Multac (dronedarone)

Back when my a-fib started, my regular cardiologist prescribed me to take 400 mg of Multac twice a day. It’s an anti-arrhythmia medication similar to amiodarone (I guess they all have the -darone ending) but with less side effects. Here’ some more info from their website.

What are possible serious side effects from taking MULTAQ?

MULTAQ may cause serious side effects including slowed heartbeat, inflammation of the lungs (including scarring and thickening), low potassium and magnesium levels in your blood, and changes in kidney function blood tests.

What are the most common side effects?

The most common side effects when taking MULTAQ include stomach problems such as diarrhea, nausea, vomiting, stomach area pain, and indigestion; feeling tired and weak; skin problems such as redness, rash, and itching. Tell your doctor about any side effect that bothers you or that does not go away.

I think I was experiencing some of the side effects while taking Multec. For sure I was vomiting more often. It was mailing at meal times but lots of fool smell or taste would trigger a reflex reaction. I think at one point I was throwing up 4x in one week. I also think my slower than normal heartbeat post-ablation is partially due to the Multac as well. Before a-fib, my heart rate was in the mid- to upper-50’s. With ablation + Multac, I was seeing high 40’s and low 50’s. Now that I’ve stopped taking Multec, heart rate seems to be a bit higher and I’m throwing up a lot less. However, if it’s like amiodarone, the half-life of the drug may be pretty long, which means some of the effects will linger for weeks.

*You can see the trend line starting to rise when I stopped taking Multac a week ago.*

Cardiac Ablation Follow-up (updated)

I had an in-office appointment with the doctor that performed my cardiac ablation procedure back in early June. To get to the office, I had to answer questions about symptoms with one person, then get temperature screened by another person, and line up for the elevator since it only takes four people at a time. It was like visiting a maximum security facility or something. This COVID=19 pandemic has drastically changed our lives.

The nurse did an EKG measurement and the doctor said everything was normal, except that my pulse is a bit slow. When I went in last time, it was at 120-130; now it’s in the low 50’s. He also stopped the anti-arrhythmia medication I was taking so one less pill. Yay!

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Here is my year-to-date resting heart rate as recorded by my Fitbit.

It started in the 60’s after heart surgery but slowed to the mid-50’s when I started taking Terbinafine, which can react with Metoprolol and cause a slower heart rate. The increase in April was from the initial a-fib, which was not fixed by cardioversion. The huge spike in May was the a-fib re-occurrence and waiting for the cardiac ablation procedure on June 5th. It has steadily dropped since then to the low 50’s. Here is this weeks heart rate readings; the gaps are when I was charging the Fitbit.

Blood Pressure Variability

My experience with blood pressure and medication has been a freak show. When I was previously on hemodialysis a year ago, my blood pressure would drop during the session, and often it would be too low when I was done (<100 systolic). I would feel lightheaded and the nurses wouldn’t let me leave in case I fainted and crashed my car.

Fast forward to heart surgery. When I got back on hemodialysis, the blood pressure was still low-ish, but quickly increased until I was hitting 180/100 consistently. We started adding medication from just Metoprolol to including Benicar (Olmesartan) and NIFEdipine, both 30 mg ER and 10 mg capsules. Post a-fib and ablation, my blood pressure was still high so last week, the rounding nephrologist told me to start taking the 30 mg ER NIFEdipine again. For the next few sessions, my blood pressure has been low when I walked in, typically in the 100/60 range. This would increase some but limits the amount of fluid that can be removed during the session. So now, I have to skip the evening NIFEdipine before dialysis (M/W/F), while keeping the 10 mg capsules for emergencies. Confusing…

I also got my dialysis dry weight dropped by another 0.5 kg to 88.0 kg. My ankles are still pretty swollen from edema so maybe this will also help drop my blood pressure further.

Cardioversion, Part III

I couldn’t sleep at all this morning. Between anxiety about the cardioversion procedure and chest pain/pressure, there was no way I was going to fall asleep. By staying up, I noticed that my heartbeat was pretty regular at 61 bpm since midnight. When 8:00 am rolled around, I called the cardiologist office to ask what I should do. The receptionist took a message and said my cardiologist would call me back. Actually, during the call, my a-fib started up again. Dang it.

