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Review
. 2023 Jul 3:10:1179892.
doi: 10.3389/fcvm.2023.1179892. eCollection 2023.

Review: Failure of current digoxin monitoring for toxicity: new monitoring recommendations to maintain therapeutic levels for efficacy

Sridhar Rao Gona  1 , Joel Rosenberg  2 , Ria C Fyffe-Freil  3 , Janet M Kozakiewicz  4 , Mary E Money  5   6
Affiliations
Review

Review: Failure of current digoxin monitoring for toxicity: new monitoring recommendations to maintain therapeutic levels for efficacy

Sridhar Rao Gona et al. Front Cardiovasc Med. .

Abstract

The current recommendations for monitoring digoxin, a narrow therapeutic index drug, are limited to confirming medication use or investigating suspicion of toxicity and fail our oath to do no harm. Numerous meta-analyses evaluating digoxin use consistently recommend frequent monitoring to maintain the level of 0.5 to ≤1.0 ng/ml because higher levels lead to increased morbidity and mortality without benefit. Data from the United States National Poison Control Center (2012-2020) show annual deaths due to digoxin of 18-36 compared to lithium's 1-7, and warfarin's 0-2 respectively. The latter drugs also have narrow therapeutic indexes like digoxin yet are more carefully monitored. Recognition of digoxin toxicity is impaired as levels are not being routinely checked after medications are added to a patient's regimen. In addition, providers may be using ranges to guide treatment that are no longer appropriate. It is imperative that monitoring guidelines and laboratory therapeutic levels are revised to reduce morbidity and mortality due to digoxin. In this review, we provide a comprehensive literature review of digoxin monitoring guidelines, digoxin toxicity, and evidence to support revising the ranges for serum digoxin monitoring.

Keywords: digoxin; digoxin monitoring recommendations; digoxin morbidity; digoxin toxicity; narrow therapeutic index and critical dose drugs; patient quality and safety; rapid atrial fibrillation/flutter; therapeutic level.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Study analysis.
Figure 2
Figure 2
Categorization of symptoms reported by digoxin toxicity patients in meritus medical center cohort (April 1, 2019–April 1, 2022).
Figure 3
Figure 3
Distribution of documented symptoms among patients with toxic digoxin levels in ED or admitted to meritus medical center from April 1, 2019, to April 1, 2022 in the following categories: (A) general/constitutional, (B) cardiovascular, (C) gastrointestinal, and (D) neurological (including visual changes).
Figure 4
Figure 4
Percentage of patients reportedly taking digoxin over the last 3 years according to data from Epic Cosmos.
Figure 5
Figure 5
Percentage of patients with atrial fibrillation diagnosis over the last 3 years according to data from Epic Cosmos.
See this image and copyright information in PMC

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