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    DigiFab (Digibind) Dosing for Digoxin Poisoning

    Doses DigiFab in patients with confirmed digoxin poisoning or overdose.
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    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.

    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:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    Frequent premature ventricular complexes (PVCs) may be closely followed by ventricular dysrhythmias.

    Critical Actions

    • Potassium abnormalities, specifically hypokalemia, may worsen digoxin toxicity, even at therapeutic digoxin levels.
    • If mild hyperkalemia, correction is not advised, as treatment with DigiFab will decrease potassium concentrations.
      • Treatment to lower serum potassium concentrations should be performed prior to DigiFab administration only if (1) hyperkalemia is believed to be worsening AV nodal block and bradycardia AND (2) DigiFab is not immediately available.
    • If hypokalemia, cautious correction is advised prior to the administration of DigiFab.
    • If worsening toxicity/dysrhythmia or if toxicity does not improve with correction of hypokalemia, DigiFab should be immediately administered.
    • Though debated, calcium salts should not be administered to patients with hyperkalemia secondary to digoxin toxicity.
    • Transcutaneous and especially transvenous pacing should be avoided in patients with digoxin toxicity due to risk for precipitating dysrhythmias.
    Content Contributors
    About the Creator
    Dr. Frédéric Lapostolle
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