I ended up going to the hospital at 9:30 am as scheduled. My sister dropped me off since they were not allowing visitors for outpatient procedures. Check-in was pretty efficient; they came out with completed paperwork so I didn’t have to talk to the admitting person for very long. On the way back to pre-op, I saw my nephrologist doing rounds at the hospital. She was surprised to see me. I thought I was a bad sign I’m recognizing random doctors walking around in a hospital.

*Pre-op room. They ended up doing everything in that room.*

The first thing they did was to get a swab for a COVID-19 test. I just had an antibody test done Friday but this was the antigen test so the nurse crammed a swab way up my nose until it felt like she was digging out some brain matter. Ouch! Thankfully it came back negative. They also drew blood for labs. Since I have a fistula in my right arm, they were limited to the left arm only. The first nurse managed to draw enough blood but took several tries. Then she tried to put in an IV but failed so another nurse came and did it after several tries. Later they said my blood sample clogged and they needed to draw more blood. The IV seemed to be one way (in only) so three nurses tried 10+ times to put in a butterfly needle but failed. My left arm was covered with gauze and bandages. Finally they called the lab for a real phlebotomist. With about 15 minutes prior to the procedure, my cardiologist showed up and the nurse said labs weren’t done because they could not draw blood. The cardiologist said, “I saw the results at my office.” Turned out he original draw was fine. I even had the results on my patient portal app. I got poked those 10+ times for nothing.

Anyway, it was pretty smooth after that. Cardiologist said she was going to set the machine at 150 Joules; not sure if that’s a lot or not but seems to be similar to a defibrillator. The anesthesiologist came and put me to sleep at around 1:00 pm and I woke up right before 2:00 pm in the post-op recovery room. The nurses there gave me some juice, crackers, and peanut butter since I haven’t eaten in 12+ hours. My sister picked me up at ~2:30 pm so I was at the hospital for a total of six hours. I went home and took several naps, probably due to the anesthesia, and heartbeat has been fine so far.

My cardiologist also stopped my Metoprolol medication so hopefully the Multaq can maintain the steady heartbeat.

Cardioversion

About two weeks ago, right before my UCLA cardiologist appointment, I had an episode of arterial fibrillation. It ended up going away after about a day and since then, I’ve had very short cases of fast heartbeat, most lasting a few hours. However, this latest episode started this Monday afternoon, and hasn’t stopped since.

When the heart rate is high, or when my heart skips beats, the Fitbit tracker has problems picking up the right pulse rate. Usually, the plot is a straight but slightly squiggly line but the above shows random fluctuations between 60 and 130 bpm.

I went in to my cardiologist’s office for an EKG yesterday and the doctor said it definitely looks like a-fib. She asked me to double up on my Metoprolol pill but so far, it has no effect. The other option is cardioversion, either through medication or electro-shock. For some reason, she thought I had this done before but it’s all new to me. I have a 3:00 pm Zoom call; let’s hope we can restore my heart rate with medication.

Prescription Drug Costs

Usually when I pick up my medication from the pharmacy, I only see the co-pay amount. For some generic drugs, the amount is $0. For others, it could be as high as $30 per prescription. For some reason, I see the pharmacy billed amount in my FHA account. I’ve already used up all the money by early February, but I still see pharmacy claims.

Many years ago, I was diagnosed with one case of a-fib. Initially, the cardiologist prescribed Cumadin to thin out my blood a bit so I don’t get a blood clot and stroke. At some point, I was in the hospital and they switched to Eliquis; I took 5 mg of it twice a day. After heart surgery, they kept me on Eliquis but reduced the dosage to 2.5 mg. So every 30 days I puck up 60 tiny tablets of Eliquis. The billed cost from the pharmacy is ~$500 and my work insurance pays $462.47.

Now I understand it costs a lot of money to research, test, and get approval for new drugs but that seems kind of excessive. If I didn’t have insurance, would I be spending $15/day on the one prescription? What if it did prevent a stroke? How much is that worth? Also, how much does the drug cost in Canada or Mexico? I heard those countries pass laws to limit the cost of drugs, which are then passed on to US consumers. If we ever get universal healthcare in the US, would that bankrupt all the pharmaceutical companies since they won’t have US consumers to bill?

