Digoxin (Lexi-Drugs)

Pronunciation

(di JOKS in)

Brand Names: US

Digitek; Digox; Lanoxin; Lanoxin Pediatric

Brand Names: Canada

APO-Digoxin; Lanoxin; PMS-Digoxin [DSC]; Toloxin

Dosing: Adult

Note: When changing from oral (tablets or liquid) to IV therapy, dosage may be reduced by 20% to 25%. Periodically monitor digoxin concentrations as appropriate for the condition being treated, especially if renal impairment occurs. Toxicity may occur even at therapeutic concentrations in some settings (eg, hypokalemia).

Atrial fibrillation or atrial flutter, rate control (alternative agent): Note: Some experts reserve digoxin for patients whose rate has not adequately been controlled with other agents or interventions (Ganz 2018; Giardina 2018). Additionally, digoxin is not effective for rate control during high-adrenergic states (eg, exercise); a beta-blocker is preferred. Do not use in patients with preexcitation associated with an accessory pathway, as this can lead to ventricular arrhythmias (AHA/ACC/HRS [January 2014]).

Total digitalizing dose (TDD): Initial: IV: 0.25 to 0.5 mg over several minutes, with repeat doses of 0.25 mg every 6 hours to a maximum of 1.5 mg over 24 hours (AHA/ACC/HRS [January 2014]) or a total of 8 to 12 mcg/kg (use lean body weight) (not to exceed 0.75 to 1.5 mg) administered by giving 50% of TDD over 5 minutes and the remaining 50% as 2 doses of 25% of TDD at 4- to 8-hour intervals after the initial dose (ACLS [Neumar 2010]); follow either of these TDD regimens with an oral maintenance regimen (Giardina 2018).

Maintenance dose: Oral: 0.125 to 0.25 mg once daily (AHA/ACC/HRS [January 2014])

Fetal tachycardia, sustained (maternal/transplacental administration) (off-label use): Note: Due to decreased placental transfer, maternal administration of digoxin may be less effective when fetal hydrops is present; direct fetal administration may be required in the presence of a hydropic fetus (AHA [Donofrio 2017]; Alsaied 2017; Jaeggi 2011; Levine 2018). The lowest effective dose should be used to avoid maternal adverse events (Moatassim 2018). Prior to use, evaluate appropriateness of therapy to the mother (eg, maternal electrolytes, renal function, ECG).

Maternal dose:

Loading dose (may be given oral or IV):

IV: 1.2 to 1.5 mg given in divided doses every 8 hours over 24 hours; follow with oral maintenance regimen (AHA [Donofrio 2017])

Oral: 1 to 2 mg given in divided doses over 24 to 48 hours (eg, 0.5 mg followed by 0.25 mg, and then 0.25 mg); follow with an oral maintenance regimen (Alsaied 2017; Jaeggi 2011; Levine 2018)

Maintenance dose: Oral: 0.375 mg to 0.75 mg per day given in divided doses every 8 to 12 hours. Adjust dose to maintain a target maternal blood level between 0.7 and 2 ng/mL (AHA [Donofrio 2017]).

Heart failure with reduced ejection fraction (HFrEF): Note: Some experts reserve use of digoxin for patients with persistent New York Heart Association functional class III or IV symptoms despite optimal guideline-directed medical therapy (ACCF/AHA [Yancy 2013]; Colucci 2018).

Maintenance dose (loading dose not recommended): Oral: 0.125 to 0.25 mg once daily; higher daily doses are rarely necessary. If patient is >70 years of age, has impaired renal function, or has a low lean body mass, low doses (eg, 0.125 mg daily or every other day) should be used initially (ACCF/AHA [Yancy 2013]). A dosing nomogram is also available based on lean body weight and CrCl (DiDomenico 2014).

Supraventricular tachycardia (eg, atrioventricular nodal reentrant tachycardia [AVNRT]), rate control (alternative agent) (off-label use): Note: Some experts reserve digoxin for supraventricular tachycardia that is not terminated or controlled by other agents or maneuvers (Knight 2018; Spragg 2018).

Total digitalizing dose: Initial:

Oral: 0.5 mg loading dose, with additional 0.125 to 0.25 mg doses administered at 6- to 8-hour intervals until evidence of adequate effect (maximum total dose over 24 hours: 8 to 12 mcg/kg [use lean body weight], not to exceed 0.75 to 1.5 mg) (ACC/AHA/HRS [Page 2015]; Giardina 2018).

IV: 0.25 to 0.5 mg bolus; may repeat 0.25 mg administered at 6- to 8-hour intervals until evidence of adequate effect (maximum total dose over 24 hours: 8 to 12 mcg/kg [use lean body weight], not to exceed 0.75 to 1.5 mg) (ACC/AHA/HRS [Page 2015]; Giardina 2018).

Maintenance dose: Oral: 0.125 to 0.25 mg once daily (ACC/AHA/HRS [Page 2015])

Dosing: Geriatric

Dose is based on assessment of lean body mass and renal function. Elderly patients with low lean body mass may experience higher digoxin concentrations due to reduced volume of distribution (Cheng 2010). Decrease dose in patients with decreased renal function (see Dosing in Renal Impairment).

Atrial fibrillation: Avoid as first-line therapy; if used, do not exceed 0.125 mg/day in patients ≥65 years (Beers Criteria [AGS 2015]).

Heart failure: If patient is >70 years of age, low doses (eg, 0.125 mg daily or every other day) should be used (ACCF/AHA [Yancy 2013]). Avoid as first-line therapy; if used, do not exceed 0.125 mg/day in patients ≥65 years (Beers Criteria [AGS 2015]).

Dosing: Renal Impairment: Adult

Oral, IV:

Loading dose: There are no dosage adjustments provided in the manufacturer’s labeling; however, 50% to 70% of a digoxin dose is excreted unchanged in the urine. The following adjustments have been recommended:

ESRD: If loading dose necessary, reduce dose by 50% (Aronoff 2007; Ohnhaus 1980).

Acute renal failure: Based on expert opinion, if patient in acute renal failure requires ventricular rate control (eg, in atrial fibrillation), consider alternative therapy. If loading digoxin becomes necessary, patient volume of distribution may be increased and reduction in loading dose may not be necessary; however, maintenance dosing will require adjustment as long as renal failure persists.

Maintenance dose (Golightly 2013):

GFR >50 mL/minute: No dosage adjustment necessary.

GFR 10 to 50 mL/minute: 0.0625 mg every 24 to 36 hours (25% to 75% of the usual dose every 24 to 36 hours)

GFR <10 mL/minute: 0.0625 mg every 48 hours (10% to 25% of the usual dose every 48 hours)

Hemodialysis: Nondialyzable (due to extensive binding to skeletal muscle and myocardium): 0.0625 mg every 48 hours (10% to 25% of the usual dose every 48 hours). No supplemental dose necessary (Mooradian 1988).

CAPD: 0.0625 mg every 48 hours (10% to 25% of the usual dose every 48 hours)

Continuous renal replacement therapy (CRRT): 0.0625 mg every 48 hours (10% to 25% of the usual dose every 48 hours)

Heart failure: Initial maintenance dose (DiDomenico 2014; Jusko 1974; Koup 1975): Note: The following suggested dosing recommendations are intended to achieve a target digoxin concentration of 0.7 ng/mL. Renal function estimated using Cockcroft-Gault formula.

CrCl >120 mL/minute: 0.25 mg once daily

CrCl 80 to 120 mL/minute: Alternate between doses of 0.25 mg and 0.125 mg once daily

CrCl 30 to 80 mL/minute: 0.125 mg once daily

CrCl <30 mL/minute: 0.125 mg every 48 hours

Note: A contemporary digoxin dosing nomogram using creatinine clearance and lean body weight or height has been published for determining the initial maintenance dose in patients with heart failure to achieve a target digoxin concentration of 0.7 ng/mL (DiDomenico 2014).

Dosing: Hepatic Impairment: Adult

No dosage adjustment necessary.

Dosing: Pediatric

Note: Dosage must be individualized due to substantial individual variation and must take into account renal function. Doses should be based on lean body weight. When changing from oral solution to IV therapy, dosage should be reduced by 20% to 25%.

Heart failure: Injection, Oral: Infants, Children, and Adolescents: The dosage tables below list dosage recommendations for normal renal function and are based upon average patient response; lower doses are needed for patients with renal impairment.

Digitalizing dose, initial regimen (optional): Total digitalizing dose should be divided (see below); digitalizing dose (loading dose) may not be necessary; consider use if rapid titration is desired. To avoid toxicity, consider doses at lower end of the recommended range; dosage should be individualized based on patient response (eg, clinical response, serum drug levels).

