Evidence Based Digoxin Therapeutic Monitoring - A Lower and Narrower Therapeutic Range

Abstract

Cardiac glycosides have been used for congestive heart failure and certain cardiac arrhythmias for more than 200 years. Despite the introduction of a variety of new classes of drugs for the management of heart failure, specifically angiotensin-converting enzyme (ACE) inhibitors, b-adrenergic antagonists (b-blockers), and the aldosterone antagonist spironolactone, digoxin continues to have an important role in long-term outpatient management. However, a narrow margin exists between therapeutic and toxic doses of digoxin, resulting in a high incidence of digoxin toxicity in clinical practice. A wide variety of placebo-controlled clinical trials have unequivocally shown that treatment with digoxin can improve symptoms, quality of life, and exercise tolerance in patients with mild, moderate, or severe heart failure. The clinical relevance of digoxin therapeutic monitoring is also proved but the SDC (Serum Digoxin Conentrations) required for optimal clinical efficacy and acceptable toxicity remains controversial. In the last years, international guidelines recommend 1.2 ng/mL as acceptable high level. In this bibliographic synthesis, we aim to collect pertinent informations from MedLine database about exposure-effect relationship in order to assess the evidence level scientific of new digoxin therapeutic monitoring.

Pemantauan Kadar Obat Indeks Terapi Sempit Melalui Estimasi Kadar Obat di Dalam Darah pada Pasien Rawat Inap di RSUD Prof. Dr. Margono Soekarjo, Purwokerto

“…Menurut Benlmouden dan Billaud (2016), rentang terapi yang direkomendasikan untuk kadar digoksin dalam darah yaitu berkisar antara 0,5-0,9 ng/mL sebab kadar digoksin ≥1,0 ng/mL meningkatkan resiko terjadinya toksisitas digoksin dan mortalitas pada pasien. 39 Pada hasil penelitian yang dilakukan oleh Maury, et al (2014) juga dinyatakan hal yang sama bahwa kadar digoksin dalam darah ≥1 ng/mL meningkatkan mortalitas. 40 Namun, kadar digoksin dalam darah 1,00-2,00 ng/mL bukan termasuk dalam kadar rentang toksik.…”

Review: Failure of current digoxin monitoring for toxicity: new monitoring recommendations to maintain therapeutic levels for efficacy

“…The maximum target serum digoxin level for atrial fibrillation is now recommended by some to be <0.9 ng/ml ( 37 ) or ≤1.2 ng/ml ( 62 ). In 2016, Benlmouden and Billaud concluded in their manuscript Evidence Based Digoxin Therapeutic Monitoring a Lower and Narrower Therapeutic Range that “The target serum digoxin concentration should be 0.5–1.0 ng/ml” ( 63 ) while in 2018 Whayne supported “low doses” with monitoring to prevent supratherapeutic levels ( 27 ).…”