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digoxin (Rx)Lanoxin

Classes: Antidysrhythmics, V; Inotropic Agents

Pediatric

Dosing & Uses

Dosage Forms & Strengths
Heart Failure/Atrial Fibrillation

Adult

Use doses at the lower end of the spectrm when treating heart failure
Dosage Forms & Strengths
Atrial Fibrillation

Reduce dose by 20-25% when changing from oral formulation or IM to IV
therapy

Rapid digitalizing (loading-dose) regimen

IV: 8-12 mcg/kg (0.008-0.012 mg/kg) total loading dose; administer
50% initially; then may cautiously give 1/4 the loading dose q6-8hr twice;
perform careful assessment of clinical response and toxicity before each 
dose
PO: 10-15 mcg/kg total loading dose; administer 50% initially; then
may cautiously give 1/4 the loading dose q6-8hr twice; peform careful 
assessment of clinical response and toxicity before each dose
Maintenance


As per ACCF/AHA guidelines, a loading dose to initiate digoxin therapy in
patients with heart failure is not necessary

PO: 1st loading dose, 17.5-30 mcg/kg; 2nd and 3rd loading doses,
8.75-15 mcg/kg q6-8hr for 2 doses; maintenance: 10-15 mcg/kg/day divided
q12hr
IV/IM: 1st loading dose, 15-25 mcg/kg; 2nd and 3rd loading doses,
7.5-12.5 mcg/kg q6-8hr for 2 doses; maintenance: 7.5-12 mcg/kg/day
divided q12hr
2-5 years

Dosing Modifications

In heart failure, higher dosages have no additional benefit and may increase

toxicity; decreased renal clearance may lead to increased toxicity
In geriatric patients, use lean body weight to calculate dose

PO: 1st loading dose, 12.5-17.5 mcg/kg; 2nd and 3rd loading doses,
6.25-8.75 mcg/kg q6-8hr for 2 doses; maintenance: 6-10 mcg/kg/day
divided q12hr
IV/IM: 1st loading dose, 10-15 mcg/kg; 2nd and 3rd loading doses, 57.5 mcg/kg q6-8hr for 2 doses; maintenance: 5-8 mcg/kg/day divided q12hr
Infants & children 1-24 months

0.125-0.25 mg PO/IV qDay; higher doses including 0.375-0.5 mg/day rarely 
needed

Adjust maintenance dose by estimating CrCl and measuring serum levels

PO: 1st loading dose, 10-15 mcg/kg; 2nd and 3rd loading doses, 57.5 mcg/kg q6-8hr for 2 doses; maintenance: 5-7.5 mcg/kg/day divided
q12hr
IV/IM: 1st loading dose, 7.5-12.5 mcg/kg; 2nd and 3rd loading doses,
3.75-6.25 mcg/kg q6-8hr for 2 doses; maintenance: 4-6 mcg/kg/day divided
q12hr
Full-term neonate

PO: 3.4-5.1 mcg/kg/day or 0.125-0.5 mg/day PO; may increase dose

every 2 weeks based on clinical response, serum drug levels, and toxicity
IV/IM: 0.1-0.4 mg qDay; IM route not preferred due to severe injection
site reaction

Heart Failure

Use lower end of dosing (0.125 mg/day) in patients with impaired renal
function or low lean body mass

Premature neonate

PO: 1st loading dose, 15-20 mcg/kg; 2nd and 3rd loading doses,
8.75-10 mcg/kg q6-8hr for 2 doses; maintenance: 7.5-10 mcg/kg/day
divided q12hr
IV/IM: 1st loading dose, 12.5-17.5 mcg/kg; 2nd and 3rd loading
doses, 6.25-8.75 mcg/kg q6-8hr for 2 doses; maintenance: 6-9 mcg/kg/day
divided q12hr

