Digitalis Toxicity Research Articles

Bidirectional ventricular tachycardia with myocardial infarction: A case report with insight on mechanism and treatment

Bidirectional ventricular tachycardia (BVT) is a rare variety of tachycardia with morphologically distinct presentation: The QRS axis and/or morphology is alternating in the frontal plane leads. Since its original description in association with digitalis,1 numerous cases of this fascinating tachycardia with disparate etiologies and mechanisms have been postulated. We report a patient with BVT in association with non-ST elevation myocardial infarction and severe cardiomyopathy in the absence of digoxin toxicity.

Would It Matter to Expose Elderly Patients Who Took Digoxin to Chinese Medications?

ObjectivesElderly patients seem vulnerable to digoxin toxicity because of their diminished organ functions and tendency to encounter drug interactions. The aim of this research was to explore the extent of the concurrent use of digoxin with Chinese medications (CMs), its contributing factors, and the relevant consequences. MethodsA retrospective population-based cohort study was conducted using Longitudinal Health Insurance databases in Taiwan. Those elderly patients being prescribed with digoxin in outpatient settings in 2006 were evaluated for the incidence, prevalence, and duration of concurrent use with concentrated CMs in 2006. After 1:1 random matching to select the corresponding digoxin-only elderly users, univariate and multivariate logistic regression analyses were performed to explore factors associated with concomitant incident digoxin-CM use and incident digoxin-specific CM use. The relevant clinical and economic outcomes for a 3-month follow-up period from the initial exposure of incident digoxin-CM use were compared. ResultsOf 185,076 elderly, 6,374 were prescribed with digoxin and 789 were CM-digoxin users in 2006. The prevalence and incidence of concomitant CM use among digoxin elderly users were 0.43% and 0.22%, respectively. Although the other factors were not statistically significantly associated with incident CM-digoxin use, patients with heart diseases and with benign prostate hypertrophy had an increased likelihood of incident CM-digoxin use of 115% and 102%, respectively. Almost all the concerned clinical and economic outcomes were not statistically significantly different between incident exposure or not, except for the use of potassium-sparing and nonsteroidal anti-inflammatory drugs. ConclusionsThere was a relatively low incidence of digoxin-CM use among the elderly in Taiwan. Although no significant effects on clinical and economic outcomes occurred, it is necessary to monitor potential side effects of digoxin more aggressively for those vulnerable elderly using digoxin with CMs, especially for those who tended to expose to incident digoxin-CM use elderly patients.

Chronic Digoxin Toxicity Precipitated by Dronedarone

To report the case of a patient who presented with chronic symptoms attributable to dronedarone-induced digoxin toxicity. A review of the literature is also provided. This case report details a case of a 77-year-old male patient who presented to the hospital with multiple ambiguous symptoms that lasted several weeks. The patient was later hospitalized for symptoms of chronic digoxin toxicity, including prolonged nausea, diarrhea, weakness, and lack of appetite. The patient had a long history of digoxin use for control of his atrial fibrillation but experienced signs and symptoms of toxicity only after the addition of dronedarone. Both the Naranjo and Drug Interaction Probability Scales indicated a "probable" relationship between the development of digoxin toxicity and dronedarone. Due to a p-glycoprotein-mediated interaction, dronedarone is able to decrease the renal clearance of digoxin, thus putting patients at risk for potentially fatal digoxin toxicity. This is the second case report detailing dronedarone-induced digoxin toxicity and the first to focus on chronic digoxin toxicity. The presentation, possible causes, and drug-drug interactions associated with digoxin toxicity are described. This report aims to increase clinicians' awareness of this possible complication. It is recommended that digoxin be discontinued prior to initiating dronedarone. If concomitant therapy is absolutely necessary, the dose of digoxin should be halved prior to initiating dronedarone. Digoxin plasma levels should be monitored closely, with frequent patient evaluation for signs and symptoms of digoxin toxicity.

