digoxin and Hyperkalemia

Accidental poisoning or overdoses occur frequently in children. These are difficult to recognise because young children cannot communicate their symptoms; this means that specific symptoms can be missed, which can delay the diagnosis. A 5-month-old boy was accidently given a tenfold dose of digoxin for 5 days. He developed feeding difficulties, vomiting, weight loss, elevated urea and creatinine levels, hyponatraemia, hyperkalaemia and ECG abnormalities. The digoxin plasma concentration was 7.6 µg/l. The patient was given digoxin antibodies, following which the digoxin concentration was < 0.3 µg/l; 12 hours later the digoxin concentration was 3.1 µg/l as a result of redistribution; 2 days after the administration of digoxin antibodies the plasma concentration was within the therapeutic range.

Topics: Antibodies; Cardiotonic Agents; Digoxin; Drug Overdose; Drug-Related Side Effects and Adverse Reactions; Humans; Hyperkalemia; Infant; Male; Medication Errors

Digitalis toxicity produces a toxidrome characterized by gastrointestinal, neurologic, electrolyte, and nonspecific cardiac manifestations. Chronic toxicity remains much more difficult to recognize compared with an acute presentation because of the nonspecific manifestations; therefore, serum glycoside levels are essential for diagnosis in this population. The mainstay of management continues to be rapid toxidrome identification followed by digoxin-specific antibody fragment therapy with supportive care. Several controversies still remain, including therapy for patients dependent on hemodialysis, appropriateness of calcium therapy for hyperkalemia, ideal agents for arrhythmia therapy, and the potential utility of plasmapheresis for removal of bound digoxin-antibody fragment complexes.

Topics: Anti-Arrhythmia Agents; Antidotes; Arrhythmias, Cardiac; Digitalis Glycosides; Digoxin; Drug Overdose; Humans; Hyperkalemia

Clinical uses of calcium channel blockers are expanding. In addition to the established uses in patients with arrhythmias, angina pectoris or hypertension, newer and to some extent investigational uses indicate widespread application. For instance, their use has been reported in hypertrophic cardiomyopathy and cold cardioplegia, as well as in pulmonary hypertension, antiplatelet therapy, asthma, achalasia and oesophageal spasm, increased intraocular pressure and in cerebral vasospasm. Their use in obstetrical practice has been proposed. Thus, the presentation of a patient who is treated with calcium channel blockers and who requires anaesthesia will become more common. Calcium channel blockers may, under certain circumstances, potentiate haemodynamic and MAC depressive effects of inhalation agents. There is also evidence that the effects of neuromuscular blocking agents may be potentiated. The anaesthetist should be aware that the potential for interactions exists with digoxin, propranolol, quinidine, theophylline or dantrolene. Of interest and some significance are the anaesthetic implications of pathophysiological alterations that can be induced by calcium channel blockers, by affecting lower oesophageal tone, intracranial hypertension, bronchomotor tone (asthma), muscular dystrophy, neuromuscular function, hypoxic pulmonary vasoconstriction, malignant hyperthermia, inhibition of platelet aggregation and hyperkalemia. Despite these significant potential anaesthetic implications and because, at this time, in some instances withdrawal has clearly demonstrated increase in the signs of myocardial ischaemia, it would not seem necessary to recommend preoperative discontinuation of calcium channel blocker medication in patients presenting for anaesthesia. It is, however, appropriate that there is a high index of awareness of potential problems, unless there is some modification in inhalation anaesthetic concentrations and neuromuscular blocker dosage. Monitoring of cardiovascular and neuromuscular functions is essential. Calcium channel blockers would appear to be currently the drugs of choice for angina pectoris, arrhythmias or hypertension in patients with associated chronic obstructive pulmonary disease.

Topics: Adrenergic beta-Antagonists; Anesthesia; Anesthetics; Animals; Asthma; Calcium; Calcium Channel Blockers; Dantrolene; Digoxin; Drug Interactions; Esophagus; Humans; Hyperkalemia; Intracranial Pressure; Malignant Hyperthermia; Neuromuscular Blocking Agents; Quinidine; Theophylline; Vasoconstriction

The electrical stability of the heart is more sensitive to the extracellular than to the intracellular potassium concentration. During exercise, extracellular potassium varies rapidly. Catecholamines also modulate the plasma potassium concentration. Hypokalaemia of any cause can precipitate arrhythmias. Ischaemic myocardium loses potassium into the extracellular space within seconds and the cell becomes depolarized. The rise of the extracellular potassium ion concentration accounts for many of the early electrophysiological changes. Abrupt changes of plasma potassium concentration in normal myocardium and a high potassium concentration in ischaemic myocardium can set up electrical forces which initiate arrhythmias. The same phenomenon can account for changes on the electrocardiogram early after the cessation of an exercise test in a patient with ischaemic heart disease. Accumulation of potassium between cells in response to an increase of heart rate is a possible mechanism for false positive exercise tests and Syndrome X.

Topics: Acidosis; Action Potentials; Angioplasty, Balloon; Animals; Catecholamines; Coronary Disease; Digoxin; Diuretics; Exercise Test; False Positive Reactions; Heart; Heart Rate; Humans; Hyperkalemia; Hypokalemia; Myocardium; Physical Exertion; Potassium; Syndrome

Digoxin is recommended in symptomatic heart failure patients with reduced ejection fraction (HF-REF) in sinus rhythm and refractory to other evidence-based therapy. Although HF-REF patients with diabetes have worse functional status than those without, the effects of digoxin have not been specifically evaluated according to diabetes status.. We examined the efficacy and safety of digoxin in HF-REF patients with and without diabetes in the Digitalis Investigation Group trial. Mortality from all-cause, cardiovascular (CV) causes and heart failure (HF), along with HF hospitalisation and suspected digoxin toxicity were analyzed according to diabetes status and randomised treatment assignment.. Of the 6800 patients, those with diabetes (n=1933) were older, more often women, had worse clinical status and more co-morbidity than those without diabetes. All-cause and CV mortality were higher in patients with diabetes than in those without and digoxin did not reduce mortality in either sub-group. The rate of HF hospitalization (per 100 person-years) in patients with diabetes was higher than in those without and was reduced by digoxin in both patient groups: diabetes - placebo 20.5 and digoxin 16.0 (HR 0.79, 95% CI: 0.68-0.91); no diabetes - placebo 12.7 and digoxin 8.7 (HR 0.69, 0.62-0.77); interaction p=0.14. Suspected digoxin toxicity in patients randomised to digoxin was more common among patients with diabetes than without (6.5% versus 5.8%), as was hospitalisation for digoxin toxicity (1.4% versus 0.8%).. Added to an ACE inhibitor, digoxin reduced HF hospitalisation in HF-REF patients with and without diabetes without a substantial risk of toxicity.

