Breakthrough episode (Update)

[ChasMartin]

My EP only put me on a miniscule dosage of sotalol as I was doing it out of hospital and couldn't be directly monitored (40mg twice a day). I feel 1000 times better, no kidding, since starting the sotalol even at this low dose. No more daily PVCs, no more extreme fatigue. After checking my QTC to ensure I wasn't getting any long QT from the sotalol with an outpatient EKG, the EP did not relay any instructions to up the dose. Tuesday I had a breakthrough episode, with very clear cause (digestive distress that caused me pain and PVCs all day until I had an episode later in the evening close to bed time, heart rate at least stayed below 200 instead of heading up to near 300)

Was a bit disheartened at first, but after looking up that the normal starter dosage of sotalol for AF is 80mg twice a day, I assume he will up my dosage to that normal amount and hopefully will work even better. I have a follow up with my regular cardiologist Tuesday, so I am going to see if he can do it.

I guess I'm wondering why he didn't up it immediately after the EKG confirmed no long QT. Anyone ever actually on 40mg twice daily for any amount of time?

[oscarfox49]

80mg once a day (I have always chosen to take 40mg twice a day) is a very normal dose. I have been taking it that way since 1995 and in general terms it has kept me stable and able to cope, although I am now in 'permanent AV' with controlled rate. I did have a stroke a couple of years ago but that was due not to sotalol or lack of it, but to the fact nobody gave me an effective anticoagulant until after the stroke. I am now on apixaban and sotalol and nothing much else if you exclude the normal statins and magnesium supplements etc

[ChasMartin in reply to oscarfox49]

Interesting. The literature for the drug states 80mg twice daily for the initial dosage while under monitoring and then you may up it in a stepping process if need be. drugs.com/dosage/sotalol.html

[oscarfox49 in reply to ChasMartin]

I think prescribing principles might have been very different right back in 1995 when I first had my attack of severe AF and got hospitalised. Apart from a junior doctor telling me I had had a 'heart attack' (I queried it at the time) my cardiologist finally explained the situation and prescribed 60 mg a day (which did not exist and would have been difficult to create even by dividing the standard 80 mg tablet.) I know there were colleagues at my workplace taking far less sotalol than me but that was for high blood pressure rather than AF.

I remember early on, I found that 80mg in one go virtually brought me to a standstill with pulse rate very slow and all the usual beta blocker effects when you are getting used to them; and then a return to ectopic beats and AF by the late evening, as the worst problems I had were during the night, leading to me being hospitalised as an emergency twice more by worried GPs.

The half life of sotalol is about 13 hours which means half of it is still in your system after 12 hours. It takes 4 days to be expelled completely from your body. To my simple mind it does make sense to have two doses as you reduce the peaks of the drug in your system while never getting to a point in the 24 hour period where you are almost without it. It certainly works well with me.

Some people may need a far higher dose but it makes sense to take the minimum amount that keeps you stable. Even with 'permanent AF' I find the rate control given by my 40mg twice a day is the best option for me.

[ChasMartin in reply to oscarfox49]

I'm currently debating whether I am going to even push the issue. I feel fantastic on the 40mg twice a day. Even the breakthrough episode was many times more tolerable than they've been in the past. 100 less bpm on average, and I didn't have the same severe "sense of doom" waves of presyncope I would normally get. I do worry taking more will make me tired again like the beta blocker did. I might just wait a bit longer and see if the episodes continue to be less frequent and as tolerable, and keep as is.

[mav7]

See you are in the US. Many doctors recommend a hospital stay of 2-3 days for monitoring when beginning sotalol. He may want more EKGs before increasing the dose.

If your heart is continually racing to over 110 bpm, recommend going to the ER.