Sotalol

[tsco]

Doc, We've talked before and I appreciate your expertise.  I have SVT, some a-flutter, PACs.  Had 4 ablations.  After my last ablation 2 yrs ago I now seem to have LBBB (rate dependent). I was on Rythmol for last couple years LBBB at 130 BPM. At Onset I have a sharp pain and then wierd rythym which would subside with rest.  Then I started getting PACs like crazy.  So we stopped Rythmol. I am now taking 75 mg 2x day Flecainide which works great at reducing the PACs.  I have however had 3 fast rate attacks during exertion in the past month. (Probably SVT 150 BPM). I can terminate the SVT with 50 mg toprol within 2 hours.  So I am thinking the Flec has lowered my LBBB rate and is triggering the SVT when it happens at approx. 120-125 bpm. I am not certain. Two of the episodes I could feel the pain at onset. So I am mixed whether the LBBB is triggering the SVT or vice versa. I told my EP this and he says Sotalol is all we have left to try. He prscribed 80 mg 2x day and stop the Flec. (haven't done yet).  The idea is to reduce my rate and widen the window for LBBB to kick in.  I also take norvasc 5 mg daily.  Questions:
1. I am happy with the diminishing of ectopics with Flec.  Is sotalol successful in eliminating pacs?
2. Is sotalol good for reducing or stopping SVT attacks?
3. He says he wants my rate in the 50s when I'm sitting around. Will I be a zombie?
4. Is there sexual side effects from sotalol?
5. If I'm on sotalol and have a fast svt rate will my toprol still be OK to use to break the fast rate?
6. Is sotalol a beta blocker like toprol?
7. To be conservative could I just start at 40 mg 2x instead of 80mg so I'm not a zombie?
8. Is it OK to take a calcium and magnesium supplement with sotalol?
9. Most post on sotalol says you should be hospitalized.  I was only told to get an EKG 48 hours after start.  Is this safe??

[Michael J. McWilliams, M.D.]

1. I am happy with the diminishing of ectopics with Flec.  Is sotalol successful in eliminating pacs?

Not as successful as flecainide but it can decrease PACs.  It is possible that the flecainide is slowing your atrial flutter as well and that could be the cause of your symptoms, that is unless it feels exactly like your left bundle sensation.

2. Is sotalol good for reducing or stopping SVT attacks?

Sotalol is good at reducing attacks but not very good at terminating them once they start.  Flecainide is better at terminating them.


3. He says he wants my rate in the 50s when I'm sitting around. Will I be a zombie?

Some people yes, others are not.  The only way to know is to try it.
4. Is there sexual side effects from sotalol?

For males there can be erectile dysfunction.

5. If I'm on sotalol and have a fast svt rate will my toprol still be OK to use to break the fast rate?

I would want to see what your heart rate and QT interval on EKG is before recommending taking a beta blocker in addition to sotalol.  Sotalol is a pretty potent non selective beta blocker and can significantly reduce heart rates.

6. Is sotalol a beta blocker like toprol?

Toprol is a selective beta blocker, it only blocks one beta receptor subtype (B1). Sotalol is non selective and blocks both B1 and B2 receptors.  

8. Is it OK to take a calcium and magnesium supplement with sotalol?

yes


7. To be conservative could I just start at 40 mg 2x instead of 80mg so I'm not a zombie? 9.Most post on sotalol says you should be hospitalized.  I was only told to get an EKG 48 hours after start.  Is this safe??

Questions 7 and 9 are combined.  I only load sotalol in the hospital and keep people in the hospital for 3 days after starting the medication.  That is the recommendation on the package insert.  Sotalol at 40 mg po  twice per day is a beta blocker and has minimal anti arrhythmic effects.  The potassium channel properties of sotalol start at 80 mg twice per day.  I would start 80 twice per day and do it in a hospital setting in my patients.

I hope this helps and the your symptoms improve soon.  Thanks for posting.

[Michael J. McWilliams, M.D.]

Atrial flutter is usually at a fixed rate -- 300 beats per minute -- and conducts to the ventricle at 1/2 that rate 150 beats per minute.  Flecainide slows atrial flutter rates and sometimes allows atrial flutter to conduct 1:1 with atrial rate =  ventricular rate in the upper 180-200's, sometimes slower.  This is only one possibility.

[tsco]

Sorry, if no follow-ups I'll pay and post again.
I don't really understand a-flutter.  What do you mean it may be slowing my a-flutter and causing the symptoms?  Are you saying a-flutter is usually at a certain rate kind of like my rate induced LBBB?
Thanks