Digoxin: Precision Heart Rate Control for Improved Cardiac Function
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Synonyms | |||
Digoxin remains a cornerstone in the management of select cardiovascular conditions, offering a unique mechanism of action that distinguishes it from other cardiac medications. As a cardiac glycoside derived from the foxglove plant (Digitalis lanata), it exerts positive inotropic effects to enhance myocardial contractility while providing negative chronotropic control of ventricular rate in atrial fibrillation. Its continued relevance in modern cardiology is supported by decades of clinical evidence and well-established therapeutic protocols when administered under appropriate medical supervision. This product card provides comprehensive information for healthcare professionals regarding the pharmacological properties, clinical applications, and safety considerations of digoxin therapy.
Features
- Chemical classification: Cardiac glycoside
- Mechanism: Na+/K+ ATPase inhibition leading to increased intracellular calcium
- Bioavailability: 60-80% (tablet formulation)
- Protein binding: Approximately 25%
- Elimination half-life: 36-48 hours (normal renal function)
- Primary excretion: Renal (unchanged)
- Therapeutic window: 0.5-2.0 ng/mL
- Available formulations: Tablets (62.5 mcg, 125 mcg, 250 mcg), injection solution
Benefits
- Provides sustained control of ventricular response rate in atrial fibrillation and atrial flutter
- Enhances myocardial contractility in heart failure with reduced ejection fraction
- Reduces heart failure symptoms and hospitalizations in appropriate patient populations
- Offers once-daily dosing convenience for improved adherence
- Maintains hemodynamic stability during long-term therapy
- Serves as adjunctive therapy when beta-blockers or calcium channel blockers are contraindicated or insufficient
Common use
Digoxin is primarily indicated for the treatment of mild to moderate heart failure, particularly in patients with reduced ejection fraction who remain symptomatic despite optimal standard therapy including ACE inhibitors, beta-blockers, and diuretics. Its second major indication involves rate control in patients with persistent or permanent atrial fibrillation and atrial flutter, especially when other rate-control agents prove inadequate or poorly tolerated. The medication may also be considered for adjunctive management of certain supraventricular tachyarrhythmias. Clinical decision-making should incorporate assessment of renal function, electrolyte status, and potential drug interactions before initiation.
Dosage and direction
Initial dosing must be individualized based on patient characteristics including age, weight, renal function, and concomitant medications. For most adults with normal renal function (creatinine clearance >50 mL/min), the typical loading dose ranges from 0.75 to 1.5 mg administered in divided doses over 24 hours, followed by a maintenance dose of 0.125 to 0.25 mg daily. For elderly patients or those with renal impairment (creatinine clearance 10-50 mL/min), maintenance doses of 0.125 mg daily or every other day are often appropriate. Serum digoxin concentrations should be measured at least 6-8 hours after the last dose, with target levels of 0.5-0.9 ng/mL for heart failure and 0.8-1.2 ng/mL for atrial fibrillation. Regular monitoring of renal function and electrolytes is essential during therapy.
Precautions
Digoxin requires careful patient selection and ongoing monitoring due to its narrow therapeutic index. Renal function must be assessed before initiation and periodically during treatment, with dose adjustments made for impaired renal function. Electrolyte disturbances—particularly hypokalemia, hypomagnesemia, and hypercalcemia—can potentiate digoxin toxicity and should be corrected before and during therapy. Thyroid function should be evaluated as both hyperthyroidism and hypothyroidism can alter digoxin requirements. Advanced age, low body weight, and underlying cardiac conduction abnormalities necessitate reduced dosing and enhanced monitoring. Patients should be educated to recognize early signs of toxicity and report them promptly.
