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toxicity

FAQs A-Fib Treatments: Medicines and Drug Therapies

FAQs A-Fib Treatments: Medicines and Drug Therapies

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

Drug Therapies for Atrial Fibrillation

Atrial Fibrillation patients often search for unbiased information and guidance about medicines and drug therapy treatments. These are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer.)

1. Which medications are best to control my Atrial Fibrillation?” “I have a heart condition. What medications work best for me?

2. “Is the “Pill-In-The-Pocket” treatment a cure for A-Fib? When should it be used?”

3. “I take atenolol, a beta-blocker. Will it stop my A-Fib.”

4. I’ve been on amiodarone for over a year. It works for me and keeps me out of A-Fib. But I’m worried about the toxic side effects. What should I do?”

5. Should everyone who has A-Fib be on a blood thinner like warfarin (Coumadin)?”

6. Which is the better anticoagulant to prevent stroke—warfarin (Coumadin) or aspirin?

7. What’s the difference between warfarin and Coumadin?

8. I’m on warfarin. Can I also take aspirin, since it works differently than warfarin? Wouldn’t that give me more protection from an A-Fib (ischemic) stroke?

9. “What are my chances of getting an A-Fib stroke?

10. “I’m worried about having to take the blood thinner warfarin (brand name Coumadin). If I cut myself, do I risk bleeding to death?

11. “I am on Coumadin (warfarin) to thin my blood and prevent A-Fib blood clots. Do I now need to avoid foods with Vitamin K which would interfere with the blood thinning effects of Coumadin?” UPDATED

12. “The A-Fib.com web site claims that an A-Fib stroke is often worse than other causes of stroke. Why is that? If a clot causes a stroke, what difference does it make if it comes from A-Fib or other causes? Isn’t the damage the same?

13. “I just had an Electrical Cardioversion. My doctor wants me to stay on Coumadin for at least one month. Why is that required? They mentioned something about a “stunned atrium.” What is that?

14. Are natural blood thinners for blood clot treatment as good as prescription blood thinners like warfarin?”

15. “How long do I have to be in A-Fib before I develop a clot and have a stroke?

16. I have to be on aspirin for stroke prevention. Which is better—the low-dose baby aspirin (81 mg) or a high dose (325 mg)? Should I take the immediate-release (uncoated) or the enteric-coated aspirin?

17. I don’t want to be on blood thinners for the rest of my life. I’ve had a successful catheter ablation and am no longer in A-Fib. But my doctor says I need to be on a blood thinner. I’ve been told that, even after a successful catheter ablation, I could still have “silent” A-Fib—A-Fib episodes that I’m not aware of.  Is there anything I can do to get off of blood thinners?

18. “My last cardiologist had me on Pradaxa. My new cardiologist wants me to switch to Eliquis. Is Eliquis easier to deal with if bleeding occurs?

19. “My doctor told me about the Tikosyn drug option that I want to consider in getting rid of my 5-month-old persistent A-Fib. That seems like something that should be discussed on your web site.

20. “I hate taking Coumadin. Is there a way to get off blood thinners all together? I know I’m at risk of an A-Fib stroke.”

21. “I”ve read about a new anticoagulant, edoxaban, as an alternative to warfarin (Coumadin) for reducing risk of stroke. For A-Fib patients, how does it compare to warfarin? Should I consider edoxaban instead of the other NOACs?

22. “Do you have information about Hormone Replacement Therapy (HRT) and if it might help or hinder my atrial fibrillation?

23. Are Anticoagulants and blood thinners the same thing? How do they thin the blood?

24. I have A-Fib, and my heart doctor wants me to take Xarelto 15 mg. I am concerned about the side effects which can involve death. What else can I do?

25. “Is the antiarrhythmic drug Multaq [dronedarone] safer than taking amiodarone? How does it compare to other antiarrhythmic drugs?”

Last updated: Wednesday, May 25, 2016

Back to FAQs by Patients with Atrial Fibrillation

FAQs A-Fib Drug Therapy: Amiodarone & Toxic Side Effects

 FAQs A-Fib Drug Therapy: Amiodarone

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

4. I’ve been on amiodarone for over a year. It works for me and keeps me out of A-Fib. But I’m worried about the toxic side effects. What should I do?”

You are correct to be concerned about toxic effects. Amiodarone is considered one of the most effective antiarrhythmic meds, but it’s also one of the most toxic. It may affect your lungs, eyes, thyroid, liver, skin, heart, and nervous system.

Also, amiodarone has a long half-life. It is retained in the body for up to 45 days after the drug has been discontinued.

(Be advised that a newer drug dronedarone (brand name Multaq) is now on the market and may be a good substitute for amiodarone. Dronedarone may not be quite as effective as amiodarone, but is much safer. However, some studies indicate that dronedarone may have problems.)