Topics: Aged; Cardiotonic Agents; Diabetes Mellitus; Digitalis; Digoxin; Female; Heart Failure; Hospitalization; Humans; Hyperkalemia; Male; Middle Aged; Retrospective Studies; Risk Factors; Stroke Volume; Treatment Outcome

Because life-threatening digitalis intoxication is unusual in children, treatment with digoxin-specific-antibody Fab fragments (Fab) has rarely been reported. We describe the efficacy of Fab in the treatment of children with severe digitalis intoxication.. Twenty-nine children with intoxication due to digoxin (28) or digitoxin (1) received Fab at 21 participating hospitals between 1974 and 1986. Data were gathered about the patients' medical illnesses, doses and serum concentrations of digitalis, responses to Fab therapy, and outcomes.. In the infants and young children with acute digoxin intoxication, the digoxin doses ranged from 0.30 to 0.96 mg per kilogram of body weight; two adolescents had severe intoxication after doses of only 0.20 and 0.26 mg per kilogram. The serum digoxin concentrations ranged from 3.0 to greater than 100 ng per milliliter (mean, 13.8). Atrioventricular block (present in 22 patients [76 percent]) was the most common sign of toxicity. All the patients in this series had severe disturbances of cardiac rhythm, hyperkalemia (mean serum potassium concentration, 5.4 mmol per liter), or both. In 27 patients (93 percent), digitalis toxicity resolved after the administration of Fab. Of the 19 patients for whom data were available on the timing of the response to Fab, 15 responded within 180 minutes. Three patients required retreatment with Fab. Seven died of complications unrelated to the administration of Fab.. We recommend that Fab be used in the treatment of digitalis poisoning in infants and young children who have ingested greater than or equal to 0.3 mg of digoxin per kilogram, who have underlying heart disease, or who have a serum digoxin concentration of greater than or equal to 6.4 nmol per liter (greater than or equal to 5.0 ng per milliliter) in the elimination phase; and who also have a life-threatening arrhythmia, hemodynamic instability, hyperkalemia, or rapidly progressive toxicity. Adolescents, who are more sensitive to the toxic effects of digoxin than younger children, may require treatment with Fab after ingesting lower doses.

Topics: Acute Disease; Adolescent; Arrhythmias, Cardiac; Child, Preschool; Digitoxin; Digoxin; Female; Heart Block; Heart Diseases; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Infant; Infant, Newborn; Male; Poisoning

Sixty-three patients with life-threatening digitalis intoxication were treated with purified fragments of digoxin-specific antibodies (Fab) obtained from sheep. Twenty-eight patients developed toxicity as the result of digitalis ingestion in a suicide attempt, 5 ingested a large amount of digoxin accidentally and 30 developed toxicity in the course of treatment for underlying heart disease. The dosage of digoxin-specific Fab was calculated to be equimolar to the amount of cardiac glycoside in the patient's body. Digitalis toxicity was completely reversed in most cases, with onset of effect usually within 30 minutes of administration of Fab fragments. Unbound and, therefore, active digoxin serum concentrations decreased to undetectable levels within minutes after administration of the fragments. In all patients who had elevated serum potassium concentrations caused by massive digitalis toxicity, treatment with the Fab fragments reversed the hyperkalemia. There were no obvious adverse reactions to treatment. Potentially life-threatening digitalis intoxication can be rapidly and safely reversed by treatment with purified digoxin-specific Fab fragments.

Topics: Adolescent; Adult; Aged; Animals; Antibody Specificity; Child; Child, Preschool; Clinical Trials as Topic; Digitalis Glycosides; Digoxin; Heart Block; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Infant; Infant, Newborn; Middle Aged; Potassium; Sheep; Time Factors

Serum creatinine-based estimated glomerular filtration rate (eGFRcr) may overestimate the glomerular filtration rate (GFR) in patients with cancer. Cystatin C-based eGFR (eGFRcys) is an alternative marker of GFR.. To determine whether the therapeutic drug levels and adverse events (AEs) associated with renally cleared medications were higher in patients with cancer whose eGFRcys was more than 30% lower than their eGFRcr.. This cohort study analyzed adult patients with cancer at 2 major academic cancer centers in Boston, Massachusetts. These patients had their creatinine and cystatin C measured on the same day between May 2010 and January 2022. The date of the first simultaneous eGFRcr and eGFRcys measurement was considered to be the baseline date.. The primary exposure was eGFR discordance, defined as an eGFRcys that was more than 30% lower than the eGFRcr.. The primary outcome was risk of the following medication-related AEs within 90 days of the baseline date: (1) supratherapeutic vancomycin trough level greater than 30 μg/mL, (2) trimethoprim-sulfamethoxazole-related hyperkalemia (>5.5 mEq/L), (3) baclofen toxic effect, and (4) supratherapeutic digoxin level (>2.0 ng/mL). For the secondary outcome, a multivariable Cox proportional hazards regression model was used to compare 30-day survival of those with vs without eGFR discordance.. A total of 1869 adult patients with cancer (mean [SD] age, 66 [14] years; 948 males [51%]) had simultaneous eGFRcys and eGFRcr measurement. There were 543 patients (29%) with an eGFRcys that was more than 30% lower than their eGFRcr. Patients with an eGFRcys that was more than 30% lower than their eGFRcr were more likely to experience medication-related AEs compared with patients with concordant eGFRs (defined as eGFRcys within 30% of eGFRcr), including vancomycin levels greater than 30 μg/mL (43 of 179 [24%] vs 7 of 77 [9%]; P = .01), trimethoprim-sulfamethoxazole-related hyperkalemia (29 of 129 [22%] vs 11 of 92 [12%]; P = .07), baclofen toxic effects (5 of 19 [26%] vs 0 of 11; P = .19), and supratherapeutic digoxin levels (7 of 24 [29%] vs 0 of 10; P = .08). The adjusted odds ratio for vancomycin levels more than 30 μg/mL was 2.59 (95% CI, 1.08-7.03; P = .04). Patients with an eGFRcys more than 30% lower than their eGFRcr had an increased 30-day mortality (adjusted hazard ratio, 1.98; 95% CI, 1.26-3.11; P = .003).. Results of this study suggest that among patients with cancer with simultaneous assessment of eGFRcys and eGFRcr, supratherapeutic drug levels and medication-related AEs occurred more commonly in those with an eGFRcys more than 30% lower than their eGFRcr. Future prospective studies are needed to improve and personalize GFR estimation and medication dosing in patients with cancer.

Topics: Adult; Aged; Baclofen; Cohort Studies; Creatinine; Cystatin C; Digoxin; Glomerular Filtration Rate; Humans; Hyperkalemia; Male; Neoplasms; Trimethoprim, Sulfamethoxazole Drug Combination; Vancomycin

We report a case of a 19-year-old woman who ingested Digitalis purpurea leaves as a suicide attempt. She developed gastro-intestinal symptoms, loss of colour vision, cardiac conduction disturbances as well as an elevated serum potassium. Treatment was initiated in analogy to medicinal digoxin poisoning by means of digoxin-specific Fab-fragments with a good effect. However during the further course we faced difficulties of prolonged intestinal absorption and inability to estimate the ingested dose or half-life of the vegetal cardiac glycoside compounds. To prevent further absorption and interrupt enterohepatic recycling, multi-dose activated charcoal was administered. Because of a relapse of cardiac conduction disturbances and hyperkalemia, two supplementary doses of Fab-fragments were given, up to a total dose of nineteen vials (one vial containing 40 mg). The important diagnostic and therapeutic differences of vegetal digitalis intoxication as compared to medicinal intoxication and the applicability of existing guidelines on medicinal digitalis intoxication in the light of these differences will be discussed here.