Bidirectional ventricular tachycardia associated with digoxin toxicity and with normal digoxin levels

Introduction Bidirectional ventricular tachycardia (VT) is a regular tachyarrhythmia of ventricular focus with 2 different QRS morphologies alternating on a beat-to-beat basis. The rate typically is between 140 and 180 bpm, with a frontal plane axis varying between –201 to –301 and 1101. Causes of this rare arrhythmia are limited and include catecholaminergic polymorphic VT, digitalis toxicity, myocarditis, left ventricular hypertrophy, myocardial infarction, herbal aconite poisoning, familial hypokalemic periodic paralysis, and Andersen-Tawil syndrome. Recently, pulmonary embolism and pheochromocytoma have also been implicated in causing this arrhythmia. We present 2 cases of bidirectional VT attributable to digoxin, one of which had a significantly raised serum digoxin level and 1 within laboratory normal limits.

PKP-007 Analysis of patients with digoxin intoxication admitted to hospital as emergencies

BackgroundDigoxin, the oldest cardiovascular drug, has been used for the treatment of heart failure and in frequency control strategies in atrial fibrillation (AF) patients. American College of Cardiology/American Heart Association...

PS-013 Analysis of polymedicated elderly patients admitted with drug toxicity

BackgroundThe ENEAS study points out that the 37.4% of the adverse events detected in admitted patients are directly caused by drugs. Elderly patients constitute a group susceptible to suffering adverse...

Clinical study of poisoned cases by some drugs admitted to the menoufia poisoning control center over 1 year (2011), with a focus on ECG changes

ObjectiveThe aim of this work was to study ECG changes in cases of poisoning by digoxin, theophylline, and antidepressant overdose that were admitted to Menoufia Poisoning Control Center (MPCC) in 2011, with a focus on evaluation of ECG changes in correlation with both arterial blood gases and electrolyte changes, together with clinical manifestations.BackgroundNumerous drugs can cause ECG changes and lead to cardiac dysrhythmias, and the diagnoses and subsequent management of patients with ECG changes following poisonings can be a challenge for even the most experienced physician. Digoxin toxicity often presents with gastrointestinal side effects, cardiac dysrhythmias, and neurological effects. Overdoses of antidepressants are common and deadly, and sudden cardiovascular deterioration is the hallmark of toxicity. Theophylline overdose can lead to neurotoxicity and cardiac toxicity associated with life-threatening dysrhythmias.Patients and methodsIn this study, patients who had overdosed on digitalis, theophylline, and antidepressants admitted to MPCC in 2011 were included. Clinical data, serum electrolytes, arterial blood gas changes, and ECG changes were assessed.ResultsA total of 77 patients were studied. Most patients in the study were females in the age group of 20 to less than 40 years, and they outnumbered males in both suicidal and accidental modes. Theophylline overdose cases were the most common, followed by antidepressants and then digoxin overdose. A significant relation was found between the type of drug overdose and clinical manifestations, wherein vomiting occurred most frequently with digoxin overdose. Convulsions occurred only in cases of overdose with antidepressants. Hypokalemia was more evident in cases of overdose with antidepressants. In terms of ECG changes, sinus bradycardia and ST segment depression were found only in digoxin overdose cases. Sinus tachycardia occurred most frequently in theophylline overdose cases. A highly significant relation was found between potassium (K + ) blood-level and ECG changes such as sinus tachycardia and ST segment depression. A significant relation was found between metabolic acidosis and a wide QRS complex. No case fatality was recorded in this study.ConclusionDrug overdose is a major and longstanding source of morbidity worldwide. Digitalis overdose manifested as sinus bradycardia and ST segment depression. Theophylline overdose manifested as sinus tachycardia and antidepressant overdose cases were characterized by sinus tachycardia and a wide QRS complex.

Digoxin overdose – an accurate method for determining free digoxin concentrations on general chemistry analysers post DigiFab treatment

Article Digoxin overdose – an accurate method for determining free digoxin concentrations on general chemistry analysers post DigiFab treatment was published on July 1, 2014 in the journal Clinical Chemistry and Laboratory Medicine (CCLM) (volume 52, issue 7).

