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“Pocket Pill Adverse Reaction”
I have used the “pocket pill” protocol without side effects to deal with afib episodes that strike about every six weeks on average. However, when I recently used it, my heart rate and BP crashed. Couldn’t stand up. Wound up in the hospital overnight for observation. All fine the next day. Same symptoms, same protocol, hugely different outcome.
Anyone else have an experience like this? Here’s the protocol I followed successfully many times, except this one:
25 mg metropolol
Wait half hour and if persists, take 2 150 mg flecainide
If your Afib continues despite taking the metoprolol 25 mg and flecainide for breakthrough episodes, you can repeat the metoprolol again after one hour and continue monitoring. You can take an additional (3rd) metoprolol 25 mg again if needed.
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What is your weight? Flecainide has a dose upper limit for people below a certain weight, especially women.
This chart suggests that flecainide can cause problems like hypotension:
https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Tools%20and%20Practice%20Support/Quality%20and%20Clinical%20Toolkits/AFib%20Toolkit/Flecainide.pdf
I would make sure your cardiologist knows of this development. You might be better off taking only that one pill, 150 mg, and waiting 45 minutes. Just winging it here...I'm no expert, nor am I qualified to give medical advice. But your cardiologist might agree to try one pill for close to an hour and then to add a second pill.
Gloaming, thank you. Weight 173 pounds +/- 5. 6’ tall. I did alert my cardiological team and they recommend ending the pocket pill approach. If afib doesn’t subside, they recommend ER. It doesn’t sound to me like a nuanced approach to my particular situation.
@zacklucy Flecainide is the most used PIP anti-arrhythmic that I see discussed. I don't know if others can be used the same way, say propafenone, or Sotalol or Multaq (both I believe require close supervision when initially administered).
I hope you won't mind this segue, especially if it's something you've strongly resisted or have an aversion to, but you should really consider submitting to a great electrophysiologist and get the 'gold standard of care' that is a catheter ablation. There is a lot to learn about that topic, but if it is successful, it really slows the typical progression of the disorder and its possible nasty outcomes. Not only that, but you get your life back and you don't need the PIP. Just throwing that out as a person who has had two ablations (the first failed to close one small gap on my third pulmonary vein, which they found second time...now three years free of AF or any other worries).
Gloaming, not only do I not mind, I am grateful that you are thoughtful enough to reply.
My second PW ablation (17 months after the first) is scheduled for next month. I think I have a top EP.
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1 Reaction@zacklucy Same for me, a top EP, even though he didn't quite manage to nip mine fully first go. I was so grateful at the one year mark that I actually called his office on that date and asked his clerk to relay my gratitude and compliments to him. She laughed...probably doesn't get many such calls on an 'anniversary'.
My wish, for you, is that this time you go on to enjoy many years carefree. May it be so, and for all of us.
Thanks, and same to you. Happy holidays.
The event you described can happen, and it’s a known risk with pill-in-the-pocket AFib protocols, especially when metoprolol and flecainide are combined.
Both drugs slow heart rate and conduction. When flecainide converts AFib back to sinus rhythm, the beta-blocker effect can suddenly become unmasked, causing an abrupt drop in heart rate and blood pressure. Repeating metoprolol doses increases this risk.
Even if the protocol worked many times before, tolerance can change due to dehydration, illness, age, lower baseline BP/HR, or timing of conversion. The same doses can suddenly cause bradycardia, hypotension, and near-syncope, often landing people in the ER for observation — then resolving once the meds wear off.
Bottom line: pill-in-the-pocket isn’t “set and forget.” A hypotensive or near-fainting episode usually means the protocol needs re-evaluation or dose adjustment.
Sources:
• NEJM – Pill-in-the-Pocket AFib (Alboni et al.)
• PubMed review: adverse events with PITP (2022)
• FDA Flecainide Prescribing Information
• FDA Metoprolol Prescribing Information
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1 Reaction@tommy901
Tommy, thank you.
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1 Reaction@zacklucy Your welcome. Glad this documented information was helpful for you!
I monitor my V1 lead when I do pill in the pocket. I’ve seen a pause of 5 seconds when converting. I try not to be up and about when I take the flecainide, those couple seconds of no pulse is unnerving. I do 37 mg metoprolol and wait at least 30 min. I want my heart rate lower than 90 when I take the flecainide. I’m failed first ablation too. It was a glorious 5 months. Now I get svt too. EP wants to wait to do my redo ablation until they figure out my mitral valve/pulmonary hypertension issue. Last night’s afib lasted 5 1/2hours despite the metop/flec. Ugh