Digoxin toxicity: Management

Digoxin toxicity: 1 or 2 amps of immune fab only, no maths required.

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Dr Betty Chan is an emergency physician and clinical toxicologist in Sydney, Australia who is an expert in digoxin toxicity. She discusses her research and a simplified method of when to give digoxin immune fab in acute and chronic overdose.

Spolier alert:

While equations exist to calculate the body load of digoxin and subsequent dose of Fab fragment required this overestimates the total amount required due to the toxicokinetics (specifically the distribution) of digoxin.

A far more practical approach is:

  • Acute toxicity:         give 2 vials & repeat hourly as required
  • Chronic toxicity:      give 1 vial & repeat hourly as required

The DORA study has questioned the role of digoxin-Fab in patients with chronic toxicity as it produced a median increase in heart rate of 8 beats per minute and a median decrease of 0.3 mmol/L potassium in a group of 36 patients with chronic digoxin toxicity. This group typically has multiple co-morbidities and take multiple cardiovascular medications such as beta blockers, calcium channel blockers and ACE inhibitors. Digoxin-Fab should not be relied upon in isolation to improve heart rate nor correct hyperkalaemia.


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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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