5 mcg/kg.75-7.75 mcg/kg q6-8hr for 2 doses. maintenance: 2-3 mcg/kg/day Adverse Effects Warnings 1-10% Dizziness (4. 58.5 mcg/kg. maintenance: 4-8 mcg/kg/day divided q12hr Frequency Not Defined Visual disturbance (blurred or yellow vision) Heart block (1°/2°/3°) Asystole >10 years & <100 kg Tachycardia PO: 1st loading dose.2%) Vomiting (1. electrical cardioversion.2%) Headache (3. maintenance: 5-10 mcg/kg/day divided q12hr IV/IM: 1st loading dose. 2. hypothyroidism or hyperthyroidism.5 ng/mL Generally avoid if left ventricular systolic function preserved. 4-6 mcg/kg.9%) Mental disturbances (4. ventricular tachycardia.53. >2.6%) <1% Anorexia Cardiac dysrhythmia Arrhythmia in children (consider a toxicity) Contraindications Hypersensitivity Ventricular fibrillation Cautions Use caution in chronic constrictive pericarditis.5-2 ng/mL (target 0.1%) Diarrhea (3. toxic range. 2nd and 3rd loading doses.6%) Maculopapular rash (1. 7. renal disease. severe heart failure.5-1 ng/mL).5-10 years     PO: 1st loading dose. 0. 3. 5-7.2%) Nausea (3.75 mcg/kg q6-8hr for 2 doses. electrolyte imbalance. severe pulmonary disease.5-5 mcg/kg/day IV/IM: 1st loading dose. hypoxia. severe bradycardia.5-15 mcg/kg. idiopathic hypertrophic subaortic stenosis. sick sinus syndrome. 2nd and 3rd loading doses. maintenance: 2. ventricular premature contractions. 2nd and 3rd loading doses.5 mcg/kg q6-8hr for 2 doses. concomitant diuretics Not recommended in patients with acute myocardial infarction Avoid in patients with myocarditis Risk of advanced or complete heart block in patients with sinus node disease and AV block Very narrow margin between effective therapeutic and toxic dosages: Therapeutic range. although may be used for ventricular rate control in subgroup with chronic atrial fibrillation . 2-3 mcg/kg q6-8hr for 2 doses. 2nd and 3rd loading doses. Wolff-Parkinson-White syndrome. 10-17.

which subsequently promotes calcium influx via sodium-calcium exchange pump IV Compatibilities In supraventricular arrhythmias. floxacillin. suppresses AV node conduction.Less effective in presence of hypokalemia or hypocalcemia. D5W. cimetidine. meropenem. and enhanced vagal tone Additive: Bretylium. 5-30 min (IV) for initial effect and 1. remifentanil. ranitidine. avoid hypercalcemia or hypomagnesemia. includes bile) Administration In heart failure. meperidine. 70-85% (elixir) Solution: D5/½NS with potassium chloride 20 mEq.5-4 hr for maximal effect Duration: 3-4 days Heart failure patients with preserved ventricular function including acute cor pulmonale. treat underlying condition before initiating therapy Pharmacology Mechanism of Action Peak serum time: 1-3 hr (PO) Distribution Protein bound: 20-25% Vd: 6-7 L/kg Metabolism Metabolized by liver Metabolites: (active) Digoxigenin bisdigitoxoside. decreased ventricular rate. lidocaine. causing positive inotropic effect. NS Syringe: Heparin. inamrinone. milrinone. increases contractility by inhibiting sodium/potassium ATPase pump in myocardial cells. famotidine. ciprofloxacin. which may predispose to serious arrhythmias Onset: 0.5-2 hr (PO) for initial effect and 2-6 hr for maximal effect. midazolam. milrinone . bioavailability varies Serum levels drawn within 6-8 hours of dose will be falsely high because of prolonged distribution phase Increased risk of estrogenlike effects in geriatric patients Beriberi heart disease may not respond adequately if underlying thiamine deficiency not corrected Atrial arrhythmias are difficult to treat if associated with hypermetabolic (hyperthyroidism) or hyperdynamic (hypoxia) states. feces (9-13%. and constrictive pericarditis may be susceptible to digoxin toxicity May cause false-positive ST-T changes during exercise testing Do not switch between different PO forms or between brand and generic forms of digoxin. Hextend. potassium chloride. digoxigenin monodigitoxoside Elimination Half-life: 1-3 days Excretion: Urine (57-80%). verapamil Absorption Y-site: Bivalirudin. amyloid heart disease. which increases refractory period and decreases conduction velocity. gatifloxacin. linezolid. ½NS. fenoldopam. vitamins B and C Bioavailability: 60-80 % (tablet). dexmedetomidine. furosemide. diltiazem. LR. morphine sulfate. heparin with hydrocortisone. cisatracurium. tacrolimus.

