Should Digoxin Continue To Be Used for the Management of Atrial Fibrillation?

DiDomenico, Robert J.; Leung, Ann N.; Kertland, Heather

doi:10.4212/cjhp.v70i5.1701

Cited by 3 publications

(2 citation statements)

References 19 publications

(2 reference statements)

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“…Digoxin is known to be less effective during states of increased sympathetic drive [ 31 ] and catecholaminergic medication use [ 32 ]. Its slower onset of action is also recognised [ 33 ]. These characteristics may explain our findings of inferior performance in comparison to amiodarone in patients treated on an ICU.…”

Section: Discussionmentioning

confidence: 99%

Comparative effectiveness of common treatments for new-onset atrial fibrillation within the ICU: Accounting for physiological status

Bedford

Johnson²,

Redfern

et al. 2022

Journal of Critical Care

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Background New-onset atrial fibrillation (NOAF) is common in patients on an intensive care unit (ICU). Evidence guiding treatments is limited, though recent reports suggest beta blocker (BB) therapy is associated with reduced mortality. Methods We conducted a multicentre cohort study of adult patients admitted to 3 ICUs in the UK and 5 ICUs in the USA. We analysed the haemodynamic changes associated with NOAF. We analysed rate control, rhythm control, and hospital mortality associated with common NOAF treatments. We balanced admission and post-NOAF, pre-treatment covariates across treatment groups. Results NOAF was followed by a systolic blood pressure reduction of 5 mmHg ( p < 0.001). After adjustment, digoxin therapy was associated with inferior rate control versus amiodarone (adjusted hazard ratio (aHR) 0.56, [95% CI 0.34–0.92]). Calcium channel blocker (CCB) therapy was associated with inferior rhythm control versus amiodarone (aHR 0.59 (0.37–0.92). No difference was detected between BBs and amiodarone in rate control (aHR 1.15 [0.91–1.46]), rhythm control (aHR 0.85, [0.69–1.05]), or hospital mortality (aHR 1.03 [0.53–2.03]). Conclusions NOAF in ICU patients is followed by decreases in blood pressure. BBs and amiodarone are associated with similar cardiovascular control and appear superior to digoxin and CCBs. Accounting for key confounders removes previously reported mortality benefits associated with BB treatment.

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Section: Discussionmentioning

confidence: 99%

Comparative effectiveness of common treatments for new-onset atrial fibrillation within the ICU: Accounting for physiological status

Bedford

Johnson²,

Redfern

et al. 2022

Journal of Critical Care

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“…Although clinical guidelines from the major cardiology thought leaders have translated scientific evidence into clinical practice for heart failure, there remains a lack of consensus on a definitive therapeutic range for digoxin when used for atrial fibrillation. The maximum target serum digoxin level for atrial fibrillation is now recommended by some to be <0.9 ng/ml ( 37 ) or ≤1.2 ng/ml ( 62 ). In 2016, Benlmouden and Billaud concluded in their manuscript Evidence Based Digoxin Therapeutic Monitoring a Lower and Narrower Therapeutic Range that “The target serum digoxin concentration should be 0.5–1.0 ng/ml” ( 63 ) while in 2018 Whayne supported “low doses” with monitoring to prevent supratherapeutic levels ( 27 ).…”

Section: Introductionmentioning

confidence: 99%

Review: Failure of current digoxin monitoring for toxicity: new monitoring recommendations to maintain therapeutic levels for efficacy

Gona,

Rosenberg,

Fyffe-Freil

et al. 2023

Front. Cardiovasc. Med.

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The current recommendations for monitoring digoxin, a narrow therapeutic index drug, are limited to confirming medication use or investigating suspicion of toxicity and fail our oath to do no harm. Numerous meta-analyses evaluating digoxin use consistently recommend frequent monitoring to maintain the level of 0.5 to ≤1.0 ng/ml because higher levels lead to increased morbidity and mortality without benefit. Data from the United States National Poison Control Center (2012–2020) show annual deaths due to digoxin of 18–36 compared to lithium's 1–7, and warfarin's 0–2 respectively. The latter drugs also have narrow therapeutic indexes like digoxin yet are more carefully monitored. Recognition of digoxin toxicity is impaired as levels are not being routinely checked after medications are added to a patient's regimen. In addition, providers may be using ranges to guide treatment that are no longer appropriate. It is imperative that monitoring guidelines and laboratory therapeutic levels are revised to reduce morbidity and mortality due to digoxin. In this review, we provide a comprehensive literature review of digoxin monitoring guidelines, digoxin toxicity, and evidence to support revising the ranges for serum digoxin monitoring.

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Pharmacokinetics Parameters of Diagoxin among Saudi Patients in Qassim Region, Saudi Arabia

Allihimy

Almeman

Alnassar

et al. 2021

DML

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Background: The pharmacodynamic effects of digoxin are susceptible to multiple factors, most notably, heart uptake of the digoxin dose and its concentration in the serum. Another important factor to mention is the renal function state of an individual. Objective: In this study, we aimed to develop a simple algorithm based on subsets of clinically relevant information, which will help to personalize digoxin based on pharmacokinetic (PK) approach, which can help on marketing the appropriate utilization of this medication. Method: This was a retrospective chart review and analysis of 48 patients who were admitted to the Drug and Poison Information Center in Buraidah, Saudi Arabia, between January 2016 and April 2019. All pharmacokinetic parameters were added according to the C-peaks and C-troughs. MONOLiX® was used for pharmacokinetic data analysis. Results: Twenty-seven (56%) were males, and twenty-one (44%) were females with an average age of 63.6 years across both genders. The mean volume of distribution was 496.6 litres with an average clearance of 6.6 L/h. For females, their average volume of distribution was slightly higher than that for males (526 litres compared to 473 liters). In addition, the clearance rate between both genders showed a 2.1 litre/hour discrepancy (7.8 L/h for females compared to 5.7 L/h for males). Conclusion: In order to individualize the digoxin dosage regimens, this model can be used to predict digoxin serum concentration. Further studies are needed to clarify the effects of nutritional status and co-administration of medications on digoxin pharmacokinetics.

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Should Digoxin Continue To Be Used for the Management of Atrial Fibrillation?

Abstract: -

Cited by 3 publications

References 19 publications

Comparative effectiveness of common treatments for new-onset atrial fibrillation within the ICU: Accounting for physiological status

Comparative effectiveness of common treatments for new-onset atrial fibrillation within the ICU: Accounting for physiological status

Review: Failure of current digoxin monitoring for toxicity: new monitoring recommendations to maintain therapeutic levels for efficacy

Pharmacokinetics Parameters of Diagoxin among Saudi Patients in Qassim Region, Saudi Arabia

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