Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute ingestion, low to moderate toxicity

1st line – activated charcoal

Back
ACUTE
|
acute ingestion, low to moderate toxicity
1st line – 

activated charcoal

Activated charcoal is administered to decrease gastrointestinal absorption of the drug; however, serum concentrations may also be decreased by facilitating gut dialysis via the enterohepatic and enteroenteric recirculation of digoxin (and other cardioactive corticosteroids).[39][40]

Effective in the first 6-8 hours post-ingestion.

If severe toxicity, activated charcoal may be omitted and digoxin immune Fab given immediately.

Caution should be taken in patients who vomit or those with altered mental status. They are at risk of pulmonary aspiration when drinking the solution.

Primary options

charcoal, activated: 1 g/kg orally as a single dose, repeat every 2-4 hours if required, maximum 4 doses total

Plus – supportive care

Back
ACUTE
|
acute ingestion, low to moderate toxicity
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

General supportive care includes attaching patients to a cardiac monitor, providing intravenous fluids in patients with hypotension or volume depletion (with caution for patients with congestive heart failure), supplemental oxygen, and/or repletion of electrolytes in patients with electrolyte abnormalities. Patients with hypokalemia or hypomagnesemia require additional potassium or magnesium with careful monitoring to restore normal serum levels.

Plus – potassium replacement

Back
ACUTE
|
acute ingestion, low to moderate toxicity
|
with hypokalemia
Plus – 

potassium replacement

Treatment recommended for ALL patients in selected patient group

Potassium should be given via cautious intravenous infusion to restore serum potassium to normal levels.

Replacement should follow local hospital protocols.

The serum potassium should be checked at intervals and therapy adjusted as needed.

Plus – observation ± correction of hyperkalemia

Back
ACUTE
|
acute ingestion, low to moderate toxicity
|
with hyperkalemia
Plus – 

observation ± correction of hyperkalemia

Treatment recommended for ALL patients in selected patient group

Hyperkalemia is only corrected (e.g., with insulin/glucose) if it is considered life-threatening, because of the risk of producing hypokalemia.

If required, correction should follow local hospital protocols. Calcium is not used to treat hyperkalemia in patients with suspected digoxin toxicity as it may induce arrhythmia or cardiac arrest.

Plus – magnesium replacement

Back
ACUTE
|
acute ingestion, low to moderate toxicity
|
with hypomagnesemia
Plus – 

magnesium replacement

Treatment recommended for ALL patients in selected patient group

Magnesium should be given via cautious intravenous infusion to restore serum magnesium to normal levels.

Replacement should follow local hospital protocols.

The serum magnesium should be checked at intervals and therapy adjusted as needed.

chronic ingestion, low to moderate toxicity

1st line – supportive care

Back
ACUTE
|
chronic ingestion, low to moderate toxicity
1st line – 

supportive care

Treatment of chronic toxicity is based on a clinical syndrome, not the serum digoxin concentration, which might be just above the therapeutic range. If a serum digoxin concentration cannot be obtained, patients are managed based on their presentation, ECG findings, and laboratory results.

General supportive care includes attaching patients to a cardiac monitor, providing intravenous fluids in patients with hypotension or volume depletion (with caution for patients with congestive heart failure), supplemental oxygen, and/or repletion of electrolytes in patients with electrolyte abnormalities. Patients with hypokalemia or hypomagnesemia require additional potassium or magnesium with careful monitoring to restore normal serum levels.

Plus – potassium replacement

Back
ACUTE
|
chronic ingestion, low to moderate toxicity
|
with hypokalemia
Plus – 

potassium replacement

Treatment recommended for ALL patients in selected patient group

Potassium should be given via cautious intravenous infusion to restore serum potassium to normal levels.

Replacement should follow local hospital protocols.

The serum potassium should be checked at intervals and therapy adjusted as needed.

Plus – observation ± correction of hyperkalemia

Back
ACUTE
|
chronic ingestion, low to moderate toxicity
|
with hyperkalemia
Plus – 

observation ± correction of hyperkalemia

Treatment recommended for ALL patients in selected patient group

Hyperkalemia is only corrected (e.g., with insulin/glucose) if it is considered life-threatening, because of the risk of producing hypokalemia.

