From the Guidelines
Yes, digoxin can be used in patients with Chronic Kidney Disease (CKD), but with caution and dose adjustment.
Important Considerations
- The dose of digoxin should be reduced in patients with impaired renal function, with a recommended dose of 0.125 or 0.0625 mg o.d. 1
- Serum digoxin levels should be monitored closely in patients with CKD, as impaired renal function can elevate serum digoxin levels and increase the risk of digitalis toxicity 1
- The concomitant use of certain drugs, such as clarithromycin, erythromycin, amiodarone, itraconazole, cyclosporine, verapamil, or quinidine, can increase serum digoxin concentrations and may increase the likelihood of digitalis toxicity 1
Dosing and Monitoring
- A single daily maintenance dose of 0.25 mg is commonly employed in adults with normal renal function, but this dose should be reduced in patients with CKD 1
- Therapy with digoxin is commonly initiated and maintained at a dose of 0.125 to 0.25 mg daily, with low doses (0.125 mg daily or every other day) recommended for patients with impaired renal function or low lean body mass 1
- Serum digoxin levels should be monitored to achieve a concentration of 0.5 to 1.0 ng per mL, as levels above 1.0 ng per mL may not be associated with a superior outcome and may increase the risk of digitalis toxicity 1
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.
Yes, digoxin can be used in patients with Chronic Kidney Disease (CKD), but caution is required. The dose of digoxin should be reduced in patients with impaired renal function to avoid toxicity. The patient’s renal function, preferably evaluated on the basis of estimated creatinine clearance, should be considered when selecting a dose of digoxin 2.
From the Research
Digoxin Use in Patients with Chronic Kidney Disease (CKD)
- Digoxin is commonly prescribed for heart failure and atrial fibrillation, but its safety in patients with CKD is a concern 3, 4.
- Studies have shown that digoxin use is associated with increased mortality in patients with advanced CKD 3 and cardiorenal syndrome 4.
- The risk of cardiovascular events, such as acute coronary syndrome and ischemic stroke, was not significantly different between digoxin users and non-users in patients with advanced CKD 3.
- However, digoxin use was associated with a higher risk of heart failure hospitalization and end-stage renal disease in patients with cardiorenal syndrome 4.
Renal Function and Digoxin Concentrations
- Renal function is an important factor in determining digoxin concentrations, and decreased glomerular filtration rate is common in older patients with CKD 5, 6.
- Serum cystatin C is a sensitive renal function biomarker that can predict supratherapeutic digoxin concentrations in elderly patients with heart failure and CKD 5.
- A population pharmacokinetic model of digoxin in older patients with heart failure and CKD has been established, and dosage simulations suggest that lower doses may be necessary for patients with reduced kidney function 6.
Loading Dose and Kidney Function
- The optimal loading dose of digoxin in patients with reduced kidney function is unknown, and tertiary references recommend reduced loading doses 7.
- However, a retrospective analysis found that the frequency of supratherapeutic digoxin concentrations after a loading dose was similar between patients with acute kidney injury, CKD, and normal kidney function 7.
- Further studies are needed to determine the relationship between kidney function and digoxin peak concentrations, particularly in patients with CKD.