Skeletal muscle binding and renal excretion of digoxin in man

Oral digoxin effects on exercise performance, K+ regulation and skeletal muscle Na+ ,K+ -ATPase in healthy humans

Abstract

We investigated whether digoxin lowered muscle Na⁺,K⁺‐ATPase (NKA), impaired muscle performance and exacerbated exercise K⁺ disturbances. Ten healthy adults ingested digoxin (0.25 mg; DIG) or placebo (CON) for 14 days and performed quadriceps strength and fatiguability, finger flexion (FF, 105%_{peak‐workrate}, 3 × 1 min, fourth bout to fatigue) and leg cycling (LC, 10 min at 33% VO2peak and 67% VO2peak, 90% VO2peak to fatigue) trials using a double‐blind, crossover, randomised, counter‐balanced design. Arterial (a) and antecubital venous (v) blood was sampled (FF, LC) and muscle biopsied (LC, rest, 67% VO2peak, fatigue, 3 h after exercise). In DIG, in resting muscle, [³H]‐ouabain binding site content (OB‐F_ab) was unchanged; however, bound‐digoxin removal with Digibind revealed total ouabain binding (OB+F_ab) increased (8.2%, P = 0.047), indicating 7.6% NKA–digoxin occupancy. Quadriceps muscle strength declined in DIG (−4.