More Information for UK Steve (and others interested)

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don
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More Information for UK Steve (and others interested)

Post by don » September 17th, 2005, 2:25 pm

Hi Steve

I again read your post and you seemed to indicate that your doctor wasn't well versed in the medication switch from amio to sotalol. That inspired me to get off my lazy backside and check the numbers again. When I was young and handsome I could keep all this stuff in my head, but not a chance now.

Steve, the danger of switching medications is that both medications prolong the qt interval. You indicated you didn't know what that was. The qt interval is the time it takes for the heart to go through a complete cycle of polarization/depolarization, i.e. a heartbeat.

If the qt interval is too long it can cause an especially virulent arrhythmia called Torsades de Pointes (that's French for "twisting of the points" and refers to the appearance of the arrhythmia on an ecg).

The qt interval changes with heart rate, so the measurements should be taken at rest.

Sotalol should not be initiated if the qt interval is over 450ms (that's 45 thousands of a second). Amiodarone often pushes the qt interval to over 500ms, as does sotalol. We're dealing in very small numbers here, but they are numbers that can mean life or death.

Sotalol should be started as an in-patient in a facility equipped for constant heart monitoring and equipped to handle cardiac emergencies. Some doctors don't think that's necessary. I started sotalol outside the hospital, BUT I wasn't switching off amiodarone when I started sotalol. You should be kept in the hospital for three days while your ECG is monitored. During that three days if your qt interval exceeds 520ms, the dosage should be reduced or sotalol discontinued.

The normal starting dose of sotalol is 80mg bid (twice a day). ONLY if that dosage doesn't work well for you should it be increased. An increase in dosage should be in conjunction with another three day hospital stay for the same reasons as the first.

When we talked about the stress test I told you they might administer adenosine to speed your heart up rather than have you on the treadmill. I forgot to tell you the drugs they use to visualise the blood flow. There are two common ones, Thallium and Cardiolite. They are both radioactive materials and are administered in accordance with your weight. Cardiolite seems to be the drug of choice in the U.S. right now because it is eliminated from the body faster than Thallium. If I remember correctly it takes several days to eliminate Thallium while the Cardiolite is eliminated in a number of hours.

Both are highly controlled substances and hard to obtain. Just as an aside, among those who can get it, thallium is a pretty popular way to poison their enemies. Dump a little in their drink and they're gone. It doesn't show up on the normal blood work at autopsy so often goes undetected. See what a college education can do for you? I'm lucky that my wife liked me because she worked in a hospital.

Just another aside, because I doubt your doctors have explained this to you. Neither amiodarone, sotalol or any of the other antiarrhythmics prolong life. Their only purpose is to make you more comfortable while you're here. That's one reason I can't understand people taking drugs with horrible side effects. If I only had two or three shocks a year I wouldn't take a darned thing. I take sotalol because I don't have shocks. I have electrical storms of five or six shocks in a row. BTW, I haven't had any since starting sotalol and I haven't experienced any side effects. Another aside, amiodarone has been shown to have absolutely no positive effect in the treatment of congestive heart failure.

Steve, please keep us posted. Don't let my cautions frighten you about changing drugs. You are doing the right thing. I just want to insure that you are doing it in the right way. Your doctor might need a little more education. I'm especially interested in what they discover about the clogged graft. They may find that your body has built a good network of collateral vessels to feed the heart muscle and it doesn't matter that the graft has clogged. Twelve or fourteen years ago I refused bypass surgery. The reason I refused was simply that I had endured so many surgeries I just was not going to put up with another. Since then my heart has built a wonderful network of collateral vessels and the part that wasn't getting a blood flow is now in excellent condition.

Okay, enough of my babbling. I hope there's something there you can use.

Namaste

don

UK Steve

Post by UK Steve » September 18th, 2005, 12:46 am

Hi Don ,God its 06:30am here Ive just got in from work thought I would take a peek at the board.What can I say but a huge thanx for the effort you've gone to to give me this information,I think I understand things a lot better , Can I run this by you.... I will not see my consultant till the 27th October,Im due to start taking Sotalol on the 30th of september that makes it 4 weeks on sotalol unsupervised,The way I see this is perhaps I should stay on the Amio untill I see him then show him the information you've supplied,I dont see that 4 more weeks on Amio is a big thing considering this qt/interval thing being sorted,Him telling me no Amio for 2 weeks now seems very hit or miss,Im not asking for your input for any other reason than I respect your views and would like to know what you would do in my position,I certainly am inclined to make him do this properly, Let me know what you think,(PLEASE) Thanx UK Steve

jana
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Post by jana » September 19th, 2005, 1:35 am

Steve -- Not to say that Don is wrong (because he's done much more research than I ever will, and so far, I haven't known him to be very far off base [other than beer doesn't sound very appetizing to me :D] ...) My sister was started on Sotalol w/o being hospitalized. Did fine except for the day she took one 8 or 9 hours after a previous dose (she didn't realize that "every 12 hours" meant just that, not "twice a day"), and then she felt like she was going to pass out. I was also started on Sotalol not hospitalized.