Emergency Department Visits and Hospitalizations for Digoxin Toxicity

Background— Recent data on digoxin prescribing and adverse events are lacking but could help inform the management of digoxin in contemporary heart failure treatment. Methods and Results— We determined nationally representative numbers and rates of emergency department (ED) visits for digoxin toxicity in the United States using 2005 to 2010 reports from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project and the National Ambulatory (and Hospital Ambulatory) Medical Care Surveys. Based on 441 cases, an estimated 5156 (95% confidence interval [CI], 2663–7648) ED visits for digoxin toxicity occurred annually in the United States; more than three fourths (78.8% [95% CI, 73.5%–84.1%]) resulted in hospitalization. Serum digoxin level was ≥2.0 ng/mL for 95.8% (95% CI, 93.2%–98.4%) of estimated ED visits with levels reported (n=251 cases). The rate of ED visits per 10 000 outpatient prescription visits among patients ≥85 years was twice that of patients 40 to 84 years (rate ratio, 2.4 [95% CI, 1.2–5.0]); among women, the rate was twice that of men (rate ratio, 2.3 [95% CI, 1.1–4.7]). Digoxin toxicity accounted for an estimated 1.0% (95% CI, 0.6%–1.4%) of ED visits for all adverse drug events among patients ≥40 years, but an estimated 3.3% (95% CI, 2.3%–4.4%) of ED visits and 5.9% (95% CI, 4.0%–7.9%) of hospitalizations for all adverse drug events among patients ≥85 years. Estimated annual ED visits and hospitalizations remained relatively constant from 2005 to 2010. Conclusions— Digoxin toxicity is not declining; more careful prescribing to high-risk groups and improved monitoring of serum levels might be needed to reduce morbidity from outpatient digoxin use.

Bidirectional tachycardia after an acute intravenous administration of digitalis for a suicidal gesture.

Acute digoxin intoxication is a life-threating condition associated with severe cardiotoxicity. Female gender, age, low lean body mass, hypertension, and renal insufficiency may worsen the prognosis. Arrhythmias caused by digitalis glycosides are characterized by an increased automaticity coupled with concomitant conduction delay. Bidirectional tachycardia is pathognomonic of digoxin intoxication, but it is rarely observed. An 83-year-old woman was admitted to the Emergency Department after self-administration of 5 mg of digoxin i.v. for suicidal purpose. Her digoxin serum concentration was 17.4 ng/mL. The patient developed a bidirectional tachycardia and the Poison Control Center of the hospital provided digoxin immune fab. Bidirectional tachycardia quickly reversed and the patient remained stable throughout the hospital stay. This case shows that a multiple disciplinary approach, involving cardiologists and toxicologists, is essential for the management of digoxin intoxication. The optimal treatment of this rare event depends on the clinical conditions and on the serum drug concentration of the patient. Digoxin immune fab represents a safe, effective, and specific method for rapidly reversing digitalis cardiotoxicity and should be started as soon as the diagnosis is defined.

Severe suicidal digoxin and propranolol toxicity with insulin overdose

We present a case of a 32-year-old male doctor, with type I diabetes mellitus on daily insulin therapy, who allegedly consumed large doses of digoxin and propranolol along with simultaneous administration of large dose of insulin with suicidal intent. Initial investigations revealed serum digoxin levels of 7.5 ng/ml, serum insulin 500 μIU/ml, and serum C-peptide 0.43 ng/ml. He was managed with charcoal-based hemoperfusion for digoxin overdose along with injection glucagon for propranolol overdose. His blood sugar levels were maintained with continuous infusion of 20% dextrose till the patient was allowed to take oral diet. Significant clinical improvement was noticed with this therapy which was evident by progressively declining serum digoxin levels, normalization of pulse rate, and adequate blood glucose levels. Finally, with a good hemodynamic profile and a serum digoxin level well within normal limits, he was discharged following consultation with a psychiatrist.

Signs and Symptoms Indicative of Potential Adverse Drug Reactions in Homecare Patients

The purpose of this study was to determine whether homecare workers can detect signs and symptoms indicative of potential adverse drug reactions (ADRs) in homecare patients, using a standardized observation list. This observational study involved 115 patients cared for by 2 homecare organizations in The Netherlands between April 2011 and August 2011. During routine home visits, homecare workers filled out a standardized observation list of signs and symptoms indicative of potential ADRs, namely, gastrointestinal and other bleedings, electrolyte disturbances, renal and heart failure, digoxin intoxication, constipation, disturbances of diabetic control, and falls. Their observations were compared against the medications that the patients were using and their known side effects, by a panel of clinical pharmacology experts. Sensitivity, specificity, and positive and negative predicted values of the standardized observations were calculated. In total, 234 signs and symptoms indicative of potential ADRs were observed by the homecare workers, 116 (49.6%) of which were considered drug related. More than one-half of the observed signs of gastrointestinal bleeding could be considered as drug related. Observed dizziness (64.1%) and drowsiness (53.3%) could be drug related in most cases, as could most cases (71.4%) of fainting spells (indicative of renal or heart failure). Seventeen of 20 observed falls could be drug related. The specificity of the standardized observation list was high, varying from 0.70 (confidence interval 0.62-0.77) to 0.97 (confidence interval 0.95-0.98). Signs and symptoms indicative of potential ADRs recorded by homecare workers using a standardized observation list can aid in the early recognition of ADRs in homecare patients.

