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1 High Alert Contraindications/Precautions

Contraindicated in: Hypersensitivity; Uncontrolled ventricular arrhythmias; AV PDF Page #1
digoxin (di-jox-in) block (in absence of pacemaker); Idiopathic hypertrophic subaortic stenosis; Con-
Lanoxin, Toloxin strictive pericarditis; Known alcohol intolerance (elixir only).
Classification Use Cautiously in: Hypokalemia (qrisk of digoxin toxicity); Hypercalcemia (q
Therapeutic: antiarrhythmics, inotropics risk of toxicity, especially with mild hypokalemia); Hypomagnesemia (qrisk of di-
Pharmacologic: digitalis glycosides goxin toxicity); Diuretic use (may cause electrolyte abnormalities including hypoka-
lemia and hypomagnesemia); Hypothyroidism; Geri: Very sensitive to toxic effects;
Pregnancy Category C dose adjustments required for age-relatedpin renal function and body weight; Myo-
cardial infarction; Renal impairment (doseprequired); Obesity (dose should be
Indications based on ideal body weight); OB: Although safety has not been established, has been
Heart failure. Atrial fibrillation and atrial flutter (slows ventricular rate). Paroxysmal used without adverse effects on the fetus; Lactation: Similar concentrations in se-
atrial tachycardia. rum and breast milk result in subtherapeutic levels in infant, use with caution.
Action Adverse Reactions/Side Effects
Increases the force of myocardial contraction. Prolongs refractory period of the AV CNS: fatigue, headache, weakness. EENT: blurred vision, yellow or green vision.
node. Decreases conduction through the SA and AV nodes. Therapeutic Effects: CV: ARRHYTHMIAS, bradycardia, ECG changes, AV block, SA block. GI: anorexia, nau-
Increased cardiac output (positive inotropic effect) and slowing of the heart rate sea, vomiting, diarrhea. Hemat: thrombocytopenia. Metab: electrolyte imbalances
(negative chronotropic effect). with acute digoxin toxicity.
Pharmacokinetics Interactions
Absorption: 60– 80% absorbed after oral administration of tablets; 70– 85% ab- Drug-Drug: Thiazide and loop diuretics, piperacillin, ticarcillin, ampho-
sorbed after administration of elixir; 80% absorbed from IM sites (IM route not rec- tericin B, corticosteroids, and excessive use of laxatives may cause hypokalemia
ommended due to pain/irritation). which mayqrisk of toxicity. Amiodarone, some benzodiazepines, cyclospor-
Distribution: Widely distributed; crosses placenta and enters breast milk. ine, diphenoxylate, indomethacin, itraconazole, propafenone, quinidine,
Metabolism and Excretion: Excreted almost entirely unchanged by the kid- quinine, spironolactone, and verapamil mayqlevels and lead to toxicity (serum
neys. level monitoring/dosepmay be required). Levels may bepby some antineoplas-
Half-life: 36– 48 hr (qin renal impairment). tics (bleomycin, carmustine, cyclophosphamide, cytarabine, doxorubicin,
TIME/ACTION PROFILE (antiarrhythmic or inotropic effects, provided that a loading methotrexate, procarbazine, vincristine), activated charcoal, cholestyra-
dose has been given) mine, colestipol, kaolin/pectin, metoclopramide, penicillamine, rifampin,
or sulfasalazine. In a small percentage (10%) of patients gut bacteria metabolize
ROUTE ONSET PEAK DURATION digoxin to inactive compounds; macrolide anti-infectives (erythromycin, azith-
Digoxin–PO 30–120 min 2–8 hr 2–4 days† romycin, clarithromycin) and tetracyclines, by killing these bacteria, will cause
Digoxin–IM 30 min 4–6 hr 2–4 days† qlevels and toxicity; dose may need to bepfor up to 9 weeks. Additive bradycardia
Digoxin–IV 5–30 min 1–4 hr 2–4 days† may occur with beta blockers, diltiazem, verapamil, clonidine, and other anti-
†Duration listed is that for normal renal function; in impaired renal function, duration will be arrhythmics (quinidine, disopyramide). Concurrent use of sympathomimet-
longer ics mayqrisk of arrthythmias. Thyroid hormones mayptherapeutic effects.
⫽ Canadian drug name. ⫽ Genetic Implication. CAPITALS indicate life-threatening, underlines indicate most frequent. Strikethrough ⫽ Discontinued.