Dosage Recommendations for Digitalizing DoseA (Optional)
Age Total Digitalizing Dose

Administer in 3 divided dosesB

(mcg/kg)

Oral Solution Tablets IVC
ABased on lean body weight and normal renal function for age.
BDo not give full total digitalizing dose (TDD) at once. Give one-half of the TDD for the initial dose, then give one-quarter of the TDD for each of 2 subsequent doses at 6- to 8-hour intervals; prior to additional doses, clinical response should be fully evaluated (eg, ECG).
CMay also be administered by IM; however, not recommended.
1 to 24 months 35 to 60 30 to 50
2 to 5 years 30 to 45 25 to 35
5 to 10 years 20 to 35 20 to 45 15 to 30
>10 years 10 to 15 10 to 15 8 to 12
Maintenance Dosage Recommendations for DigoxinA,B
Age Daily Maintenance Dose

If ≤10 years, administer in equal divided doses twice daily

If >10 years, administer once daily

(mcg/kg/day)

Oral Solution Tablets IVC,D
ADosing reflects clinical practice and in some cases, varies from manufacturer labeling (Bakir 1994; Bendayan 1983; Latifi 2000; Park 1986).
BBased on lean body weight and normal renal function for age. Decrease maintenance dose in patients with decreased renal function.
CMay also be administered by IM; however, not recommended.
DDaily maintenance IV dose is typically 20% to 30% of total digitalizing IV dose in pediatric patients ≤24 months and 25% to 35% in older pediatric patients.
1 to 24 months 10 to 15 9 to 15
2 to 5 years 8 to 10 6 to 9
5 to 10 years 5 to 10 6 to 12 4 to 8
>10 years 2.5 to 5 2.5 to 5 2 to 3

Tachyarrhythmias, treatment: Limited data available (Escudero 2012): Injection, Oral: Infants, Children, and Adolescents:

Initial (digitalizing dose):

IV: 10 to 12 mcg/kg/dose every 8 hours for 3 doses

Oral: 13 to 17 mcg/kg/dose every 8 hours for 3 doses

Maintenance: Oral: 8 to 10 mcg/kg/day divided once or twice daily (Escudero 2012); use twice daily dosing in infants and young children (O’Sullivan 1995)

Dosing: Renal Impairment: Pediatric

Infants, Children, and Adolescents: Oral, IV:

Digitalizing (loading) dose: There are no dosage adjustments provided in the manufacturer’s labeling for digitalizing dose; however, 50% to 70% of a digoxin dose is excreted unchanged in the urine. The following adjustments have been recommended in adults with end-stage renal disease (ESRD): Reduce usual dose by 50% (Aronoff 2007).

Maintenance dose:

Manufacturer’s labeling: Dosage reductions and close monitoring recommended; see product labeling for CrCl-specific dosage recommendation

Alternate dosing: The following adjustments have been recommended (Aronoff 2007):

GFR >50 mL/minute/1.73 m2: No dosage adjustment necessary

GFR: 30 to 50 mL/minute/1.73 m2: Administer 75% of normal dose at normal intervals

GFR: 10 to 29 mL/minute/1.73 m2: Administer 50% of normal dose at normal intervals or administer normal dose every 36 hours

GFR: <10 mL/minute/1.73 m2: Administer 25% of normal dose at normal intervals or administer normal dose every 48 hours

Intermittent hemodialysis: Nondialyzable (0% to 5%). Administer 25% of normal dose at normal intervals or administer normal dose every 48 hours

Peritoneal dialysis (PD): Administer 25% of normal dose at normal intervals or administer normal dose every 48 hours

Continuous renal replacement therapy (CRRT): Administer 75% of normal dose at normal intervals; titrate to desired effect; monitor serum concentrations

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer’s labeling.

Use: Labeled Indications

Atrial fibrillation or atrial flutter, rate control: Control of ventricular response rate in adults with chronic atrial fibrillation.

Heart failure with reduced ejection fraction (HFrEF): Treatment of mild to moderate (or stage C as recommended by the ACCF/AHA) heart failure in adults; to increase myocardial contractility in pediatric patients with heart failure

Use: Off-Label: Adult

  Fetal tachycardia, sustainedLevel of Evidence [C, G]

Data from retrospective studies of fetuses with tachycardia with or without hydrops suggest that digoxin via maternal administration may be beneficial for the treatment of fetal tachycardia Ref.

Based on the American Heart Association Scientific Statement for the Diagnosis and Treatment of Fetal Cardiac Disease, digoxin may be considered for the in utero management of fetal supraventricular tachycardia (SVT) or atrial flutter with hydrops or ventricular dysfunction. Digoxin may also be considered for SVT without hydrops or ventricular dysfunction if heart rate is ≥200 bpm, atrial flutter, or other rare tachycardias with an average heart rate of ≥200 bpm Ref.

  Supraventricular tachycardia (eg, atrioventricular nodal reentrant tachycardia), rate controlLevel of Evidence [G]

Based on the American College of Cardiology/American Heart Association/Heart Rhythm Society guideline for the management of adult patients with supraventricular tachycardia, digoxin may be a reasonable alternative therapeutic option for the ongoing management of symptomatic supraventricular tachycardia (SVT) (eg, atrioventricular nodal reentrant tachycardia [AVNRT]) if preferred therapies fail in patients who are not candidates for, or prefer not to undergo, catheter ablation.

Level of Evidence Definitions
  Level of Evidence Scale
Clinical Practice Guidelines

Arrhythmias:

AATS, “2014 AATS Guidelines for the Prevention and Management of Perioperative Atrial Fibrillation and Flutter for Thoracic Surgical Procedures,” June 2014

ACC/AHA/HRS, “Guideline for the Management of Adult Patients with Supraventricular Tachycardia” 2015

AHA/ACC/HRS, “2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation,” March 2014

Canadian Cardiovascular Society, “2016 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation,” 2016

Coronary Artery Bypass Graft Surgery:

“2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery,” November 2011

Heart Failure:

ACCF/AHA, “2013 ACCF/AHA Guideline for the Management of Heart Failure,” June 2013

Canadian Cardiovascular Society, “2012 Heart Failure Management Guidelines Update: Focus on Acute and Chronic Heart Failure,” 2012

“HFSA 2010 Comprehensive Heart Failure Practice Guideline,” July 2010

Administration: IM

IV route preferred. If IM injection necessary, administer by deep injection followed by massage at the injection site. Inject no more than 2 mL per injection site. May cause intense pain.

Administration: IV

May be administered undiluted or diluted. Inject slowly over ≥5 minutes

Vesicant; ensure proper needle or catheter placement prior to and during administration; avoid extravasation.

Extravasation management: If extravasation occurs, stop IV administration immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.

When used for the management of fetal tachycardia (maternal/transplacental administration; off-label use), IV doses are administered to the mother (AHA [Donofrio 2014]).

Administration: Injectable Detail

pH: 6.8 to 7.2 (0.25 mg/mL undiluted solution)

Administration: Oral

When used for the management of fetal tachycardia (maternal/transplacental administration; off-label use), oral doses are administered to the mother (AHA [Donofrio 2014]).

Administration: Pediatric

Oral: Administer consistently with relationship to meals; avoid concurrent administration (ie, administer digoxin 1 hour before or 2 hours after) with meals high in fiber or pectin and with drugs that decrease oral absorption of digoxin

Oral solution: Only the calibrated manufacturer-provided dropper or a calibrated oral syringe should be used to measure the dose. For doses <0.2 mL the manufacturer-provided dropper is not accurate and should not be used; use a calibrated oral syringe.

Parenteral:

IV: May be slowly administered IV over ≥5 minutes (usually 5 to 10 minutes); avoid rapid IV infusion since this may result in systemic and coronary arteriolar vasoconstriction

Vesicant; ensure proper needle or catheter placement prior to and during administration; avoid extravasation. If extravasation occurs, stop IV administration immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.

IM: Not usually recommended due to local irritation, pain, and tissue damage; if necessary, administer by deep injection followed by massage at the injection site. May cause intense pain.

Vesicant/Extravasation Risk

Vesicant

Dietary Considerations

Maintain adequate amounts of potassium in diet to decrease risk of hypokalemia (hypokalemia may increase risk of digoxin toxicity).

Storage/Stability

Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Protect elixir, injection, and tablets from light.

Preparation for Administration: Adult

IM: No dilution required.

IV: May be administered undiluted or diluted fourfold in D5W, NS, or SWFI for direct injection. Less than fourfold dilution may lead to drug precipitation.

Preparation for Administration: Pediatric

Parenteral:

IV: May be administered undiluted or diluted at least fourfold in D5W, D10W, NS, or SWFI; less than fourfold dilution may lead to drug precipitation.

IM: No dilution required.

Compatibility

See Trissel’s IV Compatibility Database

Medication Patient Education with HCAHPS Considerations

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience headache or injection site pain. Have patient report immediately to prescriber severe dizziness; passing out; nausea; vomiting; severe diarrhea; vision changes; visual halos or bright colors around lights; weight loss; lack of appetite; loss of strength and energy; black, tarry, or bloody stools; vomiting blood; confusion; bradycardia; tachycardia; abnormal heartbeat; hallucinations; behavioral changes; mood changes; severe abdominal pain; or enlarged breasts (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

Medication Safety Issues
  Sound-alike/look-alike issues:
  High alert medication:
  Geriatric Patients: High-Risk Medication:
  International issues:
Contraindications

Hypersensitivity to digoxin, other forms of digitalis, or any component of the formulation; ventricular fibrillation

Warnings/Precautions

Concerns related to adverse effects:

• Digoxin toxicity: Signs and symptoms of digoxin toxicity include anorexia, nausea, vomiting, visual changes, and cardiac arrhythmias; toxicity is usually associated with digoxin levels >2 ng/mL, although symptoms may occur at lower levels. Patients at increased risk for digoxin toxicity include those with low body weight, advanced age, renal impairment, hypokalemia, hypercalcemia, or hypomagnesemia.

• Extravasation: IV administration: Vesicant; ensure proper needle or catheter placement prior to and during administration; avoid extravasation.

• Proarrhythmic effects: Monitor for proarrhythmic effects (especially with digoxin toxicity)

Disease-related concerns:

• Accessory bypass tract (eg, Wolff-Parkinson-White [WPW] syndrome): During an episode of atrial fibrillation or flutter in patients with an accessory bypass tract or pre-excitation syndrome, use has been associated with increased anterograde conduction down the accessory pathway leading to ventricular fibrillation; avoid use in such patients (ACLS [Neumar 2010]; AHA/ACC/HRS [January 2014]).