Topics: Adult; Digitalis; Digitalis Glycosides; Digoxin; Female; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Young Adult

Topics: Acute Kidney Injury; Aged, 80 and over; Amoxicillin; Anti-Arrhythmia Agents; Anti-Bacterial Agents; Atrial Fibrillation; Bradycardia; Bundle-Branch Block; Clarithromycin; Digoxin; Drug Interactions; Electrocardiography; Female; Helicobacter Infections; Helicobacter pylori; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Omeprazole; Tachycardia, Ventricular

Topics: Aged; Antidotes; Arrhythmias, Cardiac; Digitalis; Digoxin; Electrocardiography; Female; Humans; Hyperkalemia; Male; Nausea; Vomiting

We hypothesized that in chronic digoxin toxicity, anti-digoxin antibodies (Fab) would be efficacious in binding digoxin, but this may not translate into improved clinical outcomes.. This study aims to investigate changes in free digoxin concentrations and clinical effects on heart rate and potassium concentrations in chronic digoxin poisoning when anti-digoxin Fab are given.. This is a prospective observational study. Patients were recruited if they have been treated with anti-digoxin Fab for chronic digoxin poisoning. Data was entered into a standardised prospective form, supplemented with medical records. Their serum or plasma was collected, analysed for free and bound digoxin and free anti-digoxin Fab concentrations.. From September 2013 to February 2015, 36 patients (median age, 78 years; 22 females) were recruited from 18 hospitals. Median heart rate (HR) was 49 beats/min. Initial median digoxin and potassium concentrations were 4.7 nmol/L (3.6 μg/L) (range: 2.3-11.2 nmol/L) and 5.3 mmol/L (range: 2.9-9.2 mmol/L) respectively. Beta-blockers (n = 18), calcium antagonists (n = 6), spironolactone and/or angiotensin blocking agents (n = 24) were also used concomitantly. Renal impairment and gastrointestinal symptoms were present in 31 (86%) and 22 (63%) patients respectively. Five patients died from conditions unrelated to digoxin toxicity. Median change in HR was 8 beats/min post-Fab with no effect on blood pressure; they were 4, 10 and 17 beats/min for the 1, 2 and ≥3 vials of anti-digoxin Fab groups respectively. Concomitant treatments with potassium lowering agents (12/36) and inotropic drugs (7/36) were used. Gastrointestinal effects resolved in all 22 patients. The median decrease for potassium was 0.3 mmol/L. Digoxin concentration reduced from 3.8 to 0 nmol/L post-Fab. There was a rebound observed in the free digoxin concentration in 25 patients but none had associated clinical deterioration.. One to two vials of anti-digoxin Fab initially bound all free digoxin confirming Fab efficacy. However, this was associated with only a moderate improvement in HR and potassium, suggesting bradyarrhythmia and hyperkalaemia may be from other co-morbidities.

Topics: Aged; Aged, 80 and over; Bradycardia; Cardiovascular Agents; Chronic Disease; Digoxin; Drug Overdose; Female; Heart Rate; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Male; Middle Aged; Poisoning; Potassium; Prospective Studies

The objective of the study is to demonstrate a common etiology of hyperkalemia and illustrate a potential iatrogenic errors in treatment.

Topics: Aged; Anti-Arrhythmia Agents; Calcium Gluconate; Contraindications; Digoxin; Female; Heart Block; Humans; Hyperkalemia; Injections, Intravenous

Commonly used abortion agents carry potentially serious side effects for the mother. It is important for emergency physicians to be aware of the medications used in elective abortions from the late first trimester to term. If digoxin is used as an abortifacient, it is injected intrafetally or intraplacentally. With this method there is a chance of extraplacental injection, resulting in maternal systemic digoxin toxicity and serious morbidity or death.. This report presents a case report, discusses the risks of digoxin-induced abortion, and teaches the reader about the abortifacient agents currently in use, along with their associated complications.. This is a case of a 28-year-old pregnant woman of approximately 20 weeks gestation, who presented with severe muscular weakness and respiratory failure requiring intubation. She was subsequently found to have hyperkalemic paralysis from digoxin toxicity after an extraplacental injection during the first step of a two-part elective abortion.. It is important for emergency physicians to be aware of the various late first-trimester to term abortifacient agents and procedures being used in obstetrical/gynecological practice, and the potential risks of these interventions. Digoxin toxicity or hyperkalemia should be suspected when a patient presents with severe weakness and respiratory distress after an attempted abortion.

Topics: Abortifacient Agents; Abortion, Induced; Adult; Digoxin; Female; Humans; Hyperkalemia; Paralysis; Pregnancy; Pregnancy Trimester, Second

Digoxin is an inhibitor of the sodium-potassium ATPase. In overdose, hyperkalemia is common. Although hyperkalemia is often treated with intravenous calcium, it is traditionally contraindicated in digoxin toxicity.. To analyze records from patients treated with intravenous calcium while digoxin-toxic.. We reviewed the charts of all adult patients diagnosed with digoxin toxicity in a large teaching hospital over 17.5 years. The main outcome measures were frequency of life-threatening dysrhythmia within 1 h of calcium administration, and mortality rate in patients who did vs. patients who did not receive intravenous calcium. We use multivariate logistic regression to ensure that no relationship was overlooked due to negative confounders (controlling for age, creatinine, systolic blood pressure, peak serum potassium, time of development of digoxin toxicity, and digoxin concentration).. We identified 161 patients diagnosed with digoxin toxicity, and were able to retrieve 159 records. Of these, 23 patients received calcium. No life-threatening dysrhythmias occurred within 1 h of calcium administration. Mortality was similar among those who did not receive calcium (27/136, 20%) compared to those who did (5/23, 22%). In the multivariate analysis, calcium was non-significantly associated with decreased odds of death (odds ratio 0.76; 95% confidence interval [CI] 0.24-2.5). Each 1 mEq/L rise in serum potassium concentration was associated with an increased mortality odds ratio of 1.5 (95% CI 1.0-2.3).. Among digoxin-intoxicated humans, intravenous calcium does not seem to cause malignant dysrhythmias or increase mortality. We found no support for the historical belief that calcium administration is contraindicated in digoxin-toxic patients.

Topics: Aged; Arrhythmias, Cardiac; Calcium; Digoxin; Humans; Hyperkalemia; Injections, Intravenous; Treatment Outcome

Management of systolic heart failure can be particularly challenging in patients with chronic kidney disease, especially those who are not yet receiving dialysis. Few clinical trials have been performed in this particular population, so management is directed by evidence from studies of patients with limited or no renal impairment. Their heightened risk for many treatment complications mandates additional considerations regarding drug selection, dosing, and monitoring. Subspecialty consultation is driven by patient instability or disease progression, intolerance of standard treatment, or need for device placement.

