Digoxin Immune Fab

Used for both the acute or chronic overdose. Typically this is from the pharmaceutical agent digoxin. Other cardiac glycosides such as Oleander can be treated with digoxin immune fab.


Indications

Acute digoxin overdose

  • Cardiac arrest
  • life threatening cardia dysrhythmia
  • ingested dose >10mg (adult) or >4mg (child)
  • serum digoxin level >15 mmol/L (12 ng/ml)
  • serum potassium >5.5 mmol/L

Acute digoxin overdose

  • Cardiac arrest
  • Life threatening cardiac dysrhythmia
  • Cardiac dysrhythmia or increased automaticity not likely to be tolerated for a prolonged period

Administration

Place the patient in an area capable of resuscitation and on cardiac monitoring. From the Digoxin Overdose & Response to Antibody (DORA) study, suggested doses of Digoxin immune Fab are as follows:

Acute digoxin Overdose:

  • A small bolus of 80mg (2 vials), repeat if necessary, titrated against clinical effect (ECG & HR), i is likely to achieve equivalent benefits with much lower total doses than previously recommended.

Chronic digoxin poisoning:

  • It is likely that 40 mg (1 vial) is adequate, repeat after 60 mins if there is no response.
  • Digoxin toxicity may recur beyond 24 hours and necessitate further administration of digoxin immune Fab. Therefore keep your patient monitored and do not discharge within 24 hours.

Cardiac Arrest:

  • Give 5 vials of digoxin immune Fab by rapid IV injections repeat if required.

Other cardiac glycoside poisoning:

  • If the patient is stable then give 2 ampoules, repeat as required until toxicity is reversed.
  • Up to 30 ampoules have been used to reverse oleander poisoning.

Adverse reactions:

  • Hypokalaemia
  • Allergy
  • Exacerbation of atrial fibrillation or cardiac failure
  • Digoxin levels will rise post administration of the immune Fab as the assays will measure both free and Fab-bound digoxin, Ask for the “free level” for more accurate serum monitoring.

LITFL Further Reading

References


Peer Review:

Emergency Physician & Head of Clinical Toxicology at Prince of Wales Hospital. VMO toxicologist for New South Wales Poisons Information Centre. PhD on the renal excretory mechanism of Paraquat. Current research interests include digoxin, methotrexate, dihydropyridine and sodium channel blocker toxicity.

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Dr Betty Shuk Han Chan

MBBS, FACEM, PhD
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Toxicology Library

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Dr Neil Long BMBS FACEM FRCEM FRCPC. Emergency Physician at Burnaby Hospital in Vancouver Emergency. Loves the misery of alpine climbing and working in austere environments. Supporter of FOAMed, toxicology, tropical medicine, sim and ultrasound

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