Worried about too larger a dose for Pill in Pocket for my weight.

Atrial fibrillation or flutter (pharmacological cardioversion) (off-label dose): Oral: Outpatient: "Pill-in-the-pocket" dose: Note: May not repeat in ≤24 hours (Alboni 2004; AHA/ACC/HRS [January 2014]). An initial inpatient cardioversion trial should have been successful before sending patient home on this approach. Patient must be taking an AV nodal-blocking agent (eg, beta-blocker, nondihydropyridine calcium channel blocker) prior to initiation of antiarrhythmic.

<70 kg: 200 mg

≥70 kg: 300 mg

From drugs.com/ppa/flecainide.html

My GP prescribed me 300 mg but I am less than 70 kg. I am, in fact, 56 kg.

Can anybody comment on this as I am concerned about taking too much. I have great trepidation to approach the GP who prescribed this and fear other GPS may be defensive on his behalf.

At the moment I am taking Amiodarone but will stop soon. Then it will be 12 weeks after my ablation for AFib. Amiodarone has been a blessing and given me peace from the 2nd week of taking it but I know that it should only be short term. I will only have been on it for 3 months and 11 days by then.

So can anyone give advice.

Thanks

[Rellim296]

My EP said I was OK taking 100mgs of flecainide as a pill in the pocket and I may sometimes take a further 50mgs an hour or so later if needed. This is usually sufficient to get me back to normal rhythm. I'm about 57kg. I often find NSR returns within minutes of the second dose and never know if it tipped the balance or wasn't really needed. I sometimes leave taking more, if the AF is fairly mild, to later in the day and then find I don't need it. When I was taking flecainide on a daily basis my dose was 150mgs twice a day.

PS Two years ago I was taking 50mgs and then another 50 in an hour, as in the post below mentioned by Goldfish_ but I now start with 100mgs following a recent discussion with my EP.

[Hidden in reply to Rellim296]

Thank you for reply. You show that there are different doses applied to different patients.

When I took Flecainide on a daily basis with top up for nightly episodes, I can't remember how much medication, but after a fortnight Atrial Flutter just came back the next day and had inconvenient side affects.

[PeterWh]

What does it say on the manufacturer's leaflet?

You can always ask the pharmacist. They won't blame as they come across many cases of medicines being mis-prescribed.

[Hidden in reply to PeterWh]

Thank you for your reply.

I have just read "the starting dose is 50mg a day up to maximum dose of 300mg per day. So it looks like 300mg wont do any harm as a pill in the pocket. However, according to drugs.com/ppa/flecainide.html and on AFib data base it gives the dosages according to weight for pill in the pocket.

[Rellim296 in reply to Hidden]

Flecainide is usually taken twice a day as its effects are short lived. Although that isn't relevant when it's a pill in the pocket and you are taking what might be a single dose, taking 300mgs might be a bit over the top all at once. As PeterWh says, a pharmacist might offer good advice, and asking your EP will give you a good way forward and would avoid bringing the matter up with your GP. I once took too much flecainide, forgetting first thing in the morning (and alarmed by rampant AF) that I had taken some at 11 the night before. I had no ill effect. I was unable to take the full dose the following evening and felt it was an invitation for AF to return, but not so.

I am always particular about taking it on an empty stomach and then waiting an hour before eating but I am not sure that this is very important.

[mrsg46]

Perhaps it might be worth contacting your EP via their secretary to find out what they think. Obviously you won't get an answer straight away but an email sent over the weekend will be in their inbox on Monday morning and hopefully you'll get a reply the same day.

I hope you get this sorted out quickly for your own peace of mind and your recovery from the ablation will continue without the anxiety you are feeling at present.

[Hidden in reply to mrsg46]

Thank you. I did receive a phone call from the Arrhythmia Nurse after 4 days my leaving a message on the answer phone. He said he would ask the EP. I told him that it was not so pressing as I could continue with Amiodarone for the next 10 days and then I will have finished the packet of tablets. He thought the dose was a bit high.

