a very boring and very expensive 3-day hospital stay.

I was leaning towards starting the Multaq, but now they are telling me I would have to wait 2 weeks to get a cardioversion (I am assuming that the Multaq will not get me back into sinus) . That would be 3 weeks in Afib …not something I am looking forward to. I have not yet heard back regarding this but I cannot think of any reason I would have to wait 2 weeks before getting a cardioversion.
Thanks for the input.

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triplea
I have not yet heard back regarding this but I cannot think of any reason I would have to wait 2 weeks before getting a cardioversion..

Are you on anticoagulation? In the absence of doing a TEE before the ECV they may require you be on anticoagulation for a period of time prior to the ECV.

I am currently on 20mg of Xarelto daily.

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triplea
I am currently on 20mg of Xarelto daily.

For how long? You need to be on an anticoagulant for 3 weeks in order to a cardioversion safely.....

BUT...

They can do a TEE and if your heart is free of clots they can do a cardioversion in the same day no matter how long you've been on Xarelto. Talk to you EP's people.

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triplea
(I am assuming that the Multaq will not get me back into sinus) .

It is possible that Multaq would convert you—it did for me sometimes—but it isn’t as likely to convert you as some of the stronger antiarrythmics.

I’ve been on Xarelto for 2 years. I don’t see any reason for starting Multaq and then waiting 2 weeks for cardioversion .

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triplea
I’ve been on Xarelto for 2 years. I don’t see any reason for starting Multaq and then waiting 2 weeks for cardioversion .

It would seem more logical to start you on Multaq and then convert you soon after.



Edited 1 time(s). Last edit at 05/11/2023 09:36PM by Daisy.

I agree 100%…I hope to get a proper explanation tomorrow from EP.

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triplea
I’ve been on Xarelto for 2 years. I don’t see any reason for starting Multaq and then waiting 2 weeks for cardioversion .

Oh, okay, new information.

There's absolutely no reason to wait except for their scheduling convenience. I would tell them unacceptable. If they won't schedule it ASAP, you'll go to the ER.

Thanks for the feedback.
Carey, when the nurse stated that I would have to wait 2 weeks, my response was that I’ll just go to the ER and get cardioversion.

This morning Dr clariified that I don’t have to wait 2 weeks…I start taking the Multaq tonight and assuming I don’t convert this weekend they will schedule cardioversion for early next week.
Perfect example of the importance of advocating for proper treatments.

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triplea
This morning Dr clariified that I don’t have to wait 2 weeks…I start taking the Multaq tonight and assuming I don’t convert this weekend they will schedule cardioversion for early next week.
Perfect example of the importance of advocating for proper treatments.

Multaq needs to be taken with a meal for best absorption—preferably one with fat and protein. Good luck!

Dr. Natale put me on 20 mg Xarelto about two weeks before my first ablation (had been on Pradaxa for 4 years) and Multaq after the ablation. Stayed on Multaq through and after touch up six months after first ablation. When I went out of NSR asymptomatic in Sept - Oct 2021 ditched the Multaq immediately. Third ablation and Watchman in Feb 2022. All I take now at Dr. N's direction is 81 mg aspirin every other day plus 20mg Lasix and 40 MEQ Pot Chlor after Dr. N. detected pulmonary hypertension at six week post watchman TEE.

I was started on dofetilide for persistent afib after flecainide did not do anything. The dofetilide stopped my afib without any problematic side-effects for about a year and a half. But I then started having breakthrough episodes of afib that increased in both frequency and intensity. I had an ablation last June that stopped the afib. I remained on dofetilide until last January when my EP stopped it. After missing two doses, I went into afib. Fortunately, I went right back into NSR after resuming the dofetilide. I am going to have a second ablation this coming November, so I can hopefully get off of the meds.



Edited 1 time(s). Last edit at 05/17/2023 08:43AM by FibberMcGee.

This is why (just above by Fibber) I believe all except the most essential drugs should be stopped by the end of the formal blanking period. One might need to be on apixaban or equivalent for life, and maybe a statin or thyroxin, etc, but why one would continue on rate control or anti-arrhythmic drugs well into the blanking period is beyond me. How can it help but to confound the Holter?! Why should a person have a high probability of having her condition masked until the six month mark and then find out that...oops, the drug was helping to keep me stable, and my ablation failed after all?

I agree that all antiarrhythmics should be stopped by the end of the blanking period. There's no way to know if the procedure was successful if you don't. I think EPs who leave their patients on AADs following an ablation aren't confident of success. I've even seen published papers that labeled ablations that required AADs afterwards as successful, which of course is a complete distortion bordering on a lie. If I see a study do that, I throw it away because it's unreliable, dishonest trash.

For me, I had surgery under a general anesthetic while I was in the blanking period and my EP did not feel it was wise to stop my dofetilde during all of that. So, he elected to wait. I was completely comfortable with that.



Edited 1 time(s). Last edit at 05/18/2023 06:55AM by FibberMcGee.

Okay, that's a reasonable exception.

Mmmm...I'm not so sanguine. I don't, and cannot reasonably in view of my lack of expertise on the matter and on Fibber's circumstances, disagree with the decision. But if the surgery had been completed within a week or two of the blanking period expiry, it would seem to have been appropriate to discontinue the AAR as soon as possible, even within a couple of weeks at most, so that a Holter could provide a veridical assessment. Even if the Holter had to be delayed, that would have been better. Note that I'm assuming there WAS a Holter administered...maybe there wasn't in this case. I'm talking more about the generic case where, if a Holter is to be issued to assess the outcomes of a recent ablation, the patient should have ceased all rate/rhythm control probably two weeks, or more, prior to the Holter.

All-in-all, I hope you get some relief next time, FibberMcGee.

Thanks. I appreciate everyone's comments here. Afib is a learning experience for sure.