Topics: Adrenergic beta-Antagonists; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Chronic Disease; Digoxin; Heart Failure; Humans; Hyperkalemia; Kidney Diseases; Mineralocorticoid Receptor Antagonists

In contrast to patients with acute digoxin overdose, the prognostic utility of the serum potassium concentration for patients with chronic digoxin toxicity is unclear. In such patients, we aimed to evaluate the relationship between pre-treatment serum potassium and survival.. This was a case-control study at an urban Poison Control Center affiliated with a large urban medical center. We compared the serum potassium concentration between patients with chronic digoxin toxicity resulting in fatality (cases) over a 7-year period (2000-2006) versus survivors (controls) over a 1-year period (2007-2008).. During the study period, there were 13 fatalities (cases) and 13 survivors (controls), of whom seven cases and five controls received appropriately dosed digoxin-specific antibody Fab fragments (Fab). There were no statistically significant differences between cases and controls with respect to serum digoxin concentration, creatinine, age, or sex. Serum potassium elevation pre-Fab was significantly associated with fatality both in mean difference (p < 0.03) and using a dichotomous cutoff of 5.0 mEq/L (p < 0.001), which performed with 92% sensitivity (95% CI 67, 99). In 86% of deaths despite appropriate Fab administration, the clinical presentation included the combination of bradycardia plus hyperkalemia.. In these patients with chronic digoxin toxicity, elevated serum potassium was associated with fatality. The combination of bradycardia and hyperkalemia strongly predicted fatality even in cases with appropriate Fab administration.

Topics: Aged; Aged, 80 and over; Bradycardia; Cardiotonic Agents; Case-Control Studies; Digoxin; Female; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Male; Potassium; Prognosis; Prospective Studies; Retrospective Studies; Sensitivity and Specificity; Urban Health Services

Topics: Age Factors; Cardiac Pacing, Artificial; Charcoal; Digoxin; Disease Susceptibility; Gastric Lavage; Humans; Hyperkalemia; Immunization, Passive; Poisoning; Risk Factors

Topics: Acute Kidney Injury; Antidotes; Bromazepam; Digoxin; Female; Fluid Therapy; Humans; Hydroxyethyl Starch Derivatives; Hyperkalemia; Immunization, Passive; Immunoglobulin Fab Fragments; Middle Aged; Poisoning; Polygeline; Suicide, Attempted; Time Factors; Ventricular Premature Complexes

A 68 year old woman with a history of diabetes mellitus presented to the emergency department after experiencing several days of nausea and vomiting. Recorded vital signs included: blood pressure 98/32 mm Hg, heart rate 69 bpm, "normal" respirations, and no fever. Her initial ECG revealed peaked T waves and regular rhythm with no visible P waves. Initial serum electrolytes were notable for a potassium level of 7.7 mmol/L, and a creatinine level of 9.6 mg/dL (849 micromol/L). She was unable to provide a list of her current medications or other medical history. There was no old chart immediately available for comparison.

Topics: Aged; Calcium; Digoxin; Electrocardiography; Female; Humans; Hyperkalemia; Poison Control Centers; San Francisco

Topics: Acute Disease; Adolescent; Amphibian Venoms; Animals; Bufo bufo; Digoxin; Female; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Male

Acute digitalis overdosage is characterized by high electric instability, its mortality may reach 10-15 percent even nowadays.. To detect the possible risk factors which might predict severe intoxication.. Data of 50 patients treated at authors' department with acute digoxin poisoning over the past 8 years could be retrospectively evaluated. Cases were classified according to the Poison Severity Score (PSS). The following parameters were taken into consideration: age, sex, diseases influencing the severity of intoxication, dose of the drug, heart frequency, serum potassium and digoxin levels and vomiting. For statistical analysis a Kruskal-Wallis test and a chance-quotient calculation was applied.. From 50 patients 30 were mild (PSS 1, 2), 20 were severely poisoned, which subgroup included 8 deaths (PSS 4) and 12 patients who recovered (PSS 3). Based on Kruskal-Wallis test significant differences were found in the following items: greater number of primary diseases PSS 4 vs other subgroups (p < 0.05); bradycardia PSS 4 vs PSS 2 (p < 0.05) and PSS 3 vs PSS 2 (p < 0.05); hyperkalaemia PSS 3 vs PSS 2 (p < 0.01); elevated serum digoxin level PSS 3 vs PSS 2 (p < 0.05). The risk of severe poisoning (PSS 3-4) was increased in case of hyperkalaemia, bradycardia, vomiting (p < 0.001), and if the patients' age and if the drug dose exceeded 65 years or 10 mg, respectively (p < 0.05).. The predictive risk factors concerning severe acute digoxin poisoning are profuse vomiting, hyperkalaemia and bradycardia. The predictive risk factors of fatal outcome are age over 65 years associated with primary disease, vomiting and bradycardia.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Bradycardia; Cardiotonic Agents; Digoxin; Female; Heart Rate; Humans; Hyperkalemia; Male; Middle Aged; Poisoning; Predictive Value of Tests; Prognosis; Retrospective Studies; Risk Assessment; Risk Factors; Severity of Illness Index; Vomiting

Topics: Acute Kidney Injury; Aged; Cardiotonic Agents; Chronic Disease; Digoxin; Emergency Medicine; Fatal Outcome; Female; Heart Failure; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Natriuretic Peptide, Brain

We report the case of a 78-year-old woman, with previous narrow QRS atrial fibrillation, who in the presence of mild digoxin intoxication and severe hyperkalaemia, caused by chronic renal failure and usage of potassium sparing drugs, presented on her ECG two distinct wide QRS tachycardias. Initial treatment with low doses of procainamide resulted in severe bradycardia. Her original rhythm was restored after partial correction of hyperkalaemia with haemodialysis under continuous infusion of lidocaine. The electrocardiographic manifestations of hyperkalaemia and digoxin intoxication as well as the effect of lidocaine and procainamide on hyperkalaemia-induced wide QRS tachycardias are discussed.

Topics: Aged; Anti-Arrhythmia Agents; Digoxin; Electrocardiography; Female; Heart Rate; Humans; Hyperkalemia; Potassium; Tachycardia

The administration of intravenous (IV) calcium to treat hyperkalemia resulting from digoxin poisoning is considered potentially dangerous, based on a body of older literature which, in sum, reported increased cardiac glycoside toxicity with calcium administration (increased arrhythmias, higher rate of death).. This pilot study sought to determine if the administration of calcium chloride when compared to normal saline would affect time to death when given to hyperkalemic, digoxin toxic swine.. Digoxin IV at 0.25 mg/kg was determined to be appropriately toxic for this study. When arrhythmias consistent with hyperkalemia developed, animals were given either IV calcium chloride (CaCl) bolus (10 mg/kg, Group 1, n=6) or normal saline volume equivalent (Group 2, n=6). Three intervals were observed: Interval 1: time interval from digoxin administration (T0) to when ECG changes consistent with hyperkalemia developed (at which point calcium chloride or normal saline was administered); Interval 2: time interval from the development of ECG changes consistent with hyperkalemia to asystole; Interval 3: time interval from digoxin administration to asystole. Both groups were monitored for changes in heart rhythms, serum potassium levels, and time to asystole.. The intravenous digoxin dose of 0.25 mg/kg induced hyperkalemia, arrhythmias, and death approximately 1 h after administration in all animals studied. Group 1: Interval 1 averaged 18.75 (S.D. +/-7.96) min, Interval 2 averaged 16.75 (S.D. +/-17.17) min, and Interval 3 averaged 35.5 (S.D. +/-14.49) min range; Group 2: average Interval 1 24.8 (S.D. +/-4.71) min, Interval 2 averaged 19.5 (S.D.+/-15.92), Interval 3 averaged 44.3 (S.D. +/-13.80) minutes. There was no statistically significant difference between the groups at any time interval, Interval 1 (p=0.43), Interval 2 (p=0.65), Interval 3 (p=0.40). There was no difference in serum potassium throughout the study period.. The administration of intravenous CaCl in the setting of hyperkalemia from acute digoxin toxicity did not affect mortality or time to death at the dose administered.

