From the Guidelines
Digoxin is recommended for acute adult atrial fibrillation (AF) management primarily in patients with heart failure or when other rate control agents are contraindicated, as stated in the 2014 AHA/ACC/HRS guideline 1. The typical loading dose is 0.25-0.5 mg IV initially, followed by 0.125-0.25 mg IV every 4-6 hours (maximum 1.5 mg over 24 hours), then transitioning to an oral maintenance dose of 0.125-0.25 mg daily. Some key points to consider when using digoxin include:
- It has a delayed onset of action (1-2 hours)
- It is less effective during high sympathetic states like exercise
- It requires careful monitoring due to its narrow therapeutic window
- Serum levels should be maintained between 0.8-2.0 ng/mL
- Dose adjustments are necessary in renal impairment
- Clinicians should watch for signs of toxicity including visual disturbances, confusion, nausea, and cardiac arrhythmias. According to the 2022 AHA/ACC/HFSa guideline 1, digoxin is usually initiated at a low dose because higher doses are rarely required in the management of heart failure and are potentially detrimental. Some important considerations for digoxin use, as outlined in the 2022 guideline 1, include:
- The risk of death was independently associated with serum digoxin concentration, with a significantly higher risk observed in those with concentrations ≥1.2 ng/mL and ≥1.6 ng/mL
- Therapy with digoxin may either be continued in the absence of a contraindication or discontinued with caution
- Low doses (0.125 mg daily or every other day) should be used initially if the patient is >70 years of age. Overall, digoxin should be used with caution and careful monitoring, particularly in patients with heart failure, and its use should be guided by the most recent clinical guidelines 1.
From the FDA Drug Label
Digoxin is indicated for the control of ventricular response rate in patients with chronic atrial fibrillation.
The reason digoxin is recommended for acute adult AF management is for the control of ventricular response rate in patients with atrial fibrillation.
- Key points:
- Indication: control of ventricular response rate
- Condition: atrial fibrillation
- Patient population: adults 2
From the Research
Reasons for Digoxin Recommendation
- Digoxin may be useful in the presence of hypotension or an absolute contraindication to beta-blocker treatment 3
- Digoxin does not improve survival but may help to obtain satisfactory rate control in combination with a beta-blocker 3
- A median total digoxin loading dose of 750 mcg in critically ill patients with AF/AFL, targeting a serum digoxin concentration < 1.5ng/mL may be considered for acute rate control 4
Considerations for Digoxin Use
- The safety of digoxin therapy in atrial fibrillation remains ill-defined 5, 6
- Digoxin therapy was associated with increased all-cause mortality, CV mortality, and non-CV mortality, and reduced quality of life compared to beta-blocker therapy 6
- The choice of digoxin or beta-blocker therapy had no influence on the incidence of unplanned hospitalizations 6
- The elderly population appears to gain comparable benefits as does a younger population from the use of digoxin for heart failure management in terms of symptom improvement and reduction of hospitalization 7
Dosage and Monitoring
- The dosing strategy for digoxin in the elderly must be conservative and therapeutic monitoring is needed due to reduced elimination of digoxin 7
- A loading dose of digoxin in either a fixed-dose regimen, weight-based dose, or pharmacokinetic-based calculation to target a serum digoxin concentration of 0.8-1.5 ng/mL is recommended 4