Digoxin: Restore Cardiac Rhythm and Function Safely
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Synonyms | |||
Digoxin is a time-tested cardiac glycoside derived from the Digitalis lanata plant, prescribed primarily for the management of atrial fibrillation and chronic heart failure. It functions by inhibiting the sodium-potassium ATPase pump, thereby increasing intracellular calcium and enhancing myocardial contractility (positive inotropic effect). Additionally, it slows conduction through the atrioventricular node, making it invaluable for controlling ventricular rate in certain arrhythmias. Its narrow therapeutic index necessitates careful dosing and monitoring, but when used appropriately, it remains a cornerstone therapy in cardiovascular medicine.
Features
- Contains digoxin as the active pharmaceutical ingredient
- Available in oral tablets (e.g., 0.125 mg, 0.25 mg) and intravenous formulations
- Exhibits both positive inotropic and negative chronotropic effects
- Long half-life permitting once-daily dosing in most patients
- Therapeutic drug monitoring recommended due to narrow therapeutic window
Benefits
- Improves ejection fraction and cardiac output in systolic heart failure
- Controls ventricular rate in atrial fibrillation and atrial flutter
- Reduces symptoms of heart failure such as dyspnea and fatigue
- May decrease hospitalization rates in chronic heart failure patients
- Oral bioavailability allows for convenient outpatient management
- Can be used in combination with other heart failure therapies
Common use
Digoxin is indicated for the treatment of mild to moderate heart failure, particularly in patients with reduced ejection fraction who remain symptomatic despite optimal doses of diuretics, ACE inhibitors, and beta-blockers. It is also widely used for rate control in patients with atrial fibrillation or atrial flutter, especially when other rate-controlling agents are ineffective or contraindicated. Its use is generally reserved for cases where symptom relief and functional improvement are primary goals, rather than mortality reduction.
Dosage and direction
Dosing must be individualized based on renal function, age, weight, and concomitant medications. For most adults with normal renal function, a typical maintenance dose is 0.125–0.25 mg orally once daily. Loading doses may be used in urgent situations but require careful calculation and monitoring. In elderly patients or those with renal impairment, doses as low as 0.0625 mg daily may be appropriate. Serum digoxin levels should be maintained between 0.5–0.9 ng/mL for heart failure and up to 1.2 ng/mL for atrial fibrillation, with levels drawn at least 6–8 hours post-dose. Intravenous administration should be reserved for hospitalized patients under continuous ECG monitoring.
Precautions
Renal function must be assessed before initiation and monitored periodically during therapy. Electrolyte imbalances—particularly hypokalemia, hypomagnesemia, and hypercalcemia—increase the risk of toxicity and should be corrected. Thyroid dysfunction may alter digoxin metabolism and require dose adjustments. Use with caution in patients with acute myocardial infarction, sinus node disease, or Wolff-Parkinson-White syndrome. Elderly patients are at increased risk of adverse effects due to reduced renal clearance and altered volume of distribution.
Contraindications
Digoxin is contraindicated in patients with ventricular fibrillation or known hypersensitivity to digoxin or other digitalis preparations. It should not be used in cases of second- or third-degree heart block without a functioning pacemaker, or in patients with hypertrophic obstructive cardiomyopathy due to the risk of outflow tract obstruction. Concomitant use with intravenous calcium is contraindicated due to the risk of serious arrhythmias.
Possible side effect
Common side effects include nausea, vomiting, diarrhea, headache, and fatigue. Visual disturbances such as yellow-green halos or blurred vision may occur. Cardiac effects include bradycardia, AV block, and ectopic rhythms. Serious toxicity may manifest as life-threatening ventricular arrhythmias. Less frequently, gynecomastia, rash, or thrombocytopenia may be observed. Side effects are often dose-related and more frequent in the setting of electrolyte disturbances.
Drug interaction
Digoxin interacts significantly with numerous medications. Quinidine, verapamil, amiodarone, and cyclosporine increase digoxin levels. Concomitant use with diuretics (especially loop and thiazide diuretics) may precipitate hypokalemia and increase toxicity risk. Sympathomimetics and succinylcholine may enhance arrhythmogenic potential. Antibiotics like erythromycin and tetracycline may increase bioavailability. Concomitant use with beta-blockers or calcium channel blockers may exaggerate bradycardic effects.
Missed dose
If a dose is missed, it should be taken as soon as remembered on the same day. If it is near the time of the next dose, the missed dose should be skipped. Doubling the dose is not recommended due to the risk of toxicity. Patients should be advised to maintain a consistent dosing schedule and use pill organizers or reminders if necessary.
Overdose
Digoxin overdose is a medical emergency. Symptoms include severe nausea, vomiting, hyperkalemia, visual changes, and cardiac arrhythmias (e.g., ventricular tachycardia, advanced heart block). Treatment includes discontinuation of digoxin, ECG monitoring, correction of electrolyte abnormalities, and administration of digoxin-specific antibody fragments (Digibind®) in severe cases. Activated charcoal may be useful if administered soon after ingestion. Hemodialysis is not effective due to digoxin’s large volume of distribution.
Storage
Store at room temperature (15–30°C) in a tightly closed container, protected from light and moisture. Keep out of reach of children and pets. Do not use beyond the expiration date printed on the packaging. Do not transfer tablets to unlabeled containers.
Disclaimer
This information is intended for educational purposes and does not replace professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider before starting, changing, or discontinuing any medication. Individual patient factors may necessitate adjustments to dosing, monitoring, or therapy selection. The author and publisher are not liable for any adverse effects resulting from the use or misuse of this information.
Reviews
Clinical studies and decades of use support digoxin’s role in symptom management for heart failure and rate control in atrial fibrillation. While not a first-line mortality-reducing agent, it remains valuable in specific patient populations. Its narrow therapeutic window requires vigilance, but with appropriate monitoring, it offers significant symptomatic benefit. Many cardiologists consider it a useful adjunct in patients who remain symptomatic on guideline-directed medical therapy.