Digoxin (Intramuscular, Intravenous)

Overview

As a cardiac glycoside, Digoxin helps to control the rhythm and the rate of the patient's heartbeat. It can also improve the strength of the heart muscle and increase its effectiveness at pumping blood around the body.

When patients are suffering from heart failure, they can exhibit a number of symptoms. For example, patients may have trouble breathing, chest pain, extreme fatigue and/or swelling. As the heart is unable to work effectively, it cannot pump blood around the body as it should.

Although heart failure patients tend to exhibit similar symptoms, there are actually various causes of the condition. Patients may have previously experienced a heart attack, have high blood pressure, infection, and/or atrial fibrillation. Excessive alcohol consumption and coronary artery disease can also cause heart failure to occur in some patients. Alternatively, patients may develop heart disease, or cardiomyopathy, because of an unknown cause.

By affecting intracellular sodium levels and increasing intracellular calcium concentration, Digoxin can slow the heart rate down. When patients are experiencing atrial fibrillation, their heartbeat may be irregular as well as too fast. By administering Digoxin, physicians can successfully reduce the heartrate and bring it back down to an appropriate level.

Furthermore, Digoxin enables more calcium to be stored in the sarcoplasmic reticulum. As more calcium is also released, the strength of each heart contraction is stronger. Although the patient's heartrate will be stronger after Digoxin has been administered, the medication won't cause the heart muscle to work harder or expend more energy.

When used in conjunction with angiotensin-converting enzyme (ACE) inhibitors and diuretics, Digoxin can effectively treat patients with heart failure. Whilst ACE inhibitors help to dilate blood vessels and decrease blood pressure, diuretics help to relieve the build-up of fluid caused by heart failure. Although many patients experience this swelling in their legs, patients can also have excess fluid in their abdomen or on their chest. Reducing this excess fluid with diuretics often enables patients to breathe far more easily and helps to reduce the symptoms associated with cardiomyopathy.

Usually, Digoxin is prescribed orally and most patients take it in tablet form on a daily basis. In some situations, however, it may be appropriate for Digoxin to be administered via intramuscular injection or intravenously. If patients are unable to take Digoxin orally or if the medication is required in an emergency setting, physicians may decide to opt for intravenous or intramuscular delivery routes.

Conditions Treated

Heart Failure

Type Of Medicine

Cardiac glycoside

Side Effects

When receiving treatment with Digoxin, it's possible that patients may experience some adverse effects. These can be particularly common when treatment with Digoxin first begins but should decrease over time. These adverse effects may include:

  • Combativeness or agitation
  • Anxiety
  • Weakness
  • Depression
  • Uncaring attitude
  • Diarrhea
  • Fear of impending death
  • Tunnel vision
  • Hallucinations
  • Swelling of the breasts
  • Rash
  • Loss of vision
  • Blurred vision
  • Double vision
  • Soreness of breast tissue in male and female patients
  • Headache
  • Loss of appetite
  • Lack of emotion or feeling
  • Difficulty tolerating bright light
  • Night blindness

There are, however, a number of other side-effects which may occur after Digoxin has been administered. If patients experience any of the following side-effects, they should seek medical advice:

  • Dizziness
  • Irregular, pounding or fast pulse or heartbeat
  • Fainting
  • Slow heartbeat
  • Tarry, black stools
  • Nausea
  • Bleeding gums
  • Pain or discomfort in chest
  • Blood in stools or urine
  • Unusual bruising or bleeding
  • Bloody vomit
  • Severe stomach pain
  • Pinpoint spots on skin, usually red in color
  • Rash with small raised lesions or flat lesions on skin
  • Trouble breathing
  • Swelling of the lower legs and/or feet
  • Sweating
  • Shortness of breath
  • Unusual weakness or tiredness

In addition to this, patients should seek medical help if they display any side-effects which aren't listed here.