Thank you for your kind words. Receiving kindness does help lift the spirit and sooth the soul. This is not something I would discuss with anyone.

[Buffafly]

Amen sister!

[rosyG]

I think you are wise to be taking notice of the instructions re body weight yo posted. Also, the second part of your post is very important- it is supposed to be given in hospital first and also must have a beta blocker or channel blocker if beta blockers are not suitable, This stops Flecanide from have other unwanted effects the heart

I am not giving advice here as we mustn't advise re meds but jus saying you are on the right lines!

[ILowe in reply to rosyG]

Sorry, not everyone agrees with you that Flecainide MUST be taken with a beta blocker or channel blocker. For years, pre-AF, I was on Flecainide alone. Post-AF, the British Cardiologist prescribed Pill in the Pocket for me, and said I needed to also take some bisoprolol as part of the PIP since people prescribed PIP are usually on betablockers.

Since my AF is stress related, usually, I only take Flecainide as PIP and that works. And in times of high stress I go on Flecainide for weeks at a time, in order to keep a lid on things.

I agree with you though on body weight. It is so important, and often ignored, that I routinely point it out to doctors, and ask about reducing dose for almost any medicine. This is especially important with Flec (probably other heart meds as well) since it is well known, too much can create the problem you are trying to avoid.

[Hidden in reply to ILowe]

Thank you for confirming my suspicions. Most helpful. I am glad I have put off stopping Amiodarone. Only have 10 tablets left. This medication has given me peace from AFib for which I am most grateful but I know it is toxic and I have to come off it.

[rosyG in reply to ILowe]

Hi

You have been lucky that the Flecanide taken alone has't been a problem - from what you say it seems your cardiologist doesn't know why most people who take flecanide are also on a beta blocker!! Please ask your EP if you have one and they will explain what can happen and why flecanide does need other meds with it

[Hidden in reply to rosyG]

Hi RosyG, Are you sure you are not related to Honey G on XFactor

I have not taken any Flecainide. I only went to the GP because the Consultant's secretary told me to do so. In fact, I asked the Arrhymia Nurse to enquire about my having a contingency plan before a possible next ablation but the Consultant was out and he, the AN, did not think it fit to make a note and ask the Consultant after he returned. In fact, he told me just to be positive. I replied that I was but I was only being expedient.

Now I will wait until the Arrhythmia Nurse comes back and tells me what the Consultant says.

So I am only on Rivaroxaban and will take Amiodarone for a further week. It is after that I will start to worry if I don't get properly attended to. Probably will have to go privately just to get the information needed but my follow-up appointment should be at the beginning of December, as they have put it back. Also my appointment at the other hospital is on the 9th December. I am just covering myself.

[rosyG in reply to Hidden]

No relation !! Yes I was replying to Lowe above who has taken Flecanide without other meds! Flecanide is well thought of but needs other meds with them.

Hope you get proper information in time

[ILowe in reply to rosyG]

Where do you get this from?

My UK cardiologist permitted it because she had read my detailed case history. She well knew that I had been on and off it for years. Your experience may differ from that. She also knows that with my slight tendency to Asthma, I should use bisoprolol as little as possible.

[rosyG in reply to ILowe]

Hi ILowe

You asked where I get this from.

We started a patient support group locally and have a medical director (Cardiologist and EP) . Both he and other Cardiologists who have given talks to our group have said these meds are needed with Flecanide. One patient who can't have Bisoprolol was given a calcium blocker as apparently these can also. like beta blockers, stop the unwanted effects of Flecanide on its own. ( Flecanide is, of course a highly thought of drug)

It's best that you be guided by someone who knows your own history - we don't put meds advice on here as it's very individual but , having been told the risks involved, I think anyone being prescribed should check this out.

