The risks of digoxin in the elderly
Riesgos de la digoxina en el anciano
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Soy Muner, S. Nogué Xarau" "autores" => array:3 [ 0 => array:3 [ "Iniciales" => "M." "apellidos" => "Pujal Herranz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "D." "apellidos" => "Soy Muner" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:4 [ "Iniciales" => "S." "apellidos" => "Nogué Xarau" "email" => array:1 [ 0 => "snogue@clinic.ub.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Farmacia, Consorci Sanitari, Terrassa, Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicio de Farmacia, Hospital Clínic, Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Servicio de Urgencias, Hospital Clínic, Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Riesgos de la digoxina en el anciano" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10481_108_9213_en_10481_f1.jpg" "Alto" => 525 "Ancho" => 473 "Tamanyo" => 42402 ] ] "descripcion" => array:1 [ "en" => "Proposed rapid digitalisation nomogram in the control of auricular fibrillation and digoxin maintenance dose according to the patient¿s ClcrCG" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor, </span></p><p class="elsevierStylePara">In a “Letter to the Editor” recently published by Suarez et al,<span class="elsevierStyleSup">1</span> a case of digitalis poisoning is described in an 82-year-old woman, with a history of heart failure and chronic renal failure (CRF). The patient attended the emergency department with signs of confusion, observing a nodal rhythm of 34 beats/min and blood pH level of 7.29, potassium 6.8mEq/l, creatinine 4.8mg/dl and digoxinemia 5.4ng/ml. She was treated with intravenous hydration and haemodialysis, with good results. After reading the letter, we would like to present a series of observations.</p><p class="elsevierStylePara">Given the significance of CRF as a main cause of digitalis poisoning in elderly patients, the importance of individualised dosage of digoxin according to kidney function should be emphasised. We have proposed a theoretical rapid digitalisation nomogram and maintenance doses of digoxin according to the Cockroft-Gault (Clcr<span class="elsevierStyleInf">CG</span>) glomerular filtration index (figure 1),<span class="elsevierStyleSup">2-4 </span>in accordance with the information obtained in bibliographic searches regarding recommendations for adjusting digoxin dosage in CRF and supported by our practical clinical experience. If we apply this to the case presented, the recommended maintenance dose would have been 0.125mg daily (½ tablet), adjusted to the moderate CRF that the patient presented (ClCr<span class="elsevierStyleInf">CG </span>of approximately 40ml/min).</p><p class="elsevierStylePara">Furthermore, we would like to insist on the importance of pharmacological interactions of digoxin as a potential risk factor of digitalis poisoning. This point is especially relevant in polymedicated patients. Along with the mentioned verapamil and amiodarone, we should add other calcium antagonists such as diltiazem and diuretics such as spironolactone, due to their frequent simultaneous use in heart disease patients. In addition, given the high incidence of infection in the elderly, the interaction between digoxin and a variety of antibiotics, in particular macrolides, such as erythromycin and clarithromycin and tetracyclines, should be kept in mind.<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">In their "Letter", the authors mention hyperkalaemia as a predictive risk factor concerning the severity of digitalis poisoning. It should be clarified that hyperkalaemia has been described as a marker with poor prognosis only in acute digitalis poisoning and is not useful as a prognostic factor in chronic poisoning, as seems to be the case of the “Letter”.