Digoxin: Precision Heart Rate Control for Cardiac Patients
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Synonyms | |||
Digoxin is a time-honored cardiac glycoside derived from the foxglove plant (Digitalis lanata), prescribed for its potent inotropic and chronotropic effects. It remains a cornerstone in the management of certain heart conditions, particularly heart failure with reduced ejection fraction and atrial fibrillation, where precise control of ventricular rate is paramount. Its mechanism involves inhibition of the sodium-potassium ATPase pump, increasing intracellular calcium and enhancing myocardial contractility while slowing atrioventricular nodal conduction. Careful therapeutic drug monitoring is essential due to its narrow therapeutic index.
Features
- Contains digoxin as the active pharmaceutical ingredient
- Available in oral tablets (62.5 mcg, 125 mcg, 250 mcg) and intravenous formulations
- High oral bioavailability (~60–80%) with extensive tissue binding
- Long elimination half-life (36–48 hours in patients with normal renal function)
- Primarily excreted renally unchanged
- Requires therapeutic drug monitoring (target serum concentration 0.5–0.9 ng/mL)
Benefits
- Enhanced cardiac output through positive inotropic effect, improving symptoms of heart failure
- Control of ventricular rate in atrial fibrillation by prolonging AV nodal refractory period
- Reduced hospitalization rates in heart failure patients when used appropriately
- Flexible dosing regimens allowing for once-daily administration in most patients
- Long-standing clinical evidence supporting efficacy in select patient populations
- Cost-effective treatment option compared to many newer cardiovascular agents
Common use
Digoxin is indicated for the treatment of mild to moderate heart failure in patients who remain symptomatic despite appropriate ACE inhibitor, beta-blocker, and diuretic therapy. It is also approved for control of ventricular response rate in patients with chronic atrial fibrillation. The medication may be used as adjunctive therapy in patients with supraventricular tachyarrhythmias, particularly when other rate-control agents are ineffective or contraindicated. Off-label uses include certain cases of fetal tachycardia and junctional reentrant tachycardia.
Dosage and direction
Dosing must be individualized based on lean body weight, renal function, and clinical indication. For most adults with normal renal function (creatinine clearance >50 mL/min), the typical loading dose is 10–15 mcg/kg ideal body weight administered in divided doses over 12–24 hours. Maintenance dosing typically ranges from 62.5 to 250 mcg daily, with lower doses (62.5–125 mcg) recommended for elderly patients or those with renal impairment. Administration should occur at the same time each day, with or without food. Intravenous administration requires slow infusion over at least 5 minutes with continuous ECG monitoring.
Precautions
Regular monitoring of serum digoxin levels, renal function, and electrolytes (particularly potassium, magnesium, and calcium) is mandatory. Hypokalemia, hypomagnesemia, and hypercalcemia predispose to toxicity. Use with extreme caution in patients with renal impairment, as decreased clearance may lead to accumulation. Elderly patients require dose reduction due to age-related decline in renal function and lean body mass. Concomitant use of drugs that affect renal function or electrolyte balance requires increased vigilance. Periodic assessment of clinical response and potential toxicity signs is essential.
Contraindications
Digoxin is contraindicated in patients with ventricular fibrillation, known hypersensitivity to digoxin or other digitalis preparations, and in cases of digoxin toxicity. Additional contraindications include certain arrhythmias such as Wolff-Parkinson-White syndrome with atrial fibrillation, where it may accelerate ventricular response. It should not be used in patients with amyloid cardiomyopathy or constrictive pericarditis unless specifically indicated for rate control in atrial fibrillation.
Possible side effect
Common adverse effects include nausea, vomiting, diarrhea, headache, dizziness, and visual disturbances (chromatopsia, photophobia). Cardiac effects may include various arrhythmias, particularly PVCs, PAT with block, or junctional rhythms. Neuropsychiatric effects such as fatigue, malaise, and rarely psychosis may occur. Less frequently, gynecomastia in males and rash may develop. Most side effects are dose-dependent and often indicate elevated serum concentrations.
Drug interaction
Numerous significant interactions exist. Diuretics (especially thiazides and loop diuretics) may cause hypokalemia, increasing toxicity risk. Amiodarone, verapamil, quinidine, and cyclosporine increase digoxin levels. Concomitant use with beta-blockers or calcium channel blockers may excessively slow heart rate. Antibiotics such as erythromycin and tetracycline may increase bioavailability. Antacids, cholestyramine, and certain antineoplastics may decrease absorption. Sympathomimetics may increase risk of arrhythmias.
Missed dose
If a dose is missed, it should be taken as soon as remembered unless it is nearly time for the next scheduled dose. In that case, the missed dose should be skipped and the regular dosing schedule resumed. Patients should never double the dose to make up for a missed administration. Consistent timing is important for maintaining stable serum concentrations, particularly given the drug’s narrow therapeutic index.
Overdose
Digoxin overdose constitutes a medical emergency requiring immediate attention. Manifestations include severe nausea and vomiting, hyperkalemia, visual changes, and life-threatening arrhythmias. Treatment involves discontinuation of digoxin, correction of electrolyte abnormalities, and administration of digoxin-specific antibody fragments (Digibind®) for serious toxicity. Activated charcoal may be effective if administered soon after ingestion. Temporary cardiac pacing may be necessary for significant bradyarrhythmias.
Storage
Store at controlled room temperature (20–25°C or 68–77°F) in the original container, protected from light and moisture. Keep tightly closed and out of reach of children. Do not transfer to other containers, as this may affect stability. Do not use if tablets show signs of discoloration or deterioration. Proper disposal of unused medication is essential to prevent accidental ingestion.
Disclaimer
This information is provided for educational purposes only and does not constitute medical advice. Digoxin is a prescription medication that should only be used under the supervision of a qualified healthcare provider. Individual patient factors must be considered in dosing and monitoring decisions. The prescriber should be familiar with complete prescribing information and current clinical guidelines before initiating therapy.
Reviews
“Digoxin remains invaluable in my cardiology practice for patients with difficult-to-control atrial fibrillation who cannot tolerate beta-blockers or calcium channel blockers. The key is careful dosing and monitoring.” — Dr. Eleanor Roberts, Cardiologist
“After twenty years of heart failure management, I still find selected patients who derive significant symptomatic benefit from digoxin when added to guideline-directed medical therapy.” — Dr. Michael Chen, Heart Failure Specialist
“While newer agents have emerged, digoxin’s cost-effectiveness and specific hemodynamic effects maintain its role in contemporary cardiovascular therapeutics, particularly in resource-limited settings.” — Dr. Sarah Johnson, Clinical Pharmacologist