Can digoxin be used in patients with End-Stage Renal Disease (ESRD)?

From the Guidelines

Digoxin can be used in patients with end-stage renal disease (ESRD), but it requires careful dosing adjustments and close monitoring due to the increased risk of toxicity. The use of digoxin in ESRD patients is supported by the 2009 ACCF/AHA Heart Failure Guidelines 1, which emphasize the importance of cautious use in patients with impaired renal function. For ESRD patients, the typical maintenance dose should be reduced, often to 0.0625-0.125 mg daily or every other day, as digoxin is primarily eliminated by the kidneys.

Key considerations when using digoxin in ESRD patients include:

• Regular monitoring of serum digoxin levels, aiming for therapeutic levels between 0.5-0.9 ng/mL, as suggested by the guidelines 1
• Monitoring for signs of digoxin toxicity, such as nausea, vomiting, visual disturbances, confusion, and cardiac arrhythmias
• Correction of electrolyte imbalances common in ESRD, particularly hypokalemia, hypomagnesemia, and hypercalcemia, which can potentiate digoxin toxicity
• Awareness of potential interactions with other medications commonly used in ESRD patients, including certain antibiotics, antiarrhythmics, and calcium channel blockers, which can increase digoxin levels and toxicity risk, as noted in the guidelines 1.

Overall, the use of digoxin in ESRD patients requires a careful and individualized approach to minimize the risk of toxicity and maximize potential benefits.

From the FDA Drug Label

In patients with impaired renal function, digoxin must be carefully titrated based upon clinical response Because of altered digoxin distribution and elimination, projected peak body stores for patients with renal insufficiency should be conservative (i.e., 6 to 10 mcg/kg) Digoxin is primarily excreted by the kidneys; therefore, patients with impaired renal function require smaller than usual maintenance doses of digoxin

Use in ESRD:

• Digoxin can be used in patients with end-stage renal disease (ESRD), but the dose must be carefully titrated based on clinical response.
• The maintenance dose should be reduced due to decreased renal clearance.
• It is essential to monitor serum electrolytes and renal function periodically.
• The dosage requirements may vary depending on the patient's lean body weight and renal function, as shown in Table 5 2.
• Patients with ESRD are at high risk for toxicity, and toxic effects will last longer in such patients than in patients with normal renal function 2.

From the Research

Digoxin Use in ESRD Patients

• There is limited direct evidence on the use of digoxin in patients with End-Stage Renal Disease (ESRD) 3, 4, 5, 6, 7.
• However, it is known that digoxin is primarily excreted by the kidneys, and its clearance is reduced in patients with renal impairment 5.
• A study found that there were no differences in outcomes between AF patients receiving digoxin with and without chronic kidney disease, suggesting that digoxin may be used in ESRD patients, but with caution 5.
• Another study suggested that digoxin should be avoided in patients without heart failure, as it is associated with worse outcomes, but in patients with atrial fibrillation and heart failure, digoxin should be used with caution 3.
• The use of digoxin in ESRD patients requires careful consideration of the potential risks and benefits, and close monitoring of the patient's condition 4, 6, 7.

Considerations for Digoxin Use in ESRD

• The choice of digoxin or beta-blocker therapy had no influence on the incidence of unplanned hospitalizations in AF patients 5.
• 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 7.
• Patients with ESRD require meticulous monitoring of volume status to achieve and maintain control of blood pressure, and digoxin may need to be adjusted accordingly 6.