digoxin (Rx)Lanoxin

Classes: Antidysrhythmics, V; Inotropic Agents

Pediatric

Dosing & Uses

Dosage Forms & Strengths

Heart Failure/Atrial Fibrillation

Adult

Use doses at the lower end of the spectrm when treating heart failure
Dosage Forms & Strengths
Atrial Fibrillation

Reduce dose by 20-25% when changing from oral formulation or IM to IV

therapy

Rapid digitalizing (loading-dose) regimen

IV: 8-12 mcg/kg (0.008-0.012 mg/kg) total loading dose; administer

50% initially; then may cautiously give 1/4 the loading dose q6-8hr twice;
perform careful assessment of clinical response and toxicity before each
dose
PO: 10-15 mcg/kg total loading dose; administer 50% initially; then
may cautiously give 1/4 the loading dose q6-8hr twice; peform careful
assessment of clinical response and toxicity before each dose
Maintenance

As per ACCF/AHA guidelines, a loading dose to initiate digoxin therapy in

patients with heart failure is not necessary

PO: 1st loading dose, 17.5-30 mcg/kg; 2nd and 3rd loading doses,
8.75-15 mcg/kg q6-8hr for 2 doses; maintenance: 10-15 mcg/kg/day divided
q12hr
IV/IM: 1st loading dose, 15-25 mcg/kg; 2nd and 3rd loading doses,
7.5-12.5 mcg/kg q6-8hr for 2 doses; maintenance: 7.5-12 mcg/kg/day
divided q12hr
2-5 years

Dosing Modifications

In heart failure, higher dosages have no additional benefit and may increase

toxicity; decreased renal clearance may lead to increased toxicity

In geriatric patients, use lean body weight to calculate dose

PO: 1st loading dose, 12.5-17.5 mcg/kg; 2nd and 3rd loading doses,
6.25-8.75 mcg/kg q6-8hr for 2 doses; maintenance: 6-10 mcg/kg/day
divided q12hr
IV/IM: 1st loading dose, 10-15 mcg/kg; 2nd and 3rd loading doses, 57.5 mcg/kg q6-8hr for 2 doses; maintenance: 5-8 mcg/kg/day divided q12hr
Infants & children 1-24 months

0.125-0.25 mg PO/IV qDay; higher doses including 0.375-0.5 mg/day rarely

needed

Adjust maintenance dose by estimating CrCl and measuring serum levels

PO: 1st loading dose, 10-15 mcg/kg; 2nd and 3rd loading doses, 57.5 mcg/kg q6-8hr for 2 doses; maintenance: 5-7.5 mcg/kg/day divided
q12hr
IV/IM: 1st loading dose, 7.5-12.5 mcg/kg; 2nd and 3rd loading doses,
3.75-6.25 mcg/kg q6-8hr for 2 doses; maintenance: 4-6 mcg/kg/day divided
q12hr
Full-term neonate

PO: 3.4-5.1 mcg/kg/day or 0.125-0.5 mg/day PO; may increase dose

every 2 weeks based on clinical response, serum drug levels, and toxicity
IV/IM: 0.1-0.4 mg qDay; IM route not preferred due to severe injection
site reaction

Heart Failure

Use lower end of dosing (0.125 mg/day) in patients with impaired renal
function or low lean body mass

Premature neonate

PO: 1st loading dose, 15-20 mcg/kg; 2nd and 3rd loading doses,
8.75-10 mcg/kg q6-8hr for 2 doses; maintenance: 7.5-10 mcg/kg/day
divided q12hr
IV/IM: 1st loading dose, 12.5-17.5 mcg/kg; 2nd and 3rd loading
doses, 6.25-8.75 mcg/kg q6-8hr for 2 doses; maintenance: 6-9 mcg/kg/day
divided q12hr

5-10 years

PO: 1st loading dose, 10-17.5 mcg/kg; 2nd and 3rd loading doses, 58.75 mcg/kg q6-8hr for 2 doses; maintenance: 5-10 mcg/kg/day divided
q12hr
IV/IM: 1st loading dose, 7.5-15 mcg/kg; 2nd and 3rd loading doses,
3.75-7.5 mcg/kg q6-8hr for 2 doses; maintenance: 4-8 mcg/kg/day divided
q12hr

