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    Patent Pending

    DigiFab (Digibind) Dosing for Digoxin Poisoning

    Doses DigiFab in patients with confirmed digoxin poisoning or overdose.

    IMPORTANT

    This dosing tool is intended to assist with calculation, not to provide comprehensive or definitive drug information. Always double-check dosing of any drug and consult a pharmacist when necessary.

    INSTRUCTIONS

    Therapeutic range for serum digoxin level is 0.8–2.0 ng/mL (1.0–2.6 nmol/L). If acute poisoning and serum digoxin confirmed >10 ng/mL, give empiric dose (10-20 vials). See Evidence for details.

    Additional considerations for treatment of digoxin toxicity include:

    • Atropine 0.5 mg IV for acute toxicity if bradydysrhythmias or high degree AV block.
    • Cautious correction of electrolyte abnormalities, specifically hypokalemia and hypomagnesemia (may result in dysrhythmias at lower serum digoxin levels).
    When to Use
    Pearls/Pitfalls
    Why Use

    General:

    • Acute, acute on chronic, or chronic digoxin toxicity.
    • Poisoning with cardioactive steroid.

    Specific indications:

    • Any digoxin-related life-threatening dysrhythmia (independent of digoxin level).
    • Potassium concentration >5 mEq/L in acute digoxin poisoning.
    • Elevated serum digoxin level, chronic digoxin toxicity associated with dysrhythmias, significant gastrointestinal symptoms, or altered mental status.
    • Serum digoxin level >15 ng/mL (19.2 nmol/L) at any time, or >10 ng/mL (12.8 nmol/L) 6-hours post-ingestion (independent of symptoms).
    • Acute ingestion >10 mg digoxin in an adult.
    • Acute ingestion >4 mg digoxin in a child.
    • Poisoning with a non-digoxin cardioactive steroid (e.g. plants like foxglove and lily of the valley).
    • Cardioactive steroid toxicity can cause nearly any dysrhythmia with the exception of a rapidly conducted supraventricular tachydysrhythmia.
    • The serum digoxin level must be considered in the context of the patient’s clinical presentation; a reliable serum digoxin level must be obtained at steady-state (i.e., obtained ≥6 hours after ingestion). The serum digoxin level may be misleadingly high if obtained <6 hours after ingestion.
    • Digoxin levels measured after administration of DigiFab will be falsely elevated. If required, free digoxin levels will need to be measured (not readily available at all labs).
    • Hyperkalemia acts as a marker of poisoning severity in acute digoxin overdose. Correcting mild elevations in serum potassium without administering DigiFab will not improve survival (see Next Steps for details).
    • Impaired creatinine clearance and aging (associated with decreased function of renal, hepatic, and cardiac systems) may result in clinical toxicity at lower serum digoxin levels.
    • Electrolyte abnormalities (specifically hypokalemia, but including hypomagnesemia, hypercalcemia, hypernatremia) may result in dysrhythmias at lower serum digoxin levels.
    • Drugs including quiNIDine, verapamil, dilTIAZem, carvedilol, amiodarone, and spironolactone will result in decreased digoxin protein binding, thereby increasing free digoxin levels.

    Tips from the creator:

    • The calculator is appropriate for vials containing (approximately) 40 mg of antibodies.
    • Slow infusion (i.e., 2 hours) improves Fab efficacy. This way of infusion is preferable when rhythm disturbances are not life-threatening.
    • In the case of chronic overdose, if digoxin level (in prehospital setting for example) is missing, a dose of 3 vials is appropriate (experience-based recommendation).

    DigiFab is an effective antidote for acute, acute on chronic, and chronic digoxin toxicity. It is also indicated for poisoning from other cardioactive steroids.

    Serum digoxin level
    Amount ingested

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights
    Dr. Frédéric Lapostolle

    About the Creator

    Frédéric Lapostolle, MD, PhD, is an emergency physician at Avicenne Hospital in Bobigny, France. He is deputy medical director of Samu 93 Emergency Rescue Service. Dr. Lapostolle is a professor of emergency medicine and has authored or co-authored over 100 papers in his specialty.

    To view Dr. Frédéric Lapostolle's publications, visit PubMed

    Are you Dr. Frédéric Lapostolle? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
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    Dr. Frédéric Lapostolle
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