Digoxin for HFrEF

Digoxin can be added to therapy for patients with persistent symptomatic HFrEF not adequately controlled by optimal doses of a renin-angiotensin system inhibitor, beta blocker, mineralocorticoid receptor antagonist, sodium-glucose co-transporter 2 inhibitor and loop diuretic.

Most patients with HFrEF can be started on low-dose digoxin without the need for a loading dose. If digoxin is appropriate, use:

Monitor plasma digoxin concentration in patients who require a high dose, older patients and patients with kidney impairment. Aim for a trough concentration of 0.5 to 0.8 micrograms/L. Avoid concentrations above 1.2 micrograms/L to minimise the risk of toxicity.

In patients with normal kidney function, the half-life of digoxin is at least 24 hours. After starting therapy or changing the digoxin dose, it takes at least 5 days (5 half-lives) to achieve a steady state. In patients with kidney impairment it may take much longer to reach a steady state and a lower maintenance dose of digoxin may be required.