Frequency Not Defined

Visual disturbance (blurred or yellow vision)
Heart block (1/2/3)
Asystole

>10 years & <100 kg

Tachycardia

PO: 1st loading dose, 5-7.5 mcg/kg; 2nd and 3rd loading doses, 2.53.75 mcg/kg q6-8hr for 2 doses; maintenance: 2.5-5 mcg/kg/day
IV/IM: 1st loading dose, 4-6 mcg/kg; 2nd and 3rd loading doses, 2-3
mcg/kg q6-8hr for 2 doses; maintenance: 2-3 mcg/kg/day
Adverse Effects

Warnings

1-10%
Dizziness (4.9%)
Mental disturbances (4.1%)
Diarrhea (3.2%)
Headache (3.2%)
Nausea (3.2%)
Vomiting (1.6%)
Maculopapular rash (1.6%)
<1%
Anorexia
Cardiac dysrhythmia
Arrhythmia in children (consider a toxicity)

Contraindications
Hypersensitivity
Ventricular fibrillation
Cautions
Use caution in chronic constrictive pericarditis, electrical cardioversion,
severe bradycardia, severe heart failure, severe pulmonary disease, sick
sinus syndrome, ventricular tachycardia, ventricular premature contractions,
Wolff-Parkinson-White syndrome, electrolyte imbalance, hypothyroidism or
hyperthyroidism, hypoxia, idiopathic hypertrophic subaortic stenosis, renal
disease, concomitant diuretics
Not recommended in patients with acute myocardial infarction
Avoid in patients with myocarditis
Risk of advanced or complete heart block in patients with sinus node disease
and AV block
Very narrow margin between effective therapeutic and toxic dosages:
Therapeutic range, 0.5-2 ng/mL (target 0.5-1 ng/mL); toxic range, >2.5
ng/mL
Generally avoid if left ventricular systolic function preserved, although may
be used for ventricular rate control in subgroup with chronic atrial fibrillation

Less effective in presence of hypokalemia or hypocalcemia; avoid

hypercalcemia or hypomagnesemia, which may predispose to serious
arrhythmias

Onset: 0.5-2 hr (PO) for initial effect and 2-6 hr for maximal effect; 5-30 min
(IV) for initial effect and 1.5-4 hr for maximal effect
Duration: 3-4 days

Heart failure patients with preserved ventricular function including acute cor
pulmonale, amyloid heart disease, and constrictive pericarditis may be
susceptible to digoxin toxicity
May cause false-positive ST-T changes during exercise testing
Do not switch between different PO forms or between brand and generic
forms of digoxin; bioavailability varies
Serum levels drawn within 6-8 hours of dose will be falsely high because of
prolonged distribution phase
Increased risk of estrogenlike effects in geriatric patients
Beriberi heart disease may not respond adequately if underlying thiamine
deficiency not corrected
Atrial arrhythmias are difficult to treat if associated with hypermetabolic
(hyperthyroidism) or hyperdynamic (hypoxia) states; treat underlying
condition before initiating therapy
Pharmacology
Mechanism of Action

Peak serum time: 1-3 hr (PO)

Distribution
Protein bound: 20-25%
Vd: 6-7 L/kg
Metabolism
Metabolized by liver
Metabolites:
(active)

Digoxigenin

bisdigitoxoside,

digoxigenin

monodigitoxoside

Elimination
Half-life: 1-3 days
Excretion: Urine (57-80%), feces (9-13%; includes bile)
Administration

In heart failure, increases contractility by inhibiting sodium/potassium ATPase

pump in myocardial cells, which subsequently promotes calcium influx via
sodium-calcium exchange pump

IV Compatibilities

In supraventricular arrhythmias, suppresses AV node conduction, which

increases refractory period and decreases conduction velocity, causing
positive inotropic effect, decreased ventricular rate, and enhanced vagal
tone

Additive: Bretylium, cimetidine, floxacillin, furosemide, lidocaine, ranitidine,

verapamil

Absorption

Y-site: Bivalirudin, ciprofloxacin, cisatracurium, dexmedetomidine, diltiazem,

famotidine, fenoldopam, gatifloxacin, heparin with hydrocortisone, Hextend,
inamrinone, linezolid, meperidine, meropenem, midazolam, milrinone,
morphine sulfate, potassium chloride, remifentanil, tacrolimus, vitamins B
and C

