From the Guidelines
Digoxin is contraindicated in patients with certain cardiac conditions, including ventricular fibrillation, ventricular tachycardia (unless caused by heart failure), hypertrophic cardiomyopathy with outflow obstruction, and Wolff-Parkinson-White syndrome, as well as in patients with AV block without a pacemaker, significant sinus bradycardia, or second or third-degree heart block. The use of digoxin in these conditions can worsen conduction abnormalities and increase the risk of digoxin toxicity 1.
Key Contraindications and Precautions
- Certain cardiac conditions: ventricular fibrillation, ventricular tachycardia (unless caused by heart failure), hypertrophic cardiomyopathy with outflow obstruction, and Wolff-Parkinson-White syndrome
- AV block without a pacemaker
- Significant sinus bradycardia or second or third-degree heart block
- Electrolyte disturbances: hypokalemia, hypomagnesemia, and hypercalcemia
- Renal impairment: requires dose adjustment
- Elderly patients: decreased renal function and increased sensitivity to digoxin
- Thyroid disorders: hypothyroidism increases sensitivity to digoxin, while hyperthyroidism may reduce its effects
According to the 2013 ACCF/AHA guideline for the management of heart failure, digoxin toxicity can occur with lower digoxin levels, especially if hypokalemia, hypomagnesemia, or hypothyroidism coexists 1. The concomitant use of certain drugs, such as clarithromycin, dronedarone, erythromycin, amiodarone, itraconazole, cyclosporine, propafenone, verapamil, or quinidine, can increase serum digoxin concentrations and may increase the likelihood of digoxin toxicity 1.
Important Considerations
- Dose adjustment is necessary in patients with renal impairment or those taking certain medications that can increase serum digoxin concentrations
- Careful monitoring is required in patients with thyroid disorders or electrolyte disturbances
- Elderly patients require careful consideration due to decreased renal function and increased sensitivity to digoxin
- The use of digoxin should be avoided in patients with certain cardiac conditions or significant conduction abnormalities, as it can worsen these conditions and increase the risk of toxicity 1.
From the FDA Drug Label
Digitalis glycosides are contraindicated in patients with ventricular fibrillation or in patients with a known hypersensitivity to digoxin. A hypersensitivity reaction to other digitalis preparations usually constitutes a contraindication to digoxin. The contraindications for digoxin are:
- Ventricular fibrillation
- Hypersensitivity to digoxin
- Hypersensitivity reaction to other digitalis preparations [ 2 ]
From the Research
Contraindications for Digoxin
The following are contraindications for digoxin:
- Idiopathic hypertrophic subaortic stenosis (unless atrial fibrillation is present) 3
- Significant sinus or atrioventricular block, unless the block has been treated with a permanent pacemaker 4
- Wolff-Parkinson-White syndrome (in some patients) 3
- Patients with atrial fibrillation and heart failure who have a rapid ventricular response should not be given high doses of digoxin (>0.25 mg daily) for rate control 4
Precautions
Digoxin should be used cautiously in patients who receive other agents known to depress sinus or atrioventricular nodal function, such as:
- Amiodarone 4
- Beta-blockers 4
- Patients with hypokalemia, hypomagnesemia, or hypothyroidism, as these conditions can increase the risk of digoxin toxicity 4
- Patients taking quinidine, verapamil, spironolactone, flecainide, or amiodarone, as these drugs can increase serum digoxin levels and increase the likelihood of digoxin toxicity 4