Digoxin has a razor-thin safety margin. One extra tablet, a new antibiotic, or a dehydrating flu can tip a stable heart patient into dangerous territory. If you clicked here, you want the short list of red flags, what to do first, and how to prevent it happening again. That’s exactly what you’ll get-simple, evidence-backed steps you can use in real life. I’m a mum in Auckland, and my house has a pill lockbox for a reason.
- TL;DR: If you suspect digoxin overdose, check vitals, ECG, potassium, creatinine, and a digoxin level drawn ≥6 hours after the last dose. Call your poison center and cardiology/toxicology early.
- Red flags: persistent vomiting, confusion, visual halos/yellow vision, bradycardia or any rhythm with AV block, ventricular ectopy, acute hyperkalemia (especially in acute overdose).
- Give digoxin-specific antibody fragments (DigiFab/Digibind) for life-threatening arrhythmias, hemodynamic instability, or acute hyperkalemia. Avoid amiodarone for arrhythmias caused by digoxin.
- Fix electrolytes (K, Mg), use atropine for symptomatic bradycardia (may be unreliable), and consider pacing if unstable. Activated charcoal helps if early or sustained-release ingestion.
- Prevention: Low starting dose, renal dose-adjust, avoid interacting drugs when possible, and recheck levels/electrolytes after changes. Teach patients the exact signs that need same-day care.
What puts someone at risk (and how to prevent it)
Digoxin improves symptoms in heart failure with reduced ejection fraction and helps control rate in atrial fibrillation, but the line between therapeutic and toxic is narrow. The meds that share a shelf with it at home-antibiotics, diuretics, antiarrhythmics-often change its level. Prevention is mostly about respecting that line.
How toxicity happens in plain terms: digoxin blocks the Na/K-ATPase pump, raising intracellular calcium in heart cells. That boosts contractility but also makes the heart excitable and slows AV nodal conduction. Low potassium, low magnesium, older age, and poor kidneys crank up the effect. A level that is fine in one person can be too much in another.
- High-risk people: older age, low body weight, chronic kidney disease (eGFR < 60), hypothyroidism, dehydration, and those on loop/thiazide diuretics.
- Common triggers: new P-glycoprotein inhibitors (amiodarone, verapamil, diltiazem, macrolides like clarithromycin, azoles), reduced renal function from illness, and missed monitoring after dose changes.
- Therapeutic window: for heart failure, many cardiology sources target 0.5-0.9 ng/mL; for rate control in AF, some tolerate up to ~2.0 ng/mL, but adverse effects rise with higher levels.
- Levels don’t tell the whole story. Symptoms and ECG changes beat numbers, especially in chronic toxicity.
Prevention rules of thumb (the ones I actually stick on the clinic wall):
- Start low: 62.5-125 mcg daily in most older adults. Go slower if eGFR is reduced.
- Adjust for kidneys: dose and interval should reflect creatinine clearance, not just age and weight.
- Recheck within a week: a steady-state level 5-7 days after starting or changing dose; always draw at least 6 hours after the last dose.
- Electrolytes matter: keep K+ in the upper-normal range and Mg2+ normal; replace proactively if on diuretics.
- Drug interactions: if adding amiodarone, verapamil, diltiazem, macrolides, azoles, or dronedarone, reduce digoxin dose by 30-50% and recheck levels in 5-7 days.
- Teach the flags: nausea/vomiting that won’t quit, confusion, new visual halos/yellow-green tint, slow pulse with dizziness, or new palpitations-seek same-day care.
- Home safety: keep it in a locked spot, in the original bottle. In my place with a curious kid, that lock lives higher than Darian can climb.
Evidence notes:
- Amiodarone cuts digoxin clearance by about 50% (ACC/AHA arrhythmia guidance; digoxin label).
- Clarithromycin has been linked to a >2x risk of digoxin toxicity in older adults (population studies in Ontario; CMAJ).