Topics: Animals; Calcium Chloride; Cardiotonic Agents; Digoxin; Disease Models, Animal; Electrocardiography; Hyperkalemia; Injections, Intravenous; Pilot Projects; Poisoning; Potassium; Random Allocation; Swine

Nonoliguric hyperkalemia of premature infants probably results from a transient inhibition of membrane-bound Na+/K+-ATPase during the first 24 h after birth. We hypothesized that the endogenous digitalis-like activity of the serum of premature infants, which inhibits the Na+/K+-ATPase, triggered hyperkalemia. Serum concentrations of potassium ([K+]) and of the digoxin-like immunoreactive substance ([DLIS]) were measured during the first 24 h after birth in 60 infants including 30 infants <30 gestational weeks. Contrary to our hypothesis, there was a negative linear correlation between [DLIS] at birth and [K+] 24 h after birth (r2 = 0.24, p < 0.002). 24 h after birth there was no correlation between [DLIS] and [K+]. Thus, a major role of DLIS in nonoliguric hyperkalemia could not be established.

Topics: Cardenolides; Circadian Rhythm; Digoxin; Extracellular Space; Female; Humans; Hyperkalemia; Infant, Newborn; Intracellular Fluid; Male; Osmolar Concentration; Potassium; Saponins; Sodium-Potassium-Exchanging ATPase; Time Factors

Drug-drug interactions are a preventable cause of morbidity and mortality, yet their consequences in the community are not well characterized.. To determine whether elderly patients admitted to hospital with specific drug toxicities were likely to have been prescribed an interacting drug in the week prior to admission.. Three population-based, nested case-control studies.. Ontario, Canada, from January 1, 1994, to December 31, 2000.. All Ontario residents aged 66 years or older treated with glyburide, digoxin, or an angiotensin-converting enzyme (ACE) inhibitor. Case patients were those admitted to hospital for drug-related toxicity. Prescription records of cases were compared with those of controls (matched on age, sex, use of the same medication, and presence or absence of renal disease) for receipt of interacting medications (co-trimoxazole with glyburide, clarithromycin with digoxin, and potassium-sparing diuretics with ACE inhibitors).. Odds ratio for association between hospital admission for drug toxicity (hypoglycemia, digoxin toxicity, or hyperkalemia, respectively) and use of an interacting medication in the preceding week, adjusted for diagnoses, receipt of other medications, the number of prescription drugs, and the number of hospital admissions in the year preceding the index date.. During the 7-year study period, 909 elderly patients receiving glyburide were admitted with a diagnosis of hypoglycemia. In the primary analysis, those patients admitted for hypoglycemia were more than 6 times as likely to have been treated with co-trimoxazole in the previous week (adjusted odds ratio, 6.6; 95% confidence interval, 4.5-9.7). Patients admitted with digoxin toxicity (n = 1051) were about 12 times more likely to have been treated with clarithromycin (adjusted odds ratio, 11.7; 95% confidence interval, 7.5-18.2) in the previous week, and patients treated with ACE inhibitors admitted with a diagnosis of hyperkalemia (n = 523) were about 20 times more likely to have been treated with a potassium-sparing diuretic (adjusted odds ratio, 20.3; 95% confidence interval, 13.4-30.7) in the previous week. No increased risk of drug toxicity was found for drugs with similar indications but no known interactions (amoxicillin, cefuroxime, and indapamide, respectively).. Many hospital admissions of elderly patients for drug toxicity occur after administration of a drug known to cause drug-drug interactions. Many of these interactions could have been avoided.

Topics: Aged; Angiotensin-Converting Enzyme Inhibitors; Anti-Asthmatic Agents; Anti-Infective Agents; Antihypertensive Agents; Case-Control Studies; Clarithromycin; Contraindications; Digoxin; Diuretics; Drug Interactions; Drug-Related Side Effects and Adverse Reactions; Female; Glyburide; Hospitalization; Humans; Hyperkalemia; Hypoglycemia; Male; Ontario; Trimethoprim, Sulfamethoxazole Drug Combination

Digoxin-immune antibody fragments (Fab) for treatment of digitalis intoxication was introduced in 1976. Many reports have been published concerning this therapy for children, but few have focused on its immediate reversal of cardiac as well as extracardiac life-threatening manifestations of digoxin toxicity. We present a case of life-threatening digitalis intoxication in a child with postoperative renal insufficiency, after a Sennings procedure for transposition of the great arteries. Digoxin administration according to the nationally recommended dosage and intervals unexpectedly resulted in serum levels in the toxic range. Severe cardiac arrhythmias, haemodynamic instability and a rapid-increasing serum potassium level resulted. This report demonstrates how administration of Fab according to the manufacturer's dosage recommendation reversed the tachyarrhythmia immediately and re-established a normal level of serum potassium within minutes.

Topics: Antibodies, Blocking; Antibody Specificity; Cardiac Surgical Procedures; Cardiotonic Agents; Digoxin; Electrocardiography; Female; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Infant; Postoperative Complications; Potassium; Transposition of Great Vessels

Topics: Calcium; Digoxin; Humans; Hyperkalemia

Topics: Arrhythmias, Cardiac; Depression; Digoxin; Drug Overdose; Electrocardiography; Enzyme Inhibitors; Humans; Hyperkalemia; Male; Middle Aged; Sodium-Potassium-Exchanging ATPase; Suicide, Attempted; Vomiting

Topics: Acute Kidney Injury; Calcium Chloride; Cardiotonic Agents; Digoxin; Humans; Hyperkalemia

Topics: Acute Disease; Acute Kidney Injury; Cardiotonic Agents; Chronic Disease; Digoxin; Humans; Hyperkalemia

Topics: Acute Kidney Injury; Calcium Chloride; Cardiotonic Agents; Digoxin; Humans; Hyperkalemia

Hyperkalemia resulting from digoxin toxicity is a well-recognized phenomenon. We report a case in which hyperkalemia, bradycardia, and hypotension were unresponsive to standard therapy but appeared to respond to digoxin-specific antibodies (Fab). This case highlights the importance of a high index of suspicion for digoxin toxicity as a potential cause of refractory hyperkalemia.