If you are taking amiodarone, you should by monitored and tested frequently and scrupulously for damage to your organ systems (your doctor may already be doing this). You should keep copies of any tests. What’s important is not so much whether you are within a “normal” range, but whether your measurements are going up and how fast. Note: it’s important that baseline values for organ systems should be documented before you start taking amiodarone.

Contact your doctor immediately if, after taking amiodarone, you experience any new symptoms such as: coughing, wheezing, shortness of breath, visual changes, skin rash, pain, tingling or weakness in the arms or legs, fever, rapid heart beat, fatigue, lethargy, unusual weight gain, swelling, hair loss, cold or heat intolerance, lightheadedness or fainting.

The recommended maintenance dose of amiodarone is 200 mg/day. A possible toxic level of amiodarone may be 400 mg daily for more than two months, or a low dose for more than two years.

For a more in depth discussion, see Amiodarone: Most Effective and Most Toxic.

 Thanks to Lee Abdullah for this question.

Resources:

Jessurun, G. and Crijns, H. “Amiodarone pulmonary toxicity—Dose and duration of treatment are not the only determinants of toxicity.” BMJ, 1997, Volume 314, Number 7081, 619. http://www.bmj.com/content/314/7081/619.full

Jessurun, G. and Crijns, H. “Amiodarone pulmonary toxicity—Dose and duration of treatment are not the only determinants of toxicity.” BMJ, 1997, Volume 314, Number 7081, 619. http://www.bmj.com/content/314/7081/619.full

Return to FAQ Drug Therapies

FAQs A-Fib Drug Therapy: Medications with Heart Condition

 FAQs A-Fib Drug Therapy: Medications

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

1. “Which medications are best to control my Atrial Fibrillation?” “I have a heart condition. What medications work best for me?”

A doctor’s choice of drug therapy depends on one’s overall heart health, i.e., if there’s a heart condition other than Atrial Fibrillation.

In general, current medications don’t always work on A-Fib. People tend to react differently to meds. What works for one person may be terrible for another. What medications are best for you is a judgment call only you and your doctor can make..

When trying a new med, there is a fine line between allowing time for your body to adjust to it versus recognizing that this drug is causing bad, unacceptable side effects.

When starting a new med, your doctor may hospitalize you in order to monitor how the drug affects you and to get the dosage right.

If you’ve just been diagnosed with paroxysmal (occasional) A-Fib, flecainide (brand name Tambocor) or propafenone (Rythmol) might work for you. Some people have had good luck with the relatively new drugs dofetilide (brand name Tikosyn) and Rhythmol SR (propafenone sustained release). The newest antiarrhythmic med is Multaq (dronedarone) which is a less toxic substitute for amiodarone. Also see Treatments/Drug Therapies.

Guidelines from the ACC/AHA/ESC based on one’s overall heart health and heart conditions other than Atrial Fibrillation:

•  Minimal or no heart disease. Flecainide, propafenone, sotalol. The object is to “minimize organ toxicity,” to select drugs that will not harm the rest of the body. The above drugs can cause “proarrhythmia” (an increase in heart rhythm problems), “but in patients without heart disease, this risk is extremely small.”
•  If these drugs don’t work, then dofetilide and amiodarone can be considered. And “in experienced hands one might choose (Pulmonary Vein) Ablation (Isolation) for a primary cure.”
•  Congestive heart failure. Only dofetilide and amiodarone have been demonstrated to be safe in randomized trials.
•  Congestive heart failure and significant lung disease. “I would likely consider dofetilide as my first choice.”
•  Congestive heart failure who are “hypokalemic” (have low levels of potassium). Amiodarone.
•  Coronary artery disease. Sotalol is recommended because of its beta blocking and antiarrhythmic effects. Amiodarone or dofetilide combined with a beta blocker can also be used. Propafenone and flecainide aren’t recommended.
•  Hypertension. Propafenone or flecainide.
•  Hypertension and substantial left ventricular “hypertrophy” (increase in size). Amiodarone, because it has the least proarrhythmic effect.

(These guidelines are based on a presentation by Dr. Eric Prystowsky, see Boston AF/2003/ Prystowsky.)

Return to FAQ Drug Therapies

Amiodarone: Most Effective and Most Toxic

Amiodarone: an antiarrhythmic medication

Amiodarone: an antiarrhythmic medication

Amiodarone: Most Effective and Most Toxic

By Steve S. Ryan, PhD, Updated May 2016

Amiodarone is considered one of the most effective antiarrhythmic meds, but it’s also one of the most toxic. It may affect your lungs, eyes, thyroid, liver, skin, heart, and nervous system. Also, amiodarone has a long half-life. It is retained in the body for up to 45 days after the drug has been discontinued. It’s usually considered a drug of last resort or a drug that should only be used for a short time.