• Acute coronary syndrome: Use with caution in patients with an acute MI; may increase myocardial oxygen demand and lead to ischemia. During an acute coronary syndrome, digoxin administered IV may be used to slow a rapid ventricular response and improve left ventricular (LV) function in the acute treatment of atrial fibrillation associated with severe LV function and heart failure or hemodynamic instability (AHA/ACC/HRS [January 2014]).

• Atrial fibrillation: When used for rate control in patients with atrial fibrillation, monitor serum concentrations closely; may be associated with an increased risk of mortality especially when serum concentrations are not properly controlled (Vamos 2015).

• Beri beri heart disease: Patients with beri beri heart disease may fail to adequately respond to digoxin therapy; treat underlying thiamine deficiency concomitantly.

• Electrolyte imbalance: Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy; toxicity may occur despite therapeutic digoxin concentrations (eg, <2 ng/mL). Hypercalcemia may increase the risk of digoxin toxicity and hypocalcemia can nullify the effects of digoxin; maintain normocalcemia.

• Heart failure: Digoxin should be considered for use only in heart failure (HF) with reduced ejection fraction (HFrEF) when symptoms remain despite guideline-directed medical therapy. It may also be considered in patients with both HF and atrial fibrillation; however, beta blockers may offer better ventricular rate control than digoxin (ACCF/AHA [Yancy 2013]). Withdrawal of digoxin in clinically stable patients with HF may lead to recurrence of HF symptoms (Packer 1993). Monitor serum concentrations closely; may be associated with an increased risk of mortality especially when serum concentrations are not properly controlled (Vamos 2015).

• Hypermetabolic states: Atrial arrhythmias associated with hypermetabolic (eg, hyperthyroidism) or hyperdynamic (hypoxia, arteriovenous shunt) states are very difficult to treat; treat underlying condition first. If digoxin is used, ensure digoxin toxicity does not occur.

• Hypertrophic cardiomyopathy (HCM) with outflow tract obstruction: Outflow obstruction may worsen due to the positive inotropic effects of digoxin; avoid use unless used to control ventricular response with atrial fibrillation. Digoxin is potentially harmful in the treatment of dyspnea in patients with HCM in the absence of atrial fibrillation (Gersh 2011).

• Myocarditis: In a murine model of viral myocarditis, digoxin in high doses was shown to be detrimental (Matsumori 1999). If used in humans, therefore, digoxin should be used with caution and only at low doses (Frishman 2007). The manufacturer recommends avoiding the use of digoxin in patients with myocarditis.

• Preserved left ventricular function: Decreased cardiac output may occur in patients with preserved left ventricular systolic function, including restrictive or hypertrophic cardiomyopathy, constrictive pericarditis, amyloid heart disease, and acute cor pulmonale; in general, the manufacturer recommends to avoid use unless used to control ventricular response with atrial fibrillation.

• Renal impairment: Use with caution in patients with renal impairment; dosage adjustment needed.

• Sinus node disease and atrioventricular (AV) block: Because digoxin slows sinoatrial and AV conduction, the drug commonly prolongs the PR interval. Digoxin may cause severe sinus bradycardia or sinoatrial block particularly in patients with preexisting sinus node disease. Avoid use in patients with second- or third-degree heart block (except in patients with a functioning artificial pacemaker) (Yancy 2013); incomplete AV block (eg, Stokes-Adams attacks) may progress to complete block with digoxin administration. In such patients, if treatment with digoxin is necessary, consider the insertion of a pacemaker before treatment.

• Thyroid disease: Use with caution in patients with hypothyroidism, higher digoxin concentrations may result due to significant reduction in digoxin clearance (Burk 2010). In patients with hyperthyroidism, lower digoxin concentrations may result due to an increase in renal clearance of digoxin. No significant differences in absorption were seen in either thyroid condition compared with those with normal thyroid function (Burk 2010). Note: New-onset atrial fibrillation or exacerbation of ventricular arrhythmias should prompt evaluation of thyroid status.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Infants: Newborn infants display considerable variability to their tolerance to digoxin; premature and immature infants are particularly sensitive to the effects of digoxin.

• Low body weight: Patients with decreased body weight are at an increased risk of drug-related toxicity.

Dosage form specific issues:

• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures, and respiratory depression; use caution (AAP 1997; Zar 2007).

Other warnings/precautions:

• Elective electrical cardioversion: It is not necessary to routinely reduce or hold digoxin therapy prior to elective electrical cardioversion for atrial fibrillation; however, exclusion of digoxin toxicity (eg, clinical and ECG signs) is necessary prior to cardioversion. If signs of digoxin excess exist, withhold digoxin and delay cardioversion until toxicity subsides (AHA/ACC/HRS [January 2014]).

Geriatric Considerations

Digitalis preparations (primarily digoxin) are frequently used to treat common cardiac diseases in the elderly (heart failure, atrial fibrillation). Elderly are at risk for toxicity due to age-related changes; volume of distribution is diminished significantly; half-life is increased as a result of decreased total body clearance. Additionally, elderly frequently have concomitant diseases which affect the pharmacokinetics in digitalis glycosides; hypo- and hyperthyroidism and renal function decline will affect clearance of digoxin. Exercise in elderly will reduce serum concentrations of digoxin due to increased skeletal muscle uptake. Therefore, a knowledge of the physical activity of elderly helps interpret serum assays. Must be observant for noncardiac signs of toxicity in elderly such as anorexia, vision changes (blurred), confusion, and depression. Changes in dose may be necessary with declining renal function with age; monitor closely.

Warnings: Additional Pediatric Considerations

Children are more likely to experience cardiac arrhythmia as a sign of excessive dosing. The most common are conduction disturbances or tachyarrhythmia (atrial tachycardia with or without block) and junctional tachycardia. Ventricular tachyarrhythmias are less common. In infants, sinus bradycardia may be a sign of digoxin toxicity. Any arrhythmia seen in a child on digoxin should be considered as digoxin toxicity. The gastrointestinal and central nervous system symptoms are not frequently seen in children.

Some dosage forms may contain propylene glycol; in neonates large amounts of propylene glycol delivered orally, intravenously (eg, >3,000 mg/day), or topically have been associated with potentially fatal toxicities which can include metabolic acidosis, seizures, renal failure, and CNS depression; toxicities have also been reported in children and adults including hyperosmolality, lactic acidosis, seizures and respiratory depression; use caution (AAP 1997; Shehab 2009).

Pregnancy Considerations

Digoxin crosses the placenta.

Available guidelines note experience with digoxin in pregnancy is extensive (ESG [Regitz-Zagrosek 2018]). Based on available data, an increased risk of adverse pregnancy outcomes has not been observed. However, untreated maternal heart failure and atrial fibrillation may increase the risk of preterm birth and low birth weight, respectively. The manufacturer recommends monitoring neonates for signs and symptoms of digoxin toxicity following in utero exposure.

Due to pregnancy-induced physiologic changes, some pharmacokinetic properties of digoxin may be altered. Close monitoring of maternal serum digoxin is recommended (Hebert 2008; Luxford 1983; Martin-Suarez 2017); dose adjustments may be required during pregnancy and postpartum.

Heart failure and atrial fibrillation may worsen during pregnancy. Digoxin is recommended as a first-line agent for the chronic treatment of highly symptomatic supraventricular tachycardia (SVT) in pregnancy; the lowest effective dose is recommended (ACC/AHA/HRS [Page 2015]). Digoxin may be considered for long-term rate control of maternal atrial tachycardia or atrial fibrillation when preferred agents fail (ESG [Regitz-Zagrosek 2018]). Monitor for an increased risk of maternal arrhythmias during labor and delivery.

Digoxin (administered either maternally or directly to the fetus) may be considered for the in utero management of fetal SVT or atrial flutter with hydrops or ventricular dysfunction. Digoxin may also be considered for SVT without hydrops or ventricular dysfunction if heart rate is ≥200 bpm, atrial flutter, or other rare tachycardias with an average heart rate of ≥200 bpm (AHA [Donofrio 2014]).

Breast-Feeding Considerations

Digoxin is present in breast milk.

The manufacturer reports the relative infant dose (RID) of digoxin to be 1% to 7% of a weight-adjusted maternal dose or ~ 0.2% to 4% of a neonatal maintenance dose.

In general, breastfeeding is considered acceptable when the RID of a medication is <10% (Anderson 2016; Ito 2000).

The RID of digoxin was calculated by the manufacturer using milk concentrations of 0.4 to 1 ng/mL, providing an estimated daily infant dose via breast milk of 0.03 to 0.16 mcg/kg/day. This milk concentration was obtained following maternal administration of digoxin 0.25 mg once daily to 13 lactating women. Higher milk concentrations (<12 ng/mL) were obtained following an IV bolus dose of 500 mcg to 1 breastfeeding woman; however, digoxin levels rapidly decreased to ~1 ng/mL ~2 hours after the injection. This study found milk concentrations declined in parallel to maternal serum concentrations following either oral or IV dosing (Reinhardt 1982). Digoxin can be detected in the serum of breastfed infants (Finley 1979).

The amount of digoxin available to the infant via breast milk is not likely to be clinically significant. The World Health Organization considers digoxin to be compatible with breastfeeding (WHO 2002).

Briggs’ Drugs in Pregnancy & Lactation
Adverse Reactions

Incidence not always reported.