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2 PO (Children 5– 10 yr): Digitalizing dose— 20– 35 mcg/kg given as 50% of the

dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12
Drug-Natural Products: Licorice and stimulant natural products (aloe) may hr intervals. Maintenance dose— 5– 10 mcg/kg given daily in 2 divided doses. PDF Page #2
qrisk of potassium depletion. St. John’s wort mayplevels and effect. PO (Children 2– 5 yr): Digitalizing dose— 30– 40 mcg/kg given as 50% of the
Drug-Food: Concurrent ingestion of a high-fiber meal maypabsorption. Admin- dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12
ister digoxin 1 hour before or 2 hours after such a meal. hr intervals. Maintenance dose— 7.5– 10 mcg/kg given daily in 2 divided doses.
PO (Children 1– 24 mo): Digitalizing dose— 35– 60 mcg/kg given as 50% of the
Route/Dosage dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12
For rapid effect, a larger initial loading/digitalizing dose should be given in several di- hr intervals. Maintenance dose— 10– 15 mcg/kg given daily in 2 divided doses.
vided doses over 12– 24 hr. Maintenance doses are determined for digoxin by renal PO (Infants – full term): Digitalizing dose— 25– 35 mcg/kg given as 50% of the
function. All dosing must be evaluated by individual response. In general, doses re- dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12
quired for atrial arrhythmias are higher than those for inotropic effect.
hr intervals. Maintenance dose— 6– 10 mcg/kg given daily in 2 divided doses.
IV (Adults): Digitalizing dose— 0.5– 1 mg given as 50% of the dose initially and
PO (Infants – premature): Digitalizing dose— 20– 30 mcg/kg given as 50% of
one quarter of the initial dose in each of 2 subsequent doses at 6-12 hr intervals.
IV (Children ⬎10 yr): Digitalizing dose— 8– 12 mcg/kg given as 50% of the dose the dose initially and one quarter of the initial dose in each of 2 subsequent doses at
initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12 hr 6-12 hr intervals. Maintenance dose— 5– 7.5 mcg/kg given daily in 2 divided
intervals. doses.
IV (Children 5– 10 yr): Digitalizing dose— 15– 30 mcg/kg given as 50% of the NURSING IMPLICATIONS
dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12
hr intervals. Assessment
IV (Children 2– 5 yr): Digitalizing dose— 25– 35 mcg/kg given as 50% of the ● Monitor apical pulse for 1 full min before administering. Withhold dose and notify
dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12 health care professional if pulse rate is ⬍60 bpm in an adult, ⬍70 bpm in a child,
hr intervals. or ⬍90 bpm in an infant. Also notify health care professional promptly of any signif-
IV (Children 1– 24 mo): Digitalizing dose— 30– 50 mcg/kg given as 50% of the icant changes in rate, rhythm, or quality of pulse.
dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12 ● Pedi: Heart rate varies in children depending on age, ask physician to specify at
hr intervals. what heart rates digoxin should be withheld.
IV (Infants – full term): 20– 30 mcg/kg given as 50% of the dose initially and one ● Monitor BP periodically in patients receiving IV digoxin.
quarter of the initial dose in each of 2 subsequent doses at 6-12 hr intervals. ● Monitor ECG throughout IV administration and 6 hr after each dose. No-
IV (Infants – premature): Digitalizing dose— 15– 25 mcg/kg given as 50% of tify health care professional if bradycardia or new arrhythmias occur.
the dose initially and one quarter of the initial dose in each of 2 subsequent doses at ● Observe IV site for redness or infiltration; extravasation can lead to tissue irritation
6-12 hr intervals. and sloughing.
PO (Adults): Digitalizing dose— 0.75– 1.5 mg given as 50% of the dose initially ● Monitor intake and output ratios and daily weights. Assess for peripheral edema,
and one quarter of the initial dose in each of 2 subsequent doses at 6– 12 hr intervals. and auscultate lungs for rales/crackles throughout therapy.
Maintenance dose— 0.125– 0.5 mg/day depending on patient’s lean body weight, ● Before administering initial loading dose, determine whether patient has taken
renal function, and serum level. any digitalis preparations in the preceding 2– 3 wk.
PO (Geriatric Patients): Initial daily dosage should not exceed 0.125 mg. ● Geri: Digoxin has been associated with an increased risk of falls in the elderly. As-
PO (Children ⬎10 yr): Digitalizing dose— 10– 15 mcg/kg given as 50% of the sess for falls risk and implement prevention strategies per facility protocol.
dose initially and one quarter of the initial dose in each of 2 subsequent doses at 6-12 ● Lab Test Considerations: Evaluate serum electrolyte levels (especially potas-
hr intervals. Maintenance dose— 2.5– 5 mcg/kg given daily as a single dose. sium, magnesium, and calcium) and renal and hepatic functions periodically dur-
䉷 2015 F.A. Davis Company CONTINUED
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3 Potential Nursing Diagnoses

Decreased cardiac output (Indications) PDF Page #3
CONTINUED Implementation
digoxin ● Do not confuse Lanoxin with levothyroxine or naloxone.