Tachycardia and A-fib

Ugh. My heartbeat is all messed up again. At around noon today, I took a short nap. Since then, my heart rate has gone crazy. Initially I was just looking at my Fitbit and it was showing a heart rate of ~110. I didn’t feel weak or anything like the episode before the heart bypass surgery. I also pulled out the blood pressure monitor and my Kardia EKG. Both gave me a heart rate of 110 to 120. The EKG said I had tachycardia but otherwise normal heart rhythm. I then tried to take a nap around 6:00 pm to see if my heart rate will slow down. As I was lying down, I can hear my fistula whooshing. The rhythm was super weird so I got out the EKG again. I measured several times and it either said possible a-fib or unknown. The rhythm is very irregular. I would hear three or four fast beats, then my heart would skip a beat and continue. Something it slowed down to 70 bpm, other times it sped up to 120+.

Last time this happened, my heart rate was up at 150 bpm. I couldn’t even stand up and ended up sitting/lying down on the carpet in front of my dialysis cycler. This time, I feel okay other then then weird heartbeat. I just walked upstairs from the dining room and feel fine. I’m not sure what to do at this point. I guess I can ask the nurses at dialysis tomorrow.

I have to see a cardiologist at UCLA Wednesday morning. I’m pretty sure if this continues, I’m not going to be able to clear the hold on my transplant. Each time there’s a milestone for my transplant process, something always comes up to block or delay the schedule. Sigh…

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I was taking amiodarone for three weeks after heart surgery. While I was in the hospital, they had to give me amiodarone through an IV because my heart beat sped up again. I stopped taking the medication about three weeks after discharge but it has a very long half-life. Maybe the after-effects of the drug was keeping my heart in check, and the drug has finally worn off. Amiodarone is very toxic and has tons of side effects. I hope I don’t have to go back on the medication again.

Telemedicine, Primary Care

I had an appointment with my primary care physician today. They don’t have their video equipment set up so instead of a video conference, the appointment because a phone call. The only lab test was for Hemoglobin A1C and my result was 5.9%. It went up slightly from January when it was 5.0%. It think for diabetics, the number should be below 7.0%. My doctor said the number should be lower for patients on hemodialysis. She then asked about my daily blood sugar readings, which were below 100 in the morning. I think she was thinking about my brush with hypoglycemia awhile ago so we ended up removing the last of my blood sugar medicine.

I think it’s the first time I’ve been off diabetic medication since forever.

Pharmacy Visit

With so many prescriptions for medication, I get text messages and automated calls from my pharmacy weekly. About half of my prescriptions are on auto-refill so I’m not always expecting the notifications. My sister just picked up a few prescriptions for me Friday and my pharmacy is asking me to pick up a few more today.

My pharmacy is at the back of the local Albertsons. The supermarket is quite large and I’m sure it’s pretty busy these days. I will need to walk through two-thirds of the market and talk to the pharmacist. Worse, I will need to sign electronically for the prescriptions and I’m now paranoid about touching anything outside the house. I should have switched to the mail-order prescription service earlier.

Just Make It Stop

I don’t know how it’s possible but the numbness in my feet/legs keep getting worse. I’ve been walking in the upstairs hallway for about 30 minutes and the numbness is affecting more and more of my legs. I tried using a massage wand to massage the calf muscles and a shiatsu foot massage machine for the soles of my feet, but nothing is helping.

Today has been a terrible day. From the almost panic attack and hot flashes during dialysis, to missing several appointments due to insurance mix-up (cardiac rehab, therapist, acupuncturist), to the overwhelming numbness in my feet, this is probably one of the worst days since heart surgery. I’m trying to stay positive but right now, there’s really nothing to look forward to. I alternate between work and dialysis for six days of the week, and then lots of sleeping in on Sunday.