Cardiovascular: Accelerated junctional rhythm, asystole, atrial tachycardia with or without block, AV dissociation, first-, second- (Wenckebach), or third-degree heart block, facial edema, PR prolongation, PVCs (especially bigeminy or trigeminy), ST segment depression, ventricular tachycardia or ventricular fibrillation

Central nervous system: Dizziness (6%), mental disturbances (5%), headache (4%), apathy, anxiety, confusion, delirium, depression, fever, hallucinations

Dermatologic: Rash (erythematous, maculopapular [most common], papular, scarlatiniform, vesicular or bullous), pruritus, urticaria, angioneurotic edema

Gastrointestinal: Nausea (4%), vomiting (2%), diarrhea (4%), abdominal pain, anorexia

Neuromuscular & skeletal: Weakness

Ophthalmic: Visual disturbances (blurred or yellow vision)

Respiratory: Laryngeal edema

<1%, postmarketing, and/or case reports (limited to important or life-threatening): Asymmetric chorea, gynecomastia, thrombocytopenia, palpitation, intestinal ischemia, hemorrhagic necrosis of the intestines, vaginal cornification, eosinophilia, sexual dysfunction, diaphoresis

Allergy and Idiosyncratic Reactions
Metabolism/Transport Effects

Substrate of CYP3A4 (minor), P-glycoprotein/ABCB1; Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions 

5-Aminosalicylic Acid Derivatives: May decrease the serum concentration of Cardiac Glycosides. Risk C: Monitor therapy

Acarbose: May decrease the serum concentration of Digoxin. Risk C: Monitor therapy

Adenosine: Digoxin may enhance the adverse/toxic effect of Adenosine. Risk C: Monitor therapy

Aminoglycosides: May decrease the serum concentration of Cardiac Glycosides. This effect has only been demonstrated with oral aminoglycoside administration. Exceptions: Amikacin (Systemic); Arbekacin; Isepamicin; Plazomicin; Streptomycin; Tobramycin (Systemic). Risk C: Monitor therapy

Aminoquinolines (Antimalarial): May increase the serum concentration of Cardiac Glycosides. Risk C: Monitor therapy

Amiodarone: May increase the serum concentration of Cardiac Glycosides. Management: Reduce the dose of cardiac glycosides by 30% to 50% or reduce the frequency of administration when initiating concomitant amiodarone therapy. Monitor for increased serum concentrations and toxic effects of cardiac glycosides. Risk D: Consider therapy modification

Amphotericin B: May enhance the adverse/toxic effect of Cardiac Glycosides. Risk C: Monitor therapy

Anagliptin: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Anthracyclines: Cardiac Glycosides may diminish the cardiotoxic effect of Anthracyclines. Anthracyclines may decrease the serum concentration of Cardiac Glycosides. The effects of liposomal formulations may be unique from those of the free drug, as liposomal formulation have unique drug disposition and toxicity profiles, and liposomes themselves may alter digoxin absorption/distribution. Risk C: Monitor therapy

Antithyroid Agents: May increase the serum concentration of Cardiac Glycosides. Risk C: Monitor therapy

Asunaprevir: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

AtorvaSTATin: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Barnidipine: May enhance the adverse/toxic effect of Digoxin. Risk C: Monitor therapy

Benidipine: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Benznidazole: May enhance the adverse/toxic effect of Products Containing Propylene Glycol. Risk X: Avoid combination

Beta-Blockers: May enhance the bradycardic effect of Cardiac Glycosides. Exceptions: Levobunolol; Metipranolol. Risk C: Monitor therapy

Bile Acid Sequestrants: May decrease the absorption of Cardiac Glycosides. Exceptions: Colesevelam. Risk C: Monitor therapy

Bradycardia-Causing Agents: May enhance the bradycardic effect of other Bradycardia-Causing Agents. Risk C: Monitor therapy

Bretylium: May enhance the bradycardic effect of Bradycardia-Causing Agents. Bretylium may also enhance atrioventricular (AV) blockade in patients receiving AV blocking agents. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the bradycardic effect of Digoxin. Risk C: Monitor therapy

BuPROPion: May decrease the serum concentration of Digoxin. Risk C: Monitor therapy

Calcium Channel Blockers (Nondihydropyridine): May enhance the AV-blocking effect of Cardiac Glycosides. Calcium Channel Blockers (Nondihydropyridine) may increase the serum concentration of Cardiac Glycosides. Risk C: Monitor therapy

Calcium Polystyrene Sulfonate: May enhance the adverse/toxic effect of Cardiac Glycosides. Risk C: Monitor therapy

Calcium Salts: May enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy

Canagliflozin: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Carvedilol: Digoxin may enhance the bradycardic effect of Carvedilol. Carvedilol may increase the serum concentration of Digoxin. Risk C: Monitor therapy

Ceritinib: Bradycardia-Causing Agents may enhance the bradycardic effect of Ceritinib. Management: If this combination cannot be avoided, monitor patients for evidence of symptomatic bradycardia, and closely monitor blood pressure and heart rate during therapy. Exceptions are discussed in separate monographs. Risk D: Consider therapy modification

CloNIDine: May enhance the AV-blocking effect of Cardiac Glycosides. Sinus node dysfunction may also be enhanced. Risk C: Monitor therapy

Cobicistat: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Colchicine: Digoxin may increase the serum concentration of Colchicine. Risk C: Monitor therapy

Conivaptan: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

CycloSPORINE (Systemic): May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Daclatasvir: May increase the serum concentration of Digoxin. Management: See full interaction monograph for details. Risk D: Consider therapy modification

Diacerein: May enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy

Dronedarone: Digoxin may enhance the AV-blocking effect of Dronedarone. Digoxin may also enhance the other electrophysiologic effects of Dronedarone. Dronedarone may increase the serum concentration of Digoxin. Management: Avoid concurrent use of digoxin when possible. If concurrent use is necessary, reduce adult digoxin dose by 50%, monitor digoxin concentration closely, and increase monitoring for both clinical response to therapy and the occurrence of adverse effects. Risk D: Consider therapy modification

Edrophonium: May enhance the AV-blocking effect of Cardiac Glycosides. Risk C: Monitor therapy

Elagolix: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Eliglustat: May increase the serum concentration of Digoxin. Management: In patients receiving digoxin, measure digoxin serum concentrations prior to initiating eliglustat. Preemptively reduce digoxin doses by 30% and continue monitoring following eliglustat initiation. Risk D: Consider therapy modification

EPHEDrine (Nasal): Cardiac Glycosides may enhance the arrhythmogenic effect of EPHEDrine (Nasal). Risk C: Monitor therapy

EPHEDrine (Systemic): May enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy

Epoprostenol: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Etravirine: May increase the serum concentration of Digoxin. Management: Monitor serum digoxin concentrations and adjust dose as needed. In patients initiating a regimen of digoxin with etravirine, digoxin should be initiated at the lowest dose. Risk C: Monitor therapy

Flecainide: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Flibanserin: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Fostamatinib: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Glecaprevir and Pibrentasvir: May increase the serum concentration of Digoxin. Management: Measure serum digoxin concentrations before initiating glecaprevir/pibrentasvir. Reduce digoxin concentrations by decreasing the digoxin dose by approximately 50% or by modifying the dosing frequency; continue monitoring during concomitant therapy. Risk D: Consider therapy modification

Glycopyrrolate (Systemic): May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Ibrutinib: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Isavuconazonium Sulfate: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Itraconazole: May increase the serum concentration of Cardiac Glycosides. Management: Consider preemptive cardiac glycoside dose adjustments with initiation / changes / discontinuation of itraconazole. Risk D: Consider therapy modification

Ivabradine: Bradycardia-Causing Agents may enhance the bradycardic effect of Ivabradine. Risk C: Monitor therapy

Kaolin: May decrease the serum concentration of Cardiac Glycosides. Risk C: Monitor therapy

Lacosamide: Bradycardia-Causing Agents may enhance the AV-blocking effect of Lacosamide. Risk C: Monitor therapy

Lenalidomide: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Levosulpiride: May enhance the adverse/toxic effect of Cardiac Glycosides. Specifically, levosulpiride may diminish symptoms of cardiac glycoside-related toxicity. Risk C: Monitor therapy

Licorice: May enhance the adverse/toxic effect of Cardiac Glycosides. Risk C: Monitor therapy

Loop Diuretics: May enhance the adverse/toxic effect of Cardiac Glycosides. Specifically, cardiac glycoside toxicity may be enhanced by the hypokalemic and hypomagnesemic effect of loop diuretics. Risk C: Monitor therapy

Lumacaftor: May decrease the serum concentration of P-glycoprotein/ABCB1 Substrates. Lumacaftor may increase the serum concentration of P-glycoprotein/ABCB1 Substrates. Risk C: Monitor therapy

Macrolide Antibiotics: May increase the serum concentration of Cardiac Glycosides. Exceptions: Fidaxomicin; Roxithromycin; Spiramycin. Risk C: Monitor therapy

Metaraminol: May enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy

MetroNIDAZOLE (Systemic): May enhance the adverse/toxic effect of Products Containing Propylene Glycol. A disulfiram-like reaction may occur. Risk X: Avoid combination

Midodrine: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

MiFEPRIStone: May increase the serum concentration of Digoxin. Management: Measure serum digoxin concentration 1-2 weeks following mifepristone initiation, and in accordance with normal clinical practice thereafter, adjusting dose as needed. Risk C: Monitor therapy

Milnacipran: May enhance the adverse/toxic effect of Digoxin. The risk of postural hypotension and tachycardia may be increased, particularly with IV digoxin. Management: Avoid concurrent use of intravenous (IV) digoxin in patients receiving milnacipran. Use caution when using oral digoxin and milnacipran together, monitoring closely for possible postural hypotension and tachycardia. Risk D: Consider therapy modification

