pill in the pocket treatment for atrial fibrillation (AF)

Last edited 05/2021 and last reviewed 05/2021

Requires specialist advice.

In a selected, risk-stratified population of patients with recurrent atrial fibrillation, pill-in-the-pocket treatment is feasible and safe, with a high rate of compliance by patients, a low rate of adverse events, and a marked reduction in emergency room visits and hospital admissions (1):

• the study authors concluded that "...the pill-in-the-pocket approach appears to be feasible and safe, in view of the high rate of patient compliance and the very low incidence of adverse effects. Data from our study show that the pill-in-the-pocket strategy with flecainide and propafenone is effective for all the arrhythmic episodes in more than 80 percent of patients with recurrent atrial fibrillation, after selection of patients on the basis of clinical features and the results of in-hospital treatment. Out-of-hospital treatment minimizes the need for subsequent emergency room visits and hospitalization, which should reduce the costs associated with atrial fibrillation, albeit in a small group of patients who have this tachyarrhythmia. The safety of this approach without previous evaluation of in-hospital treatment remains to be investigated..."

Intermittent antiarrhythmic drug therapy ("pill in the pocket") may be considered in symptomatic patients with infrequent, longer-lasting episodes of AF or atrial flutter as an alternative to daily antiarrhythmic therapy (2).

NICE state that (3):

• "..where patients have infrequent paroxysms and few symptoms, or where symptoms are induced by known precipitants (such as alcohol, caffeine), a 'no drug treatment' strategy or a 'pill-in-the-pocket' strategy should be considered and discussed with the patient.."
• in people with paroxysmal atrial fibrillation, a 'pill-in-the-pocket' strategy should be considered for those who:
  • have no history of left ventricular dysfunction, or valvular or ischaemic heart disease and
  • have a history of infrequent symptomatic episodes of paroxysmal atrial fibrillation and
  • have a systolic blood pressure greater than 100 mmHg and a resting heart rate above 70 bpm and
  • are able to understand how to, and when to, take the medication

Reference:

• 1) Alboni P et al. Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach.N Engl J Med. 2004 Dec 2;351(23):2384-91.
• 2) Gillis AM et al. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: rate and rhythm management. Can J Cardiol. 2011 Jan-Feb;27(1):47-59.
• 3) NICE (April 2021). Atrial fibrillation