[ILowe in reply to rosyG]

Thanks. I will look into it. My gut feelings are that this is just one more difference of opinion in the medical profession, which leaves me the patient to decide for myself. Right now, all I have to go on is your opinion backed by the opinion of the experts you know. I am interested in the evidence on which they base their opinions, and on evidence that supports my current view.

[rosyG in reply to ILowe]

Hi Lowe

quite understand how you feel- I also like to get evidence - I think you need some information perhaps from the manufacturers of Flecanide- the lead pharmacist at your local CCG might be able to get this for you.(They may the pharmacist more info than to patients as they don't want to be alarmist )

[rosyG in reply to rosyG]

meant to say give the pharmacist...

[ILowe in reply to rosyG]

The reference says you should be on a betablocker when Flecainide is initiated. That does NOT say you should stay on them. Also, look at why they are used at initiation. I was initiated years ago and have been on them for years at a time therefore my cardiologist would only expect me to see him if a new symptom developed. The other argument is a maybe, that maybe the ventricular rate will be increased. Now I see a reason, but it is a maybe. This is not evidence. I think there is enough slack in the system so that if that happens then there is safe time and can in that eventuality.

There is a strong argument that taking betablockers with Flec is counterproductive. For some people, why does AF start? The irregularities increase, probably due to stress etc and the body compensates by initiating an increase of rate. Faster rates are usually more regular, as in classical tachycardia. At some point this battle does not resolve, rate is fighting irregularities, and no one wins. To get to a solution, you have to reduce the irregularities. You take Flec or similar. Also, a beta-blocker has undesirable effects which could be worse than the problem that 'may' happen.

Still, this is interesting enough to look into some more.

[rosyG in reply to ILowe]

Lowe,

You are getting nearer to the reasons why the other meds are needed when you talk about effects on the ventricles. I don't want to go into more details as this alarms people but I don't think you are correct to take it as only meaning when Flecanide is initiated. This is a serious matter and everyone should be advised by their own cardiologist who know their medical history. It should not be for us on the forum to be saying what meds can safely not be taken as this could have influence people and lead to serious results.

I have only advised people to ask their doctors about this so don't want to discuss further - for the reasons mentioned here

[ILowe in reply to rosyG]

Fair enough. I respect your desire to stop our discussion. However, for the record, I am NOT saying what meds can safely not be taken. Obviously the final decision is between the individual and their specialist. But, thanks to this forum I was alerted to a potential problem. And for that I am grateful. Take care.

[rosyG in reply to ILowe]

Lowe- did you look at the link which Heather put in the first post on this thread? It also says people should be on either beta blockers or channel blockers before having Flecanide- seems quite detailed review there of Flecanide in case you haven't seen it

[Hidden in reply to rosyG]

I thought copying part of my report about my very short experience with Flecainide.

13th September 2015

Atrial Flutter @ 11.30 p.m. > 115 b.p.m.

@ 3.15 a.m. > 162 b.p.m.

Duration time

11 hours.Went to A & E where it returned to sinus rhythm @ 2.15 p.m.

Now take 5mg Bisoprolol @ 8.00 a.m. together with a 50mg Flecainide tablet and

another Flecainide tablet @ 6 p.m. One extra 50mg Flecainide tablet to be taken when an Atrial Flutter occurs.

20th September 2015

Atrial Flutter 4.15 a.m. > 129 b.p.m.

Took extra Flecainide tablet

21st September 2015

Took extra Flecainide tablet @ 1.00 a.m. as it re-occurred

22nd September 2015

Took extra Flecainide tablet @ 10.00 p.m. as it re-occurred

23rd September 2015

Took two 125 mcg Digoxin tablets @ 5.30 p.m. as it still re-occurred

24th September 2015

Took two 125 mcg Digoxin tablets @ 5.30 p.m.

From the 24th September both the Digoxin and Bisoprolol tablets controlled heart rate. but it returned again on the 27th September and Atrial Flutter was still too frequent.

