From the Guidelines
Digoxin toxicity presents with a range of symptoms affecting multiple body systems, including cardiac manifestations such as bradycardia, various arrhythmias, and neurological symptoms like confusion and visual disturbances, as reported in the most recent guidelines 1. The symptoms of digoxin toxicity can be categorized into several key areas, including:
- Cardiac manifestations: bradycardia, various arrhythmias (especially ventricular arrhythmias), heart block, and atrial fibrillation with slow ventricular response
- Gastrointestinal symptoms: nausea, vomiting, diarrhea, abdominal pain, and loss of appetite
- Neurological symptoms: confusion, disorientation, headache, fatigue, weakness, dizziness, and visual disturbances such as blurred vision, yellow-green halos around objects, or color vision abnormalities Severe toxicity can lead to hyperkalemia (high potassium levels) and potentially life-threatening cardiac arrhythmias, as noted in the 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning 1. Elderly patients, those with kidney dysfunction, and patients taking certain medications that interact with digoxin (like amiodarone, verapamil, or certain antibiotics) are at higher risk for developing toxicity, as highlighted in the 2013 ACCF/AHA guideline for the management of heart failure 1. Monitoring digoxin levels is essential, with therapeutic levels typically between 0.8-2.0 ng/mL, and levels above 2.0 ng/mL often correlate with toxicity symptoms, as stated in the 2013 ACCF/AHA guideline for the management of heart failure 1. If toxicity is suspected, the medication should be held immediately and medical attention sought, as treatment may require digoxin-specific antibody fragments (Digibind) in severe cases, as recommended in the 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning 1.
From the FDA Drug Label
In this trial, the most common manifestations of digoxin toxicity included gastrointestinal and cardiac disturbances; CNS manifestations were less common. High doses of digoxin may produce a variety of rhythm disturbances, such as first-degree, second-degree (Wenckebach), or third-degree heart block (including asystole); atrial tachycardia with block; AV dissociation; accelerated junctional (nodal) rhythm; unifocal or multiform ventricular premature contractions (especially bigeminy or trigeminy); ventricular tachycardia; and ventricular fibrillation. Digoxin may cause anorexia, nausea, vomiting, and diarrhea Rarely, the use of digoxin has been associated with abdominal pain, intestinal ischemia, and hemorrhagic necrosis of the intestines. Digoxin can produce visual disturbances (blurred or yellow vision), headache, weakness, dizziness, apathy, confusion, and mental disturbances (such as anxiety, depression, delirium, and hallucination) Although digoxin may produce anorexia, nausea, vomiting, diarrhea, and CNS disturbances in young patients, these are rarely the initial symptoms of overdosage Rather, the earliest and most frequent manifestation of excessive dosing with digoxin in infants and children is the appearance of cardiac arrhythmias, including sinus bradycardia.
The symptoms of digoxin toxicity include:
- Gastrointestinal disturbances:
- Anorexia
- Nausea
- Vomiting
- Diarrhea
- Abdominal pain
- Intestinal ischemia
- Hemorrhagic necrosis of the intestines
- Cardiac disturbances:
- First-degree, second-degree (Wenckebach), or third-degree heart block (including asystole)
- Atrial tachycardia with block
- AV dissociation
- Accelerated junctional (nodal) rhythm
- Unifocal or multiform ventricular premature contractions (especially bigeminy or trigeminy)
- Ventricular tachycardia
- Ventricular fibrillation
- Sinus bradycardia (especially in infants)
- CNS manifestations:
From the Research
Symptoms of Digoxin Toxicity
The symptoms of digoxin toxicity can be diverse and affect various systems in the body. Some of the common symptoms include:
- Digestive symptoms such as nausea and vomiting 3, 4, 5, 6
- Cardiac symptoms including arrhythmias, absolute arrhythmia with a slow ventricular rate, and cardiac arrest 3, 4, 5, 6
- Neurological symptoms like confusion, proprioceptive illusions, and formed visual hallucinations 3, 5
- Visual disturbances such as blurry vision, photopsia, dyschromatopsia, and blue color vision 3, 4
Specific Cases of Digoxin Toxicity
In some cases, digoxin toxicity can present with severe and unique symptoms. For example:
- A 91-year-old woman developed snowy and blurry vision, photopsia, dyschromatopsia, and aggravated pre-existing formed visual hallucinations after taking digoxin for atrial fibrillation 3
- A 66-year-old man experienced blue color vision as a sign of digitalis poisoning after taking medigoxin for chronic heart failure and atrial fibrillation 4
- A 37-year-old female patient exhibited symptoms of confusion, nausea, and vomiting after ingesting a massive overdose of digoxin 5
- A 73-year-old man developed ventricular fibrillation and passed away despite resuscitation and administration of digoxin antibodies after ingesting 20 mg of digoxin 6
- A 53-year-old woman presented with digitalis toxicity caused by acute overdose, which manifested as atrial tachycardia with block, sinus pauses, and competing AV junctional rhythm with atrial fibrillation 7
Treatment and Management
The treatment of digoxin toxicity focuses on reduction of digoxin absorption, prevention of hypokalaemia and hyperkalaemia, treatment of symptoms, and administration of digoxin antibodies in severe cases 6. In some cases, plasma exchange may be considered as a treatment modality for recrudescent digoxin toxicity 7.