Beta Blocker

Hi everyone! 

I'm still feeling pretty well. Had pacer check last month (the one where you see the tech from pacer manufacturer, not a doctor), and it is working as it should & still records no a-fib or other incidents. Some folks were wondering how we got a-fib to seemingly disappear, and that actually ties in with my current comment/question, so:

The "winning combination" for me seems to be an anti-arrhythmic (Tikosyn) with a beta blocker (Metoprolol). Oh, and the pacemaker, to keep everything from going overboard! When I first started back on the beta blocker, I was taking half my current dose (25mg x 2 vs 50mg x 2), but I was told that the afib was still "poorly controlled", so dosage was increased. Now all looks happy, happy as far as the docs are concerned, BUT...

I don't like taking Tikosyn indefinitely, as I know it is a pretty strong drug. It's also a royal pain to take what with the timing & the prospect of hospitalization to restart if I miss more than 1 dose. My real problem, though, is with the Metoprolol. I am now pretty sure that it is the culprit in my experiencing such extreme tiredness.A problem with prescription refills (why do doctors' offices make it so difficult anyway?) had me taking half the dose for a time to make it last longer. To tell the truth, I ended up being without for a bit as well--don't yell at me! The thing is, I felt better then--got some work done outdoors, made some lengthy shopping trips, and didn't feel depressed about being tired all the time. Back on the full dose, and it's same old same old (and I mean OLD, because I feel about 100!).

I have an appointment this month with my regular cardiologist, and I want to go in with the confidence to discuss my medications with him. I find that docotors will shut down that discussion pretty quickly, just by saying my opinion is wrong, period. I'd like suggstions on how to approach it. Also, I'd like to know if anyone has changed beta blockers and had a better experience.

When I saw my EP, I did mention the tiredness--this was before my forced experiment with the beta blocker--and he was positive that it was not cardiac related at all & reccommended that I have tests to see if my sleep apnea has worsened. I haven't done that yet, so OK, I guess that's a possibility. I'm sure that is what I will be told--again!

Anxious to hear what you all think on this, because obviously I am a bit confused!


9 Comments

Doctors

by AgentX86 - 2022-06-03 12:15:20

If a doctor ever tells you that you're wrong about what you're feeling or shuts down any discussion, get another doctor immediately. He's dangerous. How to deal with it? Fire them. Read the information sheet that comes with the metoprolol.  Being tired and lethargic are right there as the most common side-effects. If he doesn't know that he should have his license pulled.

I don't know what your problem is with metoprolol prescriptions.  Metoprolol is one of the most common drugs prescribed.  It's dirt cheap, too ($25 for three months). If it's making you tired, there are a dozen other beta blockers you could try but you'd have to have a cardiologist who didn't have his head so far up his backside.

Like any drug, doses shouldn't be missed but your doctors are simply trying to scare you into comliance. The drug datasheet says that if a dose is missed, take the next dose and don't make up the missed dose (normal instructions).  It says nothing of hospitalization.  Hospitalization is only needed to see how you react to the drug.  Side-effects (plural) can be very serious but the first three days will tell how you react to the drug. There are also protocols for discontinuing Tikosyn. Any time you start on a new drug it is important to read the sheet that comes with it.  In addition read online information about the drug.  Drugs.com is a good place to read about drugs and their side-effects.

Find another doctor.

 

Beta blockers

by Selwyn - 2022-06-03 12:26:58

Atrial fibrillation is not generally considered life-threatening, and dofetilide (Tikosyn) causes an increased rate of potentially life-threatening arrhythmias in comparison to other therapies, hence it is not licensed for use in the UK. It needs to be administered initially with great care and with cardiac inpatient monitoring. Should your drug levels fall substantially due to missed dosage(s) ( and this depends on the half life of the drug), then building up drug levels could be considered as restarting.

With regard to beta blockers, it is a question of trying and seeing. Side effects vary depending on the dosage, 1/2 life of the drug,  and lipid solubility.  Personally, I could not exercise with any of the beta blockers I tried. I did have a spell on Flecainide, for atrial fibrillation, and found this quite useful. Flecainide is contraindicated with structural heart disease due to the risk of sudden death.

Listening to information and getting information from professionals is a skill. In general, it is better to seek their learning, experience and wisdom and then evaluate in the light of that  received professional opinion and your own understanding ( which may need to be modified) as to what questions to ask in a none confrontational way. It should then be possible to have an interesting discussion. Clearly, having read proper medical information is an asset in such a situation.  So many people think that the internet offers correct information when it offers individual experience which may be untypical of more accumulated experiences as typified by medical literature ( excluding case reports).