Bioavailability: 60-80 % (tablet); 70-85% (elixir)

Solution: D5/NS with potassium chloride 20 mEq, D5W, LR, NS, NS

Syringe: Heparin, milrinone

IV Incompatibilities

Action Competitively inhibits angiotensin I-converting enzyme,

Additive: Dobutamine
Syringe: Doxapram
Y-site: Amphotericin B cholesteryl sulfate, amiodarone,
foscarnet, insulin (beef, pork, and Humulin R[?]), propofol

fluconazole,

resulting in prevention of angiotensin I conversion to angiotensin II, a potent

vasoconstrictor that also stimulates aldosterone release. Clinical
consequences are a decrease in BP, reduced sodium resorption and
potassium retention.
Indications Treatment of essential hypertension.

IV Preparation
Dilute with 4-fold or greater volume of SWI, D5W, or NS
IV Administration
Administer slowly by direct IV injection over minimum of 5 minutes (longer if
given undiluted)
Do not administer if precipitate present

Contraindications Hypersensitivity or history of angioedema

related to ACE inhibitor treatment.

Route/Dosage

Drug is severe skin irritant when given IV/IM and may cause severe local skin
reaction with possible sloughing
Storage
Store at controlled room temperature
Protect from light

Uncomplicated Hypertension
ADULTS: PO Initial dose 4 mg qd; then titrate upward until BP, just before the
next dose, is controlled or a maximum of 16 mg/day. Usual maintenance
dose is 4 to 8 mg daily. PATIENTS > 65 YRS: PO Initial dose 4 mg daily in 1 or
2 divided doses; then titrate upward until BP, just before the next dose, is
controlled, or a max of 8 mg/day.
Use with Concomitant Diuretics

Perindopril Erbumine
(per-IN-doe prill ehr-BYOO-meen)
Aceon
Class: Antihypertensive/Angiotensin-converting enzyme (ACE) inhibitor

ADULTS: PO If BP is not adequately controlled with perindopril alone, a

diuretic may be added. In patients being treated with a diuretic, to reduce
the likelihood of the occurrence of symptomatic hypotension, discontinue the
diuretic 2 to 3 days prior to beginning perindopril. If the diuretic cannot be
discontinued, use an initial dose of 2 to 4 mg daily of perindopril and titrate
the dose as above.
Impaired Renal Function
ADULTS (CREATININE CLEARANCE < 30 ML/MIN): PO Initial dose 2 mg/day
(max dose 8 mg/day).

Interactions
PATIENT
CONSIDERATIONS

Administration/Storage

Diuretics: Increased risk of excessive reduction in BP. Potassium

supplements, potassium-sparing diuretics (eg, spironolactone), drugs
capable of increasing serum potassium (eg, cyclosporine, heparin,
indomethacin): Increased risk of hyperkalemia. Lithium: Increased risk of
lithium toxicity.
Lab Test Interferences None well documented.

Store at controlled room temperature in tightly closed container.

Protect from moisture.

Administer alone or in combination with other antihypertensives or

diuretics.

Adverse Reactions

CV: Palpitation; abnormal ECG. RESP: Cough; upper respiratory infection.

CNS: Headache; dizziness; sleep disorder; depression; somnolence;
nervousness. EENT: Sinusitis; ear infection; rhinitis; pharyngitis; seasonal
allergy; tinnitus. GI: Dyspepsia; diarrhea; abdominal pain; nausea; vomiting;
flatulence. GU: Proteinuria; urinary tract infection; sexual dysfunction;
menstrual disorder. HEPA: Increased ALT. DERM: Rash. META: Increased
triglycerides. OTHER: Asthenia; viral infection; upper and lower extremity
pain; hypertonia; fever; edema; chest pain; neck pain; paresthesia; joint
pain; myalgia; arthritis.
Precautions

Pregnancy: Category C (first trimester); category D (second and third

trimesters). Lactation: Undetermined. Children: Safety and efficacy not
established. Elderly: Perindopril plasma concentrations may be increased.
Angioedema: May occur and is potentially fatal if laryngeal edema occurs.
Use drug with extreme caution in patients with history of angioedema.
Cough: Chronic nonproductive cough may occur. Hepatic failure: Has
occurred rarely with other ACE inhibitors. Hypotension: Symptomatic
hypotension may occur. Neutropenia and agranulocytosis: Has occurred
rarely with other ACE inhibitors; risk appears greater with renal dysfunction,
heart failure, or immunosuppression. Renal impairment: Changes in renal
function may occur in susceptible individuals.

