Management overview for chronic digoxin accumulation

This monograph discusses the management of toxicity due to chronic accumulation of digoxin. For management of acute digoxin poisoning, see here.

Chronic digoxin use can lead to accumulation in the body if elimination is impaired. Digoxin accumulation is usually associated with an acute precipitant (eg dehydration due to an intercurrent illness). Most patients with digoxin accumulation are elderly and frail, often have multiple comorbidities (eg kidney failure, heart failure) and take multiple drugs. Digoxin accumulation can contribute to cardiovascular instability in these patients, but is rarely the sole cause.

Management of chronic digoxin accumulation involves:

• correction of precipitating factors—dehydration, electrolyte abnormalities (hypokalaemia, hypomagnesaemia)
• withholding digoxin and other contributing drugs, such as:
  • negative chronotropes—beta blockers, calcium channel blockers
  • potassium-sparing diuretics that cause hyperkalaemia
  • drugs that impair kidney function or inhibit digoxin elimination—nonsteroidal anti-inflammatory drugs (NSAIDs), macrolide antibiotics
• treatment of kidney failure and hyperkalaemia
• close monitoring for, and treatment of, life-threatening arrhythmias and heart failure
• giving digoxin-specific immune antibody fragments (digoxin immune Fab), if indicated, for cardiac complications.