Digoxin

What are the main indications of digoxin?

Atrial fibrillation and atrial flutter as prophylaxis, but it cannot be used for acute treatment or for 1-2 days after cardioversion. Heart failure for symptomatic relief.

How would you explain how digoxin works to a patient using it for atrial fibrillation?

Digoxin helps to slow your heart rate, but it also increases the force that your heart can produce when it’s pumping blood through your body. This means that it can help your heart do its job more effectively with less work, which reduces the risk that you will get another episode of atrial fibrillation. It can also help to reduce the symptoms of AF, including racing heart, chest pain and shortness of breath.

How would you explain how digoxin works to a patient using it for heart failure?

Digoxin helps to slow your heart rate, but it also increases the force that your heart can produce when it’s pumping blood through your body. This means that it can help your heart do its job more effectively with less work, which reduces the symptoms like shortness of breath, fatigue and chest pain that you can get with heart failure.

What is the appropriate dose of digoxin?

The dose ranges from 62.5-250 micrograms once daily. A normal dose is 125-250 micrograms daily, but this should be halved if CrCl <60. These are the maximum doses in renal impairment:

• CrCl >30: 250 micrograms

• CrCl 10-30: 125 micrograms

• CrCl <10: 62.5 micrograms

What is the loading dose of digoxin, and when should it be used?

A loading dose of 250-500 micrograms every 4-6 hours up to a maximum of 1.5mg can be used. It is usually only used for more rapid control of ventricular rate in AF and atrial flutter.

How should digoxin be taken?

Take 1 tablet once daily, with or without food.

How long does it take for digoxin to reach its maximum effect?

2-6 hours after an oral dose.

What are the key side effects and monitoring points for digoxin, and how should they be managed?

• All medications can have side effects, and not all of them will occur, but it’s important to be aware of what could possibly happen, so you know what to do next

• Digoxin requires regular blood tests, especially for the first 7 days after the start of treatment or increasing the dose, so your doctor knows the correct amount of medication to give you and make sure you don’t get any more serious side effects

• Side effects are more likely at higher doses, so we start at low doses to make sure this risk is low

• Main symptoms are nausea, vomiting and loss of appetite → if these persist for a few hours, tell your doctor as the dose may be too high for you

• More serious symptoms include very slow heart rate, dizziness, fatigue, or vision turning yellow → these are uncommon and usually the nausea/vomiting will happen first, but it is important to stick with your blood tests for as long as your doctor requires them

What are the red flag symptoms for digoxin?

• Very slow heart rate, dizziness, fatigue, yellow visual field → stop the medication and tell your doctor as soon as possible

What are some important counselling points for digoxin?

• Tell your doctor or pharmacist that you are taking digoxin before starting any new medications

• Keep up with your regular blood tests and doctor’s appointments, they will become less frequent once your body adjusts to digoxin

What are some important lifestyle points for patients with atrial fibrillation who are taking digoxin?

• Eat a heart-healthy diet that is low in sodium, saturated fats and cholesterol

• Try to get a good amount of sleep at night, and avoid excessive alcohol, caffeine, smoking and other triggers that can put additional stress on your heart

• Engage in regular physical activity, listening to your body and doing as much as you feel able to. It could be helpful to discuss your exercise with a physio so they can help determine a good level of exercise for you.