Dr. Keith Roach
Dear Dr. Roach: I am a 67 year old Caucasian female in generally good health. In 2022, I was diagnosed with asymptomatic atrial fibrillation (AFib). I underwent electrical cardioversion in the hospital, but the AFib continued intermittently throughout the past year, according to my heart monitor. Six weeks ago, a 14-day Holter monitor showed an AFib load of 65%, with my heart rate ranging from 34-192 bpm.
My doctor is suggesting Tikosyn, as metoprolol lowers my heart rate significantly. Unfortunately, my insurance will not cover the brand name Tikosyn, but will cover the generic version. Any concerns about the generic version?
— PS
Dear PS: AFib is a common electrical abnormality of the heart where the heart’s normal rhythm regulation is lost and the heart beats chaotically. Heart rate can be variable and your range is worrying, as 34 is too slow and 192 is extremely high for a 67 year old. Better control of your heart rate is essential.
If AFib recurs after an electrical cardioversion, medication is usually tried. There are several drugs, and clinical judgment by a cardiologist is essential in choosing the right one. I never prescribe these drugs; I leave it to the experts.
Tikosyn is a common drug. All anti-arrhythmic drugs have the potential, paradoxically, to create new rhythm disorders. About 3% of the time, Tikosyn causes a dangerous rhythm called torsade de pointes, which is life-threatening.
In most cases, this happens within three days of starting the drug, so it is essential to be in hospital when you start the medication so that your heart is constantly monitored and emergency treatment is ready. If a person gets through the three days without problems (which is usually the case), then the medication is continued after the person leaves.
Because the brand name is more than 20 times more expensive than the generic version, most people get the generic. The generic version is exactly the same drug, and an absorption study showed they are bioequivalent.
Dear Dr. Roach: For about a month and a half, I wake up with burning feet one to four times a night. I am very tired. My podiatrist said to use Biofreeze but it didn’t work. I ice my feet every time I wake up. I have been trying to get an appointment with a neurologist.
I am in my 80s and have had two major back surgeries, as well as a back stimulator, over the past three years. I’m in pain to one degree or another every time I don’t sleep. I have had MRIs, X-rays and scans and been to many doctors. I don’t know if the surgeries are related to my leg pain.
— Anon.
Dear Anon.: I suspect there is a connection between the back surgeries and the leg pain, although I can’t be sure. Burning leg pain is most likely neuropathy, which simply means that some kind of nerve problem is causing the pain.
When the pain is bilateral, metabolic problems, especially diabetes, are a very likely cause. But if you’ve had nerve damage on both sides, the underlying condition for the back surgery—or perhaps the surgery itself—may have led to the nerve damage and neuropathic pain you have now.
A neurologist can help establish a diagnosis (sometimes this is not possible) or prescribe more effective treatments.
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