Dronedarone-Induced Digoxin Toxicity

Dronedarone is a relatively new antiarrhythmic drug approved for paroxysmal or persistent atrial fibrillation. Dronedarone can inhibit P-glycoprotein-mediated digoxin clearance and increase steady-state digoxin level 2.5 times. It is important to closely monitor plasma digoxin levels or administer a lower loading dose of digoxin in patients taking dronedarone concomitantly. We report a case of digoxin toxicity in a patient taking concomitant dronedarone as a result of interaction between digoxin and dronedarone.

Recurrence of digoxin toxicity following treatment with digoxin immune fab in a patient with renal impairment

In patients with chronic digoxin toxicity, especially in the presence of renal impairment, a prolonged duration of continuous monitoring is required with consideration given to further doses of immune fab if necessary for re-emergence of toxicity.

Live Versus DVD Mock Trial: Are Cognitive and Affective Changes Different?

Educating nurses to provide safe, ethical patient care while being socialized into the professional role requires active learning Personal, affective growth and professional transformation occur over the course of the nursing program as a result of the synthesis of cognitive knowledge, psychomotor skills, and ethical standards into a professional identity (Benner, Sutphen, Leonard, & Day, 2010). The end result is a nurse who demonstrates ethical comportment by keeping the good of the patient at the forefront, and continually acting to protect patient safety and dignity (Benner et al.). All faculty are challenged to present didactic material while using best practices. Encouraging the internalization of content while being prudent regarding financial and faculty resources requires creativity. We decided to revisit one creative strategy for teaching ethical patient care to nursing students, that is, the mock trial and explore how viewing a live trial versus a DVD affected cognitive knowledge and changed affective learning. The purpose of this study was twofold: a) to explore how presenting didactic information, followed by experiential learning with a mock trial, enhanced the cognitive and affective domains of the learner, and b) to investigate the effectiveness of a live mock trial versus a DVD of the same trial in producing the desired changes. METHOD This mixed-methods, quasi-experimental study involved 192 generic baccalaureate nursing students at a public university in the United States. The students had completed all general education credits, including an ethics course. The mock trial took place during the first upper division semester in a professional concepts course. One cohort of 96 students experienced a live mock trial; the second cohort, also 96 students, experienced the DVD version of the same trial. Focus groups with each cohort provided insight into thoughts regarding the events of the trial and its perceived effectiveness as a teaching method. Sample Most student participants were female (89.5 percent). The race/ ethnicity membership of the total cohort was 92 percent Caucasian, 6.5 percent African American, and 1.5 percent other. All students attended focus groups. Three students did not complete both the pretest and the posttest, resulting in a final sample of 189 students. Data Collection and Analysis Cohorts completed identical learning modules covering ethical content and legal issues. After finishing the modules, students completed a pretest to determine baseline knowledge about legal concepts as discussed in The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008) as well as current affective status. Identical pre-/posttests consisted of 17 questions, assessing three faculty-identified constructs: knowledge, responsibility, and accountability. Knowledge questions measured cognitive change. Responsibility and accountability questions assessed affective change. This level of assessment was appropriate for newly promoted undergraduate students who are just beginning to interact with patients, as they were likely to be in one of the first two steps of the affective taxonomy, receiving and responding (Kirkpatrick & DeWitt, 2012). The test was a course-specific exam, and face validity was confirmed by faculty experts. The live trial took place in a courtroom and was recorded for future use. The case was a scripted scenario developed by nursing faculty and a circuit court judge. It was loosely based on a real-life case and involved a nurse who gave a miscalculated overdose of digoxin and did not record the administration of the medication. Mock trial participants playing various roles included students and faculty from law, nursing, and the drama department (March, Ford, Adams, Cheshire, & Collins, 2011). Immediately following the intervention, students participated in focus groups to determine how the mock trial affected them and to assess the acceptability and effectiveness of the strategy. …

