What is the recommended dose of digoxin (digitalis glycoside) for a patient with right ventricular rupture (RVR) after a mixed dose?

From the Guidelines

Digoxin is not recommended for patients with right ventricular rupture (RVR) after any type of dosing, and its use can worsen the patient's condition and potentially lead to fatal outcomes. The management of RVR is a surgical emergency that requires immediate intervention, including emergency surgical repair, hemodynamic stabilization with inotropic support, volume resuscitation, and possibly mechanical circulatory support 1.

Key Considerations

• The use of digoxin in patients with RVR can increase wall stress on the already compromised right ventricle and potentially expand the rupture.
• Digoxin has a narrow therapeutic window, and in the setting of acute cardiac injury with potentially fluctuating renal function, the risk of toxicity is significantly elevated.
• If a patient with RVR has previously received digoxin, monitoring serum levels and preparing for potential digoxin-specific antibody fragments (Digibind) may be necessary to reverse any toxic effects.

Recommended Approach

• Avoid the use of digoxin in patients with RVR.
• Focus on surgical emergency repair and hemodynamic stabilization.
• Consider the use of inotropic support, volume resuscitation, and mechanical circulatory support as needed.
• Monitor serum levels and prepare for potential digoxin-specific antibody fragments (Digibind) if the patient has previously received digoxin.

Evidence-Based Guidelines

• The 2009 ACCF/AHA Heart Failure Guidelines recommend that digoxin be used cautiously in patients with heart failure, and that doses of 0.125 to 0.25 mg daily are commonly used for initiation and maintenance 1.
• The 2013 ACCF/AHA Guideline for the Management of Heart Failure recommends that therapy with digoxin be initiated and maintained at a dose of 0.125 to 0.25 mg daily, with low doses used initially in patients over 70 years old or with impaired renal function 1.
• The ACC/aha 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult recommends that therapy with digoxin be initiated and maintained at a dose of 0.125 to 0.25 mg daily, with low doses used initially in patients over 70 years old or with impaired renal function 1.

From the FDA Drug Label

1. DOSAGE & ADMINISTRATION 2.1 Important Dosing and Administration Information In selecting a digoxin dosing regimen, it is important to consider factors that affect digoxin blood levels (e.g., body weight, age, renal function, concomitant drugs) since toxic levels of digoxin are only slightly higher than therapeutic levels.

The FDA drug label does not provide a specific recommended dose of digoxin for a patient with right ventricular rupture (RVR) after a mixed dose.

• Key factors to consider when selecting a digoxin dosing regimen include:
  • Body weight
  • Age
  • Renal function
  • Concomitant drugs However, the label does provide general dosing information, including:
• Loading dose: The recommended loading dose for adults and pediatric patients over 10 years old is provided in Table 1.
• Maintenance dose: The recommended starting maintenance dose for adults and pediatric patients over 10 years old with normal renal function is provided in Table 2.
• Dose adjustment: Doses may be increased every 2 weeks according to clinical response, serum drug levels, and toxicity. 2

From the Research

Recommended Dose of Digoxin

There are no research papers to assist in answering this question regarding the recommended dose of digoxin for a patient with right ventricular rupture (RVR) after a mixed dose.

Available Information on Right Ventricular Rupture and Failure

• The available studies discuss right ventricular rupture and failure in the context of myocardial infarction, cardiogenic shock, and the use of various treatments such as milrinone 3, 4, inhaled nitric oxide 5, and mechanical circulatory support devices 6.
• A case study reported a patient with right ventricular rupture after myocardial infarction, who underwent pericardial drainage without myocardial repair and had a favorable prognosis 7.
• The effects of milrinone on right ventricular failure after left ventricular assist device implantation have been reported, showing significant reduction in pulmonary vascular resistance and increase in left ventricular assist device flow 3.
• Inhaled nitric oxide has been shown to improve hemodynamic function in patients with right ventricular myocardial infarction and cardiogenic shock, by decreasing right ventricular afterload and increasing cardiac index 5.
• A comparison of the effects of milrinone and dobutamine on right ventricular systolic function in patients with congestive heart failure found that both drugs improved cardiac performance, but milrinone caused a greater reduction in right ventricular afterload 4.
• Mechanical circulatory support devices have been introduced as a treatment for acute right ventricular failure, providing an opportunity to rapidly stabilize patients with cardiogenic shock involving the right ventricle 6.