When is digoxin (digitalis) used in atrial fibrillation?

From the Guidelines

Digoxin should be used in atrial fibrillation primarily for rate control in patients with reduced ejection fraction who cannot tolerate or have contraindications to first-line agents like beta-blockers and calcium channel blockers, as recommended by the European Society of Cardiology in 2012 1.

Key Considerations

• The decision to use digoxin in atrial fibrillation should be based on the patient's symptoms, heart failure status, and ability to tolerate other rate-control medications.
• Digoxin may be particularly useful in patients with heart failure and reduced ejection fraction who have persistent atrial fibrillation with rapid ventricular response.
• The typical dosing of digoxin starts at 0.125-0.25 mg daily, with adjustments based on renal function, age, and body weight, as suggested by the American College of Cardiology Foundation/American Heart Association in 2013 1.

Important Precautions

• Digoxin has a narrow therapeutic window, so serum levels should be monitored (target: 0.5-0.9 ng/mL), especially in patients with fluctuating renal function.
• It should be used cautiously in patients with significant hypokalemia, hypomagnesemia, or advanced heart block, as these conditions increase the risk of digoxin toxicity, as noted in the European Journal of Heart Failure in 2002 1.

Clinical Context

• The use of digoxin in atrial fibrillation should be individualized based on the patient's clinical context, including their symptoms, heart failure status, and ability to tolerate other medications.
• The American College of Cardiology Foundation/American Heart Association recommends considering the addition of digoxin in patients with persistent symptoms of heart failure with reduced ejection fraction (HFrEF) during guideline-directed medical therapy (GDMT) 1.
• The European Society of Cardiology suggests that digoxin may be used to control the ventricular rate in atrial fibrillation, especially if it has not been possible to up-titrate the dose of beta-blocker 1.

From the FDA Drug Label

Digoxin is indicated for the control of ventricular response rate in patients with chronic atrial fibrillation. In patients with chronic atrial fibrillation, digoxin slows rapid ventricular response rate in a linear dose-response fashion from 0.25 to 0.75 mg/day.

Digoxin is used in atrial fibrillation for the control of ventricular response rate in patients with chronic atrial fibrillation 2. The dose of digoxin for this purpose is typically in the range of 0.25 to 0.75 mg/day 2.

• Key points:
  • Indicated for control of ventricular response rate
  • Used in chronic atrial fibrillation
  • Dose range: 0.25 to 0.75 mg/day
  • Slows rapid ventricular response rate in a linear dose-response fashion 2

From the Research

Use of Digoxin in Atrial Fibrillation

Digoxin is used to control ventricular rate in patients with atrial fibrillation (AF), particularly in those with heart failure (HF) 3. The following are scenarios where digoxin may be considered:

• In patients with permanent AF, digoxin monotherapy is ineffective to control ventricular rate during exercise, but the combination of digoxin with a beta-blocker or a non-dihydropyridine calcium channel antagonist can control heart rate both at rest and during exercise 3.
• Digoxin may be useful in the presence of hypotension or an absolute contraindication to beta-blocker treatment 4.
• In patients with AF and HF, digoxin use is not associated with an increased risk of all-cause mortality when used for rate control 5.

Patient Selection

When selecting patients for digoxin therapy, the following factors should be considered:

• Patients with HF have been excluded in most studies, so the safety profile of digoxin in this population has not been directly addressed 3.
• Digoxin may be an appropriate agent for ventricular rate control in the elderly, particularly those with heart failure or a sedentary lifestyle 6.
• The elderly population appears to gain comparable benefits as does a younger population from the use of digoxin for heart failure management in terms of symptom improvement and reduction of hospitalization 6.

Safety Considerations

The safety of digoxin in patients with AF has been evaluated in several studies:

• Only a few randomised, controlled studies have evaluated the adverse effects of digoxin in patients with AF in a systematic way, and side effects requiring drug withdrawal have rarely been reported 3.
• The most frequent adverse effects of digoxin were cardiac arrhythmias (ventricular arrhythmias, AV block of varying degrees and sinus pauses) 3.
• Early recognition of an arrhythmia related to digoxin intoxication, as well as recognition of concomitant medications or medical conditions that may alter the pharmacokinetic profile of digoxin, is essential for safe and effective use of digoxin in patients with AF 3.