COVID-19 Pandemic Impact on Physicians’ Decision-making: Digoxin Toxicity in View of Combination of Hydroxychloroquine and Azithromycin: A Case Report

Abstract

BACKGROUND: Since the WHO declaration of COVID-19 being a global pandemic, the population in general and health-care providers, in particular, became under extraordinary pressure that remarkably impacts their decisions at multiple levels as all of us should make decisions quickly while being uncertain in many times.
 CASE REPORT: We are reporting a 64-year-old lady with a medical history of atrial fibrillation and mitral regurgitation that treated with digoxin and warfarin therapy, she was suspected to be a COVID-19 case and prescribed empirical hydroxychloroquine and azithromycin combination without proper adjustment of her baseline therapy, accordingly she developed adverse effect of this combination in the form of digoxin toxicity and long QT, this case highlights how this unprecedented pandemic affects the decision-making of physicians.
 CONCLUSION: We should be critical and vigilant in making a decision of prescription or marketing non-evidence-based therapy, and when we are obligated for this decision, we should take all precautions to minimize the adverse effects of these drugs.

Benefit versus toxicity risk of digoxin in patients with COVID-19

“…Thus, COVID-19 patients using digoxin for CHF are at increased risk of digoxin toxicity and serum digoxin levels should be closely monitored. 2 Furthermore, atrial fibirllation and flutter were observed in 16% of hospitalised patients with COVID-19 and 60% of arrhythmias were reported as new onset. 3 However, due to the high mortality risk, atrial fibrillation and flutter should be treated, even with the risk of drug toxicity.…”

“…1 Increased intracellular calcium due to inhibition of Na-K transporter is the primary pathway of digoxin toxicity. 2 Factors such as renal function, age, lean body weight, cytokine levels and concomitant medications should be considered carefully during digoxin treatment to minimise toxicity. 1 Digoxin toxicity may cause various electrocardiographic changes.…”

“…1 Digoxin toxicity may cause various electrocardiographic changes. 2 The common signs of digoxin toxicity include nausea, vomiting, abdominal pain, yellow vision, headache, lethargy confusion, dizziness and delirium. 2 The beneficial effect of digoxin in patients with COVID-19 and atrial arrhythmias has been reported.…”

“…2 The common signs of digoxin toxicity include nausea, vomiting, abdominal pain, yellow vision, headache, lethargy confusion, dizziness and delirium. 2 The beneficial effect of digoxin in patients with COVID-19 and atrial arrhythmias has been reported. Several studies have also reported on the antiviral and anti-inflammatory properties of cardiac glycosides via inhibition of the entrance of coronavirus into the cells and suppression of a cytokine storm.…”