- Target lower digoxin levels in heart failure (0.5-0.9 ng/mL) reduce adverse events (DIG trial subgroup analyses; HFSA/ACC/AHA guidance).
| Risk/Trigger | Effect on Digoxin | What to Do | Notes |
|---|---|---|---|
| Amiodarone | ~50% ↓ clearance | Cut digoxin dose by 30-50%; check level in 5-7 days | Arrhythmia guidelines |
| Verapamil/Diltiazem | ↑ level | Lower dose; monitor | P-gp inhibition |
| Clarithromycin/Erythromycin | ↑ level; toxicity risk doubles | Avoid if possible; close monitoring | Population data in older adults |
| Azole antifungals | ↑ level | Monitor; adjust dose | P-gp inhibition |
| Loop/Thiazide diuretics | Hypokalemia → ↑ toxicity | Replace K/Mg; monitor | Keep K high-normal |
| CKD (eGFR <60) | Accumulation | Lower dose/extend interval; monitor level | Renal dosing |
| Dehydration/Illness | ↓ clearance | Hold or halve dose during acute illness | Reassess when well |
How to recognize toxicity fast
Most cases start quietly: nausea, loss of appetite, vague dizziness. Then the heart shows its hand. The pattern varies between acute overdose (sudden large ingestion) and chronic toxicity (build-up over days to weeks). You don’t have to guess which is which to act, but it helps frame risk.
Acute overdose clues:
- Early GI: persistent vomiting, abdominal pain.
- Neuro/visual: confusion, blurred vision, yellow/green halos.
- Cardiac: bradycardia, AV block, sinus node dysfunction; or ventricular ectopy/VT/VF in severe cases.
- Labs: hyperkalemia is common and prognostic; severe elevations correlate with worse outcomes in acute overdose.
Chronic toxicity clues:
- Subacute GI upset (nausea, anorexia), fatigue, confusion or delirium in older adults.
- Visual changes may be subtle or absent.
- ECG: slow atrial fibrillation, junctional rhythms, AV block, atrial tachycardia with block (classic).
- Potassium can be low or normal; hypokalemia often triggers the spiral.
First tests to order (and why):
- ECG right away. Look for bradyarrhythmias, AV block, junctional rhythms, atrial tachycardia with AV block, or ventricular arrhythmias.
- Serum digoxin level-timed. Draw ≥6 hours after the last dose or at presentation for suspected acute overdose; repeat later if within 6 hours to avoid misleadingly high levels.
- Electrolytes: K+, Mg2+, Ca2+, creatinine, and BUN. Low Mg and K are arrhythmia fuel; rising creatinine hints at accumulation.
- Glucose and troponin if indicated; digoxin can cause ST changes, so avoid anchoring on ACS without context.
Red flags that push you toward antidote:
- Any life-threatening arrhythmia (sustained VT/VF, severe bradycardia with hypotension, high-grade AV block with symptoms).
- Acute hyperkalemia (especially >5.0-5.5 mmol/L) after overdose.
- Shock, syncope, ongoing chest pain with arrhythmia.
- Significant ingestion of sustained-release digoxin.
Credible sources for recognition patterns: American College of Medical Toxicology (ACMT) Position Statement on Digoxin-Specific Antibody Fragments, AHA ACLS bradycardia/tachycardia algorithms (2020), and Goldfrank’s Toxicologic Emergencies, 11th ed.
Treatment: step-by-step (what to do now)
Stabilize first, then fix the digoxin problem, then clean up the risk factors. Here’s a simple sequence that lines up with toxicology and cardiology guidance.
- Airway, breathing, circulation. Oxygen, IV access, cardiac monitor. Treat hypotension with fluids (careful in heart failure); add vasopressors if needed.
- ECG-guided actions.
- Bradycardia with symptoms: atropine 1 mg IV, repeat every 3-5 minutes to max 3 mg (AHA 2020). Response may be limited in digoxin toxicity.
- If unstable and atropine fails: transcutaneous pacing; consider transvenous pacing if arrhythmia persists. Discuss with cardiology-toxicity can make the myocardium irritable.
- Ventricular arrhythmias: lidocaine is preferred; phenytoin is a reasonable alternative. Avoid amiodarone if the arrhythmia is due to digoxin.
- Avoid electrical cardioversion unless the patient is crashing; if you must shock, use the lowest effective energy and sedation.
- Digoxin-specific antibody fragments (DigiFab/Digibind). This is the antidote.
- Indications: life-threatening arrhythmias, hemodynamic instability, acute hyperkalemia from overdose, significant ingestion of sustained-release product, or severe/chronic toxicity with persistent symptoms.
