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Digoxin Toxicity
An Evaluation in Current Clinical Practice
Kristin M. Williamson, PharmD, BCPS;
Kimberly A. Thrasher, PharmD, BCPS;
Kathey B. Fulton, PharmD;
Nancy M. Allen LaPointe, PharmD;
Gary D. Dunham, PharmD;
April A. Cooper, PharmD;
Pamela S. Barrett, PharmD;
J. Herbert Patterson, PharmD, FASHP, FCCP, BCPS
Arch Intern Med. 1998;158:2444-2449.
Background Serum digoxin concentrations (SDCs) are frequently sampled before completion of drug distribution. If elevated, these concentrations may be misinterpreted, potentially leading to a misdiagnosis of digoxin toxicity.
Objectives To determine the frequency of elevated SDCs (>2.6 nmol/L [>2.0 ng/mL]) obtained at appropriate postdosing intervals and to evaluate the frequency of clinically defined digoxin toxicity in patients with elevated SDCs.
Methods The medical records of adult patients with SDCs assayed at 5 general hospitals in North Carolina during a 3-month period (May 1 through July 31, 1996) were prospectively evaluated. Data on SDC, inpatient or outpatient status, and medical or surgical service were collected for all patients. Data on patient demographics, serum chemistry values, indication for digoxin treatment, clinical evidence of digoxin toxicity, and timing of the blood sample relative to administration of the last dose of digoxin were collected for patients with SDCs higher than 2.6 nmol/L (>2.0 ng/mL).
Results Of 3434 SDCs assayed in 2009 patients, 320 (9.3%) were higher than 2.6 nmol/L (>2.0 ng/mL). Fifty-one (15.9%) of the 320 SDCs were drawn at 6 hours or less following a digoxin dose. Sampling time relative to the digoxin dose could not be determined in 70 (21.9%) of the 320 elevated SDCs, leaving 199 (62.2%) of 320 SDCs in 138 patients evaluable for digoxin toxicity. Eighty-three of the 138 patients had clinical evidence of digoxin toxicity for an overall incidence of 4.1%.
Conclusions Digoxin toxicity occurs less frequently than historically reported. Continued emphasis needs to be placed on obtaining appropriately timed SDCs.
From Quintiles Cardiovascular Therapeutics, Quintiles Inc, Research Triangle Park, NC (Dr Williamson); Schools of Pharmacy (Drs Williamson, Thrasher, LaPointe, Dunham, Cooper, and Patterson) and Medicine (Dr Patterson), University of North Carolina at Chapel Hill; Division of Pharmacotherapy, Coastal Area Health Education Center, Wilmington, NC (Dr Thrasher); Pitt County Memorial Hospital, Greenville, NC (Dr Fulton), and Campbell University School of Pharmacy, Buies Creek, NC (Drs Fulton and Dunham); Duke Heart Center (Drs LaPointe and Dunham) and Department of Medicine (Dr Dunham), Duke University Medical Center, Durham, NC; Raleigh Community Hospital, Raleigh, NC (Dr Cooper); and Glaxo Wellcome Inc, Research Triangle Park (Dr Barrett).
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