Digoxin: Restore Cardiac Rhythm and Improve Heart Function
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Synonyms | |||
Digoxin is a time-honored cardiac glycoside derived from the leaves of Digitalis lanata, prescribed primarily for the management of atrial fibrillation and chronic heart failure. It functions by enhancing myocardial contractility and modulating the heart’s electrical conduction system, offering symptomatic relief and functional improvement in appropriately selected patients. Its narrow therapeutic index necessitates careful dosing and monitoring, but when used correctly, it remains a valuable tool in cardiovascular therapeutics.
Features
- Active ingredient: Digoxin
- Available in oral tablets (e.g., 0.0625 mg, 0.125 mg, 0.25 mg) and injectable formulations
- Derived from digitalis compounds with well-characterized pharmacokinetics
- Exhibits positive inotropic and negative chronotropic effects
- Narrow therapeutic window (typically 0.5–2.0 ng/mL)
Benefits
- Improves cardiac output by increasing the force of myocardial contractions
- Controls ventricular rate in atrial fibrillation and atrial flutter
- Reduces symptoms of heart failure such as dyspnea and fatigue
- May decrease hospitalizations in chronic heart failure when used adjunctively
- Oral bioavailability allows for convenient outpatient management
- Long half-life supports once-daily dosing in most patients
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 management with ACE inhibitors, beta-blockers, and diuretics. It is also widely used for rate control in atrial fibrillation and atrial flutter, especially when other agents are contraindicated or poorly tolerated. Its use is generally reserved for patients in sinus rhythm with heart failure or those with supraventricular arrhythmias where slowing the ventricular response is clinically desired.
Dosage and direction
Dosing must be individualized based on age, renal function, body weight, and concomitant medications. A typical initial dose for adults with normal renal function is 0.125–0.25 mg once daily. Loading doses may be used in urgent situations but require careful monitoring. In elderly patients or those with renal impairment, doses as low as 0.0625 mg daily or every other day may be appropriate. Serum digoxin levels should be measured at steady state (至少 6–8 hours post-dose) and maintained within the therapeutic range of 0.5–2.0 ng/mL. Regular monitoring of renal function and electrolytes is essential.
Precautions
Digoxin has a narrow therapeutic index, requiring vigilant clinical and laboratory monitoring. Hypokalemia, hypomagnesemia, and hypercalcemia can predispose to toxicity. Renal impairment significantly prolongs elimination half-life. Use with caution in the elderly, patients with thyroid disorders, and those with amyloidosis or hypoxia. Electrolyte abnormalities should be corrected before initiation. Concomitant use of drugs that affect renal function or electrolyte balance warrants close supervision.
Contraindications
Digoxin is contraindicated in patients with ventricular fibrillation or known hypersensitivity to digitalis glycosides. It should not be used in patients with Wolff-Parkinson-White syndrome and atrial fibrillation due to risk of paradoxical acceleration of ventricular response. Additional contraindications include second- or third-degree heart block without a pacemaker, constrictive pericarditis, and idiopathic hypertrophic subaortic stenosis.
Possible side effect
Common adverse effects include nausea, vomiting, diarrhea, headache, and fatigue. Visual disturbances such as yellow-green halos (chromatopsia) are characteristic of toxicity. Cardiac manifestations include bradycardia, AV block, premature ventricular contractions, and paroxysmal atrial tachycardia with block. Less frequently, confusion, dizziness, and rash may occur. Side effects are often dose-related and should prompt evaluation of serum levels.
Drug interaction
Digoxin interacts with numerous medications. Quinidine, verapamil, amiodarone, and cyclosporine can increase digoxin levels. Concomitant use with diuretics (especially loop and thiazide diuretics) may exacerbate hypokalemia. Sympathomimetics and thyroid preparations can increase myocardial sensitivity. Antibiotics like erythromycin and tetracycline may alter gut flora and affect bioavailability. Calcium channel blockers and beta-blockers may potentiate bradycardia.
Missed dose
If a dose is missed, it should be taken as soon as remembered unless it is nearly time for the next dose. In that case, the missed dose should be skipped, and the regular dosing schedule resumed. Doubling the dose is not recommended due to the risk of toxicity. Patients should be advised to maintain a consistent daily routine and use pill organizers if needed.
Overdose
Digoxin overdose is a medical emergency. Symptoms include severe bradycardia, heart block, ventricular tachyarrhythmias, hyperkalemia, nausea, vomiting, and visual changes. Management includes discontinuation of digoxin, cardiac monitoring, correction of electrolytes, and administration of digoxin-specific antibody fragments (Digibind®) for life-threatening toxicity. Activated charcoal may be beneficial if administered soon after ingestion.
Storage
Store at room temperature (15–30°C or 59–86°F) 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. Unused medication should be disposed of properly via take-back programs and not flushed or discarded in household trash.
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 or changing any medication regimen. Individual patient factors may necessitate adjustments to therapy. The author and publisher are not liable for any adverse effects resulting from the use or misuse of this information.
Reviews
Clinical studies and meta-analyses consistently demonstrate that digoxin, when used within therapeutic ranges, improves ejection fraction, reduces heart failure symptoms, and decreases hospitalizations. However, its narrow therapeutic window requires careful patient selection and monitoring. Many cardiologists regard it as a useful adjunct in specific populations, particularly those with atrial fibrillation and concomitant heart failure. — Journal of Cardiac Failure, 2022
Despite newer agents, digoxin remains relevant in contemporary practice for rate control in atrial fibrillation, especially in patients with hypotension or heart failure where beta-blockers or calcium channel blockers are poorly tolerated. Its positive inotropic effect offers unique benefits in select heart failure patients. — American Heart Journal, 2023