Digoxin Toxicity: Crucial To Diagnose: International Journal of Basic & Clinical Pharmacology

www.ijbcp.
com International Journal of Basic & Clinical Pharmacology | July-August 2012 | Vol 1 | Issue 1 Page 39
IJBCP International Journal of Basic & Clinical Pharmacology
Print ISSN: 2319-2003 | Online ISSN: 2279-0780
Case Report
Digoxin toxicity: crucial to diagnose
Tejas A. Acharya
a,
*, Dimple S. Mehta
a
, Ritesh S. Vekariya
b

INTRODUCTION
Digoxin is cardiac glycoside, which is obtained from the
digitalis lanta.
1
Digoxin is mainly used for heart failure
and arrhythmias like atrial flutter and fibrillation.
2
Digoxin effect is to increase intracellular amounts of Ca
2+

ions and K
+
conductance. Other effects of this drug are
increase in the refractory period of SA and AV nodes,
decreasing it in the atria and ventricles, and so increase in
excitability.
3
Digoxin is like double edged sword because
of its potency to cause life threatening complications like
various arrhythmias.
4
furthermore, it is difficult and
important to recognize cardio toxicity caused by digoxin
to prevent threat to life. We report a case which was
initially diagnosed as arrhythmia and later turned as
digoxin toxicity.
CASE REPORT
A 63 year old male hindu patient, belong to lower
socioeconomic, came at medicine OPD of our tertiary
care centre on 23
rd
March 2011 as follow up case of
myocardial infarction with heart failure. Patient was
relatively asymptomatic when he came for follow up at
medicine OPD. Patient was known case of MI with CCF
for 2.5 months. Before 2.5 months he was admitted to our
tertiary care centre and received treatment. For last 2.5
months patient was receiving following drugs:
combination of aspirin, atorvastatin and glycine (75 mg,
10 mg and 37.5 mg OD respectively), digoxin (0.25 mg
OD), losartan (50mg OD), combination of torsamide and
spironolactone (25 mg and 40 mg OD respectively) and
carvedilol (3.125mg BD). All drugs were introduced
orally. While examination, in OPD suddenly patient
became unconscious. Patient was admitted to medicine
ICU. On examination his pulse was 100/min and blood
pressure was 100/90 mm of Hg. On ECG he was
diagnosed as having ventricular tachycardia.
After initial diagnosis of ventricular tachycardia
emergency management was done with O
2
inhalation (2
lit/min), DC shock (200 J) and amiodarone (150mg IV
over 10 min followed by 3.3 ml/hour after diluting with
50 ml normal saline). Rest of the treatment was continued
as patient was receiving for 2.5 months. Patient became
conscious after emergency management. Laboratory
analysis was done including routine blood reports, serum
creatinine and electrolytes, blood sugar and urine routine
report. All the parameters were within normal limit. After
4 hours, patients condition started deteriorating and pulse
fell down to 30/min. In spite of proper management
deteriorating condition aroused suspicion of digoxin
induced ventricular tachycardia and serum digoxin level
was advised on second day. Treatment modification was
done by stopping amiodarone infusion and administration
of atropine (1 mg IV stat). On third day, serum digoxin
level suggested high level with value of 2.88 ng/ml,
which was considerably high to cause toxicity. Digoxin
introduction was stopped immediately and patient was
monitored for general condition. After 24 hour of close
observation, on fourth day; patients pulse rate improved
to 64/min with 108/60 mm of Hg blood pressure.
Patients general condition was improved with minor
complain of constipation, which was treated with syrup
lactulose (15 ml HS). This adverse drug reaction was
reported by pharmacovigilance centre of our tertiary care
ABSTRACT
Digoxin is mainly used for heart failure and arrhythmias
like atrial flutter and fibrillation. Digoxin is like double
edged sword because of its potency to cause life
threatening complications like various arrhythmias.
Furthermore, it is difficult and important to recognize
cardio toxicity caused by digoxin to prevent threat to
life. We report a case which was initially diagnosed as
arrhythmia and later turned as digoxin toxicity.

