Is digoxin (digitalis glycoside) considered first-line treatment for any medical condition?

From the Guidelines

Digoxin is not considered a first-line treatment for any cardiovascular condition in current medical practice. While it was historically used as a primary therapy for heart failure and atrial fibrillation, it has been replaced by more effective and safer medications. For heart failure with reduced ejection fraction, first-line therapies now include ACE inhibitors, ARBs, beta-blockers, SGLT2 inhibitors, and mineralocorticoid receptor antagonists, as recommended by the 2013 ACCF/AHA guideline for the management of heart failure 1. For atrial fibrillation, rate control is typically achieved with beta-blockers or calcium channel blockers, as outlined in the 2016 ESC guidelines for the management of atrial fibrillation 1, while rhythm control utilizes antiarrhythmic drugs or ablation procedures.

Key Points to Consider

• The 2016 ESC guidelines suggest that beta-blockers, such as bisoprolol, carvedilol, metoprolol, nebivolol, and esmolol, are preferred for rate control in atrial fibrillation due to their efficacy and safety profile 1.
• Calcium channel blockers, including diltiazem and verapamil, are also effective for rate control but should be avoided in patients with heart failure with reduced ejection fraction due to their negative inotropic effects 1.
• Digoxin is now reserved as an adjunctive therapy in specific situations, such as for patients with heart failure and atrial fibrillation who remain symptomatic despite optimal therapy with first-line agents, or in patients who cannot tolerate preferred medications.
• The shift away from digoxin as first-line therapy stems from its narrow therapeutic window, potential for toxicity, numerous drug interactions, and the development of medications with better efficacy and safety profiles that have demonstrated superior outcomes in clinical trials 1.

Clinical Implications

• Clinicians should prioritize the use of beta-blockers and calcium channel blockers for rate control in atrial fibrillation, reserving digoxin for specific situations where its use is justified.
• Patients with heart failure and atrial fibrillation should be managed with a comprehensive approach that includes optimal medical therapy, lifestyle modifications, and device therapy as needed.

From the Research

Digoxin as a First-Line Treatment

• Digoxin is not typically considered a first-line treatment for most conditions, but it may be used in certain situations, such as in patients with atrial fibrillation and heart failure who cannot tolerate beta-blockers 2.
• In patients with atrial fibrillation and heart failure, digoxin may be used to control ventricular rate, especially in those with hypotension or an absolute contraindication to beta-blocker treatment 2.
• However, the use of digoxin in patients with atrial fibrillation and heart failure is not without controversy, and some studies have suggested that it may be associated with increased mortality in certain patient populations 3.

Specific Patient Populations

• In elderly patients (aged ≥65 years), digoxin may be an appropriate agent for ventricular rate control in those with heart failure or a sedentary lifestyle, but its use requires careful consideration of pharmacokinetics and potential drug interactions 4.
• A randomized clinical trial found that low-dose digoxin was associated with improved patient-reported quality of life and reduced adverse events compared to bisoprolol in patients with permanent atrial fibrillation and symptoms of heart failure 5.
• Another study found that digoxin use was not associated with increased mortality in patients with atrial fibrillation and heart failure, but its use should be cautious and instituted with assessment of drug concentrations, particularly in older patients 6.

Key Considerations

• The decision to use digoxin as a first-line treatment should be based on individual patient characteristics, including age, comorbidities, and treatment goals.
• Careful consideration of pharmacokinetics, potential drug interactions, and monitoring of drug concentrations is necessary when using digoxin, especially in elderly patients or those with renal impairment.
• Further research is needed to fully understand the benefits and risks of digoxin use in different patient populations and to inform evidence-based treatment decisions 2, 3, 4, 5, 6.