 

I understand your dilemma completely - I have been there

by Gemita - 2022-06-03 17:05:12

You are not confused TLee.  You just know what you want.  A life with “controlled” AF without the need for powerful, potentially dangerous meds like Tikosyn and ever increasing doses of a beta blocker like Metoprolol.  What could be clearer?  I have successfully achieved this when it could all have been so different if I had stayed on Flecainide, Digoxin and Bisoprolol.  I am now on Bisoprolol alone with well controlled AF.  For me, my anti arrhythmic meds proved to be pro arrhythmic in the end.  In your case, Tikosyn seems to have given you a lot of respite from AF, so it is difficult to recommend changing anything, but that doesn’t mean you shouldn’t try if you have real concerns and troublesome symptoms with your present meds.  You might even be pleasantly surprised to find your AF might have settled and can be controlled without Tikosyn.  

Based on what you have told us, I would say something to your cardiologist along the following lines:

"While I am relieved that my AF is under good control with the treatment you have kindly provided, I would like to try to slowly reduce my reliance on Tikosyn to see whether my AF can be controlled with a lower dose, with the aim of eventually stopping the med completely.  I would really appreciate your support to do this safely and successfully over a long period of time without hopefully triggering worsening rhythm disturbances.  I would not be too concerned if I experienced the odd episode of AF in order to be free from Tikosyn especially if my heart rate was well controlled with a rate control med and my symptoms kept to a minimum.  I would really value your support and encouragement to do this since I am not happy to stay on Tikosyn long term because of the very real risk of developing a more serious arrhythmia like torsades de pointes.  I also want to see whether my AF can be controlled with minimum meds and with the support now of my pacemaker.   My pacemaker has made a real difference to my quality of life.

I would also like to ask, but perhaps not at the same time as reducing Tikosyn, about changing my beta blocker Metoprolol in the future to either another beta blocker to see whether it would suit me better or to change to another rate control med which would be safe to take with Tikosyn?  I am really struggling with extreme fatigue on Metoprolol.  Although I am determined to keep my AF under firm control, there has to be a balance sought between tolerance of any treatment and quality of life and with your help I want to try to find a better balance for me".

What have you got to lose TLee.  Follow your instincts with the support of a good doctor.  Be positive.  It is your life and your body and you need to find the treatment that works best for you. If your doctor won’t listen, then find someone who will and with whom you can work.  If changing treatments triggers worsening rhythm disturbances, then you can always reassess, but you won't know until you try.  Rate control meds (like beta blockers and calcium channel blockers) I was told were safer than anti arrhythmic meds for long term use and control of AF.  Perhaps finding the appropriate rate control med for you is all that you will need going forward.  I hope this helps you have a meaningful discussion with your cardiologist

Getting discussion started

by Gotrhythm - 2022-06-04 13:42:29

Sometimes I think all pacemakers should come with a short course on how to talk to cardiologists.

I have 40 years experience interviewing people, neverthelss, I frequently came away empty-handed, swearing I'd never go back.

Though I still can't claim I ever had a heart-to-heart (Ha!) talk with one, I did learn to get what I wanted sometimes.

When I hope/wish for better/different treatment options, here's a formula I have worked out that seems to promote the kind of discussion I'm looking for.

   A factual statement  plus an embedded question worded as {I'm wondering if ___}  

In your case, that would sound like, "I'm happy the afib is controlled but on the current dosage of metropolol, I'm experiencing excessive fatigue. I'm wondering what other drugs might work almost as well?"

"I'm happy the afib is controlled, but I sometimes worry about long term effects. I'm wondering how you weigh the risks/benefits of staying indefinitely on a drug like Tikosyn?"

Some people (especially men) will think this approach is "too soft." It doesn't sound like how "real men" talk. Fine. Just add some masculine body language. Picture how John Wayne could say exactly these words as he leans back in his chair and spreads his knees wide.

Notice how this approach tells the truth. You are wondering those things,that's why you wrote this post. At the same time, it avoids the appearance of challenging or confrontation.

How to talk to doctors ?

by IAN MC - 2022-06-04 14:49:02

I think your formula is brilliant , Gotrhythm !

i often wonder how Drs really feel about facing opinionated patients armed with the snippets of medical info they have picked up from Google.

After all the training and experience they have , it must sometimes be galling for doctors to be confronted by patients with so little knowledge of the broader picture.

My own formula works on the principle of preserving the doctor's ego e.g. I start sentences with phrases such as  " with your experience ".  or " I realise that I may be over-simplifying this but ......... "    or   " It may be a dumb question but ... "

I must say, I don't share the macho responses from some contributors on here along the lines of  " fire your doctor " immediately if he/she doesn't  respond in the way we expect.

Doctors have seen far more patients than we could ever imagine and every patient increases their knowledge base.

Ian

Fire your doctor

by AgentX86 - 2022-06-04 15:06:42

Sorry but if you're not getting your questions answered and worse, being blown off, or telling you don't know what you're feeling, when it's your body and you feel what you feel. Yes, fire your doctor.  How can you have "informed consent" without the "informed" part?  I had one PCP fit this category.  He was a self-important prick and doodled during the entire appointment. You bet I fired his ass.