● High Alert: Digoxin has a narrow therapeutic range. Medication errors associ-
ing therapy. Notify health care professional before giving dose if patient is hypoka- ated with digoxin include miscalculation of pediatric doses and insufficient moni-
lemic. Hypokalemia, hypomagnesemia, or hypercalcemia may make the patient toring of digoxin levels. Have second practitioner independently check original
more susceptible to digitalis toxicity. Pedi: Neonates may have falsely elevated se- order and dose calculations. Monitor therapeutic drug levels.
rum digoxin concentrations due to a naturally occurring substance chemically ● For rapid digitalization, the initial dose is higher than the maintenance dose; 50%
similar to digoxin.Geri: Older adults may be toxic even when serum concentra- of the total digitalizing dose is given initially. The remainder of the dose will be ad-
tions are within normal range; assess for clinical symptoms of toxicity even when ministered in 25% increments at 4– 8 hr intervals.
serum levels are normal. ● When changing from parenteral to oral dose forms, dose adjustments may be nec-
● Toxicity and Overdose: Therapeutic serum digoxin levels range from 0.5– 2
ng/mL. Serum levels may be drawn 6– 8 hr after a dose is administered, although essary because of pharmacokinetic variations in percentage of digoxin absorbed:
they are usually drawn immediately before the next dose. Bacteria in the GI tract 100 mcg (0.1 mg) digoxin injection ⫽ 125 mcg (0.125 mg) tablet or 125 mcg
can metabolize a substantial amount of digoxin before it is absorbed. Patients re- (0.125 mg) of elixir.
ceiving erythromycin or tetracycline, which kill gut bacteria, can develop toxicity ● PO: Administer oral preparations consistently with regard to meals. Tablets can be
on their usual doses of digoxin. Geri: Older adults are at increased risk for toxic crushed and administered with food or fluids if patient has difficulty swallowing.
effects of digoxin (appears on Beers list) due to age-related decreased renal clear- Use calibrated measuring device for liquid preparations; calibrated dropper is not
ance, which can exist even when serum creatinine levels are normal. Digoxin re- accurate for doses of less than 0.2 mL or 10 mcg. Do not alternate between dose
quirements in the older adult may change and a formerly therapeutic dose can be- forms; bioavailability of capsules is greater than that of tablets or elixir.
come toxic. ● IM: Administer deep into gluteal muscle and massage well to reduce painful local
● Observe for signs and symptoms of toxicity. In adults and older children, the first reactions. Do not administer more than 2 mL of digoxin in each IM site. IM admin-
signs of toxicity usually include abdominal pain, anorexia, nausea, vomiting, visual istration is not generally recommended.
disturbances, bradycardia, and other arrhythmias. In infants and small children,
the first symptoms of overdose are usually cardiac arrhythmias. If these appear, IV Administration
withhold drug and notify health care professional immediately. ● Direct IV: Diluent: May be administered undiluted. May also dilute 1 mL of di-
● If signs of toxicity occur and are not severe, discontinuation of digitalis glycoside goxin in 4 mL of sterile water for injection, D5W, or 0.9% NaCl. Less diluent will
may be all that is required. cause precipitation. Use diluted solution immediately. Rate: Administer over at
● If hypokalemia is present and renal function is adequate, potassium salts may be least 5 min.
administered. Do not administer if hyperkalemia or heart block exists. Correct
● Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, amikacin, aminoca-
any other electrolyte abnormalities.
● Correction of arrhythmias resulting from digitalis toxicity may be attempted with proic acid, aminophylline, amphotericin B lipid complex, anidulafungin, argatro-
lidocaine, procainamide, quinidine, propranolol, or phenytoin. Temporary ven- ban, ascorbic acid, atracurium, atropine, azithromycin, aztreonam, benztropine,
tricular pacing may be useful in advanced heart block. bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chlo-
● Treatment of life-threatening arrhythmias may include administration of digoxin ride, calcium gluconate, carboplatin, carmustine, cefazolin, cefoperazone, cefo-
immune Fab (Digibind), which binds to the digitalis glycoside molecule in the taxime, cefotetan, cefoxitin, ceftaroline, ceftazidime, ceftriaxone, cefuroxime,
blood and is excreted by the kidneys. chloramphenicol, chlorpromazine, ciprofloxacin, cisatracurium, cisplatin, clin-
⫽ Canadian drug name. ⫽ Genetic Implication. CAPITALS indicate life-threatening, underlines indicate most frequent. Strikethrough ⫽ Discontinued.