Keywords: Cardiac glycoside, Arrhythmia, Congestive
heart failure

a
Department of Pharmacology, C.U. Shah Medical
College and Hospital, Surendranagar 363001, India,
b
Department of Medicine, C.U. Shah Medical
College and Hospital, Surendranagar 363001, India

Received: 7 August 2012
Accepted: 9 August 2012

*Correspondence to:
Dr. Tejas A. Acharya,
Email: [email protected]
doi: 10.5455/2319-2003.ijbcp001012
Acharya TA et al. Int J Basic Clin Pharmacol. 2012 Aug;1(1):39-40
International Journal of Basic & Clinical Pharmacology | July-August 2012 | Vol 1 | Issue 1 Page 40
centre and WHO causality
5
assessment was done, which
categorized it as certain event. Patient was observed for
next four days with outcome of stabilized pulse rate of
64/min and 130/90 mm of Hg blood pressure with
relieved ventricular tachycardia. Patient was discharged
with advice of oral treatment with combination of aspirin,
atorvastatin and glycine (75 mg, 10 mg and 37.5 mg OD
respectively), losartan (50mg OD), combination of
torsamide and spironolactone (25 mg and 40 mg OD
respectively), amiodarone (200 mg OD) and syrup
lactulose (15 ml HS). After 7 days on follow up, patients
condition was better with all parameters within normal
range.
DISCUSSION
Digoxin usage has decreased in the treatment of
congestive heart failure and atrial fibrillation as a result of
its inferiority to beta-adrenergic inhibitors and agents that
interfere with the deleterious effects of the activated
renin-angiotensin-aldosterone system.
6
As use of digoxin
has decreased and when it is used usually at lower dose
adverse effects has become lower but it is often
overlooked whenever it occurs. Factors responsible for
toxicity are older age, female sex, low lean body mass,
and renal insufficiency. In present case patient was
initially treated as arrhythmia and DC shock was given
but DC shock is contraindicated in patients with high
serum digoxin level, as it can lead to ventricular
fibrillation and may be fatal for patient.
7
Furthermore
amiodarone was introduced for ventricular tachycardia
but it can cause fatal interaction with digoxin if serum
digoxin level is already high.
8
It clearly indicates how
crucial is to diagnose digoxin toxicity and manage it
properly.
REFERENCES
1. Hollman A. Digoxin comes from Digitalis lanata.
BMJ. 1996; 312:912.
2. Tripathi KD. Cardiac glycosides and drugs for heart
failure. Essentials of medical pharmacology. 6
th
ed.
New Delhi: Jaypee Brothers; 2009:493-507.
3. Zand F, Asadi S, Katibeh P. Good Outcome after
Digoxin Toxicity Despite Very High Serum
Potassium Level. Iran Red Crescent Med J 2011; 13:
680-1.
4. Doering W, Konig E, Sturm W. Digitalis
intoxication: specifity and significance of cardiac
and extracardiac symptoms. part I: Patients with
digitalis-induced arrhythmias. Z Kardiol 1977; 66:
121-8.
5. The Uppsala monitoring centre. The use of WHO-
UMC system for standardised case causality
assessment. Available at http://www.who-umc.org.
Accessed 1 August 2012.
6. Yang EH, Shah S, Criley JM. Digitalis toxicity: a
fading but crucial complication to recognize. Am J
Med 2012; 125:337-43.
7. Maron BA, Rocco TP. Pharmacotherapy of
congestive heart failure. In: Bruton LS, editor.
Goodman & Gillmans The Pharmacological basis
of Therapeutics. 12
th
ed. USA: Mc Graw Hill
publication; 2011:789-813.
8. Lexi-Comp Online Interaction Lookup, 2010.
Available at
http://www.uptodate.com/crlsql/interact/frameset.jsp
. Accessed 1 August 2012.

Digoxin Toxicity: Crucial To Diagnose: International Journal of Basic & Clinical Pharmacology

Uploaded by

Copyright:

Available Formats

Digoxin Toxicity: Crucial To Diagnose: International Journal of Basic & Clinical Pharmacology

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Digoxin Toxicity: Crucial To Diagnose: International Journal of Basic & Clinical Pharmacology

Uploaded by

Copyright:

Available Formats

www.ijbcp.

You might also like