I told her to start in hospital, but our doc said that it's not necessary any more. I wondered if they didn't put me in because I have the ICD to start me up if the Sotalol had any bad effects, but when he started her when she has no ICD, I wondered if they determined that the effects aren't as bad as previously thought, or that small dosages (the 80mg Don suggested) aren't as big of a problem as maybe a larger dose would be.

However, where you're coming off Amio, could be a different situation, as Don said. You'd have two meds in your system that could cause toures de pointe (otherwise -- Long QT -- not the sydrome, just episodes). I don't know if that happens if the ICD will always save you, or if you can get an "extreme" case where maybe it puts you so out of whack that the ICD can't get you back in rhythm. I'm sure Don will enlighten you more on that one when he responds.

Does your doc have email? Maybe you could send the info and see if he responds before starting Sotalol. And, if you're not feeling quite right about it, I always say DON'T DO IT! There is a lot to how we feel about decisions we're making. If I'm calm about it, I go ahead. If not, I don't. (And, it's not just "women's intuition" -- men have it, too!)

I guess another question could be, what would be the effects of not being on anything, supposing the amio has cleared your system (which, of course, you don't know) and you don't kick in with anything else. Would you feel horrible? Would your heart be so out of control you couldn't take it? Would you get zapped repeatedly?

Keep looking at it and keep asking questions. Call the nurse. Send a letter or email. Whatever it takes to be sure that you and your doc know what you're doing before doing it!

Good luck.

Jana

P.S. I'm attaching some links that I found in a search.

http://my.webmd.com/drugs/drug-8848-Sot ... talol+Oral

http://www.drugdigest.org/DD/DVH/Uses/0 ... ol,00.html

http://www.nlm.nih.gov/medlineplus/drug ... 93010.html

All three say to be hospitalized. Maybe I'll have to ask my doc again what he's studied lately!!

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Post by don » September 19th, 2005, 7:00 am

Hi Steve

Sorry I didn't get right back to you. My computer wasn't working yesterday but a new part and a lot of cursing has it back in good condition.

I have a few comments about the challenge you brought up, but you understand I can't tell you what to do.

Medicine in the UK is not practiced the same way it is in the US. One reason I think UK doctors are so enamored of amio is that it was invented in Belgium and has been in use in the UK for much longer than here. Maybe a regional pride thing.

Another comment is that I often don't do what I tell other people they should do. I tell people the proper way, then do what I decide I am willing to take a chance with. I told you that I started amio outside the hospital though everyone from the manufacturer to the Food and Drug Administration says to start it in hospital. Did you start amio in hospital? That's supposed to require an eight day stay.

I re-read your original post and I think I'm now getting into your doctor's thinking. I had glossed over the fact that he was starting you on 40mg daily. That's one third the normal therapeudic dose, i.e. a VERY small dose. I would assume he intends to increase it slowly over time. In addition I'm sure he is taking into account the fact that you have an ICD if you should have a problem. Also, sotalol leaves the body very quickly - hours instead of the months amio takes.

Here's a laugh for you. Years ago when they started me on amio in intensive care I left the hospital, threw them in the trash and went on about my business. No tapering off for me, I just quit.

About your specific question. After reading and re-reading It's becoming apparent that your doctor has given some thought to this situation and trying to do it safely. Going a month without seeing him is not a problem. If there's going to be a problem it will surface in the first two or three days. 40mg sotalol isn't likely to have an appreciable effect on your qt interval. It would be good if you could call your doctor and ask what the qt interval on your last ecg was. If it was a 5ms or less a reaction is highly unlikely.

Steve, it's a bit of a gamble but I think it's a gamble that's weighted in your favor. I'm not going to tell you what to do because I don't want to feel guilty if something goes wrong. I feel comfortable in telling you that, under the guidelines you've offered, I'd probably go for it.

Let us know what you decide.

Namaste

don

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