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So the only difference between yesterday and today is the Tylenol PM I took last night as a sleep aid. The active ingredient for the “PM” part is diphenhydramine, which is the same ingredient for Benadryl. Each caplet contains 500 mg of acetaminophen and 25 mg of diphenhydramine. I took two caplets per the instructions on the bottle. Looking at WebMD, there are many side effects to diphenhydramine. Under common side effects, it lists an increase in the thickness of lung secretions. I think I had that last night, causing me to cough a lot more. Under rare side effects, it has chest discomfort, difficulty sleeping, excessive sweating, and numbness and tingling. I know it says “rare” side effects, but those symptoms showed up or intensified suddenly last night/today. Since it didn’t help me sleep last night, I’m going to skip taking Tylenol PM to see if my breathing and numbness gets better.

Traditional Chinese Medicine

My acupuncturist mentioned today that she wants to me to try some herbal medicine. Since I’m Chinese, I’ve tried some of this stuff growing up. Usually it’s more of a supplement than actively trying to cure something. For example, some of the Chinese desserts my mom makes has goji berry (枸杞) and snow fungus (银耳) in it.

I’m a bit concerned since I’m on a lot of medications already. My acupuncturist did ask for my list of medications but I wonder how much Western Medicine is covered in an Oriental Medicine degree? For Chinese herbal medicine to be effective, it will probably interact with some of my current medications. There are a lot of websites with herbal information so I guess I also need to do my own research.

I hope she sticks to herbs and plants and doesn’t give me weird or endangered species stuff like rhinoceros horn or pangolin scales. I also need to ask about cost since it’s likely none of this is covered by insurance.

Dialysis Blood Pressure 2/27/2020

I’m off to a bad start. First two sitting blood pressure readings are in the 190’s. I forgot to take the NIFEdipine ER pill last night since I fell asleep at 10 :00 pm. I did take all my blood pressure medications this morning but wasn’t sure if the ER effects carry over from last night. I guess it takes four pills to lower my blood pressure to normal levels.

I’m debating whether to take another 10 mg of NIFEdipine sin e blood pressure may get worse as some of the other meds get dialyzed out.

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Hmm, not sure what is happening with my blood pressure. I’ve been sitting up blogging so the reading should be slightly better. The last reading at 10:50 am was 164/89/60. Usually the readings start increasing aroun 11:00 am as the Metoprolol starts getting dialyzed out.

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The reading at 11:20 am was 151/82/61. Doesn’t make any sense.

Acetaminophen-Codeine #3, Part II

The magic pill worked again. The pill I took at 1:00 am lasted until morning and I slept for a combined 9+ hours last night. The pain was mostly gone this morning so I didn’t take anymore pills. It’s about 5:00 pm now and there is no pain, even after eating a large bowl of hot Vietnamese noodles for lunch. I guess my gums were super irritated during the dental appointment but no lasting damage afterwards.

*Lunch. Probably too much sodium and too much soup but it was good!*

Acetaminophen-Codeine #3

That’s what it says on the pill bottle from the pharmacy but it may as well be magic pills. After taking one pill yesterday, the pain in my gums and tooth disappeared after 15 minutes. The pill didn’t just dull or diminish the pain, it was gone. I can see how this can become addictive if you had chronic pain. Tylenol #3 is not even that potent as an opioid painkiller. That fentanyl stuff must be amazing and scary.

Along this line sufentanil, fentanyl and buprenorphine are being regarded as high potency opioids, methadone, oxycodone, morphine, ketobemidone and hydromorphone as medium potency opioids and codeine, hydrocodone, tramadol and tapentadol as low potency opioids.
British Journal of Clinical Pharmacology article

After the pain disappeared, I was still wary of eating solid food so I drank a bottle of the Muscle Milk protein shake I bought. It has pretty high levels of potassium and phosphorus but since we just took blood samples for labs today, I have an entire month to make up for it. Still hungry, I drank a second protein shake (milk chocolate Ensure) for dinner. Along with a mixed berry Nepro I had for lunch, I think it’s the first time I drank three protein shakes in one day instead of eating real food.

