Tools for Practice Outils pour la pratique

#139 Digoxin: Old friend or best left on the shelf?

Does digoxin change clinical outcomes for patients with congestive heart failure or atrial fibrillation?

For systolic congestive heart failure (CHF), a randomized controlled trial (RCT) demonstrated that digoxin decreases CHF related hospitalizations (for one in 13 patients) without altering mortality. Stopping digoxin in stable CHF patients may worsen symptoms. Post-hoc analysis suggests low serum digoxin levels may actually decrease mortality. Cohort data for atrial fibrillation (AF) or CHF suggests digoxin increases mortality, although cause and effect is not established. 

CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session

  • Systolic CHF:  
    • High quality RCT of 6,800 patients (NYHA class II-III, mean age 63) on digoxin (median 0.25 mg/day) or placebo1 which contributed 98% of outcomes to subsequent systematic review2 found at three years: 
      • Overall mortality or hospitalizations: No difference. 
      • CHF hospitalizations: 27% Digoxin versus 35% placebo, Number Needed to Treat (NNT)=13. 
      • Limitation: Study occurred before routine beta blocker (BB) use.  
    • Post-hoc analysis:3  
      • Digoxin levels: 
        • <0.9 ng/ml: 6% absolute lower mortality and overall hospitalizations rate compared to placebo. 
        • >1.2 ng/ml: 12% absolute higher mortality. 
    • 12 week RCTs of Digoxin withdrawal in stable CHF resulted in:4,5 
      • Clinical deterioration (necessitating study withdrawal)4 or treatment failure (adding/increasing CHF meds, emergency department visit/admission)5 
      • Number Needed to Harm ~5.4,5 
      • Deterioration more likely in patients older, not on angiotensin converting enzyme inhibitors (ACEI) or more cardiomegaly/CHF symptoms.6 
  • AF:  
    • A systematic review of 12 cohort studies (235,047 patients)7 including three largest studies from US,8 Sweden,9 and Canada10 using digoxin post hospital discharge8,9 or outpatient visit9,10 demonstrated a 29% increased mortality associated with digoxin (HR 1.29; 95% CI, 1.21-1.39).  
      • Limitations: Unsure if possible residual confounding (patients receiving digoxin are sicker). 
  • Current guidelines recommend digoxin after: 
    • Diuretics, ACEI, BBs, and aldosterone antagonists in CHF.11 
    • Calcium channel blockers or BBs in AF.12 
  • Clinical symptoms, age, and renal function should guide digoxin dosing, digoxin levels being ordered if questioning toxicity. 
  • Digoxin toxicity typically presents with cardiac arrhythmias, visual, or gastrointestinal symptoms13 and remains a relatively common reason for hospitalizations in the elderly.14 

tia renouf November 14, 2023


Latest Tools for Practice
Derniers outils pour la pratique

#363 Making a difference in indifference? Medications for apathy in dementia

In patients with dementia, how safe and effective are stimulants, antidepressants, and antipsychotics for treating apathy?
Read Lire 0.25 credits available Crédits disponibles

#362 Facing the Evidence in Acne, Part I: Oral contraceptives and spironolactone in females

How effective are combined oral contraceptives (COC) and spironolactone for treating acne of at least mild-moderate severity in females?
Read Lire 0.25 credits available Crédits disponibles

#361 Preventing RSV Infections in Infants

How safe and effective are monoclonal antibodies to prevent respiratory syncytial virus (RSV) infections in infants?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session

  • Michael R Kolber BSc MD CCFP MSc
  • Tafi Madzimure MBChB

1. The Digitalis Investigation Group Investigators. N Engl J Med. 1997; 336:525-33.

2. Hood WB Jr, Dans AL, Guyatt GH, et al. Cochrane Database Syst Rev. 2014; 4:CD002901.

3. Rathore SS, Curtis JP, Wang Y, et al. JAMA. 2003; 289:871-8.

4. Packer M, Gheorghiade M, Young JB, et al. N Engl J Med. 1993; 329:1-7.

5. Uretsky BF, Young JB, Shahidi FE, et al. J Am Coll Cardiol. 1993; 22(4):955-62.

6. Adams KF Jr, Gheorghiade M, Uretsky BF, et al. Am Heart J. 1998; 135:389-97.

7. Vamos M, Erath JW, Hohnloser SH. Eur Heart J. 2015 May 4. pii: ehv143 [Epub ahead of print]

8. Turakhia MP, Santangeli P, Winkelmayer WC, et al. J Am Coll Cardiol. 2014; 64: 660-8.

9. Hallberg P, Lindbäck J, Lindahl B, et al. Eur J Clin Pharmacol. 2007; 63:959-71.

10. Shah R, Meytal A, Cynthia A. Am J Cardiol. 2014; 114:401-6.

11. McKelvie RS, Moe GW, Ezekowitz JA, et al. Can J Cardiol. 2013; 29:168-81.

12. Verma A, Cairns J, Mitchell B, et al. Can J Cardiol. 2014; 30 (10): 1114-30.

13. Yang E, Shah S, Criley JM. Am J Med. 2012; 125:337-43.

14. Budnitz DS, Lovegrove MC, Shehab N, et al. N Engl J Med. 2011; 365:2002-12.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.