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Principles of Heart Failure Pharmacotherapy
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Erika L. Hellenbart, Stephanie Dwyer Kaluzna, Robert J. DiDomenico
Digoxin is associated with several adverse effects. Digoxin can cause bradycardia and heart block, particularly in elderly patients and in those taking drugs known to interfere with SA or AV nodal conduction (e.g., beta-blockers, calcium channel blockers, or ivabradine) or enhance vagal tone (e.g., cholinesterase inhibitors). The narrow therapeutic range makes patients susceptible to digoxin toxicity, often in the setting of inappropriate dosing or WRF.78–80 Symptoms of digoxin toxicity may include anorexia, nausea, vomiting, and visual disturbances.78,79 In more serious cases, digoxin toxicity can cause complete heart block, hyperkalemia, and life-threatening ventricular arrhythmias.78,79
Heart failure
Published in Henry J. Woodford, Essential Geriatrics, 2022
There is some irony in the suggestion that digoxin could reduce hospital admissions in frail older people given that it is often cited as a cause of adverse drug reaction leading to admission.49,50 Hospitalisation for suspected digoxin toxicity is more common in older age, having been found to affect 4.4% of people aged over 80 taking digoxin.51
Drugs, accidents and poisoning
Published in Jagdish M. Gupta, John Beveridge, MCQs in Paediatrics, 2020
Jagdish M. Gupta, John Beveridge
15.10. Which of the following statements is/are true of digoxin therapy?It is the drug of choice for treatment of congestive cardiac failure in newborn infants.Hypokalaemia potentiates its toxicity.A high serum digoxin level indicates digoxin toxicity.Anorexia (poor feeding) may be the only symptom of toxicity.It takes at least 4 h for plasma and tissue equilibrium to occur.
Comment on: clinical experience with titrating doses of digoxin antibodies in acute digoxin poisoning
Published in Clinical Toxicology, 2022
Sarah Mahonski, Mary Ann Howland, Mark K. Su
Acute digoxin toxicity is rare and potentially life-threatening. This paper defines acute digoxin toxicity as a “history of acute digoxin overdose, elevated serum digoxin concentration, and signs and symptoms of toxicity” [1]. Patients with digoxin toxicity present with neurologic and cardiac manifestations; gastrointestinal symptoms are more prominent in acute toxicity [2]. Since all of the patients in this study were previously taking digoxin, except for one, it would be more appropriate to classify these patients as “acute-on-chronic” overdose rather than “acute” digoxin overdose. Furthermore, classifying patients as having digoxin toxicity based on a serum concentration is problematic since digoxin is a two-compartment model in vivo; toxicity is unlikely to correlate with a predistribution serum digoxin concentration [3,4]. The inherent subjectivity in determining which patients have “signs and symptoms” of digoxin toxicity limits both the internal and external validity of the study. Further information such as details on the specific signs and symptoms and the correlating digoxin-fab doses administered would be useful.
Clinical experience with titrating doses of digoxin antibodies in acute digoxin poisoning. (ATOM-6)
Published in Clinical Toxicology, 2022
Betty S. Chan, Geoffrey K. Isbister, Angela Chiew, Katherine Isoardi, Nicholas A. Buckley
Acute digoxin poisoning is a rare presentation as most poisons centre would manage just a few acute digoxin poisoning per year [1]. Most previous case series of digoxin poisoning combine the results of acute and chronic digoxin poisoning [2–4], despite them being quite different clinical syndromes. People with chronic poisoning typically have multiple underlying illnesses, are prescribed multiple cardiotoxic medications and develop renal failure [5,6]. Deaths were not generally due to chronic digoxin toxicity, but were attributed to medical causes such as cardiac or respiratory failure, renal failure, sepsis or a combination of co-morbidities [6]. In contrast, acute digoxin poisoning typically involves deliberate ingestion of much larger doses by a generally healthier population and potentially requires a different management approach [7]. Pharmacokinetic modelling supported the use of less expensive and safer digoxin-Fab dosing strategies to manage acute digoxin poisoning [7].
An analysis of fatal iatrogenic therapeutic errors reported to United States poison centers
Published in Clinical Toxicology, 2021
James B. Leonard, Faisal S. Minhaj, Wendy Klein-Schwartz
The agents included in this series are consistent with those considered high-risk [11]. In a large systematic review, the medications associated with the most fatal and non-fatal medication errors included methotrexate, warfarin, opioids, digoxin, theophylline, and other anticoagulants [11]. This is somewhat consistent with the most commonly reported medications in our series. Notably, the most common medications in our series were morphine, diltiazem, colchicine, local anesthetics, methotrexate, and digoxin. Morphine and other opioids were distributed evenly among all age groups, probably because of their ubiquitous use. Errors included multiple opioids, parenteral administration of oral formulations, and 10-fold errors. Calcium channel blocker errors were primarily in patients age 70–89 years. Inadvertent intravascularization of local anesthetics is a well-documented cause of mortality [12]. Fortunately, well-published errors and deaths after the administration of intravenous colchicine resulted in the removal of IV colchicine from the market [13]. Teasing out the cause of death in patients with elevated digoxin concentrations is incredibly difficult since many patients with digoxin toxicity die from multi-factorial reasons [14]. These agents are all commonly used in elderly patients, who are at higher risk of error due to polypharmacy and more susceptibility to adverse outcome of errors. Interestingly warfarin was only coded in one case and the patient did not have an abnormal INR and none of the cases included theophylline, two agents of concern in the elderly.