Mirabegron: May increase the serum concentration of Digoxin. Management: Consider using the lowest dose of digoxin when initiating concurrent mirabegron. Monitor serum digoxin concentrations closely to help guide digoxin dosing. Risk D: Consider therapy modification

Multivitamins/Fluoride (with ADE): May enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy

Multivitamins/Minerals (with ADEK, Folate, Iron): May enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy

Multivitamins/Minerals (with AE, No Iron): May enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy

Nefazodone: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Neratinib: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Neuromuscular-Blocking Agents: May enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy

NIFEdipine: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Ombitasvir, Paritaprevir, and Ritonavir: May increase the serum concentration of Digoxin. Management: When initiating the ombitasvir/paritaprevir/ritonavir combination product in patients taking digoxin, decrease the digoxin dose by 30% to 50% and monitor serum digoxin levels to determine further dose adjustments. Risk D: Consider therapy modification

Parathyroid Hormone: May enhance the adverse/toxic effect of Cardiac Glycosides. More specifically, Parathyroid Hormone-related hypercalcemia may predispose to digitalis toxicity.Risk C: Monitor therapy

Paricalcitol: May enhance the adverse/toxic effect of Digoxin. Risk C: Monitor therapy

PenicillAMINE: May decrease the serum concentration of Digoxin. Risk C: Monitor therapy

P-glycoprotein/ABCB1 Inducers: May decrease the serum concentration of P-glycoprotein/ABCB1 Substrates. P-glycoprotein inducers may also further limit the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.). Risk C: Monitor therapy

P-glycoprotein/ABCB1 Inhibitors: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates. P-glycoprotein inhibitors may also enhance the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.). Risk C: Monitor therapy

Polyethylene Glycol 3350: May decrease the serum concentration of Digoxin. Risk C: Monitor therapy

Polyethylene Glycol 4000: May decrease the serum concentration of Digoxin. Risk C: Monitor therapy

Posaconazole: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Potassium-Sparing Diuretics: May diminish the therapeutic effect of Cardiac Glycosides. In particular, the inotropic effects of digoxin appear to be diminished. Potassium-Sparing Diuretics may increase the serum concentration of Cardiac Glycosides. This particular effect may be unique to Spironolactone. Risk C: Monitor therapy

Propafenone: May increase the serum concentration of Cardiac Glycosides. Risk C: Monitor therapy

QuiNIDine: May increase the serum concentration of Cardiac Glycosides. Management: Upon quinidine initiation, consider reducing cardiac glycoside dose by 25% to 50%, with continued monitoring of glycoside serum concentrations and clinical response until the quinidine reaches steady state (5-10 days). Risk D: Consider therapy modification

QuiNINE: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Ranolazine: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Regorafenib: May enhance the bradycardic effect of Digoxin. Risk C: Monitor therapy

Reserpine: May enhance the adverse/toxic effect of Cardiac Glycosides. Risk C: Monitor therapy

Ritonavir: May increase the serum concentration of Digoxin. Risk D: Consider therapy modification

Roxithromycin: May increase the serum concentration of Cardiac Glycosides. Risk C: Monitor therapy

Ruxolitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Management: Ruxolitinib Canadian product labeling recommends avoiding use with bradycardia-causing agents to the extent possible. Risk C: Monitor therapy

Sarecycline: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Simeprevir: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Siponimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Siponimod. Management: Avoid coadministration of siponimod with drugs that may cause bradycardia.Risk D: Consider therapy modification

SITagliptin: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Sodium Polystyrene Sulfonate: May enhance the adverse/toxic effect of Digoxin. Risk C: Monitor therapy

Spironolactone: May increase the serum concentration of Digoxin. Spironolactone (and/or its metabolites) may also interfere with the assays used to determine Digoxin concentrations, falsely increasing or decreasing Digoxin concentrations. Risk C: Monitor therapy

St John’s Wort: May decrease the serum concentration of Digoxin. Risk C: Monitor therapy

Sucralfate: May decrease the serum concentration of Digoxin. Specifically, sucralfate may decrease the absorption of digoxin. Management: Administer digoxin at least 2 hours before or at least 6 hours after sucralfate. Risk D: Consider therapy modification

Telmisartan: May increase the serum concentration of Cardiac Glycosides. Risk C: Monitor therapy

Terlipressin: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Thiazide and Thiazide-Like Diuretics: May enhance the adverse/toxic effect of Cardiac Glycosides. Specifically, cardiac glycoside toxicity may be enhanced by the hypokalemic and hypomagnesemic effect of thiazide diuretics. Risk C: Monitor therapy

Ticagrelor: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Tofacitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Tolvaptan: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Trimethoprim: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Valbenazine: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Vandetanib: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Velpatasvir: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Vemurafenib: May increase the serum concentration of Digoxin. Management: Avoid coadministration of vemurafenib and digoxin when possible. If concomitant use cannot be avoided, consider digoxin dose reduction. Risk D: Consider therapy modification

Venetoclax: May increase the serum concentration of Digoxin. Management: Administer digoxin at least 6 hours before venetoclax when concomitant therapy is required. Risk D: Consider therapy modification

Vilazodone: May increase the serum concentration of Digoxin. Risk C: Monitor therapy

Vitamin D Analogs: May enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy

Food Interactions

Digoxin peak serum concentrations may be decreased if taken with food. Meals containing increased fiber (bran) or foods high in pectin may decrease oral absorption of digoxin.

Test Interactions

Spironolactone may interfere with digoxin radioimmunoassay.

Monitoring Parameters

Heart rate and rhythm should be monitored along with periodic ECGs to assess desired effects and signs of toxicity; baseline and periodic serum creatinine. Periodically monitor serum potassium, magnesium, and calcium especially if on medications where these electrolyte disturbances can occur (eg, diuretics), or if patient has a history of hypokalemia or hypomagnesemia. Observe patients for noncardiac signs of toxicity, confusion, and depression.

When to draw serum digoxin concentrations: Digoxin serum concentrations are monitored because digoxin possesses a narrow therapeutic serum range; the therapeutic endpoint is difficult to quantify and digoxin toxicity may be life-threatening. Digoxin serum concentrations should be drawn at least 6 to 8 hours after last dose, regardless of route of administration (optimally 12 to 24 hours after a dose). Note: Serum digoxin concentrations may decrease in response to exercise due to increased skeletal muscle uptake; a period of rest (eg, ~2 hours) after exercise may be necessary prior to drawing serum digoxin concentrations.

Initiation of therapy:

If a loading dose is given: Digoxin serum concentration may be drawn within 12 to 24 hours after the initial loading dose administration. Concentrations drawn this early may confirm the relationship of digoxin plasma concentrations and response but are of little value in determining maintenance doses.

If a loading dose is not given: Digoxin serum concentration should be obtained after 3 to 5 days of therapy.

Maintenance therapy:

Trough concentrations should be followed just prior to the next dose or at a minimum of 6 to 8 hours after last dose.

Digoxin serum concentrations should be obtained within 5 to 7 days (approximate time to steady-state) after any dosage changes. Continue to obtain digoxin serum concentrations 7 to 14 days after any change in maintenance dose. Note: In patients with end-stage renal disease, it may take 15 to 20 days to reach steady-state.

Patients who are receiving electrolyte-depleting medications such as diuretics, serum potassium, magnesium, and calcium should be monitored closely.

Digoxin serum concentrations should be obtained whenever any of the following conditions occur:

Questionable patient compliance or to evaluate clinical deterioration following an initial good response

Changing renal function

Suspected digoxin toxicity

Initiation or discontinuation of therapy with drugs (eg, amiodarone, quinidine, verapamil) which potentially interact with digoxin.

Any disease changes (eg, thyroid disease)

Reference Range

Digoxin therapeutic serum concentrations:

Heart failure: 0.5 to 0.9 ng/mL (SI: 0.6 to 1.2 nmol/L) (ACCF/AHA [Yancy 2013])

Adults: 0.8 to 2 ng/mL (SI: 1.0 to 2.6 nmol/L); <0.5 ng/mL (SI: <0.6 nmol/L) probably indicates underdigitalization unless there are special circumstances. A serum concentration ≥1.2 ng/mL (SI: 1.5 nmol/L) may be associated with increased all-cause mortality in patients with atrial fibrillation (regardless of heart failure) (Lopes 2018).

Toxic: Risk increases with serum concentrations >2 ng/mL (>2.6 nmol/L), but toxicity can occur at any time and may occur at lower levels in the setting of hypokalemia, hypomagnesemia, or hypothyroidism (ACCF/AHA [Yancy 2013]).

Digoxin-like immunoreactive substance (DLIS) may cross-react with digoxin immunoassay. DLIS has been found in patients with renal and liver disease, heart failure, neonates, and pregnant women (third trimester).

Advanced Practitioners Physical Assessment/Monitoring

Assess results of laboratory tests when beginning or changing dosage, especially with IV administration. Monitor for signs of digoxin toxicity. IV: Monitor ECG continuously. Oral: Monitor apical pulse before administering any dose.

Nursing Physical Assessment/Monitoring

Monitor laboratory tests when beginning or changing dosage, especially with IV administration. IV: Monitor ECG continuously. Oral: Monitor apical pulse before administering any dose. Teach patient to report noncardiac signs of toxicity (eg, anorexia, blurred vision, “yellow” vision, confusion).

