What are the indications for digoxin?

From the Guidelines

Digoxin is primarily indicated for the treatment of heart failure with reduced ejection fraction and for rate control in atrial fibrillation, with its use guided by the most recent guidelines to minimize toxicity risk and maximize therapeutic benefit 1. The indications for digoxin have evolved based on clinical evidence, with a focus on its role in managing symptoms in heart failure and controlling ventricular rate in atrial fibrillation.

Key Indications

• Heart failure with reduced ejection fraction: Digoxin is used as an add-on therapy for patients who remain symptomatic despite optimal treatment with ACE inhibitors, beta-blockers, and diuretics 1.
• Atrial fibrillation: Digoxin is used for rate control, particularly in patients who cannot tolerate or do not respond to beta-blockers or calcium channel blockers 1.

Dosage and Monitoring

• The usual maintenance dose of digoxin ranges from 0.125 to 0.25 mg daily, with lower doses recommended for elderly patients, those with renal impairment, or individuals with low body weight 1.
• Regular monitoring of serum digoxin levels (therapeutic range 0.8-2.0 ng/mL) and electrolytes is crucial to minimize the risk of toxicity, which can be increased by hypokalemia, hypomagnesemia, and hypercalcemia 1.

Considerations

• The concomitant use of certain drugs, such as clarithromycin, erythromycin, amiodarone, itraconazole, cyclosporine, verapamil, or quinidine, can increase serum digoxin concentrations and the likelihood of toxicity, necessitating dose adjustments 1.
• Digoxin should be used with caution in patients with renal impairment, as it is primarily eliminated by the kidneys, and in post-MI patients, particularly if they have ongoing ischemia 1.

From the FDA Drug Label

INDICATIONS AND USAGE Digoxin is indicated for the treatment of mild to moderate heart failure. Digoxin increases left ventricular ejection fraction and improves heart failure symptoms as evidenced by exercise capacity and heart failure symptoms as evidenced by exercise capacity and heart failure-related hospitalizations and emergency care, while having no effect on mortality. Where possible, digoxin should be used with a diuretic and an angiotensin-converting enzyme inhibitor, but an optimal order for starting these three drugs cannot be specified. Heart Failure: Digoxin is indicated for the control of ventricular response rate in patients with chronic atrial fibrillation. Atrial Fibrillation:

The indications for digoxin are:

• Treatment of mild to moderate heart failure
• Control of ventricular response rate in patients with chronic atrial fibrillation 2

From the Research

Indications for Digoxin

The indications for digoxin are as follows:

• Digoxin should be considered for the outpatient treatment of all patients who have persistent symptoms of heart failure (NYHA class II-IV) despite conventional pharmacologic therapy with diuretics, ACE inhibitors, and a beta-blocker when the heart failure is caused by systolic dysfunction 3.
• Digoxin may be useful in the presence of hypotension or an absolute contraindication to beta-blocker treatment in patients with atrial fibrillation and heart failure 4.
• Digoxin is recommended for ventricular rate control only in patients with heart failure or sedentary lifestyle, or in those who cannot tolerate other rate-control agents 5.
• Digoxin is best reserved for patients with atrial fibrillation and a rapid ventricular response, and for those whose heart failure is not controlled with an ACE inhibitor plus a diuretic 6.

Contraindications and Precautions

• Digoxin is not indicated as primary treatment for the stabilization of patients with acutely decompensated heart failure 3.
• Digoxin should not be administered to patients who have significant sinus or atrioventricular block, unless the block has been treated with a permanent pacemaker 3.
• The drug should be used cautiously in patients who receive other agents known to depress sinus or atrioventricular nodal function (such as amiodarone or a beta-blocker) 3.
• The elderly population appears to have reduced elimination of digoxin, so if digoxin is to be used, the dosing strategy must be conservative and therapeutic monitoring is needed 5.

Dosage and Administration

• The dosage of digoxin should be 0.125-0.25 mg daily in the majority of patients 3.
• The lower dose should be used in patients over 70 years of age, those with impaired renal function, or those with a low lean body mass 3.
• Loading doses of digoxin are not necessary during initiation of therapy for patients with chronic heart failure 3.