CARE

Assessment/Interventions

Obtain patient history, including drug history and any known

allergies.

Monitor for signs of hypersensitivity including angioedema involving

swelling of the face, lips, and tongue. If occurring, withold therapy
and notify the primary care provider. Where there is involvement of
the tongue, glottis, or larynx likely to cause airway obstruction,
promptly administer emergency therapy, which could include
epinephrine.

Monitor BP and pulse. Should hypotension, tachycardia, or

bradycardia result, hold the medication and notify the primary care
provider.

Monitor for adverse reactions and drug interactions.

Monitor laboratory tests for increases in serum creatinine and BUN,

hemoglobin, hematocrit, and liver function tests.

Institute fall precautions in unstable patients including the elderly

and patients with CHF.

Assist patient with position changes and ambulation during initial

phases of therapy.

OVERDOSAGE: SIGNS & SYMPTOMS

Hypotension, hypothermia, circulatory
arrest, death

Patient/Family Education

Instruct patient to take the medication as prescribed at the same

time each day, and not to discontinue medication suddenly even if
feeling better.

Inform patient that perindopril can control but does not cure
hypertension.

Instruct patient in BP and pulse measurement skills. Caution patient

to call primary care provider should abnormal readings occur or if
experiencing lightheadedness.

Instruct patient to stop medication and consult physician if fainting

occurs.

Instruct patient in methods of fall prevention including arising slowly

and sitting on the side of the bed before standing, especially early in
therapy.

Warn patient that inadequate fluid intake, excessive perspiration,

diarrhea, or vomiting, resulting in reduced fluid volume, may lead to
an excessive fall in BP resulting in lightheadedness and possible
fainting.

Tell patient not to use potassium supplements or salt substitutes

containing potassium without consulting physician.

Instruct patient to report any indications of an infection such as a

sore throat that could indicate neutropenia.

Caution patient to notify physician or dentist prior to surgery or

treatment.

Caution female patients to notify primary care provider at once if

pregnant, planning to become pregnant, or planning to breastfeed.

Spironolactone
(SPEER-oh-no-LAK-tone)
Aldactone, Spironolactone,

Novo-Spiroton, Novo-Spirozine

Class: Potassium-sparing diuretic

Inform patient of the importance of adjunct therapies such as dietary

planning, a regular exercise program, weight reduction, a low sodium
diet, smoking cessation program, alcohol reduction, and stress
management.

Instruct patient to report the following symptoms to primary

caregiver: Dyspnea, loss of taste, swelling of eyes, face, lips, tongue,
or throat, difficulty breathing, speaking, or swallowing.

Instruct patient to monitor renal, hepatic, and hematologic

symptoms including urinary output and any discomfort during
urination, weakness, fatigue, dizziness, lightheadedness, jaundice,
and inform their primary care provider should symptoms arise.

Explain to patient that chronic cough may occur. Instruct patient to

avoid cough, cold, or allergy medication, and to notify the physician.

Action

Competitively

inhibits

aldosterone

in

distal

tubules,

resulting in increased excretion of sodium and water and decreased

excretion of potassium.
Indications

Short-term

preoperative

treatment

of

primary

hyperaldosteronism; long-term maintenance therapy for idiopathic

hyperaldosteronism; management of edematous conditions in CHF, cirrhosis
of liver and nephrotic syndrome; management of essential hypertension;
treatment of hypokalemia. Unlabeled use(s): Treatment of hirsutism; relief
of PMS symptoms; short-term treatment of familial male precocious puberty;
and short-term treatment of acne vulgaris.

