Podcast: Play in new window | Download
In your last Q&A session you mentioned pill-in-the-pocket. Can you tell me a little more about it? I have an appointment coming up with my EP and I’d like to discuss this with him. Thanks.
What is Pill-in-the-Pocket for Atrial Fibrillation?
Pill-in-the-pocket is a treatment protocol where you take an antiarrhythmic drug (flecainide or propafenone) in a large dose at the onset of an episode. What makes this treatment protocol unique is that you only take the drug when needed vs. taking it every day.
What is considered a “large dose?”
154 lbs or greater = 300mg of flecainide
Less than 154 lbs = 200mg of flecainide
154 lbs or greater = 600mg of propafenone
Less than 154lbs = 450mg of propafenone
*These are typical prescription doses for pill-in-the-pocket but your actual dose may vary. Your doctor will ultimately determine what your prescription dose will be. DO NOT attempt to do pill-in-the-pocket on your own! Always consult with your doctor before proceeding.
Pill-in-the-pocket is a great option for younger paroxysmal afibbers or really any paroxysmal afibber who has a strong, healthy heart.
In some cases, you’ll be required to start the pill-in-the-pocket protocol in a hospital so your doctor can monitor how your heart responds to these drugs when taken in large doses. I was encouraged to do so by one of my EPs while my other EP said I was perfectly fine to try it on my own without hospital supervision. These contradictory opinions really confused me and scared me so my flecainide sat on the counter for months. I was too scared to try it “on my own” and I didn’t want to deal with the fuss of going to the hospital to take it either.
Out of desperation one day during an intense episode I decided the heck with it, I’m just going to take it. I’m glad I did because it changed everything! For starters, not only did I convert into normal sinus rhythm within a few hours but for the first time I felt I had some control over my afib! From that point forward I didn’t fear afib as much. I knew if I had an episode I could just pop my flecainide and I would be back to normal in just a few short hours. I no longer had to worry about having to go to the E.R. The pill-in-the-pocket was a total game changer for me.
Pill-in-the-pocket worked great for me but will it work great for you?
Does Pill-in-the-Pocket Work?
I can tell you the vast majority of afibbers I’ve talked to that follow this protocol say it works. I can only recall a couple examples where the pill in the pocket didn’t work but even in those cases the protocol worked for a while at first but just lost its efficacy over time.
In addition to the anecdotal evidence there is a study I’d like to highlight. I’m going to reference an article titled, “Outpatient treatment of recent-onset atrial fibrillation with the pill-in-the-pocket approach.”
The article details a study that was conducted to assess the feasibility and safety of treatment with either flecainide or propafenone administered as a single oral dose outside the hospital to terminate atrial fibrillation of recent onset in patients without severe heart disease who have infrequent, well-tolerated arrhythmic episodes (paroxysmal afib).
Treatment was considered successful if the interval between taking the drug and conversion to sinus rhythm was six hours or less with no observable side effects.
There were a total of 268 patients with recent onset atrial fibrillation that were first treated in the hospital with flecainide or propafenone. 58 patients were not given out-of-hospital treatment moving forward for various reasons. See the study for those reasons.
The remaining 210 patients in the study were discharged and given flecainide or propafenone as a pill in the pocket to treat any future afib episodes.
The mean follow up period was 15 months + or – 5 months. 4 patients of the original 210 patients were lost to follow up. Of the remaining 206 patients, 41 (20 percent) did not have any episodes during the follow up period.
165 patients did have episodes during the follow up period. They reported a total of 618 episodes. 569 of those episodes (92 percent) were treated with either flecainide or propafenone. The other 49 episodes were not treated with flecainide or propafenone because the patient felt that the afib attack was mild or the drug was unavailable.
Flecainide was used in 254 of the 569 episodes (45 percent) and propafenone was used in the other 315 episodes (55 percent).
The drugs were effective (i.e. episodes were interrupted within 6 hours) in 534 of the 569 episodes (94 percent).
139 of the 165 patients that used flecainide or propafenone as a pill in the pocket at the onset of an afib episode were able to successfully terminate ALL of their afib episodes (84 percent). The other 26 patients (16 percent) had at least one episode that lasted more than six hours after taking the drug.
Recap Findings of the Study
The study found that oral flecainide and propafenone when used as a pill in the pocket as out of hospital treatment, stopped 94 percent of the afib episodes within 6 hours, and in 84 percent of the patients, the treatment was effective for ALL afib episodes, with a mean conversion time of about 2 hours. In addition, the incidence of adverse side effects was low. Only one patient (.6 percent) felt a marked acceleration of the heart rate after taking flecainide and was shown to have atrial flutter with a rapid ventricular rate by an ECG in the emergency room.
Bottom Line: The study concluded that the pill-in-the-pocket approach appears to be feasible and safe (and I would add successful!).
If you take the results of that study along with the anecdotal evidence, I’d say the pill-in-the-pocket protocol does work and should definitely be considered for any paroxysmal case – especially young people with paroxysmal afib!
There you have it, Scott, that is my very long-winded answer to your very simple question.
If you have a question you’d like featured in a future Q&A session, please contact me. As I always say, everyone that contacts me will get a personal response from me whether I feature it in a future Q&A session or not.
Are you doing pill-in-the-pocket to treat your atrial fibrillation? If so, are you taking flecainide or propafenone? Does it work for you? Share you experiences in the comments below!