<span class="elsevierStyleSup">6</span> </p><p class="elsevierStylePara">As mentioned in the text, the presence of sinus bradycardia or advanced blockage that do not respond to pharmacology and with a haemodynamic deterioration would be due to the use of a pacemaker. The risk of electro-catheter (internal pacemaker) placement should be mentioned for patients with digitalis poisoning given the myocardial irritability induced by the drug, where anti-digoxin antibodies could be used as a alternative therapy.<span class="elsevierStyleSup">7</span> </p><p class="elsevierStylePara">The “Discussion” refers to stomach pumping as a therapeutic option in digitalis poisoning. It should be pointed out that digestive decontamination is only effective in patients with acute oral digitalis poisoning (accidental intake or suicide attempt), and provided that no more than two hours have passed since its consumption. In the event of the patient being conscious, oral administration of activated charcoal should be considered as the best therapeutic option.</p><p class="elsevierStylePara">Meanwhile, the authors mention a rebound effect with differed increase of digoxinaemia after an initial administration of anti-digital antibodies in CRF patients. In reference to this, we would like to point out that this effect can occur in all patients, since it is due to the pharmacokinetic behaviour of digoxin and not to an alteration in kidney function.<span class="elsevierStyleSup">8</span> After administering the anti-digital antibodies, in 1-2 minutes, the free digoxin in the blood is quickly reduced to values close to zero, due to the formation of anti-digital digoxin-antibody complexes, which creates a concentration gradient that promotes mobilisation of tissue digoxin to the blood where it is newly activated by the formation of antibody complexes which are still free. This mobilisation involves an increase in the total digoxin in blood and represents an index of efficacy of the antibodies.<span class="elsevierStyleSup">8,9</span></p><p class="elsevierStylePara">Lastly, it should be added that the evaluation of the severity of intoxication cannot only consider digoxinaemia, given the frequent discrepancy between plasma concentrations of the drug and the cardiovascular repercussions. To calibrate the importance of the poisoning, it is necessary to have data regarding kidney function, plasma ion concentration, ECG, haemodynamic evaluation and systemic repercussions.</p><p class="elsevierStylePara"><a href="grande/10481_108_9213_en_10481_f1.jpg" class="elsevierStyleCrossRefs"><img src="10481_108_9213_en_10481_f1.jpg" alt="Proposed rapid digitalisation nomogram in the control of auricular fibrillation and digoxin maintenance dose according to the patient¿s ClcrCG"></img></a></p><p class="elsevierStylePara">Figure 1. Proposed rapid digitalisation nomogram in the control of auricular fibrillation and digoxin maintenance dose according to the patient¿s ClcrCG</p>" "pdfFichero" => "P1-E503-S2295-A10481-EN.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10481_108_9213_en_10481_f1.jpg" "Alto" => 525 "Ancho" => 473 "Tamanyo" => 42402 ] ] "descripcion" => array:1 [ "en" => "Proposed rapid digitalisation nomogram in the control of auricular fibrillation and digoxin maintenance dose according to the patient¿s ClcrCG" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Suárez, Pobles A, Quiñones L, Forascepi R. Los riesgos de la digoxina en el anciano. Comunicaciones breves en investigación o experiencias clínicas. Nefrologia 2010;30(1):131-2. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20098476" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Reuning RH, Geraets DR, Rocci ML, Vlasses PH. Digoxin. En: Evans WE, Schentag JJ, Jusko WJ (eds.). Applied pharmacokinetics: principles of therapeutic drug monitoring (3.ª ed.).\u{A0}Vancouver: Applied Therapeutics, Inc., 1992." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Keys PW, Stafford RW. Digoxin: therapeutic use and serum concentration monitoring. 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Clinical Pharmacokinetics (3.ª ed.).\u{A0}U.S.: Patent and trademark office: American society oh health-system pharmacists, Inc., 2005;147-159.ISBN 1-58528-088-7." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Pap C, Zacher G, Kárteszi M. Prognosis in acute digitalis poisoning. Orv Hetil 2005;146(11):507-13. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15813189" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Taboulet P, Baud FJ, Bismuth C, Vicaut E. Acute digitalis intoxication: is pacing still appropiate? Clin Toxicol 1993;31:261-3." 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| 2022 May | 35 | 43 | 78 |
| 2022 April | 52 | 49 | 101 |
| 2022 March | 48 | 50 | 98 |
| 2022 February | 36 | 45 | 81 |
| 2022 January | 55 | 27 | 82 |
| 2021 December | 36 | 46 | 82 |
| 2021 November | 41 | 32 | 73 |
| 2021 October | 76 | 48 | 124 |
| 2021 September | 42 | 36 | 78 |
| 2021 August | 42 | 31 | 73 |
| 2021 July | 42 | 28 | 70 |
| 2021 June | 47 | 26 | 73 |
| 2021 May | 43 | 27 | 70 |
| 2021 April | 105 | 47 | 152 |
| 2021 March | 66 | 27 | 93 |
| 2021 February | 58 | 15 | 73 |
| 2021 January | 29 | 17 | 46 |
| 2020 December | 39 | 10 | 49 |
| 2020 November | 34 | 20 | 54 |
| 2020 October | 28 | 13 | 41 |
| 2020 September | 18 | 4 | 22 |
| 2020 August | 33 | 6 | 39 |
| 2020 July | 32 | 11 | 43 |
| 2020 June | 39 | 13 | 52 |
| 2020 May | 44 | 11 | 55 |
| 2020 April | 43 | 12 | 55 |
| 2020 March | 23 | 10 | 33 |
| 2020 February | 48 | 19 | 67 |
| 2020 January | 27 | 16 | 43 |
| 2019 December | 58 | 22 | 80 |
| 2019 November | 29 | 14 | 43 |
| 2019 October | 24 | 6 | 30 |
| 2019 September | 43 | 17 | 60 |
| 2019 August | 44 | 11 | 55 |
| 2019 July | 51 | 25 | 76 |
| 2019 June | 37 | 9 | 46 |
| 2019 May | 44 | 23 | 67 |
| 2019 April | 69 | 32 | 101 |
| 2019 March | 48 | 17 | 65 |
| 2019 February | 28 | 13 | 41 |
| 2019 January | 38 | 13 | 51 |
| 2018 December | 101 | 28 | 129 |
| 2018 November | 112 | 13 | 125 |
| 2018 October | 104 | 11 | 115 |
| 2018 September | 79 | 20 | 99 |
| 2018 August | 59 | 11 | 70 |
| 2018 July | 67 | 10 | 77 |
| 2018 June | 55 | 12 | 67 |
| 2018 May | 70 | 8 | 78 |
| 2018 April | 61 | 12 | 73 |
| 2018 March | 52 | 6 | 58 |
| 2018 February | 46 | 4 | 50 |
| 2018 January | 28 | 7 | 35 |
| 2017 December | 47 | 8 | 55 |
| 2017 November | 36 | 5 | 41 |
| 2017 October | 38 | 5 | 43 |
| 2017 September | 53 | 10 | 63 |
| 2017 August | 60 | 11 | 71 |
| 2017 July | 46 | 12 | 58 |
| 2017 June | 49 | 8 | 57 |
| 2017 May | 45 | 6 | 51 |
| 2017 April | 37 | 10 | 47 |
| 2017 March | 20 | 38 | 58 |
| 2017 February | 23 | 5 | 28 |
| 2017 January | 29 | 10 | 39 |
| 2016 December | 65 | 5 | 70 |
| 2016 November | 65 | 6 | 71 |
| 2016 October | 113 | 10 | 123 |
| 2016 September | 116 | 3 | 119 |
| 2016 August | 166 | 5 | 171 |
| 2016 July | 148 | 4 | 152 |
| 2016 June | 127 | 0 | 127 |
| 2016 May | 108 | 0 | 108 |
| 2016 April | 82 | 0 | 82 |
| 2016 March | 98 | 0 | 98 |
| 2016 February | 91 | 0 | 91 |
| 2016 January | 98 | 0 | 98 |
| 2015 December | 117 | 0 | 117 |
| 2015 November | 95 | 0 | 95 |
| 2015 October | 74 | 0 | 74 |
| 2015 September | 66 | 0 | 66 |
| 2015 August | 72 | 0 | 72 |
| 2015 July | 56 | 0 | 56 |
| 2015 June | 38 | 0 | 38 |
| 2015 May | 38 | 0 | 38 |
| 2015 April | 13 | 0 | 13 |
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