Digoxin
Digoxin is a cardiac glycoside used primarily for its positive inotropic (increased contractility) and negative chronotropic (decreased heart rate) effects. It is utilized in veterinary medicine to treat congestive heart failure (CHF) and supraventricular tachyarrhythmias, such as atrial fibrillation or flutter. **Clinical Pearls:** * **Narrow Therapeutic Index:** The margin between a therapeutic dose and a toxic dose is extremely small. Careful dosing and therapeutic drug monitoring (TDM) are essential. * **Shifting Paradigm:** While historically a cornerstone of CHF management, digoxin is no longer considered first-line therapy for heart failure in dogs and cats due to the availability of safer and more effective inodilators like pimobendan. It is now primarily reserved for rate control in atrial fibrillation, often used adjunctively with diltiazem. * **Dosing Basis:** Because digoxin does not distribute well into fat or ascitic fluid, dosing must be based on **lean body weight**. * **Species Sensitivity:** Cats are highly sensitive to digoxin toxicity compared to dogs.
Mechanism: Digoxin exerts its effects through the reversible inhibition of the **Naโบ/Kโบ-ATPase** pump in the myocardial cell membrane. * **Positive Inotropy (Contractility):** Inhibition of **Naโบ/Kโบ-ATPase** โ Increased intracellular Naโบ โ Decreased driving force for the **Naโบ/Caยฒโบ exchanger (NCX)** โ Decreased Caยฒโบ extrusion โ Increased intracellular Caยฒโบ โ Increased Caยฒโบ uptake into the sarcoplasmic reticulum. Upon the next action potential, more Caยฒโบ is released, leading to increased myocardial contractility. * **Negative Chronotropy/Dromotropy (Heart Rate/Conduction):** Digoxin increases vagal (parasympathetic) tone โ Decreased conduction velocity through the **AV node** and prolonged effective refractory period (ERP) โ Slowed ventricular response rate in supraventricular arrhythmias. * **Neurohormonal Effects:** At low doses, digoxin restores baroreceptor sensitivity, which decreases sympathetic outflow and reduces the neurohormonal activation seen in heart failure.
Dosing by species
- Dilated cardiomyopathy or advanced atrioventricular valve insufficiency ยท 0.007 mg/kg PO every other day ยท PO ยท q48h ยท Use lean body weight. Measure serum level 10+ days later, 8-10 hours after dosing. Therapeutic level: 1-2 ng/mL.
- Starting dose for normal cats weighing less than 3 kg ยท 1/4th of a 0.125 mg tablet administered every other day ยท PO ยท q48h ยท Tablets are better tolerated than the alcohol-based elixir.
- Starting dose for normal cats weighing 3 to 6 kg ยท 1/4th of a tablet every day ยท PO ยท q24h ยท Using 0.125 mg tablet.
- Starting dose for normal cats weighing more than 6 kg ยท 1/4th of a tablet every day to q12h ยท PO ยท q12h-q24h ยท Using 0.125 mg tablet.
- Management of supraventricular tachyarrhythmias ยท 10 ฮผg/kg (equating to 1/4 of a 125 ฮผg tablet). Start at lower dose range and titrate up. ยท PO ยท q24-48h ยท Long-term ยท Cats are highly sensitive to toxicity.
- Management of supraventricular tachyarrhythmias (Emergency/Rare) ยท 1-1.6 ฮผg/kg ยท IV ยท q12h ยท As needed ยท Only use IV if essentially indicated. Administer very slowly.
- Dilated cardiomyopathy ยท 0.01 mg/kg PO once daily initially ยท PO ยท q24h ยท Use oral liquid. May increase to twice daily if necessary.
- Maintenance ยท 0.005-0.01 mg/kg PO once to twice daily ยท PO ยท q12h-q24h ยท Using the elixir; monitor blood levels if possible.
- Dilated cardiomyopathy long-term maintenance ยท 0.01 mg/kg q24h ยท PO ยท q24h ยท Long-term ยท Used with furosemide (2 mg/kg q12h) and enalapril (0.5 mg/kg q48h).