Topics: Digoxin; Female; Humans; Hyperkalemia; Kidney Failure, Chronic; Middle Aged

During February 1993-May 1995, the New York City Poison Control Center (NYCPCC) was informed about onset of illness in five previously healthy men after they ingested a substance marketed as a topical aphrodisiac; four of the men died. These cases were investigated by the New York City Department of Health, the New York City Department of Environmental Protection, and the Food and Drug Administration (FDA). Four cases were referred to the NYCPCC and one case to the New York City medical examiner's office. The decedents died from cardiac dysrhythmias, and all five patients had measurable levels of digoxin* detected in their serum. Digoxin had not been prescribed for therapeutic purposes for any of these patients, and none had medical conditions associated with endogenous digoxin-like immunoreactive substances. The purported aphrodisiac contains bufadienolides, naturally occurring cardioactive steroids that have digoxin-like effects. This report describes three of the five case reports, summarizes the investigations of the five cases, and underscores the health risks associated with inappropriate use of preparations containing digoxin-like substances.

Topics: Adolescent; Adult; Aphrodisiacs; Arrhythmias, Cardiac; Bufanolides; Digoxin; Fatal Outcome; Heart Arrest; Humans; Hyperkalemia; Hypotension; Male; New York City; Poisoning

Topics: Adolescent; Adult; Arrhythmias, Cardiac; Bufanolides; Digoxin; Fatal Outcome; Heart Arrest; Humans; Hyperkalemia; Hypotension; Male; New York City; Poisoning

The relationship between levels of potassium in the serum and the development of malignant arrhythmias was examined in a retrospective study involving 1011 patients presenting with acute myocardial infarction. Thirteen percent of the overall patients studied had significant hypokalemia (k less than 3.5 mmol/liter). The average initial level of potassium in patients who developed malignant arrhythmias was (4.10 mmol/liter) significantly lower (P less than 0.01) than those patients who did not develop such arrhythmias (4.19 mmol/liter). To determine whether the level of potassium was, in itself, the primary cause of malignant arrhythmias following myocardial infarction, a subgroup analysis of factors influencing these levels was performed. It was determined that diabetics have a higher level of potassium than nondiabetics (4.2 mmol/liter versus 4.11 mmol/liter - P = 0.01) and a lower incidence of malignant arrhythmias (50.5% versus 63.5% - P = 0.002). No correlation was found between treatment with either digitalis or diuretics and malignant arrhythmias. Size and location of infarcted areas was found to have a direct relationship with development of arrhythmias. Size and location of infarctions, however, were not found to be related to levels of potassium in the serum. Our findings support and clarify earlier suggestions establishing the levels of potassium in the serum as an important causative factor, together with size and location of infarctions, in the development of malignant arrhythmias.

Topics: Adrenergic beta-Antagonists; Aged; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Diabetes Mellitus; Digoxin; Diuretics; Female; Heart Block; Homeostasis; Humans; Hyperkalemia; Hypokalemia; Male; Middle Aged; Myocardial Infarction; Potassium; Retrospective Studies; Tachycardia; Ventricular Fibrillation

In 9 patients with atrial fibrillation the effect of zero, low and high levels of serum digoxin on exercise-induced hyperkalemia was assessed by bicycle exercise tests. Exercise at each level of serum digoxin was associated with a significant (up to 20%) rise in plasma potassium. At a work load of 75 W the highest level of serum digoxin was associated with a significantly higher maximum plasma potassium concentration as compared to the maximum valueatazero serum digoxin. The enhancement of exercise-induced hyperkalemia may add to the arrhythmogenic effect of digitalis.

Topics: Adult; Aged; Atrial Fibrillation; Coronary Disease; Digoxin; Exercise Test; Humans; Hyperkalemia; Male; Middle Aged; Potassium

Digoxin excess can produce characteristic bradyarrhythmias, tachyarrhythmias, and hyperkalemia. The bradyarrhythmias, which consist of disturbances in conduction and block at the level of the atrioventricular and sinus nodes, are mediated by a direct and vagotonic effect. The vagotonic effect of excess digoxin may also result in a marked slowing of the sinus rate in the setting of severe toxicity. Digoxin increases automatic and triggered electrical activity in atrial muscle, His-Purkinje system, and ventricular muscle, which predisposes to tachycardias. Many of the tachyarrhythmias are relatively specific for the toxic effects of digoxin. Atrial tachycardias with variable atrioventricular block, accelerated junctional rhythms (especially in the setting of atrial fibrillation), and fascicular tachycardias are characteristic digoxin toxic rhythms. Digoxin-specific antibody fragments should be considered the treatment of choice for any digoxin toxic arrhythmia associated with hemodynamic compromise or the threat of hemodynamic compromise. Hyperkalemia, when due to acute severe digoxin toxicity, is also an appropriate indication for digoxin-specific Fab fragment therapy. When assessing the risk:benefit ratio for using digoxin-specific Fab fragment therapy, one needs to determine, in addition to the electrocardiographic manifestations and patient's hemodynamic status (1) the severity of toxicity, as indexed by the amount ingested and/or the serum digoxin concentration; (2) the expected time course for reversal of toxicity, which is usually determined by the status of renal function; (3) the need for digoxin to provide ventricular rate control or improved ventricular contractility and therapeutic alternatives to digoxin; (4) the presence of a strong allergy history; (5) the presence of such factors as increased age and severity of heart disease that may predispose to digoxin toxicity.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Arrhythmias, Cardiac; Causality; Clinical Protocols; Digoxin; Electrocardiography; Hemodynamics; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Poisoning

We report a hypertensive patient with nonazotemic hyperkalemia caused by a combined disturbance in both the internal and external balance of potassium. During a follow-up of 30 months, exacerbations of hyperkalemia were observed, interposed with a return to the previous baseline. Two brief normokalemic periods were recorded. Blood pressure tended to be higher during hyperkalemic peaks. The following findings were detected: (1) hyperchloremic hyperkalemic acidosis with normal glomerular filtration rate, adequately elevated plasma aldosterone levels, and normovolemia; (2) a tubular defect in potassium excretion, refractory to intravenous sodium sulfate (nonreabsorbable anion) and mineralocorticoids; (3) impaired tissue uptake of potassium under insulin administration; (4) exaggerated hyperkalemia following beta-adrenergic blockade and blunted hypokalemic response to a beta-agonist; and (5) a defect in Na/K transport in erythrocytes detected in vitro, coexistent with an elevated level of free digoxin-like immunoreactive factor in serum. These results suggest that our patient had a generalized abnormality in potassium transport.

