Is digoxin (digitalis) recommended for treating pulmonary hypertension?

Digoxin in Pulmonary Hypertension

Digoxin is not recommended as a primary treatment for pulmonary hypertension, but may be considered in specific situations such as when patients with pulmonary hypertension develop right ventricular failure or atrial fibrillation. 1

Current Recommendations for Pulmonary Hypertension

• According to the 2016 ESC/ERS guidelines for pulmonary hypertension, digoxin may be given to slow ventricular rate in patients with pulmonary arterial hypertension (PAH) who develop atrial tachyarrhythmias 1
• The efficacy of digoxin when administered chronically in PAH is unknown, although it has been shown to acutely improve cardiac output in idiopathic PAH 1
• Before the development of modern PAH-specific therapies, digoxin was part of the supportive therapy for PAH, along with anticoagulation, diuretics, and supplemental oxygen 2
• Recent retrospective data from 2023 raises concerns about chronic digoxin use in PAH, suggesting it may be associated with increased mortality and heart failure hospitalizations 3

Evidence for Digoxin in Right Ventricular Dysfunction

• A 1998 study demonstrated that digoxin produces a modest increase in cardiac output in patients with pulmonary hypertension and right ventricular failure 4
• The same study showed a significant reduction in circulating norepinephrine levels after digoxin administration 4
• However, long-term outcomes data specifically for digoxin in pulmonary hypertension is limited 5

Dosing Considerations if Used

• If digoxin is used in pulmonary hypertension patients (primarily for atrial fibrillation or right heart failure), therapy is commonly initiated at 0.125 to 0.25 mg daily 1, 6
• Lower doses (0.125 mg daily or every other day) should be used if the patient is over 70 years old, has impaired renal function, or has a low lean body mass 1, 6
• Target serum concentration should be maintained between 0.5-0.9 ng/mL 1, 6
• Higher doses (e.g., digoxin 0.375 to 0.50 mg daily) are rarely needed or recommended 1

Cautions and Contraindications

• Digoxin should not be given to patients with significant sinus or atrioventricular block unless they have a permanent pacemaker 1, 6
• The drug should be used cautiously in patients taking other medications that can affect digoxin levels or depress AV nodal function (e.g., amiodarone, beta-blockers) 1, 6
• Digoxin toxicity risk increases with hypokalemia, hypomagnesemia, or hypothyroidism 1, 6
• Major side effects include cardiac arrhythmias, gastrointestinal symptoms (anorexia, nausea, vomiting), and neurological complaints (visual disturbances, disorientation) 1

Current Treatment Paradigm for Pulmonary Hypertension

• First-line therapies for PAH include calcium channel blockers (for vasoreactive patients), endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and prostacyclin pathway agents 1
• Digoxin is not part of the primary treatment algorithm for PAH but remains an option for specific situations such as atrial arrhythmias 1
• For patients with PAH and right ventricular failure, diuretics are the recommended first-line therapy for fluid retention 1

Clinical Decision Making

• Consider digoxin only after optimizing PAH-specific therapies and standard supportive care 1, 2
• If atrial fibrillation develops in PAH patients, beta-blockers are usually more effective for rate control, with digoxin considered as an adjunctive agent 1
• The threshold for discontinuation of digoxin should be low if poorly tolerated, given the limited evidence for benefit 5
• Monitor serum digoxin levels, renal function, and electrolytes regularly if digoxin is prescribed 1, 6