From the Guidelines
Digoxin is indicated for rate control in atrial fibrillation with rapid ventricular response (RVR), particularly in patients with heart failure or when first-line agents are contraindicated or ineffective, as recommended by the most recent guidelines 1. The typical starting dose is 0.125 to 0.25 mg daily, with low doses (0.125 mg daily or every other day) recommended for patients over 70 years old, those with impaired renal function, or those with a low lean body mass. Key considerations for digoxin use include:
- Monitoring for toxicity, especially in patients with renal dysfunction
- Checking drug interactions, particularly with amiodarone, verapamil, and quinidine
- Measuring serum potassium, as hypokalemia increases toxicity risk
- Using caution in elderly patients and those with renal impairment, often requiring dose reduction
- Regular monitoring of digoxin levels, renal function, and electrolytes for safe use, as suggested by 1 and supported by earlier guidelines 1. It's essential to note that digoxin is generally considered a second-line agent, as it doesn't effectively control rate during exercise or stress, and its use should be guided by the most recent and highest-quality evidence available 1.
From the FDA Drug Label
Digoxin is indicated for the control of ventricular response rate in patients with chronic atrial fibrillation.
Digoxin is indicated for the treatment of atrial fibrillation with rapid ventricular response (RVR). The drug label directly supports the use of digoxin for this condition, stating that it slows rapid ventricular response rate in a linear dose-response fashion.
- Key points:
- Digoxin is used to control ventricular response rate in patients with chronic atrial fibrillation.
- The dose of digoxin for this indication is typically between 0.25 to 0.75 mg/day.
- Digoxin should not be used for the treatment of multifocal atrial tachycardia. 2
From the Research
Indication for Digoxin in Atrial Fibrillation with Rapid Ventricular Response (RVR)
- Digoxin may be useful in the presence of hypotension or an absolute contraindication to beta-blocker treatment 3
- Digoxin does not improve survival but may help to obtain satisfactory rate control in combination with a beta-blocker 3
- Digoxin as a single agent is generally inefficacious in slowing the ventricular rate in acute AF, but the addition of digoxin to the regimen causes a favorable outcome 4
- Digoxin administered alone slowed the resting heart rate more than placebo, but it did not significantly slow the rate during exercise in 4 studies 5
- Digoxin is useful when rate control during exercise is less a concern 5
Comparison with Other Agents
- Beta-blockers are the most potent at reducing exercise heart rate, followed by calcium channel blockers and digoxin 6
- Calcium-channel blockers verapamil or diltiazem, or select beta-blockers are efficacious for heart rate control at rest and during exercise for patients with atrial fibrillation without a clinically important decrease in exercise tolerance 5
- Diltiazem likely achieves rate control faster than metoprolol, though both agents seem safe and effective 7
Clinical Considerations
- The choice of agent for rate control in AF with RVR should consider the individual patient, clinical situation, and comorbidities 7
- Rate control in atrial fibrillation provides important benefits to patients in terms of symptoms, quality of life and prevention of late consequences of uncontrolled rate 6