Can digoxin be scheduled every other day?

Digoxin Can Be Administered Every Other Day in Specific Patient Populations

Yes, digoxin can be scheduled every other day for certain patients, particularly those who are elderly (>70 years), have impaired renal function, or have low lean body mass. 1, 2

Appropriate Dosing Strategies

• Standard digoxin dosing is 0.125-0.25 mg daily for most adults with normal renal function 1, 2
• Low doses (0.125 mg daily or every other day) should be used initially for:
  • Patients >70 years of age 1, 2
  • Patients with impaired renal function 1, 2
  • Patients with low lean body mass 1, 2
• Every-other-day dosing is specifically mentioned in guidelines as appropriate for these higher-risk populations 1, 3

Pharmacokinetic Considerations

• Digoxin has a long half-life (26-45 hours) in patients with normal renal function, making alternate-day dosing pharmacokinetically feasible 4
• The elimination half-life is extended in elderly patients and those with renal impairment, further supporting less frequent dosing 4, 5
• Target serum concentration should be maintained between 0.5-0.9 ng/mL, which can often be achieved with less frequent dosing in at-risk populations 1, 2, 6

Patient Monitoring

• When using every-other-day dosing, monitor:
  • Serum digoxin levels (target: 0.5-0.9 ng/mL) 1, 2, 6
  • Renal function 1, 2
  • Electrolytes, particularly potassium and magnesium 2, 6
• Signs of digoxin toxicity (even with appropriate dosing) include:
  • Cardiac arrhythmias 1
  • Gastrointestinal symptoms (anorexia, nausea, vomiting) 1
  • Neurological complaints (visual disturbances, disorientation, confusion) 1

Special Considerations

• Reduce digoxin dose (including potentially moving to every-other-day dosing) when used with medications that increase digoxin levels: 1, 2, 7
  • Amiodarone (reduce by 30-50%)
  • Dronedarone (reduce by at least 50%)
  • Verapamil, clarithromycin, erythromycin, itraconazole, cyclosporine, propafenone, quinidine
• Patients on peritoneal dialysis may benefit from every-other-day dosing as dialysis does not effectively remove digoxin 8

Clinical Indications for Digoxin

• Heart failure with reduced ejection fraction (HFrEF): Can reduce hospitalizations but has no mortality benefit 1, 2
• Atrial fibrillation: Useful for rate control, often in combination with beta-blockers 1, 2

Contraindications for Digoxin (Any Dosing Schedule)

• Significant sinus or atrioventricular block without a permanent pacemaker 1
• Pre-excitation syndromes (e.g., WPW with AF/atrial flutter) 1, 2
• Previous evidence of digoxin intolerance 2

Every-other-day digoxin dosing is a well-established approach for high-risk patients that can maintain therapeutic efficacy while minimizing toxicity risk. This approach is particularly valuable for elderly patients, those with renal impairment, and patients with low body mass.