- Empiric dose when unstable and amount unknown: adults often start with 10-20 vials; children 5-10 vials. Reassess rhythm and perfusion; repeat dosing if needed.
- Calculated dosing options:
- Based on serum level: vials ≈ (digoxin level in ng/mL × weight in kg) / 100.
- Based on amount ingested (mg): vials ≈ (ingested mg × 0.8) / 0.5.
- Round up to whole vials. In chronic toxicity, consider partial neutralization (e.g., 3-6 vials) to avoid abrupt loss of rate control, then reassess.
- After Fab: don’t trust standard digoxin levels for a few days; assays read bound plus free drug. Watch the patient, not the number. Expect potassium to fall-treat hyperkalemia before Fab and monitor for hypokalemia after.
- Electrolytes and glucose.
- Potassium: in acute overdose with hyperkalemia, Fab is the fix. Use insulin/glucose and beta-agonists if needed, but avoid calcium salts when digoxin toxicity is suspected; the “stone heart” risk is debated, but experts still prioritize Fab.
- Magnesium: replete to normal-high; 2 g IV often used if low or if ectopy is present.
- Avoid aggressive potassium repletion if the patient is about to receive Fab-levels will drop rapidly once Fab binds digoxin.
- Decontamination.
- Activated charcoal 1 g/kg (up to 50 g) if within ~2 hours of ingestion; consider multidose charcoal for massive or sustained-release ingestion.
- Whole-bowel irrigation may be considered for large sustained-release exposures with toxicology guidance.
- Hemodialysis does not work for digoxin-it’s tissue-bound.
- Medication pitfalls to avoid.
- Do not use amiodarone to treat digoxin-induced arrhythmias.
- Beware of adding verapamil/diltiazem for rate control in suspected toxicity; they can worsen conduction block and elevate digoxin levels.
- Check for recent antibiotics (especially macrolides) or antifungals that could have raised levels.
- Observation and disposition.
- Admit patients with symptomatic toxicity, any arrhythmia beyond rare PVCs, hyperkalemia, or those who received Fab.
- Minimum observation: 6-12 hours for minor asymptomatic exposures with normal ECG and labs; longer if sustained-release, renal impairment, or chronic toxicity.
Evidence notes for treatment: ACMT Position Statement on digoxin immune Fab (2015; reaffirmed), AHA ACLS (2020) for atropine and pacing, Goldfrank’s for antiarrhythmic choices, and the DigiFab prescribing information for dosing approaches.
Follow-up, prevention, and real-world checklists
After the storm, fix the weak points that let toxicity happen. This is where you prevent the bounce-back visit and the 2 a.m. call.
Restarting or adjusting digoxin:
- Chronic toxicity: hold digoxin. When symptoms and ECG normalize, restart at a lower dose (often half), adjusted for kidney function. Aim for a heart failure target range of 0.5-0.9 ng/mL if that’s the indication.
- After Fab: wait at least several days before rechecking a level, or use a free (unbound) digoxin assay if available. Expect the immunoassay to read falsely high for days.
- If the original reason for digoxin is no longer strong (e.g., rate control can be achieved with beta-blocker), deprescribe. Discuss alternatives with cardiology.
Outpatient monitoring plan (the nuts and bolts):
- Serum digoxin: 5-7 days after dose change; then at least every 6 months, sooner if kidney function changes or meds change.
- Electrolytes and creatinine: baseline; after diuretic changes; during illness; and at least every 3-6 months in older adults.
- Pulse checks: teach patients to check their pulse daily for a week after any change and to report persistent rates <50 or symptoms.
Patient education script you can say in under a minute:
- Take it at the same time daily. Don’t double up if you miss.
- Call if you have vomiting that won’t stop, new vision changes (yellow/green halos), unusual fatigue, confusion, or a very slow or irregular pulse.
- Tell us before starting antibiotics, antifungals, or heart rhythm meds-some raise your digoxin level.
- Keep hydrated, especially during illness; if you can’t keep fluids down, hold the dose and call.
- Store the bottle locked away from kids and pets.
Quick reference: when to give the antidote (Fab):
- Life-threatening arrhythmias or hemodynamic instability.
- Acute hyperkalemia (>5.0-5.5 mmol/L) after suspected overdose.
