From the Guidelines
Digoxin should be held if the pulse is less than 60 beats per minute in adults, if systolic blood pressure is less than 90 mmHg, or if there are irregular heartbeats or new arrhythmias, as well as if serum potassium levels are below 3.5 mEq/L or serum digoxin levels exceed 2.0 ng/mL. The most recent and highest quality study, 1, provides guidance on the use of digoxin, including the initial daily dose, maximum total daily maintenance dose, potential adverse effects, and precautions. According to this study, the initial daily dose of digoxin is 0.5 mg, with additional 0.125–0.25-mg doses administered at 6–8-h intervals until evidence of adequate effect, and the maximum total daily maintenance dose is 0.25 mg. Potential adverse effects of digoxin include bradycardia, heart block, anorexia, nausea, vomiting, visual changes, and cardiac arrhythmias in cases of digoxin toxicity, which is associated with levels greater than 2 ng/mL. Precautions for the use of digoxin include renal dysfunction, WPW with AF/atrial flutter, AV block greater than first degree or SA node dysfunction, and the use of certain drugs that can increase serum digoxin concentrations, such as amiodarone, verapamil, and clarithromycin. It is essential to monitor digoxin concentrations and adjust the dose accordingly to prevent toxicity and ensure therapeutic efficacy. Additionally, the study 1 suggests that doses of digoxin that achieve a concentration of drug in plasma in the range of 0.5 to 1.0 ng per mL are recommended, and that higher doses may not be necessary or may even increase the risk of toxicity. Overall, the use of digoxin requires careful consideration of the potential benefits and risks, as well as close monitoring of vital signs and serum levels to prevent adverse effects. Key points to consider when holding digoxin include:
- Pulse less than 60 beats per minute in adults
- Systolic blood pressure less than 90 mmHg
- Irregular heartbeats or new arrhythmias
- Serum potassium levels below 3.5 mEq/L
- Serum digoxin levels exceeding 2.0 ng/mL
- Signs of toxicity, such as nausea, vomiting, visual disturbances, confusion, or cardiac arrhythmias.
From the FDA Drug Label
Laboratory Test Monitoring Patients receiving digoxin should have their serum electrolytes and renal function (serum creatinine concentrations) assessed periodically; The vital signs to be monitored for patients taking digoxin include:
- Serum electrolytes
- Renal function (serum creatinine concentrations) 2
From the Research
Vital Signs and Hold Parameters for Digoxin
- The studies provided do not directly mention vital signs and hold parameters for digoxin 3, 4, 5.
- However, the studies discuss the importance of recognizing clinical signs and symptoms of digoxin toxicity, as well as the role of electrocardiographic changes in diagnosing toxicity 3, 5.
- One study found that increasing serum digoxin concentrations were associated with progressive depression of the ST segment and decreased T-wave amplitude, which could be useful in managing patients on digitalis therapy 5.
- Another study highlights the importance of considering patient-specific factors such as age, lean body weight, and renal function when dosing digoxin to minimize drug toxicity 4.
- The studies suggest that clinicians should be aware of the potential for digoxin toxicity and take steps to recognize and treat it promptly, but do not provide specific vital signs and hold parameters for digoxin 3, 4, 5.