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arrived at an emergency ward in a mentally confused state&#46; Multiply medicated&#44; with an unknown dose of digoxin&#44; plus diuretics&#44; anticoagulants&#44; etc&#46;&#44; and no access to medical attention in the previous 4 months&#46; On examination there were signs of moderate dehydration&#44; psychomotor agitation&#44; with a blood pressure of 120&#47;60mmHg and a heart rate of 34 beats&#47;min&#46; At the emergency unit&#44; biochemistry values were&#58; Hct 42&#37;&#44; Hb 11g&#47;dl&#44; urea 199&#44; Cr 4&#46;8&#44; K 6&#46;8&#44; digoxinaemia 5&#46;4&#44; pH 7&#46;29&#44; HCO 18&#46; Chest radiograph&#44; abdominal ultrasound and CT head scans were unremarkable&#46; ECG&#58; nodal rhythm of 34 per minute&#46; She was given emergency haemodialysis without ultrafiltration&#44; controlling the hyperkalaemia without any changes in the ECG&#46; She was not considered in need for admission to the intensive care unit&#44; nor were any other measures taken&#44; such as insertion of a pacemaker or administration of digoxin antibody&#46; For 48 hours the cardiovascular and neurological status of the patient remained unchanged&#44; with subsequent resolution of the whole process after rehydration&#44; digoxin levels normalised&#44; with recovery of urine output and mental state&#46;</p><p class="elsevierStylePara">This case had several risk factors that increased the risk of drug and digoxin intoxication &#40;Table 1&#41;&#44; with the drug being responsible for the symptoms&#46;</p><p class="elsevierStylePara">In order to evaluate kidney function when administering this drug in the elderly&#44; more factors than the serum creatinine values should be taken into account&#46;<span class="elsevierStyleSup">3</span> It is likely that this patient had hidden kidney disease&#46; Our obligation as nephrologists is to carry out emergency dialysis&#44; due to the presence of oliguric acute kidney injury after a pump failure with hyperkalaemia&#44; obviously&#44; not to decrease digoxin levels&#46; The final outcome was satisfactory without any more aggressive measures being taken due to the history and age of the patient&#46;</p><p class="elsevierStylePara">Digitalis toxicity is present in 0&#46;4&#37; of hospital admissions&#44; with a toxicity of 10-18&#37; in old peoples&#8217; homes&#44; leading to a 34&#37; morbidity and mortality of 1&#37;&#46; This toxicity may be chronic&#44; sometimes accidental and also due to attempted suicide&#46;<span class="elsevierStyleSup">4</span> Situations &#40;e&#46;g&#46; kidney disease&#41; or drugs that increase their levels &#40;verapamil and&#160; amiodarone&#44; among others&#41; can lead to&#160; intoxication&#46; Moreover&#44; as is known&#44; hyperkalaemia&#44; acidosis and hypercalcaemia enhance the effect&#46;</p><p class="elsevierStylePara">Apart from the known clinical condition&#44; hyperkalaemia requires a special mention as a prognostic factor and indicator of treatment&#46; This may result in not only decreased excretion due to kidney disease&#44; but a dysfunction of the Na-K-ATPase due to the digitalis effect&#46; This would be a first order prognostic marker because it faithfully reflects the magnitude of the deleterious effect&#44; and it is an indication for treatment with digoxin antibody &#40;K &#62; 5mEq&#47;dL&#41;&#46; Intravenous calcium administration to correct the electrocardiographic effect mediated by hyperkalaemia must be avoided&#44; due to the risk of further increasing intracellular calcium linked to digitalis toxicity&#46;</p><p class="elsevierStylePara">In another sense&#44; arrhythmia therapy indications&#44; among others&#44; should be addressed by the relevant specialty&#44; and we must practically confine ourselves to the repeated administration of atropine&#44; if necessary&#44; as there is a parasympathetic hyperactivity that can influence the placement of pacemakers&#44; performing gastric lavage&#44; etc&#46; The use of digoxin antibodies seems far more efficient and faster&#44; although in kidney disease a rebound effect may occur after initial administration&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara"><a href="grande&#47;1021818078&#95;t1&#95;pag131&#46;jpg" class="elsevierStyleCrossRefs"><img src="1021818078_t1_pag131.jpg" alt="Compliance of risk factors of digitalis toxicity in kidney function before and after treatment"></img></a></p><p class="elsevierStylePara">Table 1&#46; 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                  "referenciaCompleta" => "Mehta RN, Mehta NJ, Gulati A. Late rebound digoxin toxicity after digoxinspecific antibody Fab fragments therapy in anuric patient. J Emerg Med 2002;22:203. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11858929" target="_blank">[Pubmed]</a>"
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The risk of digoxin in the elderly
Los riesgos de la digoxina en el anciano
A.. Suárez Laurésa, A.. Pobes Martíneza, Luis Quiñones Ortiza, R.. Forascepia