Topics: Acid-Base Equilibrium; Adult; Biological Transport; Blood Proteins; Cardenolides; Digoxin; Electrolytes; Furosemide; Glucose; Hormones; Humans; Hydrochlorothiazide; Hyperkalemia; Insulin; Kidney; Male; Potassium; Saponins; Sodium; Stimulation, Chemical; Sympathomimetics

Previous in vitro evidence suggests that adrenaline causes K influx in skeletal muscle by stimulating a ouabain sensitive Na/K ATPase membrane pump. However in rabbits, adrenaline induced hypokalaemia was not significantly altered by pretreatment with digoxin (50 micrograms/kg). Rats were infused with adrenaline or saline after being given a tracer dose of 42KCl. Adrenaline caused a highly significant uptake of 42K in skeletal muscle and a decrease in 42K uptake in ventricle. Rats were also studied after receiving a high dose of digoxin (1.4 mg/kg) which by itself produced a significant increase in plasma K, a decrease in plasma Na and a decreased uptake of 42K in ventricle and lung. These results suggest that adequate widespread Na/K ATPase inhibition had been achieved by this dose of digoxin but despite this, adrenaline still caused hypokalaemia and also still caused significant 42K tissue uptake by skeletal muscle. These results suggest that adrenaline causes K influx by skeletal muscle and K efflux by cardiac tissue. Furthermore, the former mechanism was not inhibited by pretreatment with digoxin.

Topics: Animals; Digoxin; Epinephrine; Hyperkalemia; Liver; Lung; Male; Muscles; Myocardium; Potassium; Rabbits; Rats; Rats, Inbred Strains; Sodium-Potassium-Exchanging ATPase

Coadministration of captopril has been shown to increase serum digoxin concentration. The effects of ramipril, a new angiotensin converting enzyme inhibitor, on serum digoxin concentration after multiple dosing were studied in 12 healthy volunteers. All subjects were receiving steady-state digoxin medication (0.5 mg daily), and ramipril (5 mg daily) was coadministered for 14 days. Serum digoxin concentration was measured repeatedly before, during and up to 1 week after ramipril coadministration at 8 a.m. (trough values) and on selected trial days at 11 a.m., 3 hours after the morning medication. Simultaneously, blood levels of ramipril and its active metabolite diacid were determined. Volunteers were followed closely for side effects and for changes in blood pressure, heart rate and electrocardiogram. Safety pharmacology included serial determination of sodium, potassium, serum glutamic oxaloacetic transaminase, creatinine and a full blood count. Mean serum digoxin concentration was not significantly influenced by ramipril coadministration with trough levels of 0.90 +/- 0.24 before, 0.93 +/- 0.38 during and 0.82 +/- 0.33 ng/ml after ramipril medication. The increase in serum digoxin concentration 3 hours after the morning dose was also not significantly affected by ramipril. Serum levels of ramipril and its diacid showed a wide range of variation. Mean serum potassium increased by 0.3 mmol/liter during ramipril coadministration with development of symptomless hyperkalemia (6.0 mmol/liter) in 1 subject. The only other side effect possibly related to ramipril was a dry cough in 1 subject. Both drugs were well tolerated. Ramipril showed no significant influence on serum digoxin levels in healthy volunteers.

Topics: Adult; Angiotensin-Converting Enzyme Inhibitors; Bridged Bicyclo Compounds; Bridged-Ring Compounds; Digoxin; Drug Interactions; Female; Heart Rate; Humans; Hyperkalemia; Male; Middle Aged; Ramipril; Sex Factors

We describe the occurrence of hyperkalemia in a stable hemodialysis patient who developed digoxin toxicity. The patient had been receiving digoxin for 2 years. His maintenance digoxin dose was increased from 0.125 to 0.25 mg three times a week, which resulted in a toxic serum level of 4.9 ng/mL (therapeutic range is 0.8 to 2.0 ng/mL). As a consequence of the digoxin toxicity, he became hyperkalemic (7.8 mEq/L), and this value returned to normal only after the digoxin level was lowered by a combination of oral charcoal and dialysis. This study shows how readily hyperkalemia can occur in an anephric patient manifesting digoxin toxicity. Thus, potentially lethal hyperkalemia can occur in hemodialysis patients who ingest therapeutic quantities of digoxin. Digoxin toxicity should be added to the differential diagnosis of hyperkalemia in patients with renal failure. This can occur despite the absence of a history of massive ingestion of a cardiac glycoside.

Topics: Aged; Digoxin; Dose-Response Relationship, Drug; Humans; Hyperkalemia; Kidney Failure, Chronic; Male; Propranolol; Renal Dialysis

In a prospective and a retrospective study, the effects of hyperkalemia on the electrocardiogram (ECG) of patients treated with customary maintenance doses of digoxin were examined and the results were compared with the effects of hyperkalemia in patients not receiving digitalis. The prospective study included 11 patients treated and 11 not treated with digitalis, and the retrospective study 27 patients treated and 61 not treated with digitalis. In all patients serum potassium concentrations (Ks) were determined within 1 hour of the recorded electrocardiogram. Serum digoxin concentrations, measured in 11 patients in the prospective and in 4 in the retrospective study, ranged from 0.7 to 5.0 ng/ml, and exceeded 2.0 ng/ml in 10 of 15 patients. Since the results of the prospective and of the retrospective study were similar, they were combined. In patients treated with digitalis, Ks ranged from 5.5 to 6.6 mEq/liter in 21 patients, from 6.7 to 7.5 mEq/liter in 17 and from 7.6 to 8.5 mEq/liter in 6; the Ks was 9.1 mEq/liter in 1 patient. The ventricular rate in patients treated with digitalis ranged from 48 to 140 beats/min, and was not significantly different from that in untreated patients within each range of Ks. Atrioventricular (AV) junctional rhythm occurred more frequently in the electrocardiograms of digitalis-treated patients (15 of 45 vs 2 of 76, p less than 0.001). The average PR intervals were longer in patients treated with digitalis who had Ks greater than 6.6 mEq/liter, but no patient in the study had greater than first-degree AV block, and no patient required a pacemaker.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Arrhythmias, Cardiac; Digitalis; Digoxin; Electrocardiography; Female; Heart Rate; Humans; Hyperkalemia; Male; Middle Aged; Plants, Medicinal; Plants, Toxic; Prospective Studies; Retrospective Studies

The effects of hyperkalemia on serum and myocardial digoxin (DX) concentration was studied in conjunction with hemodynamic changes in 31 normal dogs. The myocardial DX concentration in the hyperkalemic (HK) group was significantly lower than that in normokalemic (NK) group, despite a significantly higher serum DX concentration in the HK group. In the HK group, the myocardial sodium concentration was significantly lower than in the NK group. Coincident with these biochemical changes, no increase of LV max dP/dt after DX administration was observed in the HK group. These results suggest that there might be competitive antagonism between myocardial uptake of potassium and DX.

Topics: Animals; Blood Pressure; Digoxin; Dogs; Heart Rate; Hyperkalemia; Kidney; Liver; Myocardial Contraction; Myocardium; Potassium; Sodium

Topics: Arrhythmias, Cardiac; Digitalis Glycosides; Digoxin; Humans; Hyperkalemia; Immunoglobulin Fab Fragments

Topics: Digoxin; Hemoperfusion; Humans; Hyperkalemia; Potassium; Renal Dialysis

We used charcoal hemoperfusion coupled with hemodialysis to treat a woman with massive digoxin ingestion complicated by hyperkalemia. Although dialysis controlled the serum potassium levels, hemoperfusion removed less than 1% of the total ingested dose. Hemoperfusion has a relatively minor impact on digoxin elimination and remains of unproved value in the therapy for digoxin overdose.