My EP took me off the Digoxin when I saw him Instead he put me solely on 7.5 mg Bisoprol daily. I would take an extra 2.5 mg Bisoprol when Atrial Flutter occurred which only happened at night.

[rosyG in reply to Hidden]

how are you getting on now? You've had quite a time of it !

[ILowe in reply to rosyG]

Sorry, my reply to you got into the wrong place. Have you seen this 2011 review of Flec? There is no mention at all of betablockers, and I would expect that in a review article like this. medscape.com/viewarticle/73...

[Hidden in reply to ILowe]

Thank you. I am not registered with them. I have decided to book a private appointment and then I will know for sure.

[rosyG in reply to ILowe]

Hi- see my reply to your last post to me- best left to your own doctor `i think!

[dmac4646 in reply to ILowe]

It would appear to be as usual all about opinions my Cardio sees no reason why you cannot be on Flec on its own.

[Hidden in reply to rosyG]

Thank you for your information. It is helpful. Glad I don't automatically trust GPs.

[Goldfish_]

I'm a fan of flecainide pill in the pocket and have 50mg tabs. I am 90kg and usually just take just 50mg which usually settles my paf, but I take a second dose after 1 or 2 hours if not resolved and then only once I took a third dose totalling 150 mg after a further 1-2 hours. Never had an episode lasting more than 6 hours since diagnosis 5 years ago.

Taking a 300mg dose with your weight sounds a sledge hammer approach.

Flecainide is not without side effect the most worrying of which is precipitating a heart attack if you have pre existing coronary artery disease.

I suspect your GP may not have much experience in using flecainide in this way , but would suggest you discuss the low dose strategy with him/her informing them of your source here. As long as you have 50mg tabs, you can adjust the dose.

The data sheet doesn't give a dose recommendation for pill in the pocket and so I suspect this is not a licensed use of the drug although commonplace

medicines.org.uk/emc/medici...

There's another post about this here

healthunlocked.com/afassoci...

[irene75359 in reply to Goldfish_]

I would really like to use flecainide as a PIP. When I was first diagnosed last year, I was prescribed 2.5mg Bisoprolol and I couldn't even climb a flight of stairs. I saw an EP privately and he told me to stop, and use the Bisoprolol as a PIP. However when I had a second episode last month, to my dismay it went on for 60+ hours and although Bisoprolol slowed my heart rate I was still in AF. I was then prescribed flecainide 50mg twice a day in conjunction with Bisoprolol which I reduced myself to 1.25mg. But I keep thinking that in the nine months between my episodes to date, these were nine months that I didn't take or need drugs.

[Hidden in reply to Goldfish_]

I was prescribed Flecainide 100 mg tablets for PIP. Thank you so much Goldfish for your information.

[dmac4646 in reply to Goldfish_]

You should NOT be on Flec with existing CAD.

[Goldfish_ in reply to dmac4646]

Yes you should have had a coronary angio CT angio or similar to show absence of coronary artery disease before using flecainide.

[PeterWh in reply to Goldfish_]

That surprises me because certainly I didn't and don't recall others saying so though I think one or two may have.

I had an echocardiogram as a standard test before being prescribed flecainide.

Could the NHS afford it and do they have the resources to do one on everybody being considered for flecainide?

[Goldfish_ in reply to PeterWh]

Probably not, but it's the difference between good and excellent care. However it shouldn't be prescribed to anyone with known coronary artery disease.

[Goldfish_]

I'm not sure what your point is. This is the progressive nature of af. Initially infrequent paroxysmal episodes, becoming more persistent and prolonged with time, while heading towards permanent af.

[Hidden]

Thank you all for you information and advice.

I can't take Flecainide on a daily basis because of side effects. I thought perhaps PIP would be OK. Now I shall have to wait until the Arrhythmia Nurse comes back to me. Should be only next week.

Once again thank you. It has helped me to relax and feel more grounded.

[PeterWh]

Let us all know the results of your discussions.

[Hidden]

Yes, I gladly will. Thank you.