eMedicine Specialties > Cardiology > Arrhythmias

Digitalis Toxicity: Follow-up

Author: Vinod Patel, MD, Medical Director, Jefferson Family Medicine Center; Clinical Assistant Professor, Department of Family Medicine, State University of New York at Buffalo
Coauthor(s): Paul Arthur James, MD, IAFP Endowed Chair in Rural Medicine, Associate Professor of Family Medicine, Department of Family Medicine, University of Iowa College of Medicine
Contributor Information and Disclosures

Updated: Dec 22, 2008

Follow-up

Further Inpatient Care

  • Postimmunotherapy treatment
    • After treatment with Fab fragments, the serum digoxin level will rise considerably. Digoxin level cannot be used as a guide to treatment after administration of Fab fragments
    • Free digoxin levels can be used, but most hospitals do not have this assay available. The elimination half-life of digoxin Fab complex is 20-30 hours, although clearance is related directly to the glomerular filtration rate and consequently is prolonged in renal insufficiency. Recrudescence of digoxin toxicity is possible because the Fab complex is eliminated more rapidly than digoxin is released from tissue-binding sites.
    • Significantly, in a long-term digoxin user who requires Fab treatment for digitalis toxicity, administration can precipitate worsening heart failure by removing the beneficial inotropic activity of digoxin, causing hypokalemia and atrial arrhythmia with rapid ventricular response. Hypokalemia occurred in patients who were treated with standard therapy as well as Fab fragments. Clinically adverse phenomena have occurred in fewer than 10% of patients treated with immunotherapy.
    • Other untoward effects of Digibind include anaphylaxis and serum sickness because it is a foreign protein; these reactions are uncommon. Allergy to Fab fragments is associated with patients who have multiple allergies.
  • Hemodialysis
    • Hemodialysis (HD) and activated charcoal hemoperfusion (HP) have no role in the management of digitalis intoxication. Without the use of Fab, these procedures are not indicated because the molecular weight of digoxin is too large for HD to be successful. In addition, the volume of distribution of digoxin is too large to make either approach feasible. Hemodialysis is superfluous after administration of Fab and HP.
    • Digoxin-specific antibody fragments are effective even in anephric patients, although symptoms may recur 7–14 days later, possibly indicating the need for another dose of Fab.
    • Hemoperfusion through columns with antidigoxin antibodies bound to agarose polyacrolein microsphere beads has been accomplished, but the availability of Fab in the United States makes this modality outdated.
    • Continuous arteriovenous hemofiltration in an experimental model has failed to remove the digoxin-Fab complex.

Further Outpatient Care

  • Patients with accidental exposure and no sign of toxicity after 12 hours can be discharged home with appropriate follow-up. Observe patients for at least 6 hours on a cardiac monitor, and lab results should be normalized.
  • Suicidal, depressed patients should be cleared by a psychiatry consult for prevention of repeated toxic ingestion before discharge.

Transfer

Transfer hemodynamically unstable patients to a tertiary care center equipped with medical intensive care unit/critical care unit (MICU/CCU) capabilities. Notifying of the and discussing the treatment of the poisoning with the regional poison center also is important.

Deterrence/Prevention

  • Dosage adjustment with frequent laboratory monitoring, especially if the patient has chronic renal failure
  • Adequate hydration
  • Supplementation of potassium chloride in patients with diuretic therapy

Prognosis

Prognosis is poor with increasing age and associated comorbid conditions.

Patient Education

Miscellaneous

Medicolegal Pitfalls

Failure to provide psychiatric follow-up with suicidal ingestion is a potential pitfall. Others are failure to follow up on digitalis level with new medication prescription, a hospitalized elderly patient with recent normal outpatient digitalis level on "same" dose, regular rhythm in a patient with chronic atrial fibrillation, and teenager drug overdose.

Special Concerns

  • Digoxin in pregnancy
    • Digoxin is used widely in the acute management and prophylaxis of fetal paroxysmal supraventricular tachycardia (SVT), as well as in rate control of atrial fibrillation. It is a category C drug. Increased digoxin dosage may be necessary during pregnancy because of enhanced renal clearance and expanded blood volume.
    • No series has been published regarding toxicity in the pregnant woman. Digoxin-specific Fab fragments can be used in pregnancy with the caveat that careful monitoring of the fetus must be maintained.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Thomas P Smith Jr, MD to the development and writing of this article.



More on Digitalis Toxicity

Overview: Digitalis Toxicity
Differential Diagnoses & Workup: Digitalis Toxicity
Treatment & Medication: Digitalis Toxicity
Follow-up: Digitalis Toxicity
References
[ CLOSE WINDOW ]

References

  1. Mahdyoon H, Battilana G, Rosman H, Goldstein S, Gheorghiade M. The evolving pattern of digoxin intoxication: observations at a large urban hospital from 1980 to 1988. Am Heart J. Nov 1990;120(5):1189-94. [Medline].

  2. Barrueto F, Jortani SA, Valdes R, et al. Cardioactive steroid poisoning from an herbal cleansing preparation. Ann Emerg Med. Mar 2003;41(3):396-9. [Medline].

  3. Binder WD, Lewander WJ. Digoxin. In: Viccellio P, ed. Emergency Toxicology. Philadelphia, Pa: Lippincott-Raven; 1998:707-721.

  4. Dribben WH, Kirk MA. Digitalis glycosides. In: Tintinalli JE, Kelan G, Stapzcynsky JP, eds. Emergency Medicine: A Comprehensive Study Guide. 5th ed. New York, NY: McGraw-Hill; 1999:1139-42.

  5. Hoffman BF, Bigger T Jr. Digitalis and allied cardiac glycosides. In: Gilman AG, Rall TW, Nies AS, Taylor P, eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 8th ed. New York, NY: Pergamon Press; 1990:814-39.

  6. Howland MA. Prescription medications, digoxin-specific antibody fragments. In: Goldfrank LR, Flomenbaum NE, Lewin NA, Weis, eds. Goldfrank's Toxicologic Emergencies. 6th ed. Norwalk, Conn: Appleton & Lange; 1998:48:801-807.

  7. Lewin NA. Prescription medications, cardiac glycosides. In: Goldfrank LR, Flomenbaum NE, Lewin NA, Weis, eds. Goldfrank's Toxicologic Emergencies. 6th ed. Appleton & Lange; 1998:791-800.

  8. Roberts DJ. Common cardiovascular drugs. In: Rosen P, ed. Emergency Medicine, Concepts and Clinical Practice. 2nd ed. St Louis, Mo: Mosby; 1992:1307-12.

  9. Smith TW, Antman EM, Friedman PL, et al. Digitalis glycosides: mechanisms and manifestations of toxicity. Part I. Prog Cardiovasc Dis. Mar-Apr 1984;26(5):413-58. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

digitalis toxicity, atrial fibrillation, cardiac glycoside, congestive heart failure, CHF, digitoxin, digoxin, inotropic agent, inotropy, Digitalis purpurea, Thevetia peruviana, depletion of potassium stores, myocardial infarction, myocardial ischemia, hypothyroidism, hypercalcemia, renal insufficiency

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Vinod Patel, MD, Medical Director, Jefferson Family Medicine Center; Clinical Assistant Professor, Department of Family Medicine, State University of New York at Buffalo
Vinod Patel, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, and North American Primary Care Research Group
Disclosure: Nothing to disclose.

Coauthor(s)

Paul Arthur James, MD, IAFP Endowed Chair in Rural Medicine, Associate Professor of Family Medicine, Department of Family Medicine, University of Iowa College of Medicine
Paul Arthur James, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, North American Primary Care Research Group, Phi Beta Kappa, and Society of Teachers of Family Medicine
Disclosure: Nothing to disclose.

Medical Editor

Justin D Pearlman, MD, PhD, ME, MA, Director of Advanced Cardiovascular Imaging, Professor of Medicine, Professor of Radiology, Adjunct Professor, Thayer Bioengineering and Computer Science, Dartmouth-Hitchcock Medical Center
Justin D Pearlman, MD, PhD, ME, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Ronald J Oudiz, MD, FACP, FACC, Associate Professor of Medicine, Division of Cardiology, The David Geffen School of Medicine at UCLA; Director, Liu Center for Pulmonary Hypertension, LA Biomedical Research Institute at Harbor-UCLA Medical Center
Ronald J Oudiz, MD, FACP, FACC is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association
Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Encysive Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria; Lilly Grant/research funds Clinical Trials + honoraria; LungRx  Clinical Trials + honoraria

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Eric H Yang, MD, Assistant Professor of Medicine, Director of Coronary Care Unit, University of North Carolina at Chapel Hill School of Medicine
Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Up to Date Royalty Review panel membership

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.