Multaq alternatives: What can I take instead of Multaq?

Compare Multaq alternatives | Pacerone | Tikosyn | Flecainide | Rythmol SR | Betapace AF | Natural alternatives | How to switch meds

Have you ever felt your heart skip a beat or flutter? We sometimes joke this happens while around a new love interest, but in reality, an atrial flutter can be indicative of an abnormal heart rhythm, like atrial fibrillation – or “afib” for short. A diagnosis of atrial fibrillation is serious, and while management with electrical cardioversion is a possibility, the condition will likely require medications for treatment of the abnormal heart rhythm and prevent some common effects associated with the diagnosis—such as blood thinners like warfarin to prevent stroke. Medications targeting the actual heart rhythm take two broad routes: rate control or rhythm control. Rate control medications slow the heart rate down, while antiarrhythmic drugs, like Multaq (dronedarone), aim to restore a normal heart rhythm. 

RELATED: Here’s what actually happens when your heart skips a beat

What can I take in place of Multaq?

There are other drug therapy options available for the management of atrial fibrillation that do not respond to Multaq (dronedarone), for those who suffer from adverse effects, or for those that are simply not good candidates for this medication. Patients with severe heart failure, historically classified as NYHA class III or IV heart failure, or with decompensated heart failure within the prior four weeks should not be initiated on Multaq (dronedarone). A groundbreaking study published in the New England Journal of Medicine demonstrated the use of Multaq in these patients increases the risk of mortality. Multaq is also contraindicated in patients with liver failure, and with medications and/or supplements that prolong the QT interval. Finally, Multaq is only indicated for patients with intermittent afib, as use in patients with permanent atrial fibrillation has been demonstrated to increase mortality in another landmark clinical trial. 

Alternative Multaq prescription medications include other types of antiarrhythmic drugs, as well as those that aim to control the heart rate. These options may be more suitable for certain individuals based on other underlying health conditions, or due to their different uses, side effect profiles, and dosages. Rate control may be preferred over rhythm control in very elderly patients (e.g., greater than 80 years of age) or patients with asymptomatic and long-standing or recurrent afib, whereas rhythm control might be preferred in patients at high risk for cardiovascular complications (e.g., older age, history of a stroke, among other factors), in those who have failed rate control, in those with heart failure, and finally in younger patients (less than 65 years of age). Either way, a rhythm-control strategy is not superior to rate-control in mortality and may increase hospitalization given their proarrhythmia potential. If afib is unable to be converted to a normal rhythm, antiarrhythmics should not be continued. The decision to manage this cardiac arrhythmia with rate control versus rhythm control will be made by a healthcare professional specializing in cardiology after a detailed discussion weighing the risks and benefits of each approach for each patient.

RELATED: Antiarrhythmics: Uses, common brands, and safety info

Top 5 Multaq alternatives

The following are some of the most common alternatives to Multaq (dronedarone).

1. Pacerone (amiodarone)

Pacerone (amiodarone) is an alternative to Multaq for rhythm control in patients with concomitant congestive heart failure or left ventricular systolic dysfunction. This medication may also provide some rate control, but alternative rate control medications may be preferred given the drug interaction potential and toxicities associated with its use. 

Monitoring is required with use of Pacerone to evaluate for hepatic injury, pulmonary toxicity, thyroid function, eye exams, and other adverse effects. Up to 50% of patients taking Pacerone may experience some type of side effect, which resolves slowly with discontinuation of the medication since it has a very long half-life—taking the body a long time to be rid of the medication. Pacerone should be avoided in patients with concomitant conditions of cardiogenic shock, bradycardia (slow heart rate), and second- or third-degree AV block. 

2. Tikosyn (dofetilide)

Tikosyn comes with some of the best evidence for cardioversion (restoration of a regular heart rhythm) and is an excellent option for maintenance of sinus rhythm in patients at low risk of serious rhythm abnormalities (e.g., QT prolongation and/or torsades de pointes). Tikosyn therapy must be initiated in a controlled, inpatient setting, because of the risk of serious heart rhythm abnormalities, and doses are individualized based on the patient’s renal function and ECG findings and monitoring. 