I don't care how knowledgable patient facing doctors are, if they can't "teach", they shouldn't be doctors.  They certainly aren't going to be mine. Before I sign on the line, I want to know what I'm getting myself into.

 

Work in progress here too

by Gemita - 2022-06-04 21:23:06

TLee, Yes it can be incredibly difficult to have a meaningful conversation with our doctors, especially with the time constraints they are under.  It is still a work in progress here too, but we have to start somewhere.  However, when all is said and done, you are the one having to take the medicine, not your doctor and you are the one potentially having to live with the consequences of any adverse effects from your meds or other treatment.  If you approach the subject of coming off or changing your medication in too gentle a manner, without showing a strong desire to want to do so, your doctor may well suggest if it ain’t broke don’t fix it and he would certainly have a point.  You need to be sure in your own mind what it is you want to achieve from your consultation and against a formidable opponent like AF, otherwise you might come away feeling disappointed.  You will have to do your homework though on the advantages and disadvantages of changing your current treatment so that you can discuss the best approach for you.  

I too liked Gotrhythm’s non confrontational, gentle approach, but this may not always work.  There is also a place for changing your doctor, as AgentX86 suggests, particularly if there is a break down in trust and respect, or if you feel you are not being listened to.  In my experience, some doctors can be incredibly insensitive and unwilling to believe that we are truly symptomatic and we may struggle to be heard.  Yes doctors have the experience and medical knowledge but they are often unable to share this with us in a manner that we can understand.  Hence we have to resort to Google.  Doctors too need to learn how to communicate with their patients.  It is a two way process.

I think I will combine a little bit of everything

by TLee - 2022-06-04 21:41:26

I appreciate the comments from everyone & feel I can take a bit from each.

First, I did need the encouragement that I do know what I am feeling, and that I have every right to question & make requests of my doctor. I also have the right to feel heard & to feel that I am taken seriously. I love the support that is to be found here--it's almost like you will be going to the appointment with me!

I also can see myself using the techniques, at least at first, that keep things positive while still asking direct questions. I think I will feel comfortable trying this out & seeing what results I can get. I just need to be a bit more firm than I usually am if those results are not satisfactory, I think that having the thought in the back of my mind that I CAN fire my doctor will help me stick to my guns!

I'm carrying that thought with me into another situation that has nothing to do with my cardiologist, but thought you might get a kick out of this. I have an appointment with my primary care doctor later this month, and the main thing to be discussed is severe arthritis in my hip. There is an orthopedic practice in the same clinic where I see my pcp, and he has referred me there twice. Each time, I saw doctors so young that I know I must seem ancient to them, and I was dismissed pretty darned quickly with a few sympathetic looks & shrugs. Well, I'm firing them! I intend to ask for referral to a different practice, and I will not be shy about telling the reason. Hopefully they will learn something from it.

So, thanks to all & wish me luck!

Combine

by AgentX86 - 2022-06-04 23:38:03

Absolutely.  Don't be confrontational unless you absolutely have to.  Know where you want to go and as suggested above, don't take an BS about your symptoms.  You know what you're feeling, your doctor doesn't.   He's not inside your body.

Gotrhythm has an excellent outline for an approach to any doctor, even one you really like.  Find what works for you but her's is a good start.  The bottom line is that you have to find someway of getting a dialog going, even if you do have to fire your doctor.  I certainly don't suggest this as the first step, unless it's obvious that his style just isn't going to work for you.  I do have a doctor who's bedside manner isn't so great but he's considered the best in the area. We've gotten along fairly well.  The thoracic surgeon had a horrible bedside manner but I didn't care.  I wasn't there to find a bridge partner. I only saw him three times (but I'm told he came in to see me after).

The one thing that pisses doctors off is if you don't take meds. They, rightly so, think you're wasting their time. If you don't like them for some reason, discuss it with them but don't make such a decision unilaterally.  A huge percentage or patients just don't take their meds, then wonder why their condition is going downhill.

As far as time goes.  I've rarely had a problem with doctors taking enough time with me. I always run out of questions before they run out of time.  After my seizure, after seeing me, my cardiologist called me to his back office after the exam and we talked for another hour.

My EP talked with me for an hour, explaining my alternatives and asking how I wanted to proceed. The cardiac surgeon was a little quicker.  Same with my ortho surgeons (plural).  "Here's what we can do.  Here are the probable up/down side results, risks, and expected recovery times. "Now, Where do you want to go?"

My EP did the same.  I told him that I wanted to do the drugs, then ablation(s), and if all that failed, then the AV ablation. Didn't quite get through the whole list but...

I've had some great referrals.  It helped starting out with the best. As I said, I did fire a PCP and a PCP fired me. He couldn't deal with Obama Care and went into concierge medicine. 

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