Discuss this ArticleClick here to start your own discussion topic or reply to any comments below by clicking on the "REPLY" buttons.
I have had PAF for about 3 years. It started if I had a few drinks of alcohol so I don’t drink much. This past year I had a very stressful fast-paced job and I was having more episodes. They go away on their own after 4 hours. I tried Diltiazem but it didn’t work so I was put on 50 Mg Flecainide 2X a day. It works, YAY!
However, after 4 months I am having a lot of dizziness. I want to try to wean down, maybe 25mg, 2X a day. I will cut the pill in half. My heart is healthy, no heart disease. I weigh 125 pounds and I workout as well. Please advise. Thank you.
I’m not a doctor so I can’t recommend changes to the drugs you are taking. However, it’s quite possible the flecainide is causing dizziness. I would talk to your doctor about cutting the dose as you have suggested. I’d be surprised if he/she said no. Going from 100 to 50 per day isn’t a huge deal. The only “risk” is that with a lesser dose you may be more prone to having episodes. That will likely be your doctor’s main concern. But if you tell your doctor you just want to try this for a 3-4 week period and see how it goes I’m sure you’ll get the green light. Best of luck to you!
My cardiologist has been adamant that I could not begin taking Flec if I was in Afib. She said it had to be taken when in NSR. So confused.
After a couple of months of high stress, I had a paf event in December 2009. It lasted all night (about 7pm to 6am). My MD hubby said to wait until morning as I would likely not get looked at until then anyhow.
I’m 73 and I was just 65 when I had my first event. I meditated off and on all night. In the morning I tentatively got up and did some mild yoga before going to the hospital and it converted. I still went and had a follow up with a cardiologist who had me wear a vest for 2 weeks. I got the diagnosis of PAF. I never had another event for maybe 5 years. Again, it happened after 2 months of high stress. The event was shorter (3-5 hours) and resolved on its own.
After that I started having more frequent events often lasting 5-6 hrs. I chose to lose weight, began meditating regularly, experimented w/magnesium and supplements, etc. I do take taurine, phosphatidylserine, ashwaghanda, co q10, vitamin B, D and magnesium glycinate as well (CALM magnesium product).
My correlation so far is if my sleep is reduced, or my blood sugar is higher (stress induced) I am more apt to have an occurrence or a “pre-occurrence.” My “pill-in-the-pocket” has been homeopathic remedies Hyland’s calm and calm forte, and ignatia amara. I take them when I start to feel anxiety, or if it is hard to get my breath. I’ve increased daily mild exercise and very slowly regained better capacity to exert. I stop when I feel rushed or pushed, work to be more resilient, and distance myself from stress as needed.
I’ve also been in therapy, cranial sacral therapy and seeing a bio-energetic chiropractor. After having an episode 2-3 times/week in September 2017, I have not had an event since 11/6. At that time they had become shorter in length. I very much appreciate this blog and the information you share here. Thank you!
Thanks for sharing your experience. So you’ve created your own natural “pill-in-the-pocket” solution. That’s terrific. I hope it continues to work for you. Another natural “pill-in-the-pocket” solution is to take hawthorn berry extract and large amounts of magnesium when you have an episode. My ND gave me this protocol but I never used it. I preferred Flecainide as I knew it would work and I never had side effects from it.
Just wanted to say I have had paroxysmal afib for some 30 years (current age 64) and my attacks have lasted at most 2 hours on average with one attack lasting 6 hours years ago – back in the 90’s, I was prescribed a pill in the pocket approach but with 20 mg of inderal (propranolol) and .5 mg ativan (lorazepam) with instructions to take another dose of inderal and ativan if the first dose did not work.
Since this regimen was started, none of my attacks have lasted more than a hour and I have never had to take the second dose. The first dose has always worked on average between 20 mins to an hour. Of course it’s impossible to say with absolute certainty that the medication is acting effectively or if the attacks are spontaneously resolving on their own. But like you say, at the very least this approach has given me tools to fight attacks such that I no longer feel the same fear and trepidation when an attack does occur!
P.S. Here is a link to a short report on the pill-in-the-pocket approach employing inderal and ativan:
Your afib started at an early age as well. I can’t believe you’ve been able to control your afib with pill-in-the-pocket for so many years. That’s great it’s working so well for you!
Thanks for sharing your experience and thanks for sharing the link to the report.
I wish you well!
I have had PAF with RVR for 2 years. My original cardiologist refused to consider PIP (pill-in-the-pocket) so after four months of sotalol, which was not preventing a-fib, I got a second opinion with a University-based EP. He weaned me off sotalol and put me on flecainide and metoprolol as PIP. He also advised weight loss, diet change, etc. which I did.
I am happy to report in the last 16 months I have only had 2 mild 2-3 hour episodes. I’m happier that I haven’t had an episode in 9 months now. Because I converted in 2 hours after PIP, my EP recommended I wait an hour into an afib attack to see if I self convert. I didn’t so now I don’t wait as I see no point letting it get too ramped up. Other good news is the original first two episodes (on sotalol) my heart rate would get up to 180-200. Now the highest rate has been 120. My cardiologist is still not a believer.
Congrats on your weight loss and lifestyle changes. Glad to hear that PIP is working for you. I wish you well!
Copyright 2023 – Living with Atrial Fibrillation