Is it safe to discontinue digoxin (Digitalis glycoside) in a 91-year-old patient with atrial fibrillation (AFib) and impaired renal function, who has been on metoprolol (Beta blocker) and digoxin for 15 years?

From the Guidelines

Discontinuing digoxin is likely the safest approach for this 91-year-old patient with poor renal function and occasional acute kidney injury (AKI) who has been on both metoprolol and digoxin for atrial fibrillation for 15 years. According to the 2024 ESC guidelines for the management of atrial fibrillation 1, the primary goal of treatment is to reduce symptoms and improve quality of life. Given the patient's advanced age and compromised renal function, the risk of digoxin toxicity is significantly increased, which could lead to severe morbidity and mortality. Metoprolol alone may provide adequate rate control for the patient's atrial fibrillation, as suggested by the guidelines 1.

If discontinuation is pursued, the drug should be tapered rather than stopped abruptly, with close monitoring of heart rate and symptoms. A reasonable approach would be to reduce the dose by half for 1-2 weeks before complete discontinuation, as this allows for gradual adjustment and minimizes the risk of adverse effects. During and after discontinuation, the patient should be monitored for increased heart rate, worsening symptoms of atrial fibrillation, or signs of heart failure. If these occur, alternative rate control strategies could be considered rather than restarting digoxin.

The benefits of removing a potentially toxic medication with a narrow therapeutic window likely outweigh the risks in this elderly patient with compromised renal function. Additionally, the 2013 ACCF/AHA guideline for the management of heart failure 1 suggests that low doses of digoxin should be used initially in patients with impaired renal function, which further supports the decision to discontinue digoxin in this patient.

Key considerations in this decision include:

• The patient's advanced age and increased risk of digoxin toxicity
• The presence of poor renal function and occasional AKI, which further elevates the risk of toxicity
• The potential for metoprolol to provide adequate rate control for atrial fibrillation
• The need for close monitoring during and after discontinuation of digoxin
• The importance of considering alternative rate control strategies if necessary.

From the FDA Drug Label

Digoxin is primarily excreted by the kidneys; therefore, patients with impaired renal function require smaller than usual maintenance doses of digoxin Because of the prolonged elimination half-life, a longer period of time is required to achieve an initial or new steady-state serum concentration in patients with renal impairment than in patients with normal renal function If appropriate care is not taken to reduce the dose of digoxin, such patients are at high risk for toxicity, and toxic effects will last longer in such patients than in patients with normal renal function.

Considering the patient's poor renal function and occasional AKI, it is crucial to exercise caution when deciding whether to discontinue digoxin. The patient's long-term use of digoxin (15 years) and concomitant use of metoprolol should also be taken into account.

• The patient's renal function should be closely monitored, and the dose of digoxin should be adjusted accordingly to avoid toxicity.
• Electrolyte levels (e.g., potassium and magnesium) should also be monitored, as deficiencies can increase the risk of digitalis toxicity.
• Given the patient's age (91 years) and renal impairment, the risk of toxic reactions to digoxin may be greater, and the benefits of continuing digoxin therapy should be carefully weighed against the potential risks.
• It is essential to consider the underlying condition (atrial fibrillation) and whether alternative treatments could be used to manage the condition.
• The decision to discontinue digoxin should be made with caution, and the patient should be closely monitored for any signs of toxicity or adverse effects. 2 2 2

From the Research

Patient Profile

• Age: 91 years old
• Medical condition: Atrial fibrillation (AF)
• Medications: Metoprolol and digoxin for 15 years
• Renal function: Poor
• Occasional condition: Acute kidney injury (AKI)

Considerations for Discontinuing Digoxin

• The patient has been on digoxin for 15 years, and discontinuation may be considered due to poor renal function and occasional AKI 3, 4
• However, studies have shown that discontinuation of digoxin can be associated with worsening heart failure symptoms and increased risk of hospitalization 3, 4
• The use of intravenous digoxin in patients with acute heart failure and rapid atrial fibrillation has been shown to have no significant effect on 30-day mortality, regardless of patient age, renal function, or serum potassium levels 5

Safety of Discontinuing Digoxin

• A study found that discontinuation of digoxin in patients with heart failure with reduced ejection fraction (HFrEF) receiving beta-blockers had no association with increased risk of adverse outcomes, including heart failure readmission or death 6
• However, another study found that discontinuation of digoxin in hospitalized patients with HFrEF was associated with higher risks of heart failure readmission, all-cause readmission, and the combined endpoint of heart failure readmission or all-cause mortality 4
• The impact of digoxin on all-cause mortality and adverse effects in patients with AF and heart failure remains unclear, and more trials are needed to evaluate the effects of digoxin 7

Factors to Consider

• The patient's age, renal function, and occasional AKI should be taken into account when considering discontinuation of digoxin 5, 4
• The patient's long-term use of digoxin and metoprolol should also be considered, as well as the potential risks and benefits of discontinuing digoxin 3, 6