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Injection:

Lanoxin: 0.25 mg/mL (2 mL) [contains alcohol, usp, propylene glycol]

Lanoxin Pediatric: 0.1 mg/mL (1 mL) [contains alcohol, usp, propylene glycol]

Generic: 0.25 mg/mL (2 mL)

Solution, Oral:

Generic: 0.05 mg/mL (60 mL)

Tablet, Oral:

Digitek: 125 mcg [scored; contains fd&c yellow #10 aluminum lake]

Digitek: 250 mcg [scored]

Digox: 125 mcg [scored; contains fd&c yellow #10 aluminum lake]

Digox: 250 mcg [scored]

Lanoxin: 62.5 mcg [contains corn starch, fd&c yellow #6 (sunset yellow)]

Lanoxin: 125 mcg [DSC] [contains fd&c yellow #10 (quinoline yellow), fd&c yellow #6 (sunset yellow)]

Lanoxin: 125 mcg [scored; contains fd&c yellow #10 (quinoline yellow), fd&c yellow #6 (sunset yellow)]

Lanoxin: 187.5 mcg, 250 mcg [DSC]

Lanoxin: 250 mcg [scored]

Generic: 125 mcg, 250 mcg

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Elixir, Oral:

Toloxin: 0.05 mg/mL (115ml) [contains ALCOHOL, USP, FD&C YELLOW #10 (QUINOLINE YELLOW), METHYLPARABEN, PROPYLENE GLYCOL]

Solution, Injection:

Lanoxin: 0.25 mg/mL (2ml) [contains ALCOHOL, USP]

Generic: 0.05 mg/mL (1ml); 0.25 mg/mL (2ml)

Tablet, Oral:

Lanoxin: 62.5 mcg [DSC] [contains FD&C YELLOW #6 (SUNSET YELLOW)]

Lanoxin: 125 mcg [DSC] [contains FD&C YELLOW #10 (QUINOLINE YELLOW), FD&C YELLOW #6 (SUNSET YELLOW)]

Lanoxin: 250 mcg [DSC]

Toloxin: 62.5 mcg [contains FD&C YELLOW #6 (SUNSET YELLOW)]

Toloxin: 125 mcg [contains FD&C YELLOW #10 (QUINOLINE YELLOW)]

Toloxin: 250 mcg

Generic: 62.5 mcg, 125 mcg, 250 mcg

Anatomic Therapeutic Chemical (ATC) Classification
  • C01AA05
Generic Available (US)

Yes

Pricing: US

Solution (Digoxin Injection)

0.25 mg/mL (per mL): $3.30 – $3.74

Solution (Digoxin Oral)

0.05 mg/mL (per mL): $2.80

Solution (Lanoxin Injection)

0.25 mg/mL (per mL): $60.28

Solution (Lanoxin Pediatric Injection)

0.1 mg/mL (per mL): $120.55

Tablets (Digitek Oral)

125 mcg (per each): $2.30

250 mcg (per each): $2.30

Tablets (Digox Oral)

125 mcg (per each): $2.30

250 mcg (per each): $2.30

Tablets (Digoxin Oral)

125 mcg (per each): $1.42 – $4.56

250 mcg (per each): $1.42 – $4.56

Tablets (Lanoxin Oral)

62.5 mcg (per each): $14.91

125 mcg (per each): $14.91

187.5 mcg (per each): $14.91

250 mcg (per each): $14.91

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer’s AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Mechanism of Action

Heart failure: Inhibition of the sodium/potassium ATPase pump in myocardial cells results in a transient increase of intracellular sodium, which in turn promotes calcium influx via the sodium-calcium exchange pump leading to increased contractility. May improve baroreflex sensitivity (Gheorghiade 1991).

Supraventricular arrhythmias: Direct suppression of the AV node conduction to increase effective refractory period and decrease conduction velocity – positive inotropic effect, enhanced vagal tone, and decreased ventricular rate to fast atrial arrhythmias. Atrial fibrillation may decrease sensitivity and increase tolerance to higher serum digoxin concentrations.

Pharmacodynamics/Kinetics

Onset of action: Heart rate control: Oral: 1 to 2 hours; IV: 5 to 60 minutes

Peak effect: Heart rate control: Oral: 2 to 8 hours; IV: 1 to 6 hours; Note: In patients with atrial fibrillation, median time to ventricular rate control in one study was 6 hours (range: 3 to 15 hours) (Siu 2009)

Duration: Adults: 3 to 4 days

Absorption: By passive nonsaturable diffusion in the upper small intestine; food may delay, but does not affect extent of absorption

Distribution:

Normal renal function: 6 to 7 L/kg

Vd: Extensive to peripheral tissues, with a distinct distribution phase which lasts 6 to 8 hours; concentrates in heart, liver, kidney, skeletal muscle, and intestines. Heart/serum concentration is 70:1. Pharmacologic effects are delayed and do not correlate well with serum concentrations during distribution phase.

Hyperthyroidism: Increased Vd

Hyperkalemia, hyponatremia: Decreased digoxin distribution to heart and muscle

Hypokalemia: Increased digoxin distribution to heart and muscles

Concomitant quinidine therapy: Decreased Vd

Chronic renal failure: 4 to 6 L/kg

Decreased sodium/potassium ATPase activity – decreased tissue binding

Neonates, full-term: 7.5 to 10 L/kg

Children: 16 L/kg

Adults: 7 L/kg, decreased with renal disease

Protein binding: ~25%; in uremic patients, digoxin is displaced from plasma protein binding sites

Metabolism: Via sequential sugar hydrolysis in the stomach or by reduction of lactone ring by intestinal bacteria (in ~10% of population, gut bacteria may metabolize up to 40% of digoxin dose); once absorbed, only ~16% is metabolized to 3-beta-digoxigenin, 3-keto-digoxigenin, and glucuronide and sulfate conjugates; metabolites may contribute to therapeutic and toxic effects of digoxin; metabolism is reduced with decompensated HF

Bioavailability: Oral (formulation dependent): Elixir: 70% to 85%; Tablet: 60% to 80%

Half-life elimination (age, renal and cardiac function dependent):

Neonates: Premature: 61 to 170 hours; Full-term: 35 to 45 hours

Infants: 18 to 25 hours

Children: 18 to 36 hours

Adults: 36 to 48 hours

Adults, anephric: 3.5 to 5 days

Half-life elimination: Parent drug: 38 hours; Metabolites: Digoxigenin: 4 hours; Monodigitoxoside: 3 to 12 hours

Time to peak, serum: Oral: 1 to 3 hours

Excretion: Urine (50% to 70% as unchanged drug)

Pharmacodynamics/Kinetics: Additional Considerations

Renal function impairment: Clearance correlates with CrCl. Half-life is 3.5 to 5 days in anuric patients.

Local Anesthetic/Vasoconstrictor Precautions

Use vasoconstrictor with caution due to risk of cardiac arrhythmias with digoxin

Effects on Dental Treatment

Sensitive gag reflex may cause difficulty in taking a dental impression.

Effects on Bleeding

No information available to require special precautions

Index Terms

Digitalis; Lanoxicaps

FDA Approval Date
October 24, 1975
References

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American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults [published online ahead of print October 8, 2015]. J Am Geriatr Soc. 2015;63(11):2227-2246. doi:10.1111/jgs.13702.[PubMed 26446832]

Anderson PO, Sauberan JB. Modeling drug passage into human milk. Clin Pharmacol Ther. 2016;100(1):42-52. doi: 10.1002/cpt.377.[PubMed 27060684]10.1002/cpt.377

Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults and Children. 5th ed. Philadelphia, PA: American College of Physicians; 2007:42.

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Burk O, Brenner SS, Hofmann U, et al. The Impact of Thyroid Disease on the regulation, expression, and function of ABCB1 (MDRa/P-glycoprotein) and consequences for the disposition of digoxin. Clin Pharm Ther. 2010;88(5):685-694.[PubMed 20844484]

Cheng JW, Rybak I. Use of digoxin for heart failure and atrial fibrillation in elderly patients. Am J Geriatr Pharmacother. 2010;8(5):419-427.[PubMed 21335295]

Colucci WS, Sylvia L. Use of digoxin in heart failure with reduced ejection fraction. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 22, 2018.

DiDomenico RJ, Bress AP, Na-Thalang K, et al. Use of a simplified nomogram to individualize digoxin dosing versus standard dosing practices in patients with heart failure. Pharmacotherapy. 2014;34(11):1121-1131. doi: 10.1002/phar.1480.[PubMed 25164709]

Digitek (digoxin) tablets [prescribing information]. Morgantown, WV: Mylan; October 2015.

Digoxin (digoxin) oral solution [prescribing information]. Columbus, OH: Roxane Laboratories; November 2011.

Donofrio MT, Moon-Grady AJ, Hornberger LK, et al; American Heart Association Adults With Congenital Heart Disease Joint Committee of the Council on Cardiovascular Disease in the Young and Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular and Stroke Nursing. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association [published correction appears in Circulation. 2014;129(21):e512]. Circulation. 2014;129(21):2183-2242. doi: 10.1161/01.cir.0000437597.44550.5d.[PubMed 24763516]

Escudero C, Carr R, Sanatani S. The medical management of pediatric arrhythmias. Curr Treat Options Cardiovasc Med. 2012;14(5):455-472. doi: 10.1007/s11936-012-0194-5.[PubMed 22907424]

Falk RH, Knowlton AA, Bernard SA, et al, “Digoxin for Converting Recent-Onset Atrial Fibrillation to Sinus Rhythm, A Randomized, Double-Blinded Trial,” Ann Int Med, 1987, 106(4):503-6[PubMed 3548521]

Finley JP, Waxman MB, Wong PY, Lickrish GM. Digoxin excretion in human milk. J Pediatr. 1979;94(2):339-340.[PubMed 762640]

Frishman WH, Zeidner J, Naseer N. Diagnosis and Management of Viral Myocarditis. Curr Treat Options Cardiovas Med. 2007;9:450-464.[PubMed 18221597]

Ganz L. Control of ventricular rate in atrial fibrillation: Pharmacologic therapy. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 11, 2018.

Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124(24):e783-831.[PubMed 22068434]

Gheorghiade M and Ferguson D. Digoxin. A neurohormonal modulator in heart failure? Circulation. 1991;84(5):2181-2186.[PubMed 1834367]

Giardina EG, Sylvia L. Treatment with digoxin: Initial dosing, monitoring, and dose modification. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 14, 2018.

Golightly LK, Teitelbaum I, Kiser TH, et al, eds. Renal Pharmacotherapy: Dosage Adjustment of Medications Eliminated by the Kidneys. New York, NY: Springer Science; 2013.

Hebert MF, Easterling TR, Kirby B, et al. Effects of pregnancy on CYP3A and P-glycoprotein activities as measured by disposition of midazolam and digoxin: a University of Washington specialized center of research study. Clin Pharmacol Ther. 2008;84(2):248-253. doi: 10.1038/clpt.2008.1.[PubMed 18288078]

Hillis LD, Smith PK, Anderson JL, et al, “2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines,” Circulation, 2011, 124(23):2610-42.[PubMed 22064600]

“Inactive” ingredients in pharmaceutical products: update (subject review). American Academy of Pediatrics Committee on Drugs. Pediatrics. 1997;99(2):268-278.[PubMed 9024461]

Ito S. Drug therapy for breast-feeding women. NEJM. 2000;343(2):118-126. doi: 10.1056/NEJM200007133430208.[PubMed 10891521]

Jaeggi ET, Carvalho JS, De Groot E, et al. Comparison of transplacental treatment of fetal supraventricular tachyarrhythmias with digoxin, flecainide, and sotalol: results of a nonrandomized multicenter study. Circulation. 2011;124(16):1747-1754.[PubMed 21931080]

January CT, Wann LS, Alpert JS, et al; ACC/AHA Task Force. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society [published online March 28, 2014]. Circulation. doi:10.1161/CIR.0000000000000041.[PubMed 24682347]

Jusko WJ, Szefler SJ, Goldfarb AL. Pharmacokinetic design of digoxin dosage regimens in relation to renal function. J Clin Pharmacol. 1974;14(10):525-535.[PubMed 4430731]

Knight BP. Atrioventricular nodal reentrant tachycardia. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 18, 2018.

Koup JR, Jusko WJ, Elwood CM, Kohli RK. Digoxin pharmacokinetics: role of renal failure in dosage regimen design. Clin Pharmacol Ther. 1975;18(1):9-21.[PubMed 1149366]

Lanoxin (digoxin) tablets [prescribing information]. Research Triangle Park, NC: Glaxosmithkline; September 2018.

Lanoxin (digoxin) injection [prescribing information]. Cary, NC: Covis Pharmaceuticals Inc; February 2019.

Lanoxin (digoxin) tablets [product monograph]. Montreal, Quebec, Canada: Pharmascience; January 2016.

Latifi S, Lidsky K, Blumer JL. Pharmacology of inotropic agents in infants and children. Prog Pediatr Cardiol. 2000;12(1):57-79.[PubMed 11114547]

Levine JC, Alexander ME. Overview of the general approach to diagnosis and treatment of fetal arrhythmias. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed January 28, 2018.

Lindenfeld J, Albert NM, Boehmer JP, et al, “HFSA 2010 Comprehensive Heart Failure Practice Guideline,” J Card Fail, 2010, 16(6):e1-194.[PubMed 20610207]

Lopes RD, Rordorf R, De Ferrari GM, et al. Digoxin and mortality in patients with atrial fibrillation. J Am Coll Cardiol. 2018;71(10):1063-1074.[PubMed 29519345]

Luxford AM, Kellaway GS. Pharmacokinetics of digoxin in pregnancy. Eur J Clin Pharmacol. 1983;25(1):117-121.[PubMed 6617713]

Martin-Suarez A, Sanchez-Hernandez JG, Medina-Barajas F, et al. Pharmacokinetics and dosing requirements of digoxin in pregnant women treated for fetal supraventricular tachycardia. Expert Rev Clin Pharmacol. 2017;10(8):911-917. doi: 10.1080/17512433.2017.1344096.[PubMed 28631514]

Matsumori A, Igata H, Ono K, et al. High doses of digitalis increase the myocardial production of proinflammatory cytokines and worsen myocardial injury in viral myocarditis: a possible mechanism of digitalis toxicity. Jpn Circ J. 1999;63:934-990.[PubMed 10614837]

Miyoshi T, Maeno Y, Sago H, et al; Japan Fetal Arrhythmia Group. Antenatal antiarrhythmic treatment for fetal tachyarrhythmias: a study protocol for a prospective multicentre trial. BMJ Open. 2017;7(8):e016597. doi: 10.1136/bmjopen-2017-016597.[PubMed 28851790]

Moatassim S, Touleimat S, Hazelzet T, et al. Maternal complications induced by digoxin treatment of fetal tachycardia: A retrospective series of 18 cases. J Gynecol Obstet Hum Reprod. 2018;47(2):35-38. doi: 10.1016/j.jogoh.2017.11.013.[PubMed 29208503]

Mooradian AD. Digitalis. An update of clinical pharmacokinetics, therapeutic monitoring techniques and treatment recommendations. Clin Pharmacokinet. 1988;15(3):165-179.[PubMed 3052985]

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Ohnhaus EE, Lenzinger HR, Galeazzi RL. Comparison of two different loading doses of digoxin in severe renal impairment. Eur J Clin Pharmacol. 1980;18(6):467-472.[PubMed 7461014]

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Packer M, Gheorghiade M, Young JB, et al, “Withdrawal of Digoxin From Patients With Chronic Heart Failure Treated With Angiotensin-converting Enzyme Inhibitors, RADIANCE Study,” N Engl J Med, 1993, 329(1):1-77.[PubMed 8505940]

Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol. 2016;68:25):2922-2923]. J Am Coll Cardiol. 2016;67(13):e27-e115. doi: 10.1016/j.jacc.2015.08.856.[PubMed 26409259]

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Brand Names: International

Agoxin (BD); Cadef Elixir Pediatric (KR); Cardcor (BR, LI); Cardiacin (TW); Cardicaps (EG); Cardigo (LK); Cardiogoxin (AR); Cardioxin (PH); Cardixin (EG); Cardoxin (IL); Centoxin (BD); Digosin (JP, KR); Digox (PH); Digoxicor (LV); Digoxil (PY); Digoxin (PL); Digoxin NI (ID); Digoxin ”Dak” (DK); Digoxin-Actavis (HK); Digoxin-Sandoz (BF, BJ, CH, CI, ET, GH, GM, GN, ID, JP, KE, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SL, SN, TN, TZ, UG, ZM); Digoxin-Zori (IL); Digoxina (CO, ES, GT, HN, NI, PE); Digoxine Nativelle (LU); Digoxine Navtivelle (FR); Dilacor (BG); Dilanacin (CY, IQ, SD); Dixcool (LK); Eudigox (IT); Fargoxin (ID); Grekin (LI); Grexin (TH); Ke Li (CN); Lanacordin (ES); Lanibos (KW, SA); Lanicor (AR, AT, BB, BF, BJ, BM, BS, BZ, CI, CY, CZ, DE, EC, ET, GH, GM, GN, GR, GY, HR, IQ, IR, JM, KE, LI, LR, LU, LY, MA, ML, MR, MU, MW, NE, NG, OM, SC, SD, SL, SN, SR, SY, TN, TT, TZ, UG, VE, YE, ZM); Lanikor (RU); Lanioxin (IS); Lanitop (SA); Lanoxin (AE, AR, AU, BB, BD, BE, BF, BH, BJ, BM, BS, BZ, CI, CR, CY, DO, EG, ET, GB, GH, GM, GN, GR, GT, GY, HK, HN, IE, IL, IN, IQ, IR, IT, JM, JO, JP, KE, KR, KW, LB, LI, LR, LU, LY, MA, ML, MR, MT, MU, MW, MX, MY, NE, NG, NI, NL, NO, NZ, OM, PA, PH, PK, PT, PY, QA, RU, SA, SC, SD, SE, SG, SL, SN, SR, SV, SY, TH, TN, TR, TT, TW, TZ, UG, UY, YE, ZM, ZW); Lanoxin PG (BH, NZ, QA); Lenoxin (DE); Mapluxin (MX); Myoxin (BD); Purgoxin (ZA); Sigmaxin (AU); Toloxin (TH); Valvulan (CR, DO, GT, HN, NI, PA, SV); Vidaxil (MX)

Digoxin (Patient Education – Adult Medication)
You must carefully read the “Consumer Information Use and Disclaimer” below in order to understand and correctly use this information
Pronunciation

(di JOKS in)

