A nurse is reviewing the laboratory results of a client who is taking digoxin for heart failure

1. Skanes AC, Healey JS, Cairns JA, Dorian P, Gillis AM, McMurtry MS, et al. Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control. Can J Cardiol. 2012;28(2):125–36. Erratum in: Can J Cardiol2012:28(3)396. [PubMed] [Google Scholar]

2. Malcom J, Arnold O, Howlett JG, Ducharme A, Ezekowitz JA, Gardner M, et al. Canadian Cardiovascular Society Consensus Conference guidelines on heart failure—2008 update: best practices for the transition of care of heart failure patients, and the recognition, investigation and treatment of cardiomyopathies. Can J Cardiol. 2008;24(1):21–40. [PMC free article] [PubMed] [Google Scholar]

3. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Jr, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):e240–327. Epub 2013 Jun 5. [PubMed] [Google Scholar]

4. Digitalis Investigation Group The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med. 1997;336(8):525–33. [PubMed] [Google Scholar]

5. Turakhia MP, Santangeli P, Winkelmayer WC, Xu X, Ullal AJ, Than CT, et al. Increased mortality associated with digoxin in contemporary patients with atrial fibrillation: findings from the TREAT-AF study. J Am Coll Cardiol. 2014;64(7):660–8. [PMC free article] [PubMed] [Google Scholar]

6. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002–12. [PubMed] [Google Scholar]

7. Health Canada . Drugs and health products. Drug product database online query. Ottawa, ON: Health Canada; 2015. Available from: http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp [active ingredients: digoxin]. Accessed 2016 Feb 2. [Google Scholar]

8. Goldberger ZD, Goldberger AL. Therapeutic ranges of serum digoxin concentrations in patients with heart failure. Am J Cardiol. 2012;109(12):1818–21. Epub 2012 Apr 11. [PMC free article] [PubMed] [Google Scholar]

9. Ahmed A, Gambassi G, Weaver MT, Young JB, Wehrmacher WH, Rich MW. Effects of discontinuation of digoxin versus continuation at low serum digoxin concentrations in chronic heart failure. Am J Cardiol. 2007;100(2):280–4. Epub 2007 Jun 6. [PMC free article] [PubMed] [Google Scholar]

10. Chan KE, Lazarus JM, Hakim RM. Digoxin associates with mortality in ESRD. J Am Soc Nephrol. 2010;21(9):1550–9. Epub 2010 Jun 24. [PMC free article] [PubMed] [Google Scholar]

11. Adams KF, Jr, Patterson JH, Gattis WA, O’Connor CM, Lee CR, Schwartz TA, et al. Relationship of serum digoxin concentration to mortality and morbidity in women in the digitalis investigation group trial: a retrospective analysis. J Am Coll Cardiol. 2005;46(3):497–504. [PubMed] [Google Scholar]

12. Rathore SS, Curtis JP, Wang Y, Bristow MR, Krumholz HM. Association of serum digoxin concentration and outcomes in patients with heart failure. JAMA. 2003;289(7):871–8. [PubMed] [Google Scholar]

13. Hauptman PJ, McCann P, Romero JM, Mayo M. Reference laboratory values for digoxin following publication of Digitalis Investigation Group (DIG) trial data. JAMA Intern Med. 2013;173(16):1552–4. [PubMed] [Google Scholar]

14. Yang EH, Shah S, Criley JM. Digitalis toxicity: a fading but crucial complication to recognize. Am J Med. 2012;125(4):337–43. [PubMed] [Google Scholar]

15. Winter ME, Koda-Kimble MA, Young LY. Digoxin. In: Winter ME, editor. Basic clinical pharmacokinetics. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. pp. 183–221. [Google Scholar]

16. Ritschel WA, Kearns GL. Handbook of basic pharmacokinetics ... including clinical applications. 6th ed. Washington, DC: American Pharmacists Association; 2004. [Google Scholar]