foscarnet. Impaired Renal Function ADULTS (CREATININE CLEARANCE < 30 ML/MIN): PO Initial dose 2 mg/day (max dose 8 mg/day). IV Preparation Dilute with 4-fold or greater volume of SWI. a diuretic may be added. Usual maintenance dose is 4 to 8 mg daily. use an initial dose of 2 to 4 mg daily of perindopril and titrate the dose as above. Route/Dosage Drug is severe skin irritant when given IV/IM and may cause severe local skin reaction with possible sloughing Storage Store at controlled room temperature Protect from light Uncomplicated Hypertension ADULTS: PO Initial dose 4 mg qd. or a max of 8 mg/day. PATIENTS > 65 YRS: PO Initial dose 4 mg daily in 1 or 2 divided doses. just before the next dose. or NS IV Administration Administer slowly by direct IV injection over minimum of 5 minutes (longer if given undiluted) Do not administer if precipitate present Contraindications Hypersensitivity or history of angioedema related to ACE inhibitor treatment. In patients being treated with a diuretic. and Humulin R[?]). then titrate upward until BP. is controlled. . amiodarone. just before the next dose. then titrate upward until BP. Indications Treatment of essential hypertension. If the diuretic cannot be discontinued. D5W. pork. resulting in prevention of angiotensin I conversion to angiotensin II. discontinue the diuretic 2 to 3 days prior to beginning perindopril. insulin (beef. Use with Concomitant Diuretics Perindopril Erbumine (per-IN-doe prill ehr-BYOO-meen) Aceon Class: Antihypertensive/Angiotensin-converting enzyme (ACE) inhibitor ADULTS: PO If BP is not adequately controlled with perindopril alone. to reduce the likelihood of the occurrence of symptomatic hypotension. is controlled or a maximum of 16 mg/day. propofol fluconazole. Additive: Dobutamine Syringe: Doxapram Y-site: Amphotericin B cholesteryl sulfate.IV Incompatibilities Action Competitively inhibits angiotensin I-converting enzyme. a potent vasoconstrictor that also stimulates aldosterone release. Clinical consequences are a decrease in BP. reduced sodium resorption and potassium retention.

drugs capable of increasing serum potassium (eg. and tongue. ear infection. OTHER: Asthenia. viral infection. Elderly: Perindopril plasma concentrations may be increased. indomethacin): Increased risk of hyperkalemia. diarrhea. upper respiratory infection. paresthesia. urinary tract infection. GU: Proteinuria. Protect from moisture. Lactation: Undetermined. which could include epinephrine. menstrual disorder. vomiting. Potassium supplements. lips. Adverse Reactions CV: Palpitation. or larynx likely to cause airway obstruction. chest pain. spironolactone). hold the medication and notify the primary care provider. META: Increased triglycerides. tinnitus. Where there is involvement of the tongue. withold therapy and notify the primary care provider. myalgia. promptly administer emergency therapy. somnolence. rhinitis. Should hypotension.  Monitor BP and pulse. or bradycardia result. Neutropenia and agranulocytosis: Has occurred rarely with other ACE inhibitors.  Assist patient with position changes and ambulation during initial phases of therapy. heparin. neck pain. hematocrit. pharyngitis. depression.  Monitor laboratory tests for increases in serum creatinine and BUN.  Institute fall precautions in unstable patients including the elderly and patients with CHF. edema. Hepatic failure: Has occurred rarely with other ACE inhibitors. sexual dysfunction. cyclosporine.  Monitor for signs of hypersensitivity including angioedema involving swelling of the face. including drug history and any known allergies. HEPA: Increased ALT. hypertonia.  Administer alone or in combination with other antihypertensives or diuretics. RESP: Cough. abnormal ECG.Interactions PATIENT CONSIDERATIONS Administration/Storage Diuretics: Increased risk of excessive reduction in BP. DERM: Rash. CNS: Headache. . Renal impairment: Changes in renal function may occur in susceptible individuals. If occurring. dizziness. Precautions Pregnancy: Category C (first trimester). nervousness. risk appears greater with renal dysfunction. upper and lower extremity pain. CARE Assessment/Interventions  Obtain patient history. flatulence. joint pain.  Store at controlled room temperature in tightly closed container.  Monitor for adverse reactions and drug interactions. Children: Safety and efficacy not established. Angioedema: May occur and is potentially fatal if laryngeal edema occurs. sleep disorder. abdominal pain. nausea. potassium-sparing diuretics (eg. or immunosuppression. and liver function tests. tachycardia. GI: Dyspepsia. fever. EENT: Sinusitis. Use drug with extreme caution in patients with history of angioedema. arthritis. Lithium: Increased risk of lithium toxicity. seasonal allergy. Lab Test Interferences None well documented. category D (second and third trimesters). hemoglobin. glottis. Hypotension: Symptomatic hypotension may occur. heart failure. Cough: Chronic nonproductive cough may occur.

planning to become pregnant. treatment of hypokalemia. loss of taste. management of edematous conditions in CHF. short-term treatment of familial male precocious puberty. weight reduction. circulatory arrest. or swallowing. resulting in increased excretion of sodium and water and decreased excretion of potassium.  Instruct patient to report the following symptoms to primary caregiver: Dyspnea. Unlabeled use(s): Treatment of hirsutism. resulting in reduced fluid volume. and inform their primary care provider should symptoms arise.  Caution patient to notify physician or dentist prior to surgery or treatment. management of essential hypertension. fatigue. or allergy medication. lightheadedness. Caution patient to call primary care provider should abnormal readings occur or if experiencing lightheadedness. jaundice.  Instruct patient in methods of fall prevention including arising slowly and sitting on the side of the bed before standing. cold.  Caution female patients to notify primary care provider at once if pregnant. cirrhosis of liver and nephrotic syndrome. or throat. speaking. and to notify the physician. Novo-Spirozine Class: Potassium-sparing diuretic  Inform patient of the importance of adjunct therapies such as dietary planning. diarrhea. smoking cessation program. long-term maintenance therapy for idiopathic hyperaldosteronism. Action Competitively inhibits aldosterone in distal tubules. alcohol reduction. hepatic.  Tell patient not to use potassium supplements or salt substitutes containing potassium without consulting physician.  Warn patient that inadequate fluid intake. a low sodium diet.  Explain to patient that chronic cough may occur. or planning to breastfeed. death Patient/Family Education  Instruct patient to take the medication as prescribed at the same time each day. especially early in therapy.  Instruct patient to monitor renal.  Inform patient that perindopril can control but does not cure hypertension.OVERDOSAGE: SIGNS & SYMPTOMS Hypotension. Novo-Spiroton. hypothermia. Indications Short-term preoperative treatment of primary hyperaldosteronism. and hematologic symptoms including urinary output and any discomfort during urination. excessive perspiration. and not to discontinue medication suddenly even if feeling better. weakness.  Instruct patient to stop medication and consult physician if fainting occurs. Instruct patient to avoid cough. relief of PMS symptoms. a regular exercise program. dizziness. swelling of eyes. may lead to an excessive fall in BP resulting in lightheadedness and possible fainting. Spironolactone (SPEER-oh-no-LAK-tone) Aldactone. Spironolactone.  Instruct patient to report any indications of an infection such as a sore throat that could indicate neutropenia. or vomiting.  Instruct patient in BP and pulse measurement skills. lips. . and short-term treatment of acne vulgaris. tongue. difficulty breathing. and stress management. face.

