Parenteral Manual

Digoxin

Disclaimer: Official controlled document is the CHEO online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Alternate Name(s): 
LANOXIN®
Classification: 
Cardiac glycoside
Original Date: 
August 2005
Revised Date: 
December 2019
Indications: 
  • Inotropic agent for treatment of congestive heart failure
  • Antiarrhythmic for treatment of supraventricular arrhythmias such as atrial fibrillation, atrial flutter and paroxysmal atrial tachycardia
Reconstitution and Stability: 
  • Available as 50 mcg/mL (0.05 mg/mL). Stable at room temperature. Protect from light
  • Diluted solutions stable 48 hours at room temperature or in fridge
Compatibility: 

- Solutions Compatible: dextrose up to D10W, NS, Sterile Water for Injection, ringer's lactate

- Additives/Above Cassette Compatible: furosemide

-Y-site Compatible: KCl (up to 40 mmol/mL), morphine, TPN (amino acids/dextrose), heparin, meropenem

-Incompatible: dobutamine, propofol, fluconazole

Administration: 

(For approved routes of administration by nursing personnel, refer to Policy for the Administration of Intravenous Medications.)

SC NO
IM NO, very painful
IV Direct

NO
IV Intermittent Infusion

YES
Usual dilution: 10 mcg/mL
Infusion time: 5-10 minutes
IV Continuous Infusion NO
Dosage: 

(For neonatal dosages, refer to Neonatal IV Drug Manual.)

DIGITALIZING DOSE: (3 doses- 1st stat; 2nd in 6 hrs; 3rd in another 6 hrs)

  • Term infants-2 years: 12 mcg/kg/dose IV
  • >2 years: 10 mcg/kg/dose IV
  • Maximum total digitalizing dose: 1 mg

MAINTENANCE DOSE: Start 12 hours after last digitalizing dose

  • Term infants-2 years: 7 mcg/kg/day IV divided Q12H
  • >2-10 years: 6 mcg/kg/day IV once daily or divided Q12H
  • >10 years: 2-3 mcg/kg/day IV once daily
  • Maximum maintenance dose: 250 mcg/day

DOSAGE ADJUSTMENT IN RENAL IMPAIRMENT:
- Total digitalizing dose: reduce by 50% in end-stage renal disease
- Maintenance dose:

  • CrCl 10-50 mL/min: Administer 25-75% of normal daily dose (divided and given at normal intervals) or administer normal dose every 36 hours
  • CrCl < 10 mL/min: Administer 10-25% of normal daily dose (divided and given at normal intervals) or administer normal dose every 48 hours
Potential hazards of parenteral administration: 
  • IM injections may cause pain and muscle spasm, erratic absorption and crystal deposition in the muscle    
  • Extravasation may cause local irritation and sloughing                  
  • Non-cardiac symptoms of digoxin toxicity hard to evaluate in children; usual toxic effects reported in infants are:
    - Gastrointestinal: feeding intolerance/diminished appetite, persistent vomiting
    - Cardiac effects: the diagnosis of digoxin toxicity in neonates and infants usually 
    rests on ECG abnormalities, arrhythmias, first degree AV block, PVC's, bigeminy
    PAT with block; sinus node bradycardia is the major cardiac manifestation in low
    birth weight infants.
Notes: 
  • Monitor heart rate and rhythm, serum potassium, magnesium, calcium, ECG
  • IV dose = oral dose × 0.7
  • Oral dose = IV dose × 1.4

Treatment of overdose:

  • Discontinue drug
  • Administer potassium salts and other cardiac drugs for treating arrhythmias
  • Possibility of digitalis toxicity greater in patients who are hypokalemic, hypo or hypermagnesemic, hypercalcemic, have decreased renal function, are in premature age category, had a loading dose
  • DIGIBIND may be used as an antidote.  One vial of Digibind neutralizes 0.5 mg digoxin.

Drug levels:

  • Therapy should be monitored by clinical effect rather than serum level; useful when toxicity suspected
  • "Therapeutic" serum level 1.3-2.7 nmol/L (correlation with therapeutic effect not clearly defined)
  • Draw blood for digoxin at least 8 hrs post dose or preferably prior to next scheduled dose
  • Levels may be elevated in neonates due to endogenous digoxin-like substances
  • When administering digoxin, nurses first take the heart rate.  If the heart rate is lower than indicated below, the medication is held and the physician is notified:

    Age

    Heart Rate

    Birth- 6 months

    95 beats/minute

    6 months-18 months

    80 beats/minute

    >18 months

    65 beats/minute

                                                                                                  

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