From the Guidelines
Digoxin is currently indicated primarily for heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation with rapid ventricular response, with a typical maintenance dose ranging from 0.125 to 0.25 mg daily. In heart failure, it is typically used as an add-on therapy when patients remain symptomatic despite optimal treatment with first-line medications such as ACE inhibitors, beta-blockers, and diuretics 1. For atrial fibrillation, digoxin helps control ventricular rate, particularly in sedentary patients or as an adjunct to other rate-controlling medications. The use of digoxin in patients with HF and atrial fibrillation is supported by guidelines, which suggest that it is useful for initial control of the ventricular rate and may be considered in decompensated HF patients prior to initiation of a beta-blocker 1.
Key Considerations
- The benefit of digoxin in patients with HF remains controversial, and guideline-directed medical therapy (GDMT) is expected to be optimized before considering the addition of digoxin 1.
- Clinical worsening after withdrawal of digoxin has been shown, and therapy with digoxin may either be continued in the absence of a contraindication or discontinued with caution 1.
- Low doses (0.125 mg daily or every other day) should be used initially if the patient is >70 years of age, has impaired renal function, or has a low lean body mass 1.
- Regular monitoring of serum digoxin levels (therapeutic range 0.5-0.9 ng/mL) and electrolytes (particularly potassium, as hypokalemia increases toxicity risk) is essential 1.
Monitoring and Safety
- Digoxin has a narrow therapeutic window, and toxicity can cause nausea, visual disturbances, confusion, and potentially fatal arrhythmias, so careful dosing and monitoring are crucial for safe use.
- Serial monitoring of serum electrolytes and renal function is mandatory to minimize the risk of toxicity 1.
From the FDA Drug Label
INDICATIONS AND USAGE Digoxin is indicated for the treatment of mild to moderate heart failure. Digoxin increases left ventricular ejection fraction and improves heart failure symptoms as evidenced by exercise capacity and heart failure symptoms as evidenced by exercise capacity and heart failure-related hospitalizations and emergency care, while having no effect on mortality. Where possible, digoxin should be used with a diuretic and an angiotensin-converting enzyme inhibitor, but an optimal order for starting these three drugs cannot be specified. Heart Failure: Digoxin is indicated for the control of ventricular response rate in patients with chronic atrial fibrillation. Atrial Fibrillation:
The current indications for digoxin are:
- Treatment of mild to moderate heart failure
- Control of ventricular response rate in patients with chronic atrial fibrillation 2
From the Research
Current Indications for Digoxin
The current indications for digoxin include:
- Heart failure: Digoxin has been reported to improve symptoms and reduce hospitalization in patients with heart failure 3.
- Atrial fibrillation: Digoxin is used to control rapid ventricular rate in patients with atrial fibrillation, particularly in those with heart failure or a sedentary lifestyle 3, 4.
Specific Patient Populations
- Elderly patients: Digoxin may be an appropriate agent for ventricular rate control in elderly patients with atrial fibrillation and heart failure, as they appear to gain comparable benefits to younger populations 3.
- Patients with atrial fibrillation and heart failure: Digoxin use is not associated with an increased risk of all-cause mortality in patients with atrial fibrillation and heart failure 5.
Important Considerations
- Dosing strategy: A conservative dosing strategy is recommended for digoxin, particularly in elderly patients, due to reduced elimination and the potential for toxicity 3, 6.
- Therapeutic monitoring: Regular monitoring of digoxin levels is necessary to minimize the risk of toxicity 3, 6.
- Alternative treatments: The use of alternative treatments, such as beta-blockers, should be considered in patients with atrial fibrillation and heart failure, particularly in those with systolic dysfunction 4.