digoxin (Rx)

Brand and Other Names:Lanoxin
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

oral solution

  • 0.05mg/mL

injectable solution

  • 0.1mg/mL
  • 0.25mg/mL

tablet

  • 0.0625mg (Lanoxin only)
  • 0.125mg
  • 0.1875mg (Lanoxin only)
  • 0.25mg
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Atrial Fibrillation

Rapid digitalizing (loading-dose) regimen

  • IV: 8-12 mcg/kg (0.008-0.012 mg/kg) total loading dose; administer 50% initially; then may cautiously give 1/4 the loading dose q6-8hr twice; perform careful assessment of clinical response and toxicity before each dose
  • PO: 10-15 mcg/kg total loading dose; administer 50% initially; then may cautiously give 1/4 the loading dose q6-8hr twice; peform careful assessment of clinical response and toxicity before each dose

Maintenance

  • PO: 3.4-5.1 mcg/kg/day or 0.125-0.5 mg/day PO; may increase dose every 2 weeks based on clinical response, serum drug levels, and toxicity
  • IV/IM: 0.1-0.4 mg qDay; IM route not preferred due to severe injection site reaction

Heart Failure

As per ACCF/AHA guidelines, a loading dose to initiate digoxin therapy in patients with heart failure is not necessary

0.125-0.25 mg PO/IV qDay; higher doses including 0.375-0.5 mg/day rarely needed

Use lower end of dosing (0.125 mg/day) in patients with impaired renal function or low lean body mass

Dosing Modifications

Adjust maintenance dose by estimating CrCl and measuring serum levels

In heart failure, higher dosages have no additional benefit and may increase toxicity; decreased renal clearance may lead to increased toxicity

In geriatric patients, use lean body weight to calculate dose

Dosage Forms & Strengths

oral solution

  • 0.05mg/mL

injectable solution

  • 0.1mg/mL
  • 0.25mg/mL

tablet

  • 0.125mg
  • 0.25mg
more...

Heart Failure/Atrial Fibrillation

Use doses at the lower end of the spectrm when treating heart failure

Reduce dose by 20-25% when changing from oral formulation or IM to IV therapy

Premature neonate

  • PO: 1st loading dose, 10-15 mcg/kg; 2nd and 3rd loading doses, 5-7.5 mcg/kg q6-8hr for 2 doses; maintenance: 5-7.5 mcg/kg/day divided q12hr 
  • IV/IM: 1st loading dose, 7.5-12.5 mcg/kg; 2nd and 3rd loading doses, 3.75-6.25 mcg/kg q6-8hr for 2 doses; maintenance: 4-6 mcg/kg/day divided q12hr

Full-term neonate

  • PO: 1st loading dose, 12.5-17.5 mcg/kg; 2nd and 3rd loading doses, 6.25-8.75 mcg/kg q6-8hr for 2 doses; maintenance: 6-10 mcg/kg/day divided q12hr 
  • IV/IM: 1st loading dose, 10-15 mcg/kg; 2nd and 3rd loading doses, 5-7.5 mcg/kg q6-8hr for 2 doses; maintenance: 5-8 mcg/kg/day divided q12hr

Infants & children 1-24 months

  • PO: 1st loading dose, 17.5-30 mcg/kg; 2nd and 3rd loading doses, 8.75-15 mcg/kg q6-8hr for 2 doses; maintenance: 10-15 mcg/kg/day divided q12hr 
  • IV/IM: 1st loading dose, 15-25 mcg/kg; 2nd and 3rd loading doses, 7.5-12.5 mcg/kg q6-8hr for 2 doses; maintenance: 7.5-12 mcg/kg/day divided q12hr

2-5 years

  • PO: 1st loading dose, 15-20 mcg/kg; 2nd and 3rd loading doses, 8.75-10 mcg/kg q6-8hr for 2 doses; maintenance: 7.5-10 mcg/kg/day divided q12hr
  • IV/IM: 1st loading dose, 12.5-17.5 mcg/kg; 2nd and 3rd loading doses, 6.25-8.75 mcg/kg q6-8hr for 2 doses; maintenance: 6-9 mcg/kg/day divided q12hr

