From the Guidelines
IV digoxin is not absolutely contraindicated in patients with end-stage renal disease (ESRD) on hemodialysis (HD), but its use requires careful consideration and monitoring due to the increased risk of toxicity. The most recent and highest quality study, 1, suggests that therapy with digoxin is commonly initiated and maintained at a dose of 0.125 to 0.25 mg daily, with low doses (0.125 mg daily or every other day) recommended for patients with impaired renal function. Key considerations for the use of IV digoxin in patients with ESRD on HD include:
- Reduced initial loading dose by 25-50%, typically starting with 0.25-0.5 mg IV
- Smaller maintenance doses of 0.0625-0.125 mg daily or every other day
- Close monitoring of serum digoxin levels, aiming for therapeutic concentrations between 0.5-1.0 ng/mL
- Frequent assessment for signs of digoxin toxicity, including bradycardia, arrhythmias, visual disturbances, nausea, and confusion
- Maintenance of serum potassium levels within the normal range (3.5-5.0 mEq/L) to minimize the risk of toxicity
- Regular ECG monitoring to detect early signs of toxicity, such as PR interval prolongation or characteristic ST segment scooping. It is essential to weigh the potential benefits of digoxin against the risks of toxicity and to carefully monitor patients with ESRD on HD who receive IV digoxin, as recommended by 1 and 1.
From the FDA Drug Label
Digoxin is not effectively removed from the body by dialysis, exchange transfusion, or during cardiopulmonary bypass because most of the drug is bound to extravascular tissues. The FDA drug label does not directly answer whether IV digoxin is contraindicated in End-Stage Renal Disease (ESRD) on hemodialysis (HD). However, it does provide information on the precautions for using IV digoxin in patients with impaired renal function.
- Key Points:
- Digoxin is primarily excreted by the kidneys.
- Patients with impaired renal function require smaller than usual maintenance doses of digoxin.
- The clearance of digoxin can be primarily correlated with the renal function as indicated by creatinine clearance.
- Digoxin is not effectively removed from the body by dialysis. Based on this information, it can be inferred that IV digoxin should be used with caution in patients with ESRD on HD, and the dose should be carefully selected and monitored 2.
From the Research
Precautions for Using IV Digoxin in Patients with Impaired Renal Function Undergoing Hemodialysis
- IV digoxin is used to treat heart failure and atrial fibrillation, but its use in patients with impaired renal function requires caution due to the risk of toxicity 3, 4.
- Hemodialysis is not typically effective in removing digoxin from the body, but continuous venovenous hemodialysis may be effective in reducing digoxin levels in patients with severe renal dysfunction 3.
- The safety and efficacy of digoxin in patients with impaired renal function have been studied, with some research suggesting that intermittent low-dose digoxin may be effective and safe in patients with chronic heart failure undergoing maintenance hemodialysis 5.
- However, other studies have found that renal dysfunction is strongly associated with mortality in patients with heart failure, and that the effect of digoxin does not differ by level of renal function 6.
- A recent study found that digoxin may adversely affect renal function in patients with congestive heart failure, as evidenced by reduced estimated glomerular filtration rate (eGFR) 7.
Key Considerations
- Patients with impaired renal function undergoing hemodialysis require close monitoring of their digoxin levels and renal function to minimize the risk of toxicity 3, 4.
- The use of digoxin in these patients should be carefully considered, taking into account the potential benefits and risks, as well as alternative treatment options 5, 6.
- Further research is needed to fully understand the effects of digoxin on renal function in patients with congestive heart failure 7.