MANAGEMENT OF
DIGITALIS TOXICITY
PRESENTED BY
SHAILJA VERMA
MBBS student
BATCH-22
ROLL NO. 64
DIGITALIS
Drug class-cardiac glycosides
obtained from plants
Digitalis lanata-Digoxin
Digitalis purpurea-digitoxin
toad skin-bufotoxin
strophanthus gratus-ouabain
USES
(DIGOXIN ONLY GLYCOSIDE THAT IS CURRENTLY IN USE)
Controlling ventricular rate in
• atrialflutter(AFI)
• atrial fibrillation (AF)
Congestive Heart failure
In paroxysmal supraventricular
tachycardia(PSVT)
Mechanism
of action Increase
iontropism
Inhibit Na+/K+
pump In
myocardium
Caption
It blocks the Na+/k+ pump of cardiac muscle
Increase the intracellular sodium
Increase the intracellular calcium
Results in forceful contraction of
myocardium
Greater output per beat
Complete emptying of
heart
Delayed circulation
improved
.
PHARMACOLOGICAL
EFFECTS
On heart - Force of contraction increase
Heart rate is decreased
n kidney- causes diuresis in CHF patients
On CNS - In therapeutic dose little apparent effect. Higher
doses causes clinical manifestations
Digoxin once a pivotal for heart failure, it is no longer
a first line drug .the two main limitations are low
margin of safety and lack of effect on neurohumoral
contributors to pathogenesis of heart failure.
DOSAGE
• Therapeutic level- 0.5-2nd/ml
• Therapy initiated within
maintenance
dose(0.125-0.25mg/day) without
any loading dose
• For an early response loading dose of 0.75 -1.25 mg
spread over 24-48 hrs may be given in the
beginning,but requires close monitoring
Pharmacokinetics
of digoxin
PRECAUTIONS AND
CONTRAINDICATIONS
Hypokalemia : digitalis toxicity enhances
Elderly,renal or severe hepatic disease :patients are more
susceptible to digoxin toxicity
Thyrotoxicosis: paients are more prone to develop arryhthmias
Hypothyroidism : digoxin removal is slowed down
Ventricular tachycardia : digitalis may leads to fibrillation
Partial AV block : may lead to complete AV block
Wolff-Parkinson-white syndrome : digoxin is contraindicated ,VF
may occur
Digoxin can increase the chances of reentry by slowing conduction in
the normal AV bundle and accelerating it in aberrant path
INTERACTIONS
1. DIURETICS: cause hypokalemia which increases the risk of digitalis
arrythmias;potassium supplements should be given prophylactically.
2. Calcium : syngerises with digitalis – causes toxicity.
3. Quinidine : reduces binding of digoxin to tissue proteins as well as its
renal and biliary clearance by inhibiting efflux transporter P-
glycoprotein – plasma concentration doubles – toxicity can occur.
4. Adrenergic drugs : can induce arrythmias;increase ectopic
automaticity.
5. Digoxin absorption may be reduced by
metoclopramide,neomycin,antacids.
6. Absorption increase by atropinic drugs including tricyclic
antidepressants
7. Propranolol,verapamil, may additively depress AV conduction and
oppose inotropic effect
TOXICITY AND ADVERSE
EFFECT
Digoxin is a cumulative drug with low margin of safety (therapeutic
index- 1.5- 3).
ABOUT 25%patients develop one or more toxic symptoms.
• Extracardiac - anorexia ,nausea,vomiting .first reported due gastric
irritation,CTZ stimulation.
• diarrhoea can occur , fatigue, malaise,headache, mental
confusion ,disorientation, hyperapnoea, skin rash.
• Cardiac – arrhythmias , pulsus bigeminus , nodal and ventricular
extrasystoles ,ventricular tachycardia ,ventricular fibrillation
• Sometimes complete AV block
• Severe bradycardia
In 2/3 of patients extracardiac symptoms precede cardiac
toxicity
1
3
MANAGMENT
Discontinuation of digoxin : stop at the earliest sign of toxicity
Monitor vital sign : regularly monitor the patients vitals.
Electrolyte montoring : particulary potassium
Supportive care : provide supportive care to manage symptoms
such as nausea,vomiting and arryhthmias,in serious cases
pacemaker may be required.
Prevention : educate patients on the proper use of digoxin
medications,including dosage,sign of toxicity and when gto seek
medical help.
TREATMENT
For tachyarryhthmias – infuse KCL [Link]/hour
(max [Link]) i.v or orally give in milder cases
K+ is contraindicated in higher degree of av block is present , because can lead
to complete av block and ventricular asystole may be precipitated
For ventricular arrhythmias – lidocaine i.v is the DOC it suppresses the
automaticity
For supraventricular arrhythmias propranolol may be given i.v or orally
depending on the urgency
For AV block and bradycardia – the T/t of choice is cardiac pacing through a
temporarily inserted pacemaker. Atropine 0.6-1.2mg i.m may help
Cont..
DIGIBIND
DIGOXIN ANTIBODY – Digoxin specific antibody is highly effective in
reversing cardiotoxicity due to digoxin as well as by other glycosides.
Usage- in Europe as DIGIBIND (38 mg vial )
DIGIFAB(40mg/vial)given by i.v infusion
It is nonimmunogenic because it lacks Fc fragement
BIBLIOGRAPHY
FROM [Link] 8
TH
EDITION
ESSENTIAL OF MEDICAL
PHARMACOLOGY
THANKYOU..