On rare occasions, patients may exhibit signs of Digoxin overdose if too much medication has been administered. These symptoms may include:

  • Stomach or abdominal pain
  • Confusion
  • General feeling of illness or discomfort
  • Drowsiness
  • Yellow-green color disturbances
  • Halos around lights
  • Nervousness
  • Loss of appetite
  • Tingling or numbness in lips, hands or feet
  • Vomiting
  • Heaviness or weakness in the legs
  • Weight loss

If patients experience a Digoxin overdose, it should be treated as a medical emergency and help should be sought immediately. However, when Digoxin is administered via intramuscular injection or given intravenously, the dose will be monitored by trained healthcare practitioners. Due to this, instances of Digoxin overdose are rare.

Dosage

When determining how much Digoxin to administer, doctors will take various factors into account. The patient's diagnosis and clinical condition will have a significant impact on the amount of medication they're given, whilst their age, medical history and weight will also be taken into account.

When treating patients for atrial fibrillation, for example, physicians may recommend that patients are given 8-12mcg of Digoxin per kg of bodyweight as a loading dose. This is usually administered intravenously, with patients given half their dose initially and the rest 6-8 hours apart. Following this, a maintenance dose may be given intravenously or via intramuscular injection.

If patients in heart failure are prescribed Digoxin, they may be given 0.125-0.25mg per day, via intravenous administration. Although higher doses of 0.375-0.5mg can be given, these are rarely needed.

Whilst standard doses may be used, these are merely an example of the way Digoxin is used to treat patients. Each individual will be assessed before Digoxin is prescribed and physicians will provide specific dosage instructions. As healthcare practitioners will administer Digoxin intravenously or via intramuscular injection, patients will not have to calculate their dose or administer their own medication.

Although Digoxin can be administered via intramuscular injection, physicians often prefer to deliver the medication intravenously, if it cannot be given orally. Although delivery via intramuscular injection is effective, it can be painful for patient. If there is no other option available, a healthcare practitioner will administer the injection into a deep muscle and massage the area afterwards. If delivered intravenously, the medication will simply be injection into the patient's vein over a specific amount of time.

Whilst patients may be given Digoxin intravenously or via intramuscular injection initially, it's likely that they will be switched to an oral Digoxin tablet once their symptoms are under control and a diagnosis has been made. Providing patients are able to take Digoxin orally and it is not being used in a response to an emergency situation, oral Digoxin tablets can treat heart failure patients efficiently.

Potential Drug Interactions

As medications can interact with one another, it may not be appropriate to use Digoxin on patients who are already taking other types of medicines. Digoxin is not usually prescribed at the same time as the following medication, for example:

  • Amifampridine

Although Digoxin can be prescribed with the following medications, it is not usually recommended. If doctors feel it is beneficial to treat patients with Digoxin, in addition to one of the following medications, they may alter the patient's dose to prevent the medicines from interacting. These medications include:

  • Aceclofenac
  • Cinnarizine
  • Acemetacin
  • Chlorothiazide
  • Alprazolam
  • Calcium
  • Amiodarone
  • Chlorthalidone
  • Amlodipine
  • Celecoxib
  • Amtolmetin Guacil
  • Captopril
  • Aspirin
  • Carvedilol
  • Atorvastatin
  • Clonixin
  • Clevidipine
  • Azithromycin
  • Choline Salicylate
  • Cyclopenthiazide
  • Bemetizide
  • Crizotinib
  • Bendroflumethiazide
  • Cyclothiazide
  • Benzthiazide
  • Conivaptan
  • Boceprevir
  • Cobicistat
  • Bromfenac
  • Clopamide
  • Bufexamac
  • Daclatasvir
  • Buthiazide
  • Eliglustat
  • Canagliflozin
  • Erythromycin
  • Chan Su
  • Dronedarone
  • Demeclocycline
  • Fingolimod
  • Dexibuprofen
  • Floctafenine
  • Dexketoprofen
  • Feprazone
  • Diclofenac
  • Fenoprofen
  • Diflunisal
  • Etoricoxib
  • Diltiazem
  • Fepradinol
  • Dipyrone
  • Felbinac
  • Dofetilide
  • Felodipine
  • Dopamine
  • Etofenamate
  • Droxicam
  • Lily of the Valley
  • Epinephrine
  • Kyushin
  • Etodolac
  • Ledipasvir
  • Flufenamic Acid
  • Ketoprofen
  • Flurbiprofen
  • Lapatinib
  • Gentamicin
  • Lornoxicam
  • Itraconazole
  • Hydrochlorothiazide
  • Isradipine
  • Hydroflumethiazide
  • Ketorolac
  • Ibuprofen
  • Minocycline
  • Indapamide
  • Meclofenamate
  • Indomethacin
  • Moricizine
  • Isavuconazonium Sulfate
  • Mifepristone
  • Loxoprofen
  • Morniflumate
  • Lumiracoxib
  • Manidipine
  • Norepinephrine
  • Oxyphenbutazone
  • Mefenamic Acid
  • Oleander
  • Meloxicam
  • Oxaprozin
  • Methyclothiazide
  • Oxytetracycline
  • Metoclopramide
  • Pranoprofen
  • Metolazone
  • Proglumetacin
  • Propafenone
  • Nabumetone
  • Piketoprofen
  • Naproxen
  • Polythiazide
  • Nefazodone
  • Piroxicam
  • Nepafenac
  • Phenytoin
  • Nicardipine
  • Phenylbutazone
  • Nifedipine
  • Propyphenazone
  • Niflumic Acid
  • Propantheline
  • Nilvadipine
  • Pheasant's Eye
  • Nimesulide
  • Parecoxib
  • Nimesulide Beta Cyclodextrin
  • Ritonavir
  • Nimodipine
  • Rabeprazole
  • Nisoldipine
  • Rifampin
  • Nitrendipine
  • Ranolazine
  • Proquazone
  • Rofecoxib
  • Quinethazone
  • Rolapitant
  • Quinidine
  • Salsalate
  • Quinine
  • Salicylic Acid
  • Tiaprofenic Acid
  • Xipamide
  • Tolvaptan
  • Vilazodone
  • Saquinavir
  • Verapamil
  • Simeprevir
  • Tolmetin
  • Venetoclax
  • Sodium Salicylate
  • Vemurafenib
  • Tenoxicam
  • Sotalol
  • Telaprevir
  • Spironolactone
  • Tolfenamic Acid
  • Squill
  • Trichlormethiazide
  • Succinylcholine
  • Trimethoprim
  • Sulindac
  • Valdecoxib
  • Telmisartan
  • Vandetanib
  • Tetracycline

Similarly, taking Digoxin with the following medicines can increase the chance of side-effects occurring. In some cases, doctors may be able to modify the patient's dose to minimize the risk of them suffering adverse effects. Alternatively, doctors may prescribe additional medication to help relieve any side-effects which do occur. These medications may include:

  • Acebutolol
  • Cascara Sagrada
  • Albuterol
  • Carteolol
  • Alprenolol
  • Canrenoate
  • Arbutamine
  • Disopyramide
  • Atenolol
  • Dilevalol
  • Azosemide
  • Colchicine
  • Bepridil
  • Epoprostenol
  • Betaxolol
  • Darunavir
  • Bevantolol
  • Esmolol
  • Bisoprolol
  • Mibefradil
  • Bucindolol
  • Omeprazole
  • Celiprolol
  • Lenalidomide
  • Cyclosporine
  • Nadolol
  • Etravirine
  • Labetalol
  • Exenatide
  • Penbutolol
  • Flecainide
  • Propranolol
  • Flibanserin
  • Pancuronium
  • Fluoxetine
  • Nebivolol
  • Gatifloxacin
  • Mirabegron
  • Hydroxychloroquine
  • Oxprenolol
  • Indecainide
  • Mepindolol
  • Trazodone
  • Metipranolol
  • Talinolol
  • Metoprolol
  • Timolol
  • Miglitol
  • Telithromycin
  • Ticagrelor
  • Pindolol
  • Tertatolol
  • Rifapentine
  • Simvastatin
  • Roxithromycin
  • Sulfasalazine
  • Velpatasvir

Although Digoxin may interact with other prescription medications, it could also interact with herbal or sports supplements, vitamins and over-the-counter medicines. Patients should notify their physician if they have used any of these substances and seek medical advice before using these substances after being treated with Digoxin.