Nutritional Item	Nepro	Muscle Milk	Ensure	Total	DV
Calories	425	160	220	805	2,000
Total Fat	22.7 g	4 g	6 g	32.7 g	65 g
Saturated Fat	2.0 g	1 g	1 g	4 g	20 g
Cholesterol	6.5 mg	15 mg	<5 mg	26.5 mg	300 mg
Sodium	250 mg	210 mg	210 mg	670 mg	2,400 mg
Total Carbs	37.9 g	6 g	33 g	76.9 g	300 g
Protein	19.1 g	25 g	9 g	53.1 g	50 g
Calcium	250 mg	30%	25%	800 mg	1,000 mg
Potassium	250 mg	580 mg	10%	1,170 mg	3,400 mg
Phosphorus	170 mg	40%	15%	555 mg	700 mg

Three shake meal day

I went to sleep right after taking the Tylenol #3 pill and drinking the two shakes and was able to sleep for 5+ hours. I woke up around 1:00 am since the initial painkiller wore off and I could feel the throbbing pain in my gums again. After lying in bed for 10 minutes, I took another pill and now the pain is gone again. Amazing. I have 15 pills so hopefully my dental pain will go away before I run out.

*That was the most sleep I’ve had in awhile*

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It’s now ~3:15 am. I’m going to go back to bed and try to sleep some more before the second pill wears off.

No Sleep 2/3/2020

It’s 4:13 am Monday morning and I haven’t slept at all. I went to be around 11:30 pm and basically watched YouTube for five hours. I would try to sleep between videos to no avail.

My right arm was wrapped up pretty tightly with a compression bandage all afternoon and evening. Around 7:00 pm it appears the bleeding has stopped. There is still a compression bandage on the incision site but not as tight. However, there’s pain in both my arm and my abdominal surgery sites. I did get the prescription for Tylenol + Codeine but I’m still just taking regular Tylenol. In addition, my mom has a prescription for Hydrocodone and my dentist gave me a prescription for Vicodin. I also have some leftover Percoset from my heart bypass surgery. That’s a lot of opioid painkillers I’m trying to avoid taking.

Anyway, the post surgery pain and more intense neuropathy in my feet is making sleep very difficult. I’ve already decided not to return to work today (Monday) since I’m still bleeding from a few surgery sites. I’m not going to cardiac rehab either so I have nothing scheduled other than a phone call with my insurance patient advocate.. Maybe it will be a day of naps..

Dialysis Blood Pressure 1/25/2020 (updated)

The medications continue to work. I took all three at around 8:15 am this morning before dialysis. Here are the first several readings:

Time	Systolic	Diastolic	Pulse	Notes
9:02 am	117	74	64	Standing
9:13 am	135	75	63	Sitting/legs up
9:43 am	141	79	60	Sitting/legs up
10:13 am	151	83	60	Sitting/legs up
10:43 am	145	86	60	Sitting/legs down

I only have two data points since I started taking all three medications before dialysis, but if you look at the numbers from last session, my blood pressure increased at the 10:18 am reading. Likewise, there seems to be an increase today at 10:13 am. One or more medication is getting dialyzed out about an hour into dialysis. My guess is the Metoprolol. There was a study done on Olmesartan and it appears resistant to dialysis.

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Blood pressure increased to 168/96 at 11:43 am. Either something else is getting dialyzed out or the 10 mg of NIFEdipine is wearing off since it’s such a low dose.

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Remaining readings continued from table above:

Time	Systolic	Diastolic	Pulse	Notes
11:13 am	148	90	60	Sitting/legs down
11:43 am	168	96	62	Sitting/legs down
12:13 pm	156	88	60	Lying down
12:43 pm	157	89	62	Lying down
12:50 pm	159	92	62	Sitting/legs down
12:52 pm	127	74	65	Standing

I’m surprised that both number dropped so much on the final standing measurement. The initial increase at the beginning of dialysis when I sat down wasn’t that large. That means I still have orthostatic hypotension.

Amiodarone Revisited

Today is day 48 since I stopped taking Amiodarone. The numbness in my hands and feet is still there and continues to bother me during dialysis and sleep. I read online that the averaeg half-life of Amiodarone is 58 days, with a range from 15 to 142 days. Hopefully I’m average in this case, and there will be some reduction in the neuropathy in ~10 days.

Unfortunately, the article also says:

Chronic administration of Amiodarone hydrochloride tablets may lead to peripheral neuropathy, which may not resolve when Amiodarone hydrochloride tablets is discontinued.

If that’s the case, then my experiment with acupuncture better work or I’ll need more medication for the neuropathy.