General

High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error.

**BEERS Drug**

Pronunciation:
di-jox-in

Trade Name(s)

• Lanoxin

Ther. Class.

antiarrhythmics

inotropics

Pharm. Class.

digitalis glycosides

Indications

• HF.
• Atrial fibrillation and atrial flutter (slows ventricular rate).
• Paroxysmal atrial tachycardia.

Action

• Increases the force of myocardial contraction.
• Prolongs refractory period of the AV node.
• Decreases conduction through the SA and AV nodes.

Therapeutic Effect(s):

Increased cardiac output (positive inotropic effect) and slowing of the heart rate (negative chronotropic effect).

Pharmacokinetics

Absorption: 60–80% absorbed after oral administration of tablets; 70–85% absorbed after administration of elixir; 80% absorbed from IM sites (IM route not recommended due to pain/irritation). IV administration results in complete bioavailability.

Distribution: Widely distributed to tissues.

Metabolism and Excretion: Excreted almost entirely unchanged by the kidneys.

Half-life: 36–48 hr (↑ in renal impairment).

TIME/ACTION PROFILE (antiarrhythmic or inotropic effects, provided that a loading dose has been given)

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity;
• Uncontrolled ventricular arrhythmias;
• Heart block (in absence of pacemaker);
• Idiopathic hypertrophic subaortic stenosis;
• Constrictive pericarditis;
• Known alcohol intolerance (elixir only).

Use Cautiously in:

• Hypokalemia (↑ risk of digoxin toxicity);
• Hypercalcemia (↑ risk of toxicity, especially with mild hypokalemia);
• Hypomagnesemia (↑ risk of digoxin toxicity);
• Diuretic use (may cause electrolyte abnormalities including hypokalemia and hypomagnesemia);
• Hypothyroidism;
• MI;
• Renal impairment (↓ dose);
• Obesity (base dose on ideal body weight);
• OB:  Monitor neonates for signs/symptoms of digoxin toxicity; monitor levels in mother during pregnancy, as levels may fluctuate during pregnancy and postpartum periods; may lead to ↑ risk of arrhythmias during labor and delivery;
• Lactation: Use with caution while breastfeeding;
• Geri:  Appears on Beers list. Avoid use as first-line therapy for rate control in atrial fibrillation or for HF in older adults; if used, avoid using dose >0.125 mg/day.

Adverse Reactions/Side Effects

CV: bradycardia, ARRHYTHMIAS, ECG changes, heart block

EENT: blurred vision, yellow or green vision

GI: anorexia, nausea, vomiting, diarrhea

Hemat: thrombocytopenia

Neuro: fatigue, headache, weakness.

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

•  Thiazide  and  loop diuretics,  piperacillin/tazobactam,  amphotericin B,  corticosteroids, and excessive use of  laxatives  may cause hypokalemia, which may ↑ risk of toxicity.
•  Quinidine  and  ritonavir  may ↑ levels and lead to toxicity; ↓ digoxin dose by 30–50%.
•  Amiodarone  and  dronedarone  may ↑ levels and lead to toxicity; ↓ digoxin dose by 50%.
•  Cyclosporine,  itraconazole,  mirabegron,  propafenone,  quinine,  spironolactone, and  verapamil  may ↑ levels and lead to toxicity; serum level monitoring/dose ↓ may be required.
• Levels may be ↓ by some  antineoplastics  (bleomycin,  carmustine,  cyclophosphamide,  cytarabine,  doxorubicin,  methotrexate,  procarbazine,  vincristine ),  activated charcoal,  cholestyramine,  colestipol,  metoclopramide,  penicillamine,  rifampin, or  sulfasalazine.
• In a small percentage (10%) of patients, gut bacteria metabolize digoxin to inactive compounds macrolide anti-infectives  (erythromycin,  azithromycin,  clarithromycin ) and  tetracyclines, by killing these bacteria, will cause ↑ levels and toxicity; dose may need to be ↓ for up to 9 wk.
• Additive bradycardia may occur with  beta blockers,  diltiazem,  verapamil,  clonidine,  ivabradine, and other  antiarrhythmics  (quinidine,  disopyramide ).
• Concurrent use of  sympathomimetics  may ↑ risk of arrhythmias.
•  Thyroid   hormones  may ↓ therapeutic effects.