If required, correction should follow local hospital protocols. Calcium is not used to treat hyperkalemia in patients with suspected digoxin toxicity as it may induce arrhythmia or cardiac arrest.

Plus – magnesium replacement

Back
ACUTE
|
chronic ingestion, low to moderate toxicity
|
with hypomagnesemia
Plus – 

magnesium replacement

Treatment recommended for ALL patients in selected patient group

Magnesium should be given via cautious intravenous infusion to restore serum magnesium to normal levels.

Replacement should follow local hospital protocols.

The serum magnesium should be checked at intervals and therapy adjusted as needed.

severe toxicity or hemodynamic compromise (acute or chronic toxicity)

1st line – digoxin binding

Back
ACUTE
|
severe toxicity or hemodynamic compromise (acute or chronic toxicity)
1st line – 

digoxin binding

Digoxin binding is used in patients with severe toxicity or hemodynamic compromise; symptomatic bradyarrhythmias; ventricular dysrhythmias; any patient with digoxin overdose and potassium concentrations >5.0 mEq/L; acute ingestion of >4 mg in a healthy child (or 0.1 mg/kg); acute ingestion of >10 mg in a healthy adult; serum concentration of ≥10 nanograms/mL 4-6 hours after ingestion (steady state); and serum concentration of ≥15 nanograms/mL at any time.

There are formulae available within the package insert for calculating the neutralising dose of digoxin immune Fab, based on total body burden or total dose ingested.[44] In acute toxicity, 15 vials of Fab is the quantity typically needed to treat one patient.[27] One study suggests 1-2 vials administered in a stepwise fashion based on clinical response.[28] For patients with chronic digitalis poisoning, therapy may require only a few Fab vials.

Patients who receive digoxin immune Fab have a drop in the serum potassium as it moves intracellularly.[29][30][31] Some patients who have been treated for hyperkalemia and who have also received digoxin immune Fab develop profound hypokalemia. Therefore, serial potassium measurements are made when patients receive both digoxin immune Fab and other therapies to decrease potassium.[32]

After administration of digoxin immune Fab, serum digoxin concentrations are usually falsely elevated (10- to 30-fold). Serum digoxin concentration can be measured again 3-4 days after dose is given,​ but has been reported to be elevated for up to 10 days, especially in patients with renal insufficiency.[33][34][35]

Patients may rarely develop a rate-related infusion reaction, in which case the infusion should be stopped and restarted at a slower infusion rate. There is a higher risk for a reaction if no filter is used when giving digoxin immune Fab.

After administration, serum total digoxin concentrations are no longer useful because elevated levels reflect both free digoxin and digoxin bound to Fab.[33] There are assays that are able to determine free digoxin serum concentrations, but they are not always routinely available.

Primary options

digoxin immune Fab: consult specialist for guidance on dose

Plus – supportive care

Back
ACUTE
|
severe toxicity or hemodynamic compromise (acute or chronic toxicity)
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

General supportive care includes attaching patients to a cardiac monitor, providing intravenous fluids in patients with hypotension or volume depletion (with caution for patients with congestive heart failure), supplemental oxygen, and/or repletion of electrolytes in patients with electrolyte abnormalities.

Patients with hypokalemia or hypomagnesemia require additional potassium or magnesium with careful monitoring to restore normal serum levels.

In patients with chronic digoxin toxicity, hyperkalemia is only corrected (e.g., with insulin/glucose) if it is considered life-threatening, because of the risk of producing hypokalemia. Calcium is not used to treat hyperkalemia in patients with suspected digoxin toxicity as it may induce arrhythmia or cardiac arrest.

Plus – potassium replacement

Back
ACUTE
|
severe toxicity or hemodynamic compromise (acute or chronic toxicity)
|
with hypokalemia
Plus – 

potassium replacement

Treatment recommended for ALL patients in selected patient group

Potassium should be given via cautious intravenous infusion to restore serum potassium to normal levels.

Replacement should follow local hospital protocols.

The serum potassium should be checked at intervals and therapy adjusted as needed.

