From the Guidelines
Digoxin dosing for atrial fibrillation should be 0.0625-0.25 mg daily.
Rate Control Therapy
The dosing of digoxin is crucial in managing atrial fibrillation, and the recommended dose is 0.0625-0.25 mg daily 1.
- Intravenous administration: In acute settings, an intravenous bolus of 0.5 mg can be given, with a total dose of 0.75-1.5 mg over 24 hours in divided doses 1.
- Oral administration: For long-term oral rate control, the daily dose of digoxin should be between 0.0625-0.25 mg 1.
- Renal function: It is essential to check renal function before starting digoxin and adapt the dose in patients with chronic kidney disease (CKD) 1.
- Side effects: The most common reported adverse symptoms of digoxin include gastrointestinal upset, dizziness, blurred vision, headache, and rash 1.
Clinical Considerations
The use of digoxin in atrial fibrillation is generally recommended as a second-line agent for rate control, especially in patients who are not candidates for beta-blockers or calcium channel blockers 1.
- Combination therapy: Digoxin can be used in combination with other rate-control medications, such as beta-blockers or calcium channel blockers, to achieve optimal heart rate control 1.
- Hemodynamic instability: In patients with hemodynamic instability, intravenous amiodarone and digoxin may be used, and emergent cardioversion is recommended in cases of hemodynamic collapse 1.
From the FDA Drug Label
Peak digoxin body stores larger than the 8 to 12 mcg/kg required for most patients with heart failure and normal sinus rhythm have been used for control of ventricular rate in patients with atrial fibrillation Doses of digoxin used for the treatment of chronic atrial fibrillation should be titrated to the minimum dose that achieves the desired ventricular rate control without causing undesirable side effects. In patients with chronic atrial fibrillation, digoxin slows rapid ventricular response rate in a linear dose-response fashion from 0.25 to 0. 75 mg/day.
The appropriate dosing of Digoxin for atrial fibrillation should be titrated to the minimum dose that achieves the desired ventricular rate control without causing undesirable side effects, with doses ranging from 0.25 to 0.75 mg/day 2 2.
- The dose should be adjusted based on the patient's response to the medication.
- Digoxin should not be used for the treatment of multifocal atrial tachycardia.
- The goal is to achieve the desired ventricular rate control with the minimum effective dose.
From the Research
Appropriate Dosing of Digoxin for Atrial Fibrillation
The appropriate dosing of digoxin for atrial fibrillation is a complex issue, with various studies providing insights into the optimal dosage and potential risks associated with its use.
- A study published in 2022 3 found that a daily maintenance dose of 0.125 mg is appropriate for most Japanese patients with atrial fibrillation and heart failure, but a dose reduction is required for patients with creatinine clearance <30 mL/min or concurrent amiodarone use.
- The same study 3 also found that a daily dose of 0.0625 mg is acceptable for patients with renal impairments or concurrent amiodarone use.
- Another study published in 2018 4 suggested that digoxin should generally be avoided in patients with atrial fibrillation without heart failure, and reserved for patients with heart failure who do not achieve adequate rate control or are not tolerant of other rate control therapies.
Factors Affecting Digoxin Dosing
Several factors can affect the dosing of digoxin, including:
- Renal function: Patients with impaired renal function may require a dose reduction to avoid toxicity 3.
- Concurrent medication use: The use of amiodarone can affect digoxin clearance and increase the risk of toxicity 3.
- Serum digoxin concentration: High serum concentrations of digoxin (≥1.2 ng/ml) have been associated with an increased risk of mortality 5.
Risks Associated with Digoxin Use
Several studies have highlighted the potential risks associated with digoxin use in patients with atrial fibrillation, including:
- Increased risk of mortality: Studies have consistently shown that digoxin use is associated with an increased risk of mortality in patients with atrial fibrillation, particularly in those without heart failure 6, 7, 5.
- Increased risk of sudden cardiac death: Digoxin use has also been associated with an increased risk of sudden cardiac death in patients with atrial fibrillation 6, 5.