PP018—Storage and wastage of antibacterial agents in households in Novi Sad, Serbia

2013 e23 dry DMLA. Dyschromatopsia was confirmed by poor results on Ishihara test (1/13 OU). Computerized visual field results revealed nonspecific diffuse alterations. Full-field electroretinogram (ERG) showed moderate diffuse rod and cone dysfunction. Visual symptoms progressively improved over the next 2 months, but ERG did not. Complete resolution was not expected due to the pre-existing eye disease. The patient was finally discharged home after a 5-week hospital stay. Conclusion: Digoxin intoxication can go unrecognized by clinicians, even in a typical presentation. The range of potential visual symptoms is far greater than isolated xanthopsia (yellow vision) classically described in textbooks. Newly introduced drugs and all symptoms must be actively sought after, because they significantly affect quality of life and global functioning, especially in the elderly population, most liable not to mention them. Disclosure of Interest: None declared.

PP017—Spectrum of ocular digoxin toxicity in the elderly: A case report

PP017—Spectrum of ocular digoxin toxicity in the elderly: A case report

Possible digoxin toxicity associated with concomitant ciprofloxacin therapy

A 27 year old female with a complex history of congenital heart disease, cardiac surgery, heart failure, and arrhythmias was admitted for a Pseudomonas aeruginosa sternal wound infection and treated with intravenous antibiotics. After discharge and completion of an outpatient course of intravenous antibiotics, suppressive antibiotic therapy with ciprofloxacin was initiated. She presented to clinic with nausea and anorexia within a few days of addition of ciprofloxacin to her current regimen of medications, which included digoxin. The digoxin was discontinued, with all other medications remaining the same, and the symptoms resolved in 48 h. The dose of digoxin was restarted at 50 % of the previous dose with no further complications. The proposed cause of the nausea and anorexia was digoxin toxicity secondary to a drug-drug interaction with ciprofloxacin. Patients receiving ciprofloxacin and digoxin should be monitored closely for the risk of digoxin toxicity.

Hyperkalemic Paralysis: An Elective Abortion Gone Wrong

BackgroundCommonly used abortion agents carry potentially serious side effects for the mother. It is important for emergency physicians to be aware of the medications used in elective abortions from the late first trimester to term. If digoxin is used as an abortifacient, it is injected intrafetally or intraplacentally. With this method there is a chance of extraplacental injection, resulting in maternal systemic digoxin toxicity and serious morbidity or death. ObjectivesThis report presents a case report, discusses the risks of digoxin-induced abortion, and teaches the reader about the abortifacient agents currently in use, along with their associated complications. Case ReportThis is a case of a 28-year-old pregnant woman of approximately 20 weeks gestation, who presented with severe muscular weakness and respiratory failure requiring intubation. She was subsequently found to have hyperkalemic paralysis from digoxin toxicity after an extraplacental injection during the first step of a two-part elective abortion. ConclusionsIt is important for emergency physicians to be aware of the various late first-trimester to term abortifacient agents and procedures being used in obstetrical/gynecological practice, and the potential risks of these interventions. Digoxin toxicity or hyperkalemia should be suspected when a patient presents with severe weakness and respiratory distress after an attempted abortion.

Digoxin Toxicity with Normal Digoxin and Serum Potassium Levels: Beware of Magnesium, the Hidden Malefactor

BackgroundIn recent years, digoxin use has been on the decline, with decreased incidence of digoxin toxicity. Hence, digoxin toxicity, when it occurs, remains an elusive diagnosis to emergency physicians. ObjectiveTo present a case of digoxin toxicity with normal levels of digoxin and serum potassium, but with severe hypomagnesemia. Case ReportA 66-year-old woman presented with junctional tachycardia and ectopic atrial tachycardia. She was known to have congestive cardiac failure on diuretic therapy. Her serum digoxin level was within the normal range (2.4 nmol/L [normal = 1.9–2.6]) along with a normal serum potassium level (3.9 mmol/L [normal = 3.5–5]). However, there was severe hypomagnesemia (0.39 mmol/L [normal = 0.65–1.25]) precipitating digoxin-induced dysrhythmia, which responded well to intravenous magnesium therapy. ConclusionThis case reiterates that digoxin toxicity can occur in patients with normal digoxin and potassium levels, and in such patients, magnesium needs to be checked and treated to prevent potentially life-threatening dysrhythmias.