17. Ehle M, Patel C, Giugliano RP. Digoxin: clinical highlights: a review of digoxin and its use in contemporary medicine. Crit Pathw Cardiol. 2011;10(2):93–8. [PubMed] [Google Scholar]

18. Hack JB. Cardiac steroids. In: Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE, editors. Goldfrank’s toxicologic emergencies. 9th ed. New York, NY: McGraw-Hill Medical; 2011. pp. 936–45. [Google Scholar]

19. Wofford JL, Ettinger WH. Risk factors and manifestations of digoxin toxicity in the elderly. Am J Emerg Med. 1991;9(2 Suppl 1):11–5. [PubMed] [Google Scholar]

20. Spruill WJ, Wade WE, DiPiro JT, Blouin RA, Pruemer JM. Concepts in clinical pharmacokinetics. 6th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014. [Google Scholar]

21. Young IS, Goh EM, McKillop UH, Stanford CF, Nicholls DP, Trimble ER. Magnesium status and digoxin toxicity. Br J Clin Pharmacol. 1991;32(6):717–21. [PMC free article] [PubMed] [Google Scholar]

22. Juurlink DN, Mamdani M, Kopp A, Laupacis A, Redelmeier DA. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA. 2003;289(13):1652–8. [PubMed] [Google Scholar]

23. Gomes T, Mamdani MM, Juurlink DN. Macrolide-induced digoxin toxicity: a population-based study. Clin Pharmacol Ther. 2009;86(4):383–6. Epub 2009 Jul 15. [PubMed] [Google Scholar]

24. Guven H, Tuncok Y, Guneri S, Cavdar C, Fowler J. Age-related digoxin-alprazolam interaction. Clin Pharmacol Ther. 1993;54(1):42–4. [PubMed] [Google Scholar]

25. Mathis AS, Friedman GS. Coadministration of digoxin with itraconazole in renal transplant recipients. Am J Kidney Dis. 2001;37(2):E18. [PubMed] [Google Scholar]

26. Wang MT, Li IH, Lee WJ, Huang TY, Leu HB, Chan AL. Exposure to sennosidedigoxin interaction and risk of digoxin toxicity: a population-based nested case-control study. Eur J Heart Fail. 2011;13(11):1238–43. Epub 2011 Jul 28. [PubMed] [Google Scholar]

27. Yang XX, Hu ZP, Duan W, Zhu YZ, Zhou SF. Drug-herb interactions: eliminating toxicity with hard drug design. Curr Pharm Des. 2006;12(35):4649–64. [PubMed] [Google Scholar]

28. Packer M, Gheorghiade M, Young JB, Costantini PJ, Adams KF, Cody RJ, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. RADIANCE study. N Engl J Med. 1993;329(1):1–7. [PubMed] [Google Scholar]

29. Uretsky BF, Young JB, Shahidi FE, Yellen LG, Harrison MC, Jolly MK. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. PROVED Investigative Group. J Am Coll Cardiol. 1993;22(4):955–62. [PubMed] [Google Scholar]

30. American Geriatrics Society 2012 Beers Criteria Update Expert Panel American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31. Epub 2012 Feb 29. [PMC free article] [PubMed] [Google Scholar]

31. DigiFab [product monograph] West Conshohocken, PA: BTG International; 2014. Available from: http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp [DIN 02361043]. Accessed 2016 Feb 9. [Google Scholar]


Page 2

Patient’s medications on admission

MEDICATIONDOSAGE
Rivaroxaban20 mg/d
Diltiazem240 mg/d
Digoxin0.25 mg/d
Nitroglycerin patch0.2 mg/h to be worn 10 h/d
Spironolactone100 mg (1 tablet in the morning and half a tablet at lunch)
Furosemide40 mg/d
Celecoxib200 mg/d
Levothyroxine100 µg/d
Lansoprazole30 mg/d
Escitalopram15 mg/d
Amitriptyline75 mg at bedtime
Quetiapine100 mg twice daily
Olanzapine10 mg at bedtime
Nitrofurantoin50 mg at bedtime
Zopiclone5 mg at bedtime as needed