Warnings

Before patients are treated with Digoxin, doctors will need to be aware of their medication history. If they are suffering with any other medical conditions, it may affect their treatment. The following conditions are particularly relevant if treatment with Digoxin is a possibility:

  • AV block with no pacemaker
  • Ventricular fibrillation
  • Kidney disease
  • High calcium in blood (Hypercalcemia)
  • Low calcium in blood (Hypocalcemia)
  • Heart attack
  • Low magnesium in blood (Hypomagnesemia)
  • Electrical cardioversion procedure
  • Thyroid disease
  • Low potassium in blood (Hypokalemia)
  • Low oxygen in blood (Hypoxia)
  • Heart disease
  • Chronic diarrhea
  • Blood vessel disease
  • Wolff-Parkinson-white syndrome
  • Sick sinus syndrome

In patients with ventricular fibrillation, for example, Digoxin should not be used at all. If patients have been diagnosed with kidney disease, however, Digoxin may be used but a lower dose of the medication may be given. As kidney disease can mean that patient's take longer to process the medication, it is likely to stay in their system for longer than usual. By lowering the patient's dose of Digoxin, it should prevent a toxic amount of medication building up in their system.

If patients are due to undergo a medical procedure, such as an electrical cardioversion, treatment with Digoxin should be suspended or reduced at least 1-2 days before the procedure. If patients are due to undergo any type of procedure, they should inform the relevant medical professionals that they are being treated with Digoxin beforehand.

Generally, pediatric patients can be treated with Digoxin if they are suffering from heart failure. As younger patients may be more sensitive to the effects of Digoxin, a relatively low starting dose is usually given. However, the safety of Digoxin when treating pediatric patients for atrial fibrillation has not been confirmed. Due to this, younger patients with atrial fibrillation may be treated with an alternative medication.

Digoxin can be used to treat geriatric patients but physician should take any age-related conditions into account. Geriatric patients are more likely to have pre-existing kidney problems and this could prevent them from expelling the medication at a normal rate. Due to this, the chance of toxicity is higher than in the average patient population. Geriatric patients may, therefore, need to be treated with lower doses of Digoxin and monitored throughout their treatment.

If patients are due to undergo any medical tests after being treated with Digoxin, the medication may affect their test results. Due to this, patients should inform the relevant medical professionals that they have been treated with Digoxin before the tests are carried out.

After being treated with Digoxin, physicians may recommend that the patients wear a medical bracelet or identification card to signify that they have been treated with this medication.

Effective therapeutic levels of Digoxin are very close to harmful levels of the drug. Physicians must, therefore, calculate a patient's dose very carefully and monitor them during and after treatment. If patients experience any of the following symptoms, it may indicate that an overdose is occurring:

  • Lack of appetite
  • Nausea
  • Diarrhea
  • Vomiting
  • Vision problems
  • Fainting
  • Palpitations
  • Changes to heartrate

In children and infants, however, signs of an overdose may be more difficult to identify. Typically, the first sign of an overdose in young patients is a change in the rhythm or rate of their heartbeat.

Pregnant patients may not be treated with Digoxin due to safety concerns. If patients are pregnant and/or breastfeeding, they should inform their doctor before being treated with this medication.

Patients should notify their physician if they have any allergies before undergoing treatment and seek urgent medical help if they experience any symptoms of an allergic reaction whilst being treated with Digoxin.

Storage

Generally, Digoxin is supplied in vials when it is to be administered intravenously or via intramuscular injection. In most cases, it should be kept at a controlled room temperature and away from light.

However, patients will not need to store this form of Digoxin as it will only be delivered in a clinical setting.

Summary

Digoxin is an extremely effective way to treat patients with heart failure and it can help to control the heart's rhythm. Although patients are usually given Digoxin orally, administering the medicine intravenously or via intramuscular injection ensures that patients can be treated in an emergency setting.

As a result, Digoxin is suitable as both a short and long-term treatment for patients with atrial fibrillation and/or heart failure.