Be advised: A newer drug, dronedarone (brand name Multaq), is now on the market and may be a good substitute for amiodarone. Dronedarone may not be quite as effective as amiodarone, but is much safer. But some studies indicate that donedarone (Multaq) may have problems. 

Monitor and Test Frequently

If you are taking amiodarone, you should be monitored and tested frequently and scrupulously for damage to your organ systems (your doctor may already be doing this). You should keep copies of any tests. What’s important is not so much whether you are within a “normal” range, but whether your measurements are going up and how fast.

Note: it’s important that baseline values for organ systems should be documented before you start taking Amiodarone.

Contact your doctor immediately if, after taking amiodarone, you experience any new symptoms such as: coughing, wheezing, shortness of breath, visual changes, skin rash, pain, tingling or weakness in the arms or legs, fever, rapid heart beat, fatigue, lethargy, unusual weight gain, swelling, hair loss, cold or heat intolerance, lightheadedness or fainting.

The recommended maintenance dose of amiodarone is 200 mg/day. A possible toxic level of amiodarone may be 400 mg daily for more than two months, or a low dose for more than two years.

Susan Grider, of AmiodaroneToxicity: The Drug Amiodarone Is a Deadly Killer, emailed me this observation:

“While you do point out that amiodarone is dangerous, you’re not nearly emphatic enough about it. A patient could easily justify taking amiodarone after reading your description calculating that when symptoms present themselves, they will simply stop treatment. It’s not that easy as some have suffered permanently as a result of only one dose. In addition, the symptoms of amiodarone toxicity are not always recognized (even by the medical community) before it is too late. Amiodarone is a drug of last resort and that’s according to the FDA. Patients who take this drug should have exhausted every other treatment possibility.” See also the website: AmiodaroneToxicity: The Drug Amiodarone Is a Deadly Killer.

Damage and Toxicity to Organ Systems

LUNGS: Perhaps the most important test is for the lungs. “Amiodarone-induced pulmonary toxicity can be progressive and fatal if not recognized and treated.” You should have a chest X-Ray and Pulmonary function testing with diffusion capacity (DLCO) before starting and at least every year you are on amiodarone.

THYROID: Thyroid problems from amiodarone are all too common and can occur in as many as 22% of patients. Decreased energy, cold intolerance and weight gain are among the most common effects of decreased thyroid function. You should test for blood levels of TSH (Thyroid Stimulating Hormone), as well as the thyroid hormones free T4 and total T3. Amiodarone can also increase thyroid function with symptoms such as atrial rhythm disturbances, elevated heart rate, heat intolerance, and weight loss.

EYES: Corneal microdeposits occur in the majority of patients who take amiodarone, but they usually don’t cause any ill effects. More substantial microdeposits, however, can cause visual disturbances and even severe damage/inflammation of the optic nerve which can cause blindness. On taking amiodarone, you should have yearly eye exams. Report any visual changes immediately to your Electrophysiologist.

LIVER: Amiodarone commonly causes liver toxicity, but usually only mild increases in blood liver function tests (LFTs). The liver function tests are AST (SGOT), ALT (SGPT), and bilirubin. More severe cases can result in liver failure signaled by jaundice, abdominal pain, and distension.

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SKIN: Amiodarone increases sensitivity to the sun and sun burning. This increased sensitivity to the sun can be severe in approximately 10% of patients. Avoid the sun, apply sunscreen, and wear additional clothing.
It also can produce a blue or gray discoloration of the skin if one takes heavy doses and/or for long periods. This discoloration can persist after stopping amiodarone, but may fade very gradually (often years) after drug discontinuation.

HEART: Amiodarone can cause slow heart rhythm disorders such as slowing of the sinus rate and AV block. You may feel fatigued, lethargic, have poor exercise tolerance, and may experience dizziness and fainting. Less commonly, amiodarone may induce ventricular arrhythmias such as polymorphic ventricular tachycardias called “Torsades de Pointes” or TdP which can cause death.

You should have a 12 lead EKG before starting amiodarone and at six-month intervals in order to assess baseline heart rate, rhythm, and EKG signal intervals (PR, QRS, QTc). 

FETUS/NURSING INFANT: Amiodarone is known to cross the placenta and enter the fetus, and is excreted in breast milk. Use of amiodarone should be avoided if at all possible in women who are pregnant or likely to become pregnant. Lactating women who are taking amiodarone should not breastfeed. Due to the likelihood of toxicity if amiodarone is taken for decades, amiodarone use is strongly discouraged in children, unless there are no acceptable alternatives.

Keep in Mind

Amiodarone is a drug of last resort and that’s according to the FDA. Patients who take this drug should have exhausted every other treatment possibility.” See also the website: AmiodaroneToxicity: The Drug Amiodarone Is a Deadly Killer.

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Return to Index of Articles: Drug Therapies (Medicines)

Last updated: Tuesday, July 26, 2016

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