- Large or sustained-release ingestion with symptoms.
- Severe, persistent symptoms of chronic toxicity with conduction disease.
Special scenarios:
- Renal failure: expect prolonged bound-drug complexes after Fab; monitor clinically longer. Dose digoxin very cautiously if ever restarting.
- Pregnancy: treat the mother first; Fab is used when indicated. Discuss fetal monitoring with obstetrics.
- Elderly living alone: simplify regimens, use blister packs, set up weekly check-ins. A small change like a new antibiotic is often the spark.
- Pediatrics: any ingestion is an emergency. Weight-based charcoal and early toxicology input. Keep adult meds locked up; kids in Auckland (and everywhere) are crafty climbers.
| Threshold or Finding | Implication | Suggested Action |
|---|---|---|
| Digoxin level drawn <6 h after dose | Unreliable; can appear falsely high | Repeat level at ≥6 h or at steady state |
| K+ >5.0-5.5 mmol/L after acute overdose | Poor prognostic sign | Give Fab; temporize K+ if needed |
| Bradycardia with hypotension | Unstable conduction disease | Atropine → pacing → Fab if due to digoxin |
| Atrial tachycardia with block | Classic digoxin effect | Consider Fab if symptomatic/unstable |
| Ventricular arrhythmias | Life-threatening | Lidocaine/phenytoin; avoid amiodarone; Fab |
Credibility checkpoints for the above include: ACMT digoxin immune Fab indications, AHA ACLS algorithms (2020), Goldfrank’s 11th ed., and contemporary heart failure/atrial fibrillation guidelines (ACC/AHA/HFSA) for therapeutic levels and drug interactions.
Mini‑FAQ
Do I ever give calcium for hyperkalemia in digoxin toxicity? The old “stone heart” warning is debated. Many toxicologists still avoid calcium and push Fab first because it addresses the cause and drops potassium quickly. If the patient is peri-arrest and Fab is not immediately available, use your best judgment with expert input.
Can I dialyze digoxin out? No. It’s highly tissue-bound and not dialyzable. Fab is the antidote that works.
How soon do levels fall after Fab? Free (active) digoxin falls fast, often within minutes to hours. Standard lab assays will look falsely high for days because they measure bound drug too. Clinical status guides re-dosing, not the number.
Which antiarrhythmic should I reach for? Lidocaine first. Phenytoin is a reasonable second choice. Avoid amiodarone in true digoxin-mediated arrhythmias.
When can I send someone home? No symptoms, normal ECG, stable electrolytes/renal function, a plausible story that rules out significant overdose, and a clear follow-up plan. If in doubt, observe longer.
What about herbal cardiac glycosides (e.g., oleander, foxglove)? They behave similarly. Fab can still work, though larger doses may be needed; consult toxicology.
Is chronic low-level nausea worth acting on? Yes. Especially in an older person on a diuretic. Check electrolytes, creatinine, and a timed digoxin level.
Can I use beta-blockers for rate instead? Often, yes-many patients can be managed with a beta-blocker ± calcium channel blocker (diltiazem) instead of digoxin, depending on comorbidities. Revisit the original reason for digoxin.
What sources back this up? ACMT Position Statement on Digoxin-Specific Antibody Fragments; AHA ACLS 2020; Goldfrank’s Toxicologic Emergencies, 11th ed.; DigiFab prescribing information; ACC/AHA/HFSA heart failure and AF guidelines; and observational studies on macrolide interactions in older adults.
Next steps by persona:
- Clinician in ED: get ECG, labs (K/Mg/Cr), timed digoxin level, call toxicology early, give Fab if unstable or hyperkalemic, fix electrolytes, avoid amiodarone, admit if symptomatic.
- Primary care: if vague nausea and slow pulse in a digoxin user, bring them in today, check level/electrolytes, hold dose pending results, review meds for new interactions, and plan a lower restart or deprescribe with cardiology.
- Caregiver/family: lock the meds, know the “go-now” signs, keep a simple list of all medications, and tell the clinic before adding antibiotics or antifungals.
If you remember nothing else: the antidote saves lives, potassium is the compass, and timing of the level matters. Keep the dose low, keep the electrolytes happy, and be suspicious of any new drug that plays with P-gp or the kidneys. That small vigilance gap is where most cases start.
