Is it safer to take Flecainide with Betablocker?

My EP prescribed Flecainide 50mg BID alone for me to treat my Afib. From what I read online most people seem to take Betablocker with Flecainide for safety reason (Nodal protection). Does this mean taking Flecainide alone is unsafe? I am very symptomatic with Afib, my resting HR in Afib is 90-100, I am afraid to do anything but lying down as my HR would jump too high (120-160).

1:1 atrial flutter is a risk with flec. The BB will mitigate that risk. My understanding is the higher the dose, the higher that risk is. 50 mg BID isn't a huge dose. This is something to discuss with your EP. I was prescribed 300 mg flec on-demand in 2004 without a BB (I weigh more than 154#'s (70 kg), which is the cutoff for 300 mg, 200 mg/day for those weighing less). I've used it that way subsequently, including the last couple of years where I've used low dose flec once a day (25 mg). I've not had the 1:1 flutter issue, though I have had flec convert me to lower rate flutter when I take 300 mg, which I then have to convert to afib (using non drug approaches) before I can convert to NSR. After reducing my on-demand flec dose to 200 mg, I've not had the flutter issue. My approach is non-standard and I don't suggest others try it (certainly without EP advice).



Edited 1 time(s). Last edit at 05/14/2023 12:27PM by GeorgeN.

In a word, yes.

The risk of 1:1 conduction is low, and as George noted goes up with dosage and your dosage is small, but if you don't like a HR of 120-160 then you're really not going to like the 250+ that 1:1 conduction can produce.

Some EPs feel that the risk is so low it's not worth adding another drug, particularly if you're taking a fairly low dose as you are. Like everything in medicine, it's a judgement call and your EP likely has good reasons for their decision. Ask them about it next time.

Thanks George and Carey, I will check with my EP next time.

Quote
Yuxi
Thanks George and Carey, I will check with my EP next time.

One question you could ask is if you should take a BB if you have a breakthrough and you increase your flec dosage for conversion. This would mitigate the flutter risk from the larger dose. Also, a friend, also diagnosed with afib in 2004, recently went on daily flec to hold him in NSR till he gets a Natale ablation. During a visit with a new local EP, that EP mentioned to him that a BB would help increase the efficacy of the flec for this purpose. My friend is also taking flec without a BB.

Thanks George, do you know how long is the wait for Natale ablation?

Quote
Yuxi
Thanks George, do you know how long is the wait for Natale ablation?

My friend says it is variable, based on how bad your situation is, they triage the list. As flec is working pretty well for him, he's not at the top of the queue. I'm guessing Carey may have more insight. Also, I think you can sign up to be on a cancellation list, if you are willing to go on short notice.

Quote
GeorgeN

Thanks George, do you know how long is the wait for Natale ablation?

My friend says it is variable, based on how bad your situation is, they triage the list. As flec is working pretty well for him, he's not at the top of the queue. I'm guessing Carey may have more insight. Also, I think you can sign up to be on a cancellation list, if you are willing to go on short notice.

Yes, triage, which is really important as there are patients who need an ablation on an urgent basis and they will go first. I waited 6 months from initial contact to my ablation date because I was stable on meds. However, toward the end the meds failed and I was totally ready to jump on the table when the date came around. The cancellation list is a good option though it might mean paying more for your plane ticket and hotel.

Thanks again for the information!

Nothing important to add to what George and Daisy said. I first contacted Natale's office in early May. I was stable on meds, and my ablation occurred in late August, so that was about 4 months. I think that's pretty typical. If you can afford the travel with only a week or so of notice, then by all means ask to be put on the cancellation list.

Before my ablations with Dr. Natale, my local EP (who is an EXCELLENT EP), never recommended a beta blocker with my pill in the pocket flecainide protocol and I was taking 300mg at a time when I'd have an episode. I had to take that probably a dozen times and I never had an issue. I had no idea that it was a good idea to take a beta blocker with it until just recently.

Dr. Natale, however, recommended I take a small dose of a beta blocker (25mg of metoprolol) with every 150mg of flecainide I take. This was the protocol he gave me when I was having break through episodes of atrial flutter during my blanking period. Fortunately, I never had to take the drugs because I converted on my own!

As for a wait to get an ablation with Natale, it's about 4 months right now if you're not an urgent case. This is based on my recent ablation I just had with him in late April.

Travis

Thanks for the information!