“Pill in the Pocket” Antiarrhythmic Drugs for Orally Administered Pharmacologic Cardioversion of Atrial Fibrillation

Selected Advancements in the Management of Atrial Fibrillation from the Year 2021

“…This strategy of acute AAD administration to produce rapid termination of a new AF episode has been termed "PITP". 3 The reason that propafenone and flecainide are listed for PITP therapy whereas dofetilide and amiodarone are not is because of the time frame of their action.…”

“…Also effective for PITP therapy, though off-label and tested in fewer patients in clinical trials, is ranolazine. 3 The advantage of ranolazine is that it has no contraindication for ischemic heart disease (where it is approved for angina therapy) or heart failure. Also, as suggested previously, as PITP regimens primarily target recurrent PAF, the drug should be one that can be administered at home once verified as effective and safe under observation.…”

Rate vs Rhythm Control Strategy for Atrial Fibrillation in 2022

“…Pill-in-pocket approach can be used for acute, symptomatic, infrequent, and non-destabilizing AF episodes, preferably using a class IC AAD, provided no contraindications for the latter pre-exist, and at best, within a day of recognizing the symptom onset. 20 As a maintenance therapy, aimed at preventing recurrences of paroxysmal and persistent AF, amiodarone is more effective than other AADs, but extracardiac toxic effects are common and increase with time. For this reason, class IC AADs (flecainide, propafenone) should be considered first in patients with no major SHD.…”

Real-world utilization of the pill-in-the-pocket method for terminating episodes of atrial fibrillation: data from the multinational Antiarrhythmic Interventions for Managing Atrial Fibrillation (AIM-AF) survey

“…In this context, recently, there has been renewed interest in the AF termination approach referred to as ‘pill-in-the-pocket’ (PITP). 7 The PITP is recognized in both the US and European guidelines 1 , 2 as an effective option using an oral antiarrhythmic drug (AAD) for acute conversion of recent-onset symptomatic AF that is bothersome, does not convert spontaneously, and has no associated haemodynamic instability or ischaemic symptoms—provided it employs an AAD with rapid effect and safety precautions, and standard anticoagulation guidelines are followed. However, how PITP is used in current real-world practice has not been examined.…”