3 mg/kg/day in single or divided doses. Digitalis glycosides: May decrease digoxin clearance. Mitotane: May decrease therapeutic response to mitotane. OTHER: Gynecomastia. vomiting. Electrolyte imbalances and BUN increase: Hyperkalemia (serum potassium > 5. possibly  If single dose is prescribed. gastric ulceration. may attenuate inotropic action of digoxin. GU: Inability to achieve or maintain erection.  Take medication with food. hirsutism. drug fever. postmenopausal bleeding. Lactation: Excreted in breast milk. GI: Cramping. irregular menses or amenorrhea. administer in morning. deepening of voice.5 mEq/L). impaired resulting in cardiac arrhythmias or cardiac arrest. . META: Hyperchloremic metabolic acidosis in decompensated hepatic cirrhosis. PATIENT CONSIDERATIONS CARE Interactions Administration/Storage ACE inhibitors: May result in severely elevated serum potassium levels. diarrhea. Salicylates: May result in decreased diuretic effect. ADULTS: PO 25 to 200 mg/day in single or divided doses. carcinoma of breast. hyperkalemia. acute renal insufficiency. ataxia. headache. mental confusion. Route/Dosage digoxin values with radioimmunoassay (assay specific) for measuring digoxin. gastric bleeding. lethargy. Adverse Reactions Diagnosis of Primary Hyperaldosteronism ADULTS: PO 400 mg/day for 4 days (short test) or 3 to 4 wk (long test). CHILDREN: PO 3. gastritis. DERM: Maculopapular or erythematous cutaneous eruptions. hypochloremia and increases in BUN may occur. Potassium preparations: May severely increase serum potassium levels. Edema CNS: Drowsiness. urticaria. CHILDREN: PO 1 to 2 mg/kg bid. Do not take with potassium preparations. Lab Test Interferences Drug may cause falsely elevated serum renal excretory function.Contraindications Anuria. Pregnancy: Category D. Diuretic-Induced Hypokalemia ADULTS: PO 25 to 100 mg/day when oral potassium or other potassiumsparing regimens are inappropriate. Maintenance Therapy for Hyperaldosteronism ADULTS: PO 100 to 400 mg daily in single or divided doses. resulting in increased serum digoxin levels and toxicity. hyponatremia. Precautions Essential Hypertension ADULTS: PO 50 to 100 mg/day in single or divided doses. HEMA: Agranulocytosis.

explain that patient may feel tired for several wks because body needs to adjust to lowered BP.   Instruct patient to take drug with food to minimize GI irritation. confusion or headache occurs.  Instruct patient to avoid large quantities of potassium-rich foods or potassium salt substitutes. notify physician.  If deep rapid respirations or headaches develop. If patient develops frequency. thirst. notify physician.  Instruct patient to notify physician if new symptoms develop. notify physician. diarrhea. headache. If patient appears jaundiced and mentally confused.  Assess urinary status. skin rash.  Advise patient that drug may cause drowsiness and to use caution while driving or performing other tasks requiring mental alertness.  Suspension is stable for 30 days under refrigeration.  Obtain patient history.  Store tablets at room temperature.  Assess for any changes in hepatic status. vomiting. If drowsiness.  If nausea. If level is > 5. notify physician. Monitor serum electrolytes. distention. OVERDOSAGE: SIGNS & SYMPTOMS Electrolyte imbalance Patient/Family Education Assessment/Interventions  Explain that medication's full diuretic effect may not be achieved for 1 to 2 wk. Protect from light. May crush tablets and administer as suspension. liver and renal function studies.  Tell patient to report these symptoms to physician: GI cramping. ataxia.  Instruct patient not to take prescription or otc medications without consulting physician. weight and BP daily.  Assess fluid and electrolyte status prior to therapy.  Monitor ABGs.  Note any changes in neurologic status. dysuria. withhold medication and notify physician. I&O. lethargy. For patient being treated for hypertension.  Tell patient to weigh self twice wkly and to notify physician of any increase. notify physician. edema or reduced urinary output. menstrual abnormalities. . including drug history and any known allergies. diarrhea or anorexia occur. deepening of voice and breast enlargement in men. lethargy.5 mEq/L.   Monitor potassium levels.