Routes of administration
Contraindications
- Ventricular fibrillation
- Digitalis intoxication
- Hypertrophic cardiomyopathy in cats (relative contraindication, may increase myocardial oxygen demand and dynamic outflow obstruction)
- Frequent ventricular arrhythmias
- Atrioventricular (AV) block
- Feline hypertrophic cardiomyopathy
- Hypokalaemia
Adverse effects
- Cardiac arrhythmias (complete or incomplete heart block, bigeminy, ST segment changes, paroxysmal ventricular or atrial tachycardias, multifocal VPCs)
- Mild GI upset
- Anorexia
- Weight loss
- Diarrhea
- Vomiting (especially associated with IV injections)
- Vomiting
- Diarrhoea
- Depression
- Arrhythmias (AV block, bigeminy, paroxysmal ventricular or atrial tachycardias with block, multiform VPCs)
- Vasoconstriction (with IV administration)
Drug interactions
- Aminosalicylic Acid ยท May reduce digoxin serum levels
- Antacids ยท May reduce digoxin serum levels ยท moderate
- Chloramphenicol ยท May reduce digoxin serum levels in dogs
- Cholestyramine ยท May reduce digoxin serum levels
- Cimetidine ยท May reduce digoxin serum levels ยท moderate
- Metoclopramide ยท May reduce digoxin serum levels ยท moderate
- Neomycin (Oral) ยท May reduce digoxin serum levels
- Phenobarbital ยท May reduce digoxin serum levels
- St John's Wort ยท May reduce digoxin serum levels
- Sucralfate ยท May reduce digoxin serum levels
- Sulfasalazine ยท May reduce digoxin serum levels
- Amiodarone ยท May increase serum levels, decrease elimination rate, or enhance toxic effects ยท major
- Anticholinergics ยท May increase serum levels, decrease elimination rate, or enhance toxic effects
- Captopril (or other ACEIs) ยท May increase serum levels, decrease elimination rate, or enhance toxic effects
Monitoring
- Serum digoxin levels (Trough levels recommended: Dogs 0.8-1.2 ng/mL; Cats 0.9-2 ng/mL; Other species 0.5-2 ng/mL. Wait at least 6 days after starting therapy to reach steady-state)
- Appetite and body weight
- Cardiac rate and ECG changes
- Serum electrolytes (especially potassium)
- Renal function tests
- Clinical efficacy for CHF (improved perfusion, decreased edema)
- Serum digoxin levels (check after 7-10 days, sample taken 6-8 hours post-pill. Ideal trough therapeutic level: 0.6-1.2 ng/ml)
- ECG (monitor for AV block and ventricular arrhythmias)
- Serum potassium levels (hypokalaemia increases toxicity risk)
- Renal function (BUN, Creatinine)
Overdose
**Acute Toxicity:** In dogs, the acute toxic dose after IV administration is reported to be 0.177 mg/kg. **Treatment of Toxicity:** * **Chronic Toxicity:** Often resolves by temporarily stopping the drug and reevaluating the dosage regimen. * **Acute Ingestion:** If recent and no cardiotoxic/neurologic signs are present, empty the stomach followed by activated charcoal. Repeated charcoal administration may be beneficial due to enterohepatic recirculation. Anion-exchange resins (colestipol, cholestyramine) can reduce absorption but are rarely available. * **Supportive Care:** Continuous ECG monitoring, correct acid-base/hypoxia/fluid/electrolyte imbalances. *Note: Potassium use in normokalemic patients is controversial and requires expertise.* * **Antiarrhythmics:** Lidocaine and phenytoin are commonly used for life-threatening digitalis-induced arrhythmias. Atropine may treat sinus bradycardia, SA arrest, or AV block. * **Antidote:** **Digoxin immune Fab** (ovine antibodies) binds directly to the drug, inactivating it. It is highly effective but very expensive, and veterinary experience is limited.
VetSheet drug reference is intended for licensed veterinary professionals as a clinical decision-support aid, not a substitute for professional judgement or the manufacturerโs current label.