digitoxin and Drug-Overdose

Topics: Adams-Stokes Syndrome; Aged; Aged, 80 and over; Digitoxin; Dose-Response Relationship, Drug; Drug Overdose; Female; Humans; Metabolic Clearance Rate; Thrombocytopenia

Topics: Antidotes; Digitalis; Digoxin; Drug Overdose; Humans; Plants, Medicinal; Plants, Toxic; Poisoning

BACKGROUND In 2011, following a period with delivery problems, the only registered digitoxin drug in Norway was replaced with digoxin. As a result, approximately 21 000 patients had to replace digitoxin with digoxin. There are important pharmacokinetic differences between digitoxin and digoxin (the general term for both drugs is digitalis), which must be taken into account when changing therapy. The aim of this study was to investigate compliance of drug security, during the transition from digitoxin to digoxin in Norway.MATERIAL AND METHOD Enquiries addressed to the Norwegian Poison Information Centre and reports of fatal adverse effects to the Regional Drug Information Centres (RELIS) regarding intake of digitalis were analysed. Serum concentrations of digitoxin and digoxin analyzed at Oslo University Hospital were reviewed. All data sources were reviewed for the years 2010-2014 and patients > 20 years were included.RESULTS The total number of enquiries addressed to the Norwegian Poison Information Centre, fatal adverse drug reactions reported to RELIS, and patient samples in the toxic range analyzed at Oslo University Hospital increased from 2012, timewise related to the transition to digoxin.INTERPRETATION Despite extensive information from the Norwegian Medicines Agency, a small, transient increase was observed in the number of overdoses and reported deaths from digitalis related to change in therapy. The cause of the overdose was in many cases unknown. This study revealed several cases of incorrect dosage, simultaneous use of digitoxin and digoxin, and washout time that was insufficient or lacking before initiation of digoxin.

Topics: Aged; Aged, 80 and over; Digitoxin; Digoxin; Drug Overdose; Drug Substitution; Female; Guideline Adherence; Humans; Male; Norway; Poison Control Centers

Topics: Color Perception; Digitalis; Drug Overdose; France; History, 19th Century; Humans; Male; Portraits as Topic

Drug-related illness is an everlasting universal problem and also an important cause of admissions to hospitals. Adverse reactions are still grossly underreported by medical professions. Little information is available regarding the frequency or type of ADRs managed in hospitals. Since January 1997, we have taken part in a study, supported by the German Federal Institute for Drugs and Medical Device to improve the spontaneous drug information reporting system in Germany. Three German regionalized Departments of Clinical Pharmacology--Jena, Dresden, Rostock--serve as Pharmacovigilance Centers in collaboration with the Pharmacoepidemiology Research Group of the University of Munich. Since January 1997, the regional group in Jena has been monitoring the University Clinic of Internal Medicine for admissions caused by adverse drug reactions. All emergency cases and patients on intensive care units were checked for adverse drug reactions. We present our results, including clinical and demographic data, concerning intoxications and especially those involving digitoxin in 210 patients with ADR. Forty patients with digitoxin toxicity had an average age of 81 years (81.1+/-6.3), a low body weight (59.7+/-12.7 kg) and 3 out of 4 were women. 75% of all patients with digitoxin side effects had elevated serum digitoxin levels with concentrations higher than 25 microg/ml. The relatively high frequency of digitoxin intoxications in our hospital may reflect the advanced age and low body weight of patients. Patients received digitoxin regardless of age, weight and, sometimes, clinical indication. Physicians should be aware of drugs having a high risk when used in elderly patients. The use of digitoxin assays and keeping serum levels within or near the therapeutic range will diminish the incidence of overdoses.

Topics: Adverse Drug Reaction Reporting Systems; Age Factors; Aged; Aged, 80 and over; Anti-Arrhythmia Agents; Demography; Digitoxin; Drug Overdose; Female; Germany; Hospitalization; Humans; Male; Risk Factors

Three cases of patients with symptoms of digitalis overdosage were presented. The principal manifestations included complex supraventricular dysrhythmias and atrio-ventricular conduction disturbances. In the discussion a special attention was paid to digitalis dosage. Multiple factors influencing plasma concentration of digitalis including pharmacokinetics, bioavailability and drug interactions with glycosides were described. Short review of toxic manifestations of digitalis was made and the treatment of digitalis intoxication was outlined.

Topics: Aged; Aged, 80 and over; Arrhythmias, Cardiac; Atrioventricular Node; Captopril; Digitalis; Digitalis Glycosides; Drug Interactions; Drug Overdose; Drug Therapy, Combination; Female; Heart Conduction System; Humans; Male; Medigoxin; Middle Aged; Pentoxifylline; Plants, Medicinal; Plants, Toxic; Tachycardia, Supraventricular

Topics: Cardiotonic Agents; Digitoxin; Digoxin; Drug Administration Schedule; Drug Overdose; Heart Failure; Humans; Risk Factors; Tachycardia, Supraventricular

A 65-year-old woman, known to have peptic ulcers, developed nausea and retching. Clinical examination demonstrated pain on pressure in the epigastrium with otherwise normative findings for age. Two gastric ulcers and gastritis with erosions were seen at endoscopy. The patient, who was being treated with digitoxin for heart failure, reported having taken up to four digitoxin tablets (0.07 mg each) daily because she had insomnia. The plasma digitoxin level was between 150 and 160 nmol/l (therapeutic range 17-33 nmol/l), while the ECG showed no signs of digitalis intoxication. Initially the platelet count was 40,000/microliter: there had been no history of thrombocytopenia or symptoms of abnormal haemostasis. Other laboratory tests were within normal limits. After digitoxin had been discontinued, the platelet count rose without further treatment to 373,000/microliter 3 weeks after hospital admission by which time the digitoxin level had fallen to 48.9 nmol/l. The gastrointestinal symptoms regressed completely on treatment with omeprazole (40 mg three times daily for 8 days) and ranitidine (150 mg twice daily).