5-10 years

  • PO: 1st loading dose, 10-17.5 mcg/kg; 2nd and 3rd loading doses, 5-8.75 mcg/kg q6-8hr for 2 doses; maintenance: 5-10 mcg/kg/day divided q12hr  
  • IV/IM: 1st loading dose, 7.5-15 mcg/kg; 2nd and 3rd loading doses, 3.75-7.5 mcg/kg q6-8hr for 2 doses; maintenance: 4-8 mcg/kg/day divided q12hr

>10 years & <100 kg

  • PO: 1st loading dose, 5-7.5 mcg/kg; 2nd and 3rd loading doses, 2.5-3.75 mcg/kg q6-8hr for 2 doses; maintenance: 2.5-5 mcg/kg/day  
  • IV/IM: 1st loading dose, 4-6 mcg/kg; 2nd and 3rd loading doses, 2-3 mcg/kg q6-8hr for 2 doses; maintenance: 2-3 mcg/kg/day
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Interactions

Interaction Checker

and digoxin

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     activity indicator 
    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            1-10%

            Dizziness (4.9%)

            Mental disturbances (4.1%)

            Diarrhea (3.2%)

            Headache (3.2%)

            Nausea (3.2%)

            Vomiting (1.6%)

            Maculopapular rash (1.6%)

            <1%

            Anorexia

            Cardiac dysrhythmia

            Arrhythmia in children (consider a toxicity)

            Frequency Not Defined

            Visual disturbance (blurred or yellow vision)

            Heart block (1°/2°/3°)

            Asystole

            Tachycardia

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            Warnings

            Contraindications

            Hypersensitivity

            Ventricular fibrillation

            Cautions

            Use caution in chronic constrictive pericarditis, electrical cardioversion, severe bradycardia, severe heart failure, severe pulmonary disease, sick sinus syndrome, ventricular tachycardia, ventricular premature contractions, Wolff-Parkinson-White syndrome, electrolyte imbalance, hypothyroidism or hyperthyroidism, hypoxia, idiopathic hypertrophic subaortic stenosis, renal disease, concomitant diuretics

            Not recommended in patients with acute myocardial infarction

            Avoid in patients with myocarditis

            Risk of advanced or complete heart block in patients with sinus node disease and AV block

            Very narrow margin between effective therapeutic and toxic dosages: Therapeutic range, 0.5-2 ng/mL (target 0.5-1 ng/mL); toxic range, >2.5 ng/mL 

            Generally avoid if left ventricular systolic function preserved, although may be used for ventricular rate control in subgroup with chronic atrial fibrillation

            Less effective in presence of hypokalemia or hypocalcemia; avoid hypercalcemia or hypomagnesemia, which may predispose to serious arrhythmias

            Heart failure patients with preserved ventricular function including acute cor pulmonale, amyloid heart disease, and constrictive pericarditis may be susceptible to digoxin toxicity

            May cause false-positive ST-T changes during exercise testing

            Do not switch between different PO forms or between brand and generic forms of digoxin; bioavailability varies

            Serum levels drawn within 6-8 hours of dose will be falsely high because of prolonged distribution phase

            Increased risk of estrogenlike effects in geriatric patients

            Beriberi heart disease may not respond adequately if underlying thiamine deficiency not corrected

            Atrial arrhythmias are difficult to treat if associated with hypermetabolic (hyperthyroidism) or hyperdynamic (hypoxia) states; treat underlying condition before initiating therapy

            Avoid extravasation; ensure proper needle or catheter placement prior to and during administration