Topics: Adult; Arrhythmias, Cardiac; Charcoal; Digoxin; Female; Hemoperfusion; Humans; Hyperkalemia; Myocardium; Potassium; Renal Dialysis

Topics: Aged; Arrhythmias, Cardiac; Bethanidine; Digoxin; Drug-Related Side Effects and Adverse Reactions; Female; Furosemide; Humans; Hyperkalemia; Hypotension, Orthostatic; Male; Middle Aged; Spironolactone; Uremia

Purified Fab fragments of ovine digoxin-specific antibodies reversed severe digoxin intoxication in a patient who had taken 22.5 mg of the drug with suicidal intent. Atrioventricular block with extreme bradycardia was temporarily managed by pacing, but progressive, intractable hyperkalemia (serum potassium of 8.7 meq per liter) with increasing pacing threshold and progressive intraventricular conduction delay was controlled only after infusion of 1100 mg of Fab. Sinus rhythm returned 10 minutes after completion of Fab infusion. Within five hours, the serum potassium concentration fell to 4.0 meq per liter. Free digoxin concentrations in serum fell sharply to undetectable levels, whereas total serum digoxin concentration concomitantly increased 12-fold. Renal excretion of digoxin bound to Fab was documented. Reversal of toxicity was not accompanied by hemodynamic instability, and antibodies to sheep Fab fragments were not detected in the patient's serum after treatment. Thus, purified digoxin-specific Fab fragments are capable of rapid reversal of advanced digoxin toxicity.

Topics: Adult; Animals; Antibody Specificity; Digoxin; Electrocardiography; Heart Block; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Male; Poisoning; Sheep; Suicide, Attempted

The effect of digoxin, at two different inotropic levels, was examined in normo- and hyperkalaemic dogs. For similar inotropic responses, normo- and hyperkalaemic dogs had similar levels of (Na+, K+)-ATPase inhibition and microsomal-bound digoxin.

Topics: Adenosine Triphosphatases; Animals; Digoxin; Dogs; Dose-Response Relationship, Drug; Heart; Heart Ventricles; Hyperkalemia; Microsomes; Myocardial Contraction; Myocardium; Potassium; Sodium

4 patients tried to commit suicide by ingestion of 45 to 100 tablets of digoxin (Lanicor 0,25 mg) and acteyldigoxin (Novodigal 0,2 mg) respectively. In all patients cardiac arrhythmias occurred including 3 rd degree av-block, tachyarrhythmias and ventricular fibrillation which was lethal in two patients. After a short period hyperkaliaemia a rapid decrease of potassium in the serum was observed 3-12 hours after administration of digoxin. This loss of potassium was due to an increased excretion of potassium and sodium in the urine. It is thought that a reversible tubular leakage is responsible for the loss of electrolytes by the kidney rather than an inhibition of the ATPase in kidney tissue. From our observations the following therapy scheme for digitalis-intoxication is recommended: 1. Gastric lavage and administration of absorbents (charcoal, cholestyramin) in order to decrease the absorption of the glycosides and to interrupt the enterohepatic circulation. 2. Substitution of electrolytes by infusions and by oral route to balance sodium and potassium levels in the serum. 3. Administration of diphenylhydantoin for treatment of cardiac arrhythmias. 4. Implantation of a temporary pacemaker for treatment of cardiac arrhythmias especially for the management of bradycardias. 5. Plasmapheresis to lower the glycosid concentration in the heart muscle and in other tissues.

Topics: Adult; Arrhythmias, Cardiac; Charcoal; Digoxin; Female; Gastric Lavage; Humans; Hyperkalemia; Hypokalemia; Kidney; Male; Middle Aged; Pacemaker, Artificial; Phenytoin; Plasmapheresis; Poisoning; Potassium; Sodium; Suicide; Water-Electrolyte Balance

Topics: Adult; Arrhythmias, Cardiac; Digoxin; Electrocardiography; Female; Heart Block; Humans; Hyperkalemia; Injections, Intravenous; Magnesium Sulfate; Medical Laboratory Science; Pacemaker, Artificial; Potassium; Renal Dialysis; Self Medication; Time Factors

Topics: Acidosis; Atrial Fibrillation; Bundle-Branch Block; Calcium; Colon, Sigmoid; Diagnosis, Differential; Digoxin; Electrocardiography; Female; Humans; Hyperkalemia; Hypocalcemia; Hypokalemia; Infant; Potassium; Tachycardia; Urinary Diversion; Water-Electrolyte Balance

Topics: Acute Disease; Adult; Atropine; Bradycardia; Digoxin; Electrocardiography; Female; Furosemide; Humans; Hyperkalemia; Intensive Care Units; Pacemaker, Artificial; Poisoning; Radioimmunoassay; Suicide

Topics: Administration, Oral; Adolescent; Digoxin; Electrocardiography; Female; Half-Life; Heart Block; Humans; Hyperkalemia; Phenytoin; Poisoning; Potassium; Suicide

Topics: Adenosine Triphosphatases; Animals; Atropine; Digoxin; Dogs; Heart; Heart Rate; Heart Ventricles; Hyperkalemia; Microsomes; Myocardium; Potassium; Practolol; Sodium

Topics: Arrhythmias, Cardiac; Atropine; Bradycardia; Digoxin; Electrocardiography; Heart Arrest; Heart Atria; Heart Block; Heart Conduction System; Humans; Hyperkalemia; Male; Middle Aged; Pacemaker, Artificial; Time Factors

Topics: Animals; Blood Pressure; Digoxin; Dogs; Heart Ventricles; Hemodynamics; Hyperkalemia; Muscle Contraction; Myocardium; Potassium; Potassium Chloride; Sodium Chloride; Time Factors; Tritium

Topics: Arrhythmias, Cardiac; Digoxin; Humans; Hyperkalemia; Hypokalemia; Suicide

Topics: Adult; Aged; Bradycardia; Digoxin; Female; Humans; Hyperkalemia; Male

Topics: Adult; Diagnosis, Differential; Digitalis Glycosides; Digoxin; Electrocardiography; Endocarditis, Subacute Bacterial; Female; Humans; Hypercalcemia; Hyperkalemia; Prednisone; Rheumatic Heart Disease; Substance-Related Disorders

Topics: Acute Disease; Animals; Binding Sites; Digoxin; Dogs; Hyperkalemia; Injections, Intravenous; Myocardium; Potassium; Tritium

Topics: Animals; Digoxin; Dogs; Hyperkalemia; Hypokalemia; Myocardium; Tritium

Topics: 17-Hydroxycorticosteroids; Adrenal Glands; Aldosterone; Animals; Corticosterone; Depression, Chemical; Digoxin; Dogs; Hydrocortisone; Hyperkalemia; Hypophysectomy; In Vitro Techniques; Mineralocorticoid Receptor Antagonists; Natriuresis; Nephrectomy; Organomercury Compounds; Ouabain; Potassium; Potassium Isotopes

Topics: Acute Disease; Animals; Digoxin; Dogs; Extracellular Space; Hyperkalemia; Injections, Intravenous; Kidney; Liver; Muscles; Myocardium; Spleen; Tritium