Plus – observation ± correction of hyperkalemia

Back
ACUTE
|
severe toxicity or hemodynamic compromise (acute or chronic toxicity)
|
with hyperkalemia
Plus – 

observation ± correction of hyperkalemia

Treatment recommended for ALL patients in selected patient group

Hyperkalemia is only corrected (e.g., with insulin/glucose) if it is considered life-threatening, because of the risk of producing hypokalemia.

If required, correction should follow local hospital protocols. Calcium is not used to treat hyperkalemia in patients with suspected digoxin toxicity as it may induce arrhythmia or cardiac arrest.

Plus – magnesium replacement

Back
ACUTE
|
severe toxicity or hemodynamic compromise (acute or chronic toxicity)
|
with hypomagnesemia
Plus – 

magnesium replacement

Treatment recommended for ALL patients in selected patient group

Magnesium should be given via cautious intravenous infusion to restore serum magnesium to normal levels.

Replacement should follow local hospital protocols.

The serum magnesium should be checked at intervals and therapy adjusted as needed.

Plus – atropine or temporary pacing wire

Back
ACUTE
|
severe toxicity or hemodynamic compromise (acute or chronic toxicity)
|
with symptomatic bradycardia/high-degree atrioventricular (AV) block
Plus – 

atropine or temporary pacing wire

Treatment recommended for ALL patients in selected patient group

If digoxin-binding therapy is not immediately available patients with symptomatic bradycardia can be treated with atropine.[32]

In adults, atropine can be given every 3-5 minutes until there is a response or the 3-mg maximum dose is reached. Pediatric patients with symptomatic bradycardia require lower doses of atropine.

Alternatively, a temporary pacing wire can be inserted in patients with evidence of significant bradycardia or AV block and hemodynamic compromise if digoxin-specific antibody (Fab) fragments are not readily available.

Primary options

atropine: children: 0.02 mg/kg (minimum 0.1 mg, maximum 0.5 mg) intravenously as a single dose, may repeat once only, maximum 1 mg/total dose; adults: 0.5 mg intravenously every 3-5 minutes, maximum 3 mg/total dose

Plus – defibrillation plus antiarrhythmics

Back
ACUTE
|
severe toxicity or hemodynamic compromise (acute or chronic toxicity)
|
with ventricular tachyarrhythmias
Plus – 

defibrillation plus antiarrhythmics

Treatment recommended for ALL patients in selected patient group

Patients with ventricular fibrillation or pulseless ventricular tachycardia require defibrillation along with immunotherapy.

Antiarrhythmics are administered while awaiting digoxin immune Fab. Type IB antiarrhythmics (e.g., lidocaine, phenytoin) have a fast-on, fast-off effect at the Na+ channel, and these drugs depress the enhanced ventricular automaticity without significantly slowing atrioventricular (AV) nodal conduction. Phenytoin may perhaps enhance AV nodal conduction.[45][46] Phenytoin can terminate digitalis-induced cardiac arrhythmias better than lidocaine.[46]

Type 1A (e.g., quinidine, procainamide) and 1C (e.g., flecainide, propafenone) antiarrhythmics are contraindicated.

Primary options

phenytoin: children: 1.25 mg/kg intravenously every 5 minutes, maximum 15 mg/kg total dose; adults: 50-100 mg intravenously every 10-15 minutes, maximum 15 mg/kg total dose

Secondary options

lidocaine: children: 1 mg/kg intravenous bolus initially, followed by 30-50 micrograms/kg/min infusion; adults: 1 to 1.5 mg/kg intravenous bolus initially, followed by 1-4 mg/min infusion

ONGOING

acute or chronic toxicity after initial treatment

1st line – prescription of alternative drug and discontinuation of digoxin

Back
ONGOING
|
acute or chronic toxicity after initial treatment
1st line – 

prescription of alternative drug and discontinuation of digoxin

Ideally, digoxin is discontinued and a different medicine for rate control or a different inotrope prescribed (for atrial fibrillation, atrial flutter or congestive heart failure, respectively).

2nd line – digoxin dose adjustment and regular monitoring

Back
ONGOING
|
acute or chronic toxicity after initial treatment
2nd line – 

digoxin dose adjustment and regular monitoring

If the patient has to remain on digoxin for some reason, then the dose of digoxin is adjusted for the patient's medication profile. Glomerular filtration rate and serum digoxin concentration is monitored regularly (every 2-4 weeks).

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer