Digoxin (Lanoxin, Digitek)

Drug Class: Cardiotonic Agent (Positive Inotropic, Antiarrhythmic)

Mechanism of Action:
- Positive Ionotropic: It increases the force of contraction of the heart by inhibiting the
activity of the myocardial Na-K ATPase pump. Digoxin induces an increase in
intracellular sodium therefore allowing an influx of calcium in the heart to cause an
increase in contractility. Cardiac output increases with a subsequent decrease in
ventricular filling pressures.

- AV Node Inhibition: By stimulating the parasympathetic nervous system, it slows

electrical conduction in the AV node which decreases the heart rate. The rise in
calcium levels leads to prolongation of phase 4, and phase 0 of the cardiac action
potential thus increases the refractory period of the AV node. Slower conduction
through the AV node carries a decreased ventricular response.

Indications:
- Supraventricular Tachycardia
- Atrial Fibrillation/ Atrial Flutter: When conventional methods have not achieved the
goal. Should be used in caution in cases of pre-excitation along accessory pathways
as it may trigger ventricular tachycardias.
- Heart Failure: Increases the left ventricular ejection fraction, however, it has been
shown to have no benefit in the reduction of mortality and is considered a third-line
heart medication in heart failure cases.

Contraindications:
- Hypersensitivity to Digoxin
- Acute MI
- VFib
- Myocarditis
- Hypomagnesemia
- Hypokalemia
- Wolf-Parkinson-White Syndrome
Should be used cautiously in cases of:
- Hyper/Hypocalcemia
- Renal impairment
- Decreased SA Node
 - AV block
- Thyroid disease
- Bradycardia
- Restrictive Cardiomyopathy
- Constrictive Pericarditis

Side Effects:
- Rash
- Headache
- Gynecomastia
- Weakness

Dose:
Important considerations during administration include:
- Requesting an electrocardiogram before digoxin administration
- Electrolytes, mainly potassium levels assessed and normalized prior to digoxin
administration.
- If bradycardia is present, re-evaluate and withhold treatment as necessary.

Atrial Fibrillation
Loading Dose
- 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; perform careful assessment of clinical
response and toxicity before each dose
Maintenance Dose

- 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.
- IV/IM: 0.1-0.4 mg qDay; IM route not preferred due to severe injection site

Heart Failure

- A loading dose to initiate digoxin therapy in patients with heart failure is not
necessary
- 0.125-0.25 mg PO/IV qDay; higher doses including 0.375-0.5 mg/day rarely needed

Notes:
It is worth noting that Digoxin in clinical uses can be dangerous and lead to increased
mortality in some cases. Digoxin should only be used as a Third Line treatment for heart
failure when other options are not available or have not been successful.
Further, in cases of Atrial Fibrillation, Digoxin is not recommended as a primary measure
and should be carefully considered or ruled out due to the accessibility for less risky
measures.
Doxycycline (Vibramycin, Monodox)

Drug Class: Tetracycline Antibiotic

Mechanism of Action:
- Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and
possibly 50S ribosomal subunits of susceptible bacteria; may block dissociation
of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to
arrest.

Indications:
- Used for the treatment of gram- bacterial infections
- Acne Vulgaris
- Non-gonococcal urethritis
- URTIs
- LRTIs
- Cellulitis due to staphylococcus aureus*
- Cholera
- UTIs

Contraindications:
- Documented Hypersensitivity

Side Effects:
Diarrhea, Difficulty swallowing, Drug rash, Esophageal ulcer, Esophagitis, Facial redness,
Headache, Hives, Inflammation of the small intestine and colon (enterocolitis), Lesions on
the genitals or anus, Loss of appetite, Low blood sugar (hypoglycemia),Low levels of white
blood cells or platelets, Skin hyperpigmentation, Skin peeling (exfoliative dermatitis), Tongue
swelling, Tooth discoloration, Upper abdominal pain

Dose:

- Initial: 200 mg/day divided bid orally/intravenously (IV) on first day (IV may be given
once/day)
- Maintenance: 100-200 mg/day once/day or divided q12hr orally/intravenously (IV) (IV
may be given once/day)

Notes:
*Tetracyclines are NOT the drug of choice for any staphylococcal infection
Phenytoin (Dilantin)
Drug Class: Anti-Convulsant

Mechanism of Action:
- Stabilizes neuronal membranes and decreases seizure activity by increasing efflux or
decreasing influx of sodium ions across cell membranes in the motor cortex during
generation of nerve impulses.
- Prolongs effective refractory period and shortens action potential in the heart

Indications:
- Tonic-Clonic Seizures
- Focal Seizures
- Status Epilepticus (after failure of benzodiazepine administration)

Contraindications:
- Sinus bradycardia
- Sinoatrial block
- Second- and third-degree heart block
- Adams-Stokes syndrome

Side Effects:
- Potentially serious side effects include sleepiness, self harm, liver problems, bone
marrow suppression, low blood pressure, and toxic epidermal necrolysis

Dose:
Status epilepticus

- Load 10-15 mg/kg or 15-20 mg/kg at 25-50 mg/min, THEN

- Maintenance: 100 mg IV/PO q6-8hr PRN
Administer IV slowly; not to exceed 50 mg/min
Anticonvulsant

- Tablet, 100 mg PO TID

- Maintenance: 300-400 mg/day; increase to 600 mg/day if necessary
May adjust dose no sooner than 7-10 day intervals when indicated
- Suspension, 125 mg PO TID, initially
 - Increase to 625 mg/day if necessary
May adjust dose no sooner than 7-10 day intervals when indicated
- Extended release
- Loading dose: 1 g divided into 3 doses (400, 300, 300 mg) administered at 2
hr intervals; initiate dosage 24 hr after loading dose

Notes:
Phenytoin can be used to reverse the effects of Digoxin Toxicity.