Topics: Aged; Digitoxin; Drug Overdose; Female; Gastritis; Gastroscopy; Heart Failure; Humans; Nausea; Omeprazole; Platelet Count; Ranitidine; Stomach Ulcer; Thrombocytopenia; Vomiting

Postmortem digitoxin levels in the choroid-retina and vitreous humor of patients who had undergone digitoxin therapy (therapeutic group) and in one case of suicidal digitoxin poisoning were measured and compared with levels in femoral vein blood, myocardium, kidney and liver. The results were interpreted in light of the medical history of each patient. The digitoxin level in the choroid-retina of the single case of suicidal poisoning was far higher than the choroid-retinal levels in the therapeutic group. In the latter, variation in choroid-retinal levels was comparable to that in the other tissues. In cases where the choroid-retina of the right and left eyes were examined, digitoxin levels in both eyes were essentially equal. There was no indication of significant changes in choroid-retinal levels due to postmortem diffusion of digitoxin into the vitreous body. Based on these results, determination of digitoxin levels in the choroid-retina could contribute to improving postmortem diagnosis of lethal digitoxin poisoning.

Topics: Adult; Aged; Aged, 80 and over; Aqueous Humor; Choroid; Digitoxin; Drug Overdose; Evaluation Studies as Topic; Female; Forensic Medicine; Humans; Kidney; Liver; Male; Middle Aged; Myocardium; Poisoning; Postmortem Changes; Retina

Life-threatening digitalis intoxication is treated using digoxin specific antibody fragments (Fab) that bind and inactivate the drug. The free digoxin serum concentration could be useful in the management of Fab-treated patients, but the standard methods of measurement can be clinically misleading because Fab anti-digoxin interferes with digitalis immunoassay measurements. A case involving Fab therapy of a digoxin overdosed patient, in which two laboratory methods gave very different results, is reported. The radioimmunologic assay (RIA), widely used in laboratories, yielded high values without relation to true serum free digoxin concentration. On the contrary, the recently introduced fluoroenzymatic sequential immunoassay (FEIA), which accurately measures free glycoside concentration, was a valuable aid in monitoring Fab treatment. Therefore, cardiologists' knowledge of a possible interference of specific anti-digoxin fragment treatment with many immunoassays may greatly enhance the rational management of these patients.

Topics: Acute Disease; Aged; Digitalis; Digoxin; Drug Overdose; Female; Humans; Immunoglobulin Fab Fragments; Monitoring, Physiologic; Plants, Medicinal; Plants, Toxic; Poisoning

A 50-year-old, previously healthy, woman swallowed 1 g digoxin powder, dissolved in water, with suicidal intent. On admission to hospital one hour later, having vomited three times at home, the prominent signs were somnolence and hypersalivation. Serum digoxin level was 3.37 ng/ml. There followed repeated episodes of asystole alternating with ventricular fibrillation requiring cardiopulmonary resuscitation over 90 min and adrenaline administration. Repeated electrical defibrillation, administration of dopamine, phenytoin and lidocaine, as well as transitory transvenous electrical stimulation became necessary. Anti-digoxin antibody fragments were administered, initially 80 mg, to a total of 3,280 mg over 24 hours. After 3 days of intensive care and a further 21 days in hospital she was discharged and referred to psychiatric treatment. This case demonstrates that even severe digoxin poisoning can be successfully treated without sequelae by the appropriate administration of digoxin antidote. The main problems in this case were regulation of the dosage and acquiring the necessary amount of antidote which greatly exceeded the hospital's own depot.

Topics: Acute Disease; Antidotes; Combined Modality Therapy; Digitalis; Digoxin; Drug Overdose; Drug Therapy, Combination; Female; Gastric Lavage; Humans; Middle Aged; Plants, Medicinal; Plants, Toxic; Poisoning; Powders; Suicide, Attempted; Ventricular Fibrillation

A 48-year-old man chronically treated with digitoxin and verapamil for prevention of atrial fibrillation voluntarily ingested 2.2 mg of digitoxin. Serum digitoxin concentrations and the urinary elimination of the drug were followed over a 12-day period. Urinary data indicate that a large percentage (50%) of the drug was eliminated renally despite administration of multiple doses of activated charcoal, cholestyramine and hyperosmotic laxatives. The possible interaction with two other drugs, heparin and verapamil, is also discussed.

Topics: Charcoal; Cholestyramine Resin; Digitoxin; Drug Overdose; Humans; Male; Middle Aged

Topics: Amblyopia; Digitalis; Digitalis Glycosides; Drug Overdose; Drug Therapy; Geriatrics; Rheumatic Heart Disease; Toxicology

Topics: Atrial Flutter; Digitalis; Digitalis Glycosides; Drug Overdose; Humans; Plant Extracts; Tachycardia, Supraventricular

Topics: Arrhythmias, Cardiac; Carotid Sinus; Digitalis; Digitalis Glycosides; Drug Overdose; Humans; Tachycardia