Recommendations
Key Recommendations
Consult your approved clinical toxicology resource (e.g., TOXBASE in the UK) and/or seek advice from your national or regional poisons information service.[1] National Poisons Information Service: TOXBASE Opens in new window
Discontinue the digoxin and any other drugs that increase the serum digoxin concentration or potentiate the effects of digoxin.[20]
Be alert to the possibility of cardiac arrest.[1] Resuscitation and supportive treatment may be needed. Perform an Airway, Breathing, Circulation, Disability, Exposure (ABCDE) assessment and re-assess the patient regularly throughout treatment.[26] Ensure rapid fluid resuscitation in patients with hypovolaemia.[1] Treat hyperkalaemia, hypokalaemia, and hypomagnesaemia, as necessary.
Consider use of digoxin-specific antibody (Fab) fragments in patients with cardiac arrest, arrhythmias, or severe hyperkalaemia.[1][27]
If an intentional overdose is suspected or confirmed, establish the person’s mental and emotional state at the earliest opportunity and request a full mental health assessment.[22]
The main goal of treatment is to correct cardiac toxicity. Treatment of cardiac toxicity usually leads to resolution of central nervous system and gastrointestinal symptoms.
Initial treatment includes:
General supportive care
Discontinuation of digoxin therapy and prevention of further exposure
Prevention of further gastrointestinal absorption
Administration of digoxin-specific antibody (Fab) fragments
Treatment of specific complications: for example, dysrhythmias and electrolyte abnormalities.
Immediate urgent care
Perform an Airway, Breathing, Circulation, Disability, Exposure (ABCDE) assessment and re-assess the patient regularly throughout treatment.[26]
Be alert to the possibility of cardiac arrest.[1]
Resuscitation and supportive treatment may be needed.
If so, continue resuscitation for at least 1 hour. Only stop after discussion with a senior clinician.[1]
Observe for electrolyte abnormalities and correct if found to be present (see Electrolyte abnormality management below).[1]
Collect a sample to measure digoxin concentration, if possible.[1]
Use digoxin-binding therapy (see Digoxin-specific antibody (Fab) fragments below).
Ensure rapid fluid resuscitation in patients with hypovolaemia.[1]
If the patient has signs of haemodynamic insufficiency and/or compromise (e.g., hypotension, altered consciousness), give digoxin-specific antibody (Fab) fragments as primary management (see Digoxin-specific antibody (Fab) fragments below).
Refer patients with fluid-resistant hypotension to critical care and involve paediatrics for children.[1]
Discuss symptomatic patients and any patients with ECG abnormalities with critical care.[1]
Consult your approved clinical toxicology resource (e.g., TOXBASE in the UK) and/or seek advice from your national or regional poisons information service.[1][22] National Poisons Information Service: TOXBASE Opens in new window
Discontinue the digoxin and any other rate control agents that potentiate the effects of digoxin.[20]
Further monitoring
Check and monitor:[1]
Cardiac rhythm
Vital signs
Capillary blood glucose
Pupil size
Blood pressure
Hypotension may occur.
Consider any indications that poisoning may have been intentional as an act of self-harm:[22]
Take urgent steps to establish the patient’s emotional and mental state at the same time as assessing physical risk.
Request a psychosocial assessment by a trained member of staff. Do not delay this until after medical treatment unless life-saving treatment is needed.
Offer a safe, supportive environment for the patient to wait for treatment, with regular supervision and contact from a named staff member to ensure safety.
Observe all patients who have required assessment for at least 6 hours after ingestion. After this time, consider discharging patients if their digoxin concentration has returned to normal and they have a normal ECG. Instruct the patient to return if symptoms develop.[1]
If a mixed overdose has occurred, consult your approved clinical toxicology resource (e.g., TOXBASE in the UK). There may be specific management recommendations to bear in mind, particularly regarding the amount of time the patient should be monitored for.[1]
Correct electrolyte abnormalities in line with your local protocols. The following recommendations are from the National Poisons Information Service in the UK.[1] National Poisons Information Service: TOXBASE Opens in new window
Hyperkalaemia
Adults
Give adults with severe hyperkalaemia:[1]
10% calcium chloride by slow intravenous injection with continuous cardiac monitoring, or 10% calcium gluconate by slow intravenous injection with continuous cardiac monitoring
Repeat the initial dose after 5-10 minutes if there is no improvement in the ECG, up to a maximum dose of 30 mL (6.8 mmol).
Nebulised salbutamol
10 units of short acting insulin with 100 mL of 20% dextrose intravenously over 5 minutes.
Repeat if the hyperkalaemia does not improve.
Consider: [1]
Correcting metabolic acidosis with intravenous sodium bicarbonate.
Haemodialysis in patients with renal failure to treat severe hyperkalaemia or acidosis.