Brand Names: US

Digitek; Digox; Lanoxin; Lanoxin Pediatric

Brand Names: Canada

Digoxin Injection CSD; Lanoxin; Pediatric Digoxin CSD; Toloxin

What is this drug used for?
  • It is used to treat heart failure (weak heart).
  • It is used to treat a certain type of abnormal heartbeat (atrial fibrillation).
  • It may be given to you for other reasons. Talk with the doctor.
What do I need to tell my doctor BEFORE I take this drug?
  • If you have an allergy to digoxin or any other part of this drug.
  • If you are allergic to any drugs like this one, any other drugs, foods, or other substances. Tell your doctor about the allergy and what signs you had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs.
  • If you have other heart problems.
  • If you have had a recent heart attack.
  • This is not a list of all drugs or health problems that interact with this drug.
  • Tell your doctor and pharmacist about all of your drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for you to take this drug with all of your drugs and health problems. Do not start, stop, or change the dose of any drug without checking with your doctor.
What are some things I need to know or do while I take this drug?
  • All products:
  • Tell all of your health care providers that you take this drug. This includes your doctors, nurses, pharmacists, and dentists.
  • Check blood pressure and heart rate as the doctor has told you. Talk with the doctor.
  • Have blood work checked as you have been told by the doctor. Talk with the doctor.
  • Have your blood work (digoxin levels) checked. Have blood drawn before the daily dose (take digoxin after blood drawn). Talk with your doctor.
  • This drug may affect certain lab tests. Tell all of your health care providers and lab workers that you take this drug.
  • If you will be having certain procedures to help your heart beat normally (defibrillation cardioversion), talk with your doctor. Be sure your doctor knows you take this drug.
  • Many other drugs interact with this drug. These drugs can raise the chance of this drug’s side effects. Talk with your doctor and pharmacist to make sure that it is safe for you to use this drug with all of your other drugs.
  • Keep away from children. Accidental exposure may cause death. If a child takes this drug by accident, get medical help right away.
  • If you are 65 or older, use this drug with care. You could have more side effects.
  • Use with care in children. Talk with the doctor.
  • Tell your doctor if you are pregnant, plan on getting pregnant, or are breast-feeding. You will need to talk about the benefits and risks to you and the baby.
  • All oral products:
  • Tell your doctor if you eat high bran or fiber meals.
What are some side effects that I need to call my doctor about right away?
  • WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:
  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Very bad dizziness or passing out.
  • Upset stomach or throwing up.
  • Severe diarrhea.
  • Change in eyesight.
  • Seeing halos or bright colors around lights.
  • Weight loss.
  • Not hungry.
  • Feeling tired or weak.
  • Fast or slow heartbeat.
  • A new or worse heartbeat that does not feel normal.
  • Hallucinations (seeing or hearing things that are not there).
  • Change in how you act.
  • Mood changes.
  • Feeling confused.
  • Very bad belly pain.
  • Black, tarry, or bloody stools.
  • Throwing up blood or throw up that looks like coffee grounds.
  • Enlarged breasts.
What are some other side effects of this drug?
  • All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:
  • All products:
  • Dizziness.
  • Headache.
  • Belly pain.
  • Injection (if given in the muscle):
  • Pain where the shot was given.
  • These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.
  • You may report side effects to your national health agency.
How is this drug best taken?
  • Use this drug as ordered by your doctor. Read all information given to you. Follow all instructions closely.
  • All oral products:
  • To gain the most benefit, do not miss doses.
  • Take this drug at the same time of day.
  • Keep taking this drug as you have been told by your doctor or other health care provider, even if you feel well.
  • Liquid (solution):
  • Measure liquid doses carefully. Use the measuring device that comes with this drug.
  • Injection:
  • It is given as a shot into a muscle or vein.
What do I do if I miss a dose?
  • All oral products:
  • Take a missed dose as soon as you think about it.
  • If it is close to the time for your next dose, skip the missed dose and go back to your normal time.
  • Do not take 2 doses at the same time or extra doses.
  • Injection:
  • Call your doctor to find out what to do.
How do I store and/or throw out this drug?
  • All oral products:
  • Store at room temperature.
  • Protect from light.
  • Store in a dry place. Do not store in a bathroom.
  • Injection:
  • If you need to store this drug at home, talk with your doctor, nurse, or pharmacist about how to store it.
  • All products:
  • Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.
General drug facts
  • If your symptoms or health problems do not get better or if they become worse, call your doctor.
  • Do not share your drugs with others and do not take anyone else’s drugs.
  • Keep a list of all your drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your doctor.
  • Talk with the doctor before starting any new drug, including prescription or OTC, natural products, or vitamins.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your doctor, nurse, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened
Digoxin (Patient Education – Pediatric Medication)
You must carefully read the “Consumer Information Use and Disclaimer” below in order to understand and correctly use this information
Pronunciation

(di JOKS in)

Brand Names: US

Digitek; Digox; Lanoxin; Lanoxin Pediatric

Brand Names: Canada

Digoxin Injection CSD; Lanoxin; Pediatric Digoxin CSD; Toloxin

What is this drug used for?
  • It is used to treat heart failure (weak heart).
  • It is used to treat a certain type of abnormal heartbeat (atrial fibrillation).
  • It may be given to your child for other reasons. Talk with the doctor.
What do I need to tell the doctor BEFORE my child takes this drug?
  • If your child has an allergy to this drug or any part of this drug.
  • If your child is allergic to any drugs like this one or any other drugs, foods, or other substances. Tell the doctor about the allergy and what signs your child had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs.
  • If your child has other heart problems.
  • If your child has had a recent heart attack.
  • This is not a list of all drugs or health problems that interact with this drug.
  • Tell the doctor and pharmacist about all of your child’s drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for your child to take this drug with all of his/her drugs and health problems. Do not start, stop, or change the dose of any drug your child takes without checking with the doctor.
What are some things I need to know or do while my child takes this drug?
  • All products:
  • Tell all of your child’s health care providers that your child is taking this drug. This includes your child’s doctors, nurses, pharmacists, and dentists.
  • Have your child’s blood pressure and heart rate checked often. Talk with your child’s doctor.
  • Have blood work checked as you have been told by the doctor. Talk with the doctor.
  • Have your child’s blood work (digoxin levels) checked. Have blood drawn before the daily dose (give digoxin after blood drawn). Talk with your child’s doctor.
  • This drug may affect certain lab tests. Tell all of your child’s health care providers and lab workers that your child takes this drug.
  • If your child will be having certain procedures to help the heart beat normally (defibrillation cardioversion), talk with your child’s doctor. Be sure the doctor knows your child takes this drug.
  • Many other drugs interact with this drug. These drugs can raise the chance of this drug’s side effects. Talk with your child’s doctor and pharmacist to make sure that it is safe for your child to use this drug with other drugs.
  • Keep away from children. Accidental exposure may cause death. If a child takes this drug by accident, get medical help right away.
  • Use with care in children. Talk with the doctor.
  • If your child is pregnant or breast-feeding a baby:
  • Talk with the doctor if your child is pregnant, becomes pregnant, or is breast-feeding a baby. You will need to talk about the benefits and risks to your child and the baby.
  • All oral products:
  • Tell the doctor if your child eats high bran or fiber meals.
What are some side effects that I need to call my child’s doctor about right away?
  • WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your child’s doctor or get medical help right away if your child has any of the following signs or symptoms that may be related to a very bad side effect:
  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Very bad dizziness or passing out.
  • Upset stomach or throwing up.
  • Change in eyesight.
  • Seeing halos or bright colors around lights.
  • Feeling tired or weak.
  • Severe diarrhea.
  • Weight loss.
  • Not hungry.
  • Fast or slow heartbeat.
  • A new or worse heartbeat that does not feel normal.
  • Hallucinations (seeing or hearing things that are not there).
  • Change in how your child acts.
  • Mood changes.
  • Feeling confused.
  • Very bad belly pain.
  • Black, tarry, or bloody stools.
  • Throwing up blood or throw up that looks like coffee grounds.
  • Enlarged breasts.
What are some other side effects of this drug?
  • All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your child’s doctor or get medical help if any of these side effects or any other side effects bother your child or do not go away:
  • All products:
  • Dizziness.
  • Headache.
  • Belly pain.
  • Injection (if given in the muscle):
  • Pain where the shot was given.
  • These are not all of the side effects that may occur. If you have questions about side effects, call your child’s doctor. Call your child’s doctor for medical advice about side effects.
  • You may report side effects to your national health agency.
How is this drug best given?
  • Give this drug as ordered by your child’s doctor. Read all information given to you. Follow all instructions closely.
  • All oral products:
  • To gain the most benefit, do not miss giving your child doses.
  • Give this drug at the same time of day.
  • Keep giving this drug to your child as you have been told by your child’s doctor or other health care provider, even if your child feels well.
  • Liquid (solution):
  • Measure liquid doses carefully. Use the measuring device that comes with this drug.
  • Injection:
  • It is given as a shot into a muscle or vein.
What do I do if my child misses a dose?
  • All oral products:
  • Give a missed dose as soon as you think about it.
  • If it is close to the time for your child’s next dose, skip the missed dose and go back to your child’s normal time.
  • Do not give 2 doses at the same time or extra doses.
  • Injection:
  • Call your child’s doctor to find out what to do.
How do I store and/or throw out this drug?
  • All oral products:
  • Store at room temperature.
  • Protect from light.
  • Store in a dry place. Do not store in a bathroom.
  • Injection:
  • If you need to store this drug at home, talk with your child’s doctor, nurse, or pharmacist about how to store it.
  • All products:
  • Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.
General drug facts
  • If your child’s symptoms or health problems do not get better or if they become worse, call your child’s doctor.
  • Do not share your child’s drug with others and do not give anyone else’s drug to your child.
  • Keep a list of all your child’s drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your child’s doctor.
  • Talk with your child’s doctor before giving your child any new drug, including prescription or OTC, natural products, or vitamins.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your child’s doctor, nurse, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.