Drug-Natural Products:

•  Licorice and stimulant natural products ( aloe ) may ↑ risk of potassium depletion.
•  St. John's wort  may ↓ levels and effect.

Drug-Food:

Concurrent ingestion of a high-fiber meal may ↓ absorption. Administer digoxin 1 hr before or 2 hr after such a meal.

Route/Dosage

For rapid effect, a larger initial loading dose should be given in several divided doses over 12–24 hr. Maintenance doses are determined for digoxin by renal function. All dosing must be evaluated by individual response. In general, doses required for atrial arrhythmias are higher than those for inotropic effect.

IV IM (Adults): Loading dose:  0.5–1 mg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.

IV IM (Children  >10 yr): Loading dose:  8–12 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.

IV IM (Children  5–10 yr): Loading dose:  15–30 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.

IV IM (Children  2–5 yr): Loading dose:  25–35 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.

IV IM (Children  1–24 mo): Loading dose:  30–50 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.

IV IM (Infants : full term): Loading dose:  20–30 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.

IV IM (Infants : premature): Loading dose:  15–25 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.

PO (Adults): Loading dose:  0.75–1.5 mg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.  Maintenance dose:  0.125–0.5 mg/day depending on patient's lean body weight, renal function, and serum level.

PO Geriatric Patients: Initial daily dose should not exceed 0.125 mg.

PO (Children  >10 yr): Loading dose:  10–15 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.  Maintenance dose:  2.5–5 mcg/kg given daily as a single dose.

PO (Children  5–10 yr): Loading dose:  20–35 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.  Maintenance dose:  5–10 mcg/kg given daily in 2 divided doses.

PO (Children  2–5 yr): Loading dose:  30–40 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.  Maintenance dose:  7.5–10 mcg/kg given daily in 2 divided doses.

PO (Children  1–24 mo): Loading dose:  35–60 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.  Maintenance dose:  10–15 mcg/kg given daily in 2 divided doses.

PO (Infants : full term): Loading dose:  25–35 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.  Maintenance dose:  6–10 mcg/kg given daily in 2 divided doses.

PO (Infants : premature): Loading dose:  20–30 mcg/kg given as 50% of the dose initially and ¼ of the initial dose in each of 2 subsequent doses at 6–12 hr intervals.  Maintenance dose:  5–7.5 mcg/kg given daily in 2 divided doses.

Availability (generic available)

Tablets: 0.0625 mg, 0.125 mg, 0.25 mg

Oral solution (lime flavor): 50 mcg/mL

Solution for injection: 0.25 mg/mL

Solution for injection (pediatric): 0.1 mg/mL

Assessment

• Monitor HR for 1 full min before administering. Hold dose and notify health care provider if HR is <60 bpm in an adult, <70 bpm in a child, or <90 bpm in an infant. Notify health care provider promptly of any significant changes in rate, rhythm, or quality of pulse.
• Pedi:  HR varies in children depending on age; ask health care provider to specify at what HR digoxin should be withheld.
• Monitor BP periodically in patients receiving IV digoxin.
• Monitor ECG during IV administration and 6 hr after each dose. Notify health care provider if bradycardia or new arrhythmias occur.
• Observe IV site for redness or infiltration; extravasation can lead to tissue irritation and sloughing.
• Monitor intake and output and daily weights. Assess for peripheral edema, and auscultate lungs for rales/crackles during therapy.
• Before administering initial loading dose, determine whether patient has taken any digoxin in the preceding 2–3 wk.

Lab Test Considerations:

Evaluate serum electrolyte levels (especially potassium, magnesium, and calcium) and renal and hepatic function periodically during therapy. Notify health care provider before giving dose if patient is hypokalemic. Hypokalemia, hypomagnesemia, or hypercalcemia may make the patient more susceptible to digoxin toxicity. Pedi:  Neonates may have falsely elevated serum digoxin concentrations due to a naturally occurring substance chemically similar to digoxin.

Therapeutic serum digoxin concentrations range from 0.5–2 ng/mL. Serum levels may be drawn 6–8 hr after a dose is administered; usually drawn immediately before the next dose. Geri:  Older adults are at ↑ risk for toxic effects of digoxin (on Beers list) due to age-related ↓ renal clearance; may exist even when serum creatinine is normal. Digoxin requirements in older adult may change and a formerly therapeutic dose can become toxic.