Always monitor potassium repeatedly if digoxin-specific antibody (Fab) fragments are administered as the patient’s potassium concentration may fall rapidly.[1]
Significant hyperkalaemia is associated with a poor prognosis if not treated.[27]
Children (under 12 years)
Always discuss children with hyperkalaemia rapidly with your paediatric department and refer for specialist management.[1]
Hypokalaemia
Use oral or intravenous potassium to the high end of the normal range to correct hypokalaemia.[1]
Hypomagnesaemia
If the patient has hypomagnesaemia, give additional magnesium with careful monitoring to restore normal serum levels.
Urgently administer digoxin-specific antibody (Fab) fragments (also known as digoxin immune Fab) in patients with strongly suspected or known digoxin toxicity plus:[1][27]
Cardiac arrest
Life-threatening ventricular arrhythmia or severe bradyarrhythmia
Severe hyperkalaemia (potassium concentrations >6.5 mmol/L [>6.5 mEq/L]) resistant to conventional treatment.
Repeated doses may be required, for example if the patient remains unstable with arrhythmias or hyperkalaemia.[1]
Digoxin-specific antibody (Fab) fragments tend to be used in two doses:[1]
Full neutralisation: calculated to neutralise all the digoxin load
Half neutralisation: calculated to neutralise half of the digoxin load.
The ‘half neutralisation’ dose is adequate for most patients. It is calculated using the patient's weight and the serum digoxin concentration.
Consult your approved clinical toxicology resource (e.g., TOXBASE in the UK) to assist with calculation of the appropriate dose. In the situation of cardiac arrest when time is critical and these variables may not be known, your approved clinical toxicology resource provides advice on empirical dosing.[1] National Poisons Information Service: TOXBASE Opens in new window
Frequently monitor the patient’s serum potassium and magnesium. Correct hypomagnesaemia and hypokalaemia, if present, before or during administration of digoxin-specific antibody (Fab) fragments (see Electrolyte abnormality management below).[27]
The antibody fragments will further lower potassium.[27]
Patients who receive digoxin-specific antibody (Fab) fragments have a drop in the serum potassium as it moves intracellularly.[28][29][30]
Some patients who have been treated for hyperkalaemia and who have also received digoxin-specific antibody (Fab) fragments develop profound hypokalaemia.
Therefore, serial potassium measurements are made when patients receive both digoxin-specific antibody (Fab) fragments and other therapies to decrease potassium.[31]
The therapeutic effect of digoxin-specific antibody (Fab) fragments is usually seen within 15-30 minutes of administration.[1] Look for an improvement in the patient’s haemodynamic status, with pulse and blood pressure returning to normal. The potassium will also reduce.
Monitor the patient until there is clear clinical improvement; in practice, monitoring will continue for at least 24-48 hours. Bear in mind that after an initial response to digoxin-specific antibody (Fab) fragments, toxicity can develop again. Known as ‘rebound toxicity’, this can occur 12-24 hours after treatment, but reportedly even up to 10 days after treatment in patients with renal failure.[27]
Practical tip
Measure serum digoxin concentration every 24 hours until the patient is well and then re-establish the patient onto the therapeutic dose of digoxin, if appropriate. Re-check after a further 3 days.
For any patient with arrhythmias, consult a senior specialist colleague (cardiology or toxicology, as necessary) and refer to your approved clinical toxicology resource (e.g., TOXBASE in the UK). National Poisons Information Service: TOXBASE Opens in new window
Use digoxin-specific antibody (Fab) fragments in patients with severe bradyarrhythmia or life-threatening ventricular arrhythmia (see Digoxin-specific antibody (Fab) fragments above).[1]
If this is not immediately available, use atropine in patients with symptomatic bradycardia or atrioventricular (AV) block.[1][27][31][32] Repeat doses may be required. Paediatric patients with symptomatic bradycardia require lower doses of atropine. Consider using digoxin-specific antibody (Fab) fragments if they have become available after the patient has been treated with atropine.[1]
Consider inserting a temporary pacing wire in patients with evidence of significant bradycardia or AV block and haemodynamic compromise if digoxin-specific antibody (Fab) fragments are not readily available.[1]
Consider activated charcoal if the patient is symptomatic, or has ingested 20 micrograms/kg or more digoxin, or ingested any amount of a toxic plant.[1] Only do this provided the patient’s airway can be protected and gut motility is normal.[1]
The activated charcoal will reduce absorption.[1]
Ideally, give the activated charcoal within 2 hours of acute ingestion, although even later administration may be beneficial.[1][27] Give further doses every 4 hours by mouth or nasogastric tube. If the patient is vomiting, try giving smaller doses every 2 hours instead and consider an anti-emetic.[1]
Once the severe clinical features of toxicity have resolved, or the high digoxin plasma concentration has reduced, stop giving the activated charcoal. Also stop if the patient has evidence of an ileus. Review the patient after 4 doses have been given.[1]
Ideally, discontinue digoxin and prescribe a different medicine as needed. If the patient has to remain on digoxin, then adjust the dose for the patient's medication profile. Monitor glomerular filtration rate and serum digoxin concentration regularly (every 2-4 weeks).
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