From the Guidelines
Digoxin cannot be effectively removed by hemodialysis. The most recent and highest quality study, published in the Journal of the American College of Cardiology in 2019 1, recommends against dialysis for removal of digoxin in patients with bradycardia associated with symptoms or hemodynamic compromise attributable to digoxin toxicity, with a Class III: No Benefit designation and a Level of Evidence of C-LD. This is due to several factors, including:
- A large volume of distribution, which means the drug is extensively distributed throughout body tissues, particularly in skeletal muscle and myocardium, with only a small fraction present in the blood available for dialysis removal
- High protein binding, which further limits its dialyzability In cases of digoxin toxicity, management typically involves discontinuation of the drug, supportive care, and in severe cases, administration of digoxin-specific antibody fragments, such as Digibind or DigiFab, which bind to digoxin molecules and remove them from tissue binding sites, as recommended by the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1.
Key considerations for clinicians include:
- Discontinuation of digoxin in cases of toxicity
- Administration of digoxin-specific antibody fragments in severe cases
- Dose adjustments for patients on hemodialysis who require digoxin therapy, due to reduced renal clearance
- Avoidance of dialysis as a treatment option for digoxin removal, as stated in the guideline 1.
From the FDA Drug Label
Digoxin is primarily excreted by the kidneys; therefore, patients with impaired renal function require smaller than usual maintenance doses of digoxin Deficiencies of these electrolytes may result from ... dialysis
The FDA drug label does not answer the question.
From the Research
Digoxin Removal by Hemodialysis
- Digoxin is a cardiac glycoside used to treat heart failure and atrial fibrillation, but its toxicity can be life-threatening, especially in patients with renal failure 2, 3, 4, 5.
- Hemodialysis is not typically effective in removing digoxin from the body, as it is a large molecule with a high volume of distribution 2, 5.
- However, a case report suggests that continuous venovenous hemodialysis may be effective in removing digoxin in patients with severe renal dysfunction and digoxin toxicity 4.
- Intermittent low-dose digoxin may be effective and safe in patients with chronic heart failure undergoing maintenance hemodialysis, but this does not necessarily mean that hemodialysis is effective in removing digoxin 6.
- Other treatment options for digoxin toxicity include digoxin-specific antibody fragments, which are considered the most effective treatment available, and peritoneal dialysis, which may not be effective in removing digoxin 3, 5.
Effectiveness of Hemodialysis in Digoxin Removal
- Regular hemodialysis has been shown to be ineffective in reducing plasma digoxin concentration in a patient with chronic renal failure 2.
- Continuous venovenous hemodialysis may be a treatment option in digoxin toxicity, especially in patients with severe renal dysfunction, but more research is needed to confirm its effectiveness 4.
- Hemodialysis is not typically recommended as a treatment for digoxin toxicity, and other options such as digoxin-specific antibody fragments and supportive care should be considered first 3, 5.