Key result
Patients receiving digoxin-Fab for suspected chronic digoxin toxicity were more likely to be on maintenance therapy with beta-blockers or calcium channel blockers (95% vs 61%; OR 13.1; 95% CI 1.5-113).
Why the study?
What are the clinical characteristics and heart rate responses of patients with suspected chronic digoxin toxicity treated with versus without digoxin-Fab?
Observational (n=47)
No
What are the clinical characteristics and heart rate responses of patients with suspected chronic digoxin toxicity treated with versus without digoxin-Fab?
Digoxin-Fab is more commonly administered in patients with severe bradycardia and hyperkalemia, but its chronotropic effect is variable, suggesting the need for concurrent positive chronotropic and potassium-lowering therapies.
Answers are grounded in this paper and cite their sources.
Clinical features like bradycardia and hyperkalemia may influence digoxin-Fab decisions in chronic toxicity; leaves open optimal selection criteria for validation.
OBJECTIVE: The aim of the present study was to compare clinical features of patients with elevated serum digoxin concentrations who were treated with digoxin-Fab with those where the immunotherapy was not given by a tertiary hospital toxicology service. METHODS: This was a retrospective series of patients with supratherapeutic serum digoxin concentrations referred to the toxicology service from August 2013 to October 2015. Data collected included demographics, presenting complaint, digoxin dose, other medications taken, serum digoxin, potassium and creatinine concentration on presentation and initial and post-digoxin-Fab heart rate. RESULTS: There were 47 referrals. Digoxin-Fab was administered in 21 cases. It was given more commonly when the heart rate was <51/min or serum potassium was >5.0 mmol/L. Patients receiving digoxin-Fab were more likely to be on maintenance therapy with beta-blockers or calcium channel blockers (95% vs 61%; OR 13.1; 95% CI 1.5-113) and/or potassium-sparing medications (95% vs 54%; OR 17.1; 95% CI 2.0-147). They had elevated serum creatinine (76% vs 42%; OR 8.2; 95% CI 1.9-34), higher serum potassium (median: 5.1 mmol/L vs 4.2 mmol/L, P = 0.02), higher serum digoxin concentration (median: 3.5 nmol/L vs 2.3 nmol/L, P = 0.02) and pretreatment heart rate <51/min (66% vs 31%; OR 4.5; 95% CI 1.3-15). There were no patients with ventricular arrhythmias or hypotension. Median heart rate increased by 10/min 1 and 4 h after digoxin-Fab. However, individual heart rate response to digoxin-Fab was variable. CONCLUSION: Digoxin-Fab was more commonly administered when heart rate was <51/min. It had a small effect on increasing heart rate; however, individual response to digoxin-Fab was variable as patients were using other negative chronotropic medications. In symptomatic bradycardic patients on multiple heart failure medications, positive chronotropic and potassium-lowering therapies should be considered in concert with digoxin-Fab.
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Arbabian et al. (2018) conducted an observational in Suspected chronic digoxin toxicity (n=47). Digoxin-Fab vs. No digoxin-Fab was evaluated on Maintenance therapy with beta-blockers or calcium channel blockers (OR 13.1, 95% CI 1.5-113). Patients receiving digoxin-Fab for suspected chronic digoxin toxicity were more likely to be on maintenance therapy with beta-blockers or calcium channel blockers (95% vs 61%; OR 13.1; 95% CI 1.5-113).
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