This medication requires dose adjustments in patients with decreased renal function and is contraindicated entirely in those whose renal function is seriously compromised. Tikosyn must also be avoided in conjunction with medications known to prevent its elimination or medications which deplete certain electrolytes like potassium, as this will increase the risk of ventricular arrhythmias. 

3. Flecainide

Flecainide is another excellent option with strong evidence for cardioversion and maintenance of sinus rhythm. Flecainide may be used on an outpatient basis as a “pill-in-the-pocket” approach to intermittent atrial fibrillation after a successful inpatient cardioversion trial. Patients must also be on an AV nodal-blocking medication, such as certain beta blockers or specific calcium channel blockers, and take a dose of one of these medications 30 minutes prior to taking flecainide to minimize the risk of developing a ventricular arrhythmia. Flecainide should be avoided in patients with known coronary artery disease as it has demonstrated an increase in mortality in patients with a prior heart attack.

4. Rythmol SR (propafenone)

Rythmol SR (propafenone) is an older medication that comes with strong evidence for its cardioversion capabilities and is yet another option for the maintenance of sinus rhythm. Similar to flecainide, propafenone can be used at home to terminate an episode of afib after an inpatient trial; it also should be taken 30 minutes after an AV nodal-blocking medication. It shouldn’t be used in patients with heart disease or in patients with heart failure, asthma, severe COPD, and severe liver impairment. Propafenone also can cause significant drug interactions, such as increasing warfarin levels. 

5. Betapace AF (sotalol)

Betapace AF (sotalol) is a rhythm control option for patients with or without a history of heart failure or mild to moderate left ventricular dysfunction but is not indicated for actual cardioversion. Betapace AF is contraindicated in patients with certain pulmonary disorders, and in patients with bradycardia, sick sinus syndrome, or second- or third-degree AV block. Initiation of this medication should occur as an inpatient to monitor for the development of proarrhythmic effects. 

Natural alternatives to Multaq

Lifestyle modifications for reduction of atrial fibrillation is an ongoing area of clinical research. The American Heart Association (AHA) identifies the relationship between lifestyle and afib, and identifies the following contributing factors:

• Obesity has been linked to the development of afib through several mechanisms. A 10% reduction in weight might improve the possibility of developing afib.
•  A sedentary lifestyle may be a predictor of this condition, so regular exercise is encouraged to improve cardiovascular health. Physical activity may prevent atrial fibrillation, but if you already have afib it might reduce symptoms and improve quality of life. 
• Sleep disorders, like obstructive sleep apnea (OSA), are strongly linked with cardiovascular disease. Treating underlying sleep disorders should improve afib symptoms. 
• Alcohol consumption is a known risk factor for atrial fibrillation, so cutting back or avoiding it entirely should be considered in those with afib. 
• Type 2 diabetes patients are at a higher risk of developing atrial fibrillation. Good blood glucose control can improve the severity and frequency of afib symptoms, in conjunction with other lifestyle modifications like exercise and weight loss. 
• There is some evidence to suggest the use of antioxidant vitamins C and E may play a role in the prevention of atrial fibrillation, but further research in larger-scale clinical studies are required to allow for robust recommendations to be made. The same holds true for vitamin D, in which a deficiency might contribute to an increased risk of atrial fibrillation, but additional information is required. 

While there is limited data to support naturally curing atrial fibrillation by getting one’s heart back into a normal rhythm naturally, afib can be paroxysmal or short-term—meaning that symptoms go away on their own without treatment. Following the lifestyle modifications discussed above, your best bet for a natural management strategy over various vitamins, supplements, or herbs. 

RELATED: The best diet for heart health

How to switch to a Multaq alternative

Switching between antiarrhythmic medications should always be done in the setting of medical advice from a professional, as there is great nuance in allowing the body to eliminate these medications prior to initiation of new agents, as well as the potential for drug interaction and overlapping adverse effects. For example, Multaq should be used with great caution in patients on digoxin. In general, it is recommended to allow for two to four half-lives of one agent to pass after discontinuation prior to initiating an alternative. 

Multaq’s metabolism in the body can be inhibited by many medications, including other antiarrhythmic medications, which could result in an increased risk of side effects. 

If cost is a concern, using a SingleCare discount card can help save up to 80% off prescriptions at local participating pharmacies. Only change or add new medications after discussing options with a prescribing healthcare professional.