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4 doses. Consult health care professional if doses for 2 or more days are missed. Do
not discontinue medication without consulting health care professional.
damycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dacti- ● Teach patient to take pulse and to contact health care professional be- PDF Page #4
nomycin, daptomycin, dexamethasone, dexmedetomidine, diltiazem, diphenhy- fore taking medication if pulse rate is ⬍60 or ⬎100.
dramine, dobutamine, docetaxel, dopamine, doripenem, doxacurium, ● Pedi: Teach parents or caregivers that changes in heart rate, especially
doxorubicin liposome, doxycycline, enalaprilat, ephedrine, epinephrine, epirub- bradycardia, are among the first signs of digoxin toxicity in infants and
icin, epoetin alfa, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, eto- children. Instruct parents or caregivers in apical heart rate assessment
poside phosphate, famotidine, fenoldopam, fentanyl, fludarabine, fluorouracil, and ask them to notify health care professional if heart rate is outside of
folic acid, furosemide, ganciclovir, gemcitabine, gentamicin, glycopyrrolate, range set by health care professional before administering the next
granisetron, heparin, hetastarch, hydrocortisone, hydromorphone, ifosfamide, scheduled dose.
imipenem/cilastatin, indomethacin, irinotecan, isoproterenol, ketamine, ketoro- ● Review signs and symptoms of digitalis toxicity with patient and family. Advise pa-
lac, labetalol, leucovorin calcium, levofloxacin, lidocaine, linezolid, lorazepam, tient to notify health care professional immediately if these or symptoms of HF oc-
magnesium sulfate, mannitol, mechlorethamine, meperidine, meropenem, me- cur. Inform patient that these symptoms may be mistaken for those of colds or flu.
taraminol, methotrexate, methyldopate, methylprednisolone, metoclopramide, ● Instruct patient to keep digoxin tablets in their original container and not to mix in
metoprolol, metronidazole, midazolam, milrinone, morphine, moxifloxacin, mul- pill boxes with other medications; they may look similar to and may be mistaken
tivitamins, mycophenolate, nafcillin, nalbuphine, naloxone, nesiritide, nicardi- for other medications.
pine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, ox- ● Advise patient that sharing of this medication can be dangerous.
acillin, oxaliplatin, oxytocin, palonosetron, pamidronate, pancuronium, ● Instruct patient to notify health care professional of all Rx or OTC medications, vi-
pantoprazole, papaverine, pemetrexed, penicillin G, pentazocine, pentobarbital, tamins, or herbal products being taken and to consult health care professional be-
phenobarbital, phentolamine, phenylephrine, phytonadione, piperacillin/tazo- fore taking other Rx, OTC, or herbal products. Advise patient to avoid taking antac-
bactam, potassium acetate, potassium chloride, procainamide, prochlorperazine, ids or antidiarrheals within 2 hr of digoxin.
promethazine, propranolol, protamine, pyridoxime, ranitidine, remifentanil, ri- ● Advise patient to notify health care professional of this medication regimen before
tuximab, rocuronium, sodium acetate, sodium bicarbonate, streptokinase, suc- treatment.
cinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, ● Patients taking digoxin should carry identification describing disease process and
ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, trastuzumab, medication regimen at all times.
trimetaphan, vancomycin, vasopressin, vecuronium, verapamil, vinblastine, vin- ● Geri: Review fall prevention strategies with older adults and their families.
cristine, vinorelbine, vitamin B complex with C, voriconazole, zoledronic acid. ● Emphasize the importance of routine follow-up exams to determine effectiveness
● Y-Site Incompatibility: amiodarone, amphotericin B cholesteryl, amphotericin and to monitor for toxicity.
B colloidal, amphotericin B liposome, caspofungin, dantrolene, diazepam, dia-
zoxide, doxorubicin, foscarnet, idarubicin, mitoxantrone, paclitaxel, pentami- Evaluation/Desired Outcomes
dine, phenytoin, propofol, quinupristin/dalfopristin, trimethoprim/sulfamethox- ● Decrease in severity of HF.
azole, telavancin. ● Increase in cardiac output.
● Decrease in ventricular response in atrial tachyarrhythmias.
Patient/Family Teaching ● Termination of paroxysmal atrial tachycardia.
● Instruct patient to take medication as directed, at the same time each day. Teach
parents or caregivers of infants and children how to accurately measure medica- Why was this drug prescribed for your patient?
tion. Take missed doses within 12 hr of scheduled dose or omit. Do not double
䉷 2015 F.A. Davis Company