            Monitor for proarrhythmic effects, especially with digoxin toxicity

            Use caution in patients with acute myocardial infarction; may increase myocardial oxygen demand; during acute coronary syndrome, digoxin administered IV may be used to slow a rapid ventricular response and improve left ventricular function in the acute treatment of atrial fibrillation associated with severe LV function and heart failure or hemodynamic instability

            Monitor serum concentration closely when used for rate control in patients with atrial fibrillation; serum concentration that are not properly conrolled are associated with increased risk of mortality

            Consider use of digoxin only in heart failure with reduced ejection fraction when symptoms remain despite guideline-directed medical therapy; withdrawal of digoxin in clinically stable patients with heart failure may lead to recurrence of heart failure symptoms

            In hyperophic cariomyopathy, outflow obstruction may worsen due to positive inotropic effects of digoxin; avoid use unless used to control ventricular response with atrial fibrillation; in the absence of atrial fibrillation, digoxin is potentially harmful in the treatment of dyspnea in patients with hypertrophic cardiomyopathy

            Avoid rapid IV administration in digitalized patients; may produce serious arrhythmias

            Not necessary to routinely reduce or hold digoxin therapy prior to elective electrical cardioversion for atrial fibrillation; however, exclusion of digoxin toxicity is necessary prior to cardioverstion; whithhold digoxin and delay caridioversion until toxicity subsides if signs of digoxin excess exist

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            Pregnancy & Lactation

            Pregnancy category: C

            Lactation: Drug enters breast milk; use with caution (American Academy of Pediatrics committee states, "compatible with nursing")

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            In heart failure, increases contractility by inhibiting sodium/potassium ATPase pump in myocardial cells, which subsequently promotes calcium influx via sodium-calcium exchange pump

            In supraventricular arrhythmias, suppresses AV node conduction, which increases refractory period and decreases conduction velocity, causing positive inotropic effect, decreased ventricular rate, and enhanced vagal tone

            Absorption

            Bioavailability: 60-80 % (tablet); 70-85% (elixir)

            Onset: 0.5-2 hr (PO) for initial effect and 2-6 hr for maximal effect; 5-30 min (IV) for initial effect and 1.5-4 hr for maximal effect 

            Duration: 3-4 days 

            Peak serum time: 1-3 hr (PO) 

            Distribution

            Protein bound: 20-25% 

            Vd: 6-7 L/kg 

            Metabolism

            Metabolized by liver 

            Metabolites: Digoxigenin bisdigitoxoside, digoxigenin monodigitoxoside (active) 

            Elimination

            Half-life: 1-3 days

            Excretion: Urine (57-80%), feces (9-13%; includes bile)

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            Administration

            IV Compatibilities

            Solution: D5/½NS with potassium chloride 20 mEq, D5W, LR, ½NS, NS

            Additive: Bretylium, cimetidine, floxacillin, furosemide, lidocaine, ranitidine, verapamil

            Syringe: Heparin, milrinone

            Y-site: Bivalirudin, ciprofloxacin, cisatracurium, dexmedetomidine, diltiazem, famotidine, fenoldopam, gatifloxacin, heparin with hydrocortisone, Hextend, inamrinone, linezolid, meperidine, meropenem, midazolam, milrinone, morphine sulfate, potassium chloride, remifentanil, tacrolimus, vitamins B and C

            IV Incompatibilities

            Additive: Dobutamine

            Syringe: Doxapram

            Y-site: Amphotericin B cholesteryl sulfate, amiodarone, fluconazole, foscarnet, insulin (beef, pork, and Humulin R[?]), propofol

            IV Preparation

            Dilute with 4-fold or greater volume of SWI, D5W, or NS

            IV Administration

            Administer slowly by direct IV injection over minimum of 5 minutes (longer if given undiluted)

            Do not administer if precipitate present

            Drug is severe skin irritant when given IV/IM and may cause severe local skin reaction with possible sloughing 

            Storage

            Store at controlled room temperature

            Protect from light

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

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            • View the formulary and any restrictions for each plan.
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            • Compare formulary status to other drugs in the same class.
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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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