• Observe for signs and symptoms of toxicity.  In adults and older children,  1st symptoms of toxicity usually include abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and other arrhythmias.  In infants and small children,  1st signs of toxicty are usually cardiac arrhythmias. If these appear, withhold drug and notify health care provider immediately.
• If signs of toxicity occur and are not severe, discontinuation of digoxin may be all that is required.
• Correct electrolyte abnormalities, thyroid dysfunction, and concurrent medications. Administer potassium to maintain serum potassium between 4.0 and 5.5 mEq/L. Monitor ECG for evidence of potassium toxicity (peaked T waves).
• Treatment of life-threatening arrhythmias may include administration of digoxin immune fab  (Digibind) , which binds to the digitalis glycoside molecule in the blood and is excreted by the kidneys.

Implementation

• Do not confuse Lanoxin with levothyroxine or naloxone.
• High Alert: Digoxin has a narrow therapeutic range. Medication errors associated with digoxin include miscalculation of pediatric doses and insufficient monitoring of digoxin levels.

• For rapid digitalization, initial dose is higher than maintenance dose; 50% of total digitalizing dose is given initially. Administer remainder of dose in 25% increments at 4–8 hr intervals.

  • When changing from parenteral to oral dose forms, dose adjustments may be necessary because of pharmacokinetic variations in percentage of digoxin absorbed: 100 mcg (0.1 mg) digoxin injection = 125 mcg (0.125 mg) tablet or 125 mcg (0.125 mg) of elixir.
• PO Administer oral preparations consistently with regard to meals. Tablets can be crushed and administered with food or fluids if patient has difficulty swallowing. Use calibrated measuring device for elixir; calibrated dropper is not accurate for doses of <0.2 mL or 10 mcg.
• IM Administer deep into gluteal muscle and massage well to reduce painful local reactions. Do not administer >2 mL of digoxin in each IM site. IM administration is not generally recommended.

Patient/Family Teaching

• Instruct patient to take medication as directed, at same time each day. Teach parents or caregivers of infants and children how to accurately measure medication. Take missed doses within 12 hr of scheduled dose or omit. Do not double doses. Consult health care provider if doses for >2 days are missed. Do not discontinue medication without consulting health care provider.
• Teach patient to take HR and to contact health care provider before taking medication if HR is <60 bpm or >100 bpm.
• Pedi:  Teach parents or caregivers that changes in HR, especially bradycardia, are among the 1st signs of digoxin toxicity in infants and children. Instruct parents or caregivers in apical HR assessment and ask them to notify health care provider if HR is outside of range set by health care provider before administering the next scheduled dose.
• Review signs and symptoms of digoxin toxicity with patient and family. Advise patient to notify health care provider immediately if these or symptoms of HF occur. Inform patient that these symptoms may be mistaken for those of colds or flu.
• Instruct patient to keep digoxin tablets in their original container and not to mix in pill boxes with other medications; may look similar to and may be mistaken for other medications.
• Advise patient that sharing of this medication can be dangerous.
• Instruct patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care provider before taking other Rx, OTC, or herbal products, especially St. John's wort. Advise patient to avoid taking antacids or antidiarrheals within 2 hr of digoxin.
• Advise patient to notify health care provider of this medication regimen before treatment.
• Patients taking digoxin should carry identification describing disease process and medication regimen at all times.
• Geri:  Review fall prevention strategies with older adults and their families.
• Rep:  Advise women of reproductive potential to notify health care provider if pregnancy is planned or suspected; may ↑ risk for low birth weight or preterm birth. Digoxin is recommended as a first-line agent for chronic treatment of highly symptomatic supraventricular tachycardia in pregnancy. Monitor for maternal arrhythmias during labor and delivery. Monitor maternal serum digoxin concentrations; may require dose adjustments during pregnancy and postpartum; may lead to ↑ risk of arrhythmias during labor and delivery. Monitor neonates for signs and symptoms of digoxin toxicity (vomiting, cardiac arrhythmias). Monitor neonates for signs/symptoms of digoxin toxicity.
• Emphasize the importance of routine follow-up exams to determine effectiveness and to monitor for toxicity.

Evaluation/Desired Outcomes

• Decrease in severity of HF.
• Increase in cardiac output.
• Decrease in ventricular response in atrial fibrillation or atrial flutter.
• Termination of paroxysmal atrial tachycardia.