Contraindications
Digoxin is contraindicated in patients with known hypersensitivity to digoxin or other digitalis preparations. Additional absolute contraindications include ventricular fibrillation, second- or third-degree atrioventricular block without a functioning pacemaker, Wolff-Parkinson-White syndrome with atrial fibrillation, and known digoxin toxicity. Relative contraindications include hypertrophic obstructive cardiomyopathy, constrictive pericarditis, amyloid cardiomyopathy, and isolated diastolic heart failure. Caution is warranted in patients with renal impairment, electrolyte abnormalities, thyroid disorders, and those receiving concomitant medications that affect digoxin pharmacokinetics.
Possible side effect
Common adverse effects include nausea, vomiting, diarrhea, headache, dizziness, and visual disturbances (particularly yellow-green halos around lights). Cardiac manifestations of toxicity include various arrhythmias such as premature ventricular contractions, paroxysmal atrial tachycardia with block, accelerated junctional rhythm, and advanced heart block. Neurological effects may include fatigue, weakness, insomnia, and rarely, psychosis. Less frequently reported effects include gynecomastia, thrombocytopenia, and rash. Most side effects are dose-dependent and often reversible with dose reduction or temporary discontinuation.
Drug interaction
Digoxin interacts significantly with multiple medication classes. Diuretics (especially loop and thiazide diuretics) can cause hypokalemia, increasing toxicity risk. Amiodarone, verapamil, diltiazem, quinidine, and cyclosporine can increase digoxin serum concentrations. Concomitant use with beta-blockers or calcium channel blockers may exacerbate bradycardia or heart block. Antibiotics such as erythromycin and tetracycline may increase digoxin bioavailability in some patients. Antacids, cholestyramine, and certain anticancer drugs may decrease digoxin absorption. Sympathomimetics may increase the risk of arrhythmias.
Missed dose
If a dose is missed, patients should take it as soon as remembered unless it is nearly time for the next scheduled dose. In that case, the missed dose should be skipped and the regular dosing schedule resumed. Patients should never double the dose to make up for a missed administration. Healthcare providers should be informed about pattern of missed doses, as inconsistent dosing may lead to subtherapeutic levels or erratic serum concentrations that increase toxicity risk.
Overdose
Digoxin overdose constitutes a medical emergency requiring immediate attention. Manifestations include severe nausea and vomiting, hyperkalemia, visual changes, and life-threatening arrhythmias. Management includes immediate discontinuation of digoxin, cardiac monitoring, correction of electrolyte abnormalities, and administration of digoxin-specific antibody fragments (Digibind®) for serious toxicity. Activated charcoal may be beneficial if administered soon after ingestion. Temporary cardiac pacing may be necessary for significant bradycardia or heart block. Serum digoxin levels should be obtained, but treatment decisions should be based primarily on clinical presentation.
Storage
Digoxin tablets should be stored at controlled room temperature (20-25°C or 68-77°F) in their original container, protected from light and moisture. The medication should be kept out of reach of children and pets. Unused medication should be properly disposed according to local regulations, not flushed down toilets or drains. Liquid formulations require particular attention to expiration dates and storage conditions. Travel with digoxin should involve proper temperature maintenance and carrying adequate documentation for prescription medications.
Disclaimer
This information is intended for healthcare professionals and should not replace individualized medical advice. Digoxin requires prescription and careful medical supervision. Dosage must be determined by a qualified healthcare provider based on comprehensive patient assessment. Patients should not initiate, adjust, or discontinue digoxin without medical guidance. The prescribing information provided here is summary in nature; complete prescribing information is available in the package insert or from the manufacturer.
Reviews
Clinical studies consistently demonstrate digoxin’s efficacy in controlling ventricular rate in atrial fibrillation and improving symptoms in heart failure. The DIG trial (Digitalis Investigation Group) established its role in reducing hospitalizations for heart failure, though without demonstrating mortality benefit. Many cardiologists note its particular value in specific patient subsets, especially those with difficult-to-control atrial fibrillation or heart failure with persistent symptoms despite guideline-directed medical therapy. Monitoring requirements and narrow therapeutic index are frequently cited as limitations requiring careful patient selection and education.