Digoxin

Indications
 Oral
Heart failure
Adult: Rapid digitalisation: Loading dose of 0.75-1.5 mg during the first 24-hr period as a single dose or in divided doses every 6 hr for less urgent or greater risk cases. For mild heart failure: Loading dose may not be required, 250 mcg 1-2 times daily. For patients with normal renal function, steady-state plasma concentrations are usually achieved in about 7 days. Usual maintenance: 125-250 mcg daily but may range from 62.5-500 mcg daily.
Child: Neonate <1.5 kg: Initial: 25 mcg/kg/day in 3 divided doses for 24 hr, then 4-6 mcg/kg/day in 1-2 divided doses; neonate 1.5-2.5 kg: Initial: 30 mcg/kg/day in 3 divided doses for 24 hr, then 4-6 mcg/kg/day in 1-2 divided doses; Neonate >2.5 kg and child 1 mth-2 yr: Initial: 45 mcg/kg/day in 3 divided doses for 24 hr, then 10 mcg/kg/day in 1-2 divided doses. 2-5 yr: Initial: 35 mcg/kg/day in 3 divided doses for 24 hr, then 10 mcg/kg/day in 1-2 divided doses. 5-10 yr: Initial: 25 mcg/kg/day (max: 750 mcg/day) in 3 divided doses for 24 hr, then 6 mcg/kg/day (max: 250 mcg/day) in 1-2 divided doses. 10-18 yr: Initial: 0.75-1.5 mg/day in 3 divided doses for 24 hr, then 62.5-750 mcg/day in 1-2 divided doses. Reduce doses if patient has been given cardiac glycoside in the preceding 2 wk.
Elderly: Lower doses are given.
Renal impairment: Dosage reductions may be needed.
Oral
Supraventricular arrhythmias
Adult: Rapid digitalisation: Loading dose of 0.75-1.5 mg during the first 24-hr period as a single dose or in divided doses every 6 hr for less urgent or greater risk cases. For mild heart failure: Loading dose may not be required, 250 mcg 1-2 times daily. For patients with normal renal function, steady-state plasma concentrations are usually achieved in about 7 days. Usual maintenance: 125-250 mcg daily but may range from 62.5-500 mcg daily.
Child: Neonate <1.5 kg: Initial: 25 mcg/kg/day in 3 divided doses for 24 hr, then 4-6 mcg/kg/day in 1-2 divided doses; neonate 1.5-2.5 kg: Initial: 30 mcg/kg/day in 3 divided doses for 24 hr, then 4-6 mcg/kg/day in 1-2 divided doses; Neonate >2.5 kg and child 1 mth-2 yr: Initial: 45 mcg/kg/day in 3 divided doses for 24 hr, then 10 mcg/kg/day in 1-2 divided doses. 2-5 yr: Initial: 35 mcg/kg/day in 3 divided doses for 24 hr, then 10 mcg/kg/day in 1-2 divided doses. 5-10 yr: Initial: 25 mcg/kg/day (max: 750 mcg/day) in 3 divided doses for 24 hr, then 6 mcg/kg/day (max: 250 mcg/day) in 1-2 divided doses. 10-18 yr: Initial: 0.75-1.5 mg/day in 3 divided doses for 24 hr, then 62.5-750 mcg/day in 1-2 divided doses. Reduce doses if patient has been given cardiac glycoside in the preceding 2 wk.
Elderly: Lower doses are given.
Renal impairment: Dosage reductions may be needed.
Intravenous
Emergency heart failure
Adult: For patients who have not received cardiac glycosides in the previous 2 wk. 0.5-1 mg by IV infusion as a single dose over at least 2 hr or in divided doses with each dose given over 10-20 minutes. Maintenance dose is usually given orally.
Renal impairment: Dosage reductions may be needed.

Reconstitution: Admin undiluted or diluted with a 4-fold or greater volume of Sterile Water for Injection, 0.9% Sodium Chloride Injection, or 5% Dextrose Injection.
Incompatibility: Using less than a 4-fold volume of diluent could lead to precipitation of the digoxin.
Contraindications
 Digitalis toxicity, ventricular tachycardia/fibrillation, obstructive cardiomyopathy. Arrhythmias due to accessory pathways (e.g. Wolff-Parkinson-White syndrome).
Warnings / Precautions
 Cardiac dysrhythmias, hypokalaemia, hypertension, IHD, hypercalcaemia, hypomagnesaemia, electroconversion, chronic cor pulmonale, aortic valve disease, acute myocarditis, congestive cardiomyopathies, constrictive pericarditis, heart block, elderly, renal impairment, abnormalities in thyroid function; pregnancy. IV digoxin can only be given to patients who have not received cardiac glycosides in the preceding 2 wk.
Adverse Reactions
 Extra beats, anorexia, nausea and vomiting. Diarrhoea in elderly, confusion, dizziness, drowsiness, restlessness, nervousness, agitation and amnesia, visual disturbances, gynaecomastia, local irritation (IM/SC inj), rapid IV admin may lead to vasocostriction and transient hypertension.
Potentially Fatal: Cardiac arrhythmias in combination with heart block.
Overdose Reactions
 Symptoms: Hyperkalaemia, cardiac arrhythmias and heart block. Management: Treatment is symptomatic and supportive. Reduce absorption by gastric lavage if present within 30 min of ingestion. Do not induce vomiting or attempt passage of a gastric tube if presented >2 hr after ingestion or already has toxic manifestations, as this may induce an acute vagal episode and worsen digitalis-related arrhythmias. Activated charcoal is helpful in reducing drug absorption. Monitor serum potassium levels and keep potassium levels between 4.0-5.5 mmol/l. Digoxin-specific antibody fragments (FAB) is a specific antidote for digoxin and may be used to reverse potentially life-threatening ventricular arrhythmias due to digoxin overdosage. Haemodialysis is unlikely to be useful.
Drug Interactions
 Effectiveness reduced by phenytoin, neomycin, sulphasalazine, kaolin, pectin, antacids and in patients receiving radiotherapy. Metoclopramide may alter the absorption of solid dosage forms of digoxin. Blood levels increased by calcium channel blockers, spironolactone, quinidine and calcium salts.
Potentially Fatal: Electrolyte imbalances such as hypokalaemia and hypomagnesemia (e.g. admin of potassium-losing diuretics, corticosteroids) can increase the risk of cardiac toxicity.
See Below for More digoxin Drug Interactions
Lab Interactions
 May increase conc of urinary 17-hydroxycorticosteroids.
Food Interactions
 Absorption delayed.
Mechanism of Actions
 Digoxin is a cardiac glycoside which has positive inotropic activity characterized by an increase in the force of myocardial contraction. It also reduces the conductivity of the heart through the atrioventricular (AV) node. Digoxin also exerts direct action on vascular smooth muscle and indirect effects mediated primarily by the autonomic nervous system and an increase in vagal activity.
Absorption: Absorption from the GI tract is variable.
Distribution: Widely distributed in tissues, including the heart, brain, erythrocytes, and skeletal muscle. 20-30% bound to plasma proteins.
Excretion: Excreted mainly unchanged.
Administration
 May be taken with or without food.
Storage Conditions
 Intravenous: Store at 25°C. Oral: Store at 25°C.
ATC Classification
 C01AA05 - digoxin ; Belongs to the class of digitalis glycosides. Used in the treatment of heart failure.
Storage
 Intravenous: Store at 25°C. Oral: Store at 25°C.
Available As
  • Digoxin 0.05 mg
  • Digoxin 0.25 mg
  • Digoxin 1.5 mg
  • Digoxin 3 mg
  • Digoxin 60ml

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