a Servicio de Nefrología, Hospital Cabueñes, Gijón, España,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor&#44;</span></p><p class="elsevierStylePara">The elderly represent 17&#37; of the population and 70&#37; of drug expenditure&#46; Adverse drug events account for between 7&#46;2 and 14&#37; of hospital admissions for these patients in internal medicine in Spain&#46;<span class="elsevierStyleSup">1</span> Over the last decades this consumption has increased from 3 to 4-8&#46;2 drugs&#47;day&#44;<span class="elsevierStyleSup">2</span> and it has been shown that the quantity of drugs ingested is related to adverse effects&#46; The prevalence of hidden kidney disease in old age&#44; and internal changes in patients due to the pathology of multiple medication has led to an increase in iatrogenic events&#46; The following case of digitalis intoxication is submitted as an example of this&#46;</p><p class="elsevierStylePara">An 82-year old woman with a history of heart failure episodes&#44; with a previous serum Cr reference of 1&#46;2mg&#47;dL&#44; arrived at an emergency ward in a mentally confused state&#46; Multiply medicated&#44; with an unknown dose of digoxin&#44; plus diuretics&#44; anticoagulants&#44; etc&#46;&#44; and no access to medical attention in the previous 4 months&#46; On examination there were signs of moderate dehydration&#44; psychomotor agitation&#44; with a blood pressure of 120&#47;60mmHg and a heart rate of 34 beats&#47;min&#46; At the emergency unit&#44; biochemistry values were&#58; Hct 42&#37;&#44; Hb 11g&#47;dl&#44; urea 199&#44; Cr 4&#46;8&#44; K 6&#46;8&#44; digoxinaemia 5&#46;4&#44; pH 7&#46;29&#44; HCO 18&#46; Chest radiograph&#44; abdominal ultrasound and CT head scans were unremarkable&#46; ECG&#58; nodal rhythm of 34 per minute&#46; She was given emergency haemodialysis without ultrafiltration&#44; controlling the hyperkalaemia without any changes in the ECG&#46; She was not considered in need for admission to the intensive care unit&#44; nor were any other measures taken&#44; such as insertion of a pacemaker or administration of digoxin antibody&#46; For 48 hours the cardiovascular and neurological status of the patient remained unchanged&#44; with subsequent resolution of the whole process after rehydration&#44; digoxin levels normalised&#44; with recovery of urine output and mental state&#46;</p><p class="elsevierStylePara">This case had several risk factors that increased the risk of drug and digoxin intoxication &#40;Table 1&#41;&#44; with the drug being responsible for the symptoms&#46;</p><p class="elsevierStylePara">In order to evaluate kidney function when administering this drug in the elderly&#44; more factors than the serum creatinine values should be taken into account&#46;<span class="elsevierStyleSup">3</span> It is likely that this patient had hidden kidney disease&#46; Our obligation as nephrologists is to carry out emergency dialysis&#44; due to the presence of oliguric acute kidney injury after a pump failure with hyperkalaemia&#44; obviously&#44; not to decrease digoxin levels&#46; The final outcome was satisfactory without any more aggressive measures being taken due to the history and age of the patient&#46;</p><p class="elsevierStylePara">Digitalis toxicity is present in 0&#46;4&#37; of hospital admissions&#44; with a toxicity of 10-18&#37; in old peoples&#8217; homes&#44; leading to a 34&#37; morbidity and mortality of 1&#37;&#46; This toxicity may be chronic&#44; sometimes accidental and also due to attempted suicide&#46;<span class="elsevierStyleSup">4</span> Situations &#40;e&#46;g&#46; kidney disease&#41; or drugs that increase their levels &#40;verapamil and&#160; amiodarone&#44; among others&#41; can lead to&#160; intoxication&#46; Moreover&#44; as is known&#44; hyperkalaemia&#44; acidosis and hypercalcaemia enhance the effect&#46;</p><p class="elsevierStylePara">Apart from the known clinical condition&#44; hyperkalaemia requires a special mention as a prognostic factor and indicator of treatment&#46; This may result in not only decreased excretion due to kidney disease&#44; but a dysfunction of the Na-K-ATPase due to the digitalis effect&#46; This would be a first order prognostic marker because it faithfully reflects the magnitude of the deleterious effect&#44; and it is an indication for treatment with digoxin antibody &#40;K &#62; 5mEq&#47;dL&#41;&#46; Intravenous calcium administration to correct the electrocardiographic effect mediated by hyperkalaemia must be avoided&#44; due to the risk of further increasing intracellular calcium linked to digitalis toxicity&#46;</p><p class="elsevierStylePara">In another sense&#44; arrhythmia therapy indications&#44; among others&#44; should be addressed by the relevant specialty&#44; and we must practically confine ourselves to the repeated administration of atropine&#44; if necessary&#44; as there is a parasympathetic hyperactivity that can influence the placement of pacemakers&#44; performing gastric lavage&#44; etc&#46; The use of digoxin antibodies seems far more efficient and faster&#44; although in kidney disease a rebound effect may occur after initial administration&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara"><a href="grande&#47;1021818078&#95;t1&#95;pag131&#46;jpg" class="elsevierStyleCrossRefs"><img src="1021818078_t1_pag131.jpg" alt="Compliance of risk factors of digitalis toxicity in kidney function before and after treatment"></img></a></p><p class="elsevierStylePara">Table 1&#46; Compliance of risk factors of digitalis toxicity in kidney function before and after treatment</p>"
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Article information
ISSN: 20132514
Original language: English
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Idiomas
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