Sign-in to Ask A Doctor - 24x7
OR
Sign in with Google
What Causes Mild Indigestion While On Flecainide And Bystolic?
Question: Hi Dr. Ilir:
Thank you for sending me a follow up email. I appreciate your medical ethics and concern for the patient. It sure is good to know that there are doctors like you willing to help folks with medical problems.
Based on your suggestions and recommendations, I decided to first try the antiarrhythmic medication together with the beta blocker. Since our initial email exchanges, I have been taking Flecainide - 50 mg b.i.d. and Bystolic - 2.5 mg O.D. I recognize that these are both low doses and they may be sub-therapeutic for my PVC problem. But I felt that I first had to establish tolerance to this combination. Luckily, I have had little to no side effects; only occasional indigestion that is mild. My next appointment with the Electrophysiologist is Dec. 16. My guess is that the Electrophysiologist will recommend higher doses of Flecainide, and possibly higher doses of Bystolic. However, I will request that he prescribe a 24-hour Holter monitor to document the prevalence of PVCs. Of course, I am hoping that the low doses will have had some therapeutic effect to lower the number of PVCs. However, before agreeing to higher doses of Flecainide, I will request that he prescribe a blood test to measure plasma levels of Flecainide at Cmin after taking 50 mg doses b.i.d. for 4 weeks.
Depending on the outcomes of the above procedures, I will then decide how to proceed. As you pointed out, the cardiac ablation procedure could be the best solution. And I would definitely give it serious consideration if it turns out that the medications either are not reducing the prevalence of PVCs or, alternatively, that I require dosages that I cannot tolerate. Since I have asthma, I worry as much about the Bystolic side effects as about the Flecainide side effects.
Let me know if you agree with my strategy.
Thanks much,
Irwin Rosenblum
Thank you for sending me a follow up email. I appreciate your medical ethics and concern for the patient. It sure is good to know that there are doctors like you willing to help folks with medical problems.
Based on your suggestions and recommendations, I decided to first try the antiarrhythmic medication together with the beta blocker. Since our initial email exchanges, I have been taking Flecainide - 50 mg b.i.d. and Bystolic - 2.5 mg O.D. I recognize that these are both low doses and they may be sub-therapeutic for my PVC problem. But I felt that I first had to establish tolerance to this combination. Luckily, I have had little to no side effects; only occasional indigestion that is mild. My next appointment with the Electrophysiologist is Dec. 16. My guess is that the Electrophysiologist will recommend higher doses of Flecainide, and possibly higher doses of Bystolic. However, I will request that he prescribe a 24-hour Holter monitor to document the prevalence of PVCs. Of course, I am hoping that the low doses will have had some therapeutic effect to lower the number of PVCs. However, before agreeing to higher doses of Flecainide, I will request that he prescribe a blood test to measure plasma levels of Flecainide at Cmin after taking 50 mg doses b.i.d. for 4 weeks.
Depending on the outcomes of the above procedures, I will then decide how to proceed. As you pointed out, the cardiac ablation procedure could be the best solution. And I would definitely give it serious consideration if it turns out that the medications either are not reducing the prevalence of PVCs or, alternatively, that I require dosages that I cannot tolerate. Since I have asthma, I worry as much about the Bystolic side effects as about the Flecainide side effects.
Let me know if you agree with my strategy.
Thanks much,
Irwin Rosenblum
Brief Answer:
I would explain as follows:
Detailed Answer:
Hello dear Irwin!
Welcome back on HCM!
I am amazed by the rational way you decided to follow for properly addressing your arrhythmia issue.
First I would like to assure you that at the usual flecainide daily dosage (round 100 mg bid) the therapy is well tolerated and no potentially major adverse effects would force you to stop the treatment.
I find your decision to ask the doctor checking for flecainide Cmin coupled with Holter monitoring reasonable before deciding to increase the daily dosage.
After 4 weeks of a steady 50 mg bid, now it is time to perform a review of any potential beneficial effects.
But you should not be disappointed at this point, because 50mg bid is generally considered sub-optimal and the trough plasma level is likely to result less than 0.2µg/mL, which is considered sub-therapeutic.
As I have explained you before, after around a week every eventual flecainide dose increase has reached its steady plasma levels and would be possible to reveal any possible beneficial effects.
So, as you have decided to ask your doctor, performing periodic Holter monitoring (lets say 2-4 weeks) would be a rational way for tracking the effects.
I would advice to ask for a Holter monitoring only after Cmin has reached and exceeded 0.2µg/mL.
When on around a daily dosage of 100 mg flecainide bid for 2-3 weeks, a clinical improvement has not been observed (an important PVCs reduction of round 60-80% of the initial level), then it would be rational to switch to EP study and cardiac ablation.
I personally don't believe that increasing the daily beta blocker Bystolic further would offer any additional pharmacological effect to increasing flecainide dosage.
Wishing you are having a pleasant weekend!
Let me know about any further questions you may have!
I would like to know about your test results and how is going to proceed with the PVCs therapy.
Kind regards,
Dr. Iliri
I would explain as follows:
Detailed Answer:
Hello dear Irwin!
Welcome back on HCM!
I am amazed by the rational way you decided to follow for properly addressing your arrhythmia issue.
First I would like to assure you that at the usual flecainide daily dosage (round 100 mg bid) the therapy is well tolerated and no potentially major adverse effects would force you to stop the treatment.
I find your decision to ask the doctor checking for flecainide Cmin coupled with Holter monitoring reasonable before deciding to increase the daily dosage.
After 4 weeks of a steady 50 mg bid, now it is time to perform a review of any potential beneficial effects.
But you should not be disappointed at this point, because 50mg bid is generally considered sub-optimal and the trough plasma level is likely to result less than 0.2µg/mL, which is considered sub-therapeutic.
As I have explained you before, after around a week every eventual flecainide dose increase has reached its steady plasma levels and would be possible to reveal any possible beneficial effects.
So, as you have decided to ask your doctor, performing periodic Holter monitoring (lets say 2-4 weeks) would be a rational way for tracking the effects.
I would advice to ask for a Holter monitoring only after Cmin has reached and exceeded 0.2µg/mL.
When on around a daily dosage of 100 mg flecainide bid for 2-3 weeks, a clinical improvement has not been observed (an important PVCs reduction of round 60-80% of the initial level), then it would be rational to switch to EP study and cardiac ablation.
I personally don't believe that increasing the daily beta blocker Bystolic further would offer any additional pharmacological effect to increasing flecainide dosage.
Wishing you are having a pleasant weekend!
Let me know about any further questions you may have!
I would like to know about your test results and how is going to proceed with the PVCs therapy.
Kind regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you Dr. Iliri for your quick reply and further recommendations. I will apply your suggestions when I next visit the Electrophysiologist. Also, I will let you know the outcome of further testing.
Thanks again for your follow-up. Much appreciated.
IYR
Thanks again for your follow-up. Much appreciated.
IYR
Brief Answer:
You are welcome!
Detailed Answer:
Dear Irwin!
I would be happy to review all your uploaded tests for another professional opinion!
Wishing all the best and an Happy Christmas time!
Dr. Iliri
You are welcome!
Detailed Answer:
Dear Irwin!
I would be happy to review all your uploaded tests for another professional opinion!
Wishing all the best and an Happy Christmas time!
Dr. Iliri
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
Get personalised answers from verified doctor in minutes across 80+ specialties