Contraindications Anuria; acute renal insufficiency; impaired

resulting in cardiac arrhythmias or cardiac arrest. Do not take with potassium

preparations. Salicylates: May result in decreased diuretic effect.
Lab Test Interferences Drug may cause falsely elevated serum

renal excretory function; hyperkalemia.

Route/Dosage
digoxin values with radioimmunoassay (assay specific) for measuring
digoxin.
Adverse Reactions
Diagnosis of Primary Hyperaldosteronism
ADULTS: PO 400 mg/day for 4 days (short test) or 3 to 4 wk (long test).
Maintenance Therapy for Hyperaldosteronism
ADULTS: PO 100 to 400 mg daily in single or divided doses.
Edema

CNS: Drowsiness; lethargy; headache; mental confusion; ataxia. DERM:

Maculopapular or erythematous cutaneous eruptions; urticaria. GI:
Cramping; diarrhea; gastric bleeding; gastric ulceration; gastritis; vomiting.
GU: Inability to achieve or maintain erection. HEMA: Agranulocytosis. META:
Hyperchloremic metabolic acidosis in decompensated hepatic cirrhosis.
OTHER: Gynecomastia; irregular menses or amenorrhea; postmenopausal
bleeding; hirsutism; deepening of voice; drug fever; carcinoma of breast.

ADULTS: PO 25 to 200 mg/day in single or divided doses. CHILDREN: PO 3.3

mg/kg/day in single or divided doses.

Precautions

Essential Hypertension
ADULTS: PO 50 to 100 mg/day in single or divided doses. CHILDREN: PO 1 to
2 mg/kg bid.
Diuretic-Induced Hypokalemia
ADULTS: PO 25 to 100 mg/day when oral potassium or other potassiumsparing regimens are inappropriate.

Pregnancy: Category D. Lactation: Excreted in breast milk. Electrolyte

imbalances and BUN increase: Hyperkalemia (serum potassium > 5.5
mEq/L), hyponatremia, hypochloremia and increases in BUN may occur.

PATIENT
CONSIDERATIONS

CARE

Interactions
Administration/Storage

ACE inhibitors: May result in severely elevated serum potassium levels.

Digitalis glycosides: May decrease digoxin clearance, resulting in increased
serum digoxin levels and toxicity; may attenuate inotropic action of digoxin.
Mitotane: May decrease therapeutic response to mitotane. Potassium
preparations: May severely increase serum potassium levels, possibly

If single dose is prescribed, administer in morning.

Take medication with food.

May crush tablets and administer as suspension.

Suspension is stable for 30 days under refrigeration. Protect from

light.

Store tablets at room temperature.

OVERDOSAGE: SIGNS & SYMPTOMS

Electrolyte imbalance

Patient/Family Education

Assessment/Interventions

Explain that medication's full diuretic effect may not be achieved for
1 to 2 wk.

Obtain patient history, including drug history and any known

allergies.

Instruct patient to avoid large quantities of potassium-rich foods or

potassium salt substitutes.

Assess fluid and electrolyte status prior to therapy.

Monitor potassium levels. If level is > 5.5 mEq/L, withhold medication

and notify physician.

For patient being treated for hypertension, explain that patient may
feel tired for several wks because body needs to adjust to lowered
BP.

Instruct patient to take drug with food to minimize GI irritation.

Monitor serum electrolytes, I&O, weight and BP daily.

Monitor ABGs, liver and renal function studies.

Tell patient to weigh self twice wkly and to notify physician of any
increase.

If deep rapid respirations or headaches develop, notify physician.

Instruct patient to notify physician if new symptoms develop.

Assess urinary status. If patient develops frequency, dysuria, edema

or reduced urinary output, notify physician.

Tell patient to report these symptoms to physician: GI cramping,

diarrhea, lethargy, thirst, headache, skin rash, menstrual
abnormalities, deepening of voice and breast enlargement in men.

Assess for any changes in hepatic status. If patient appears

jaundiced and mentally confused, notify physician.

Advise patient that drug may cause drowsiness and to use caution
while driving or performing other tasks requiring mental alertness.

If nausea, vomiting, distention, diarrhea or anorexia occur, notify

physician.

Instruct patient not to take prescription or otc medications without

consulting physician.

Note any changes in neurologic status. If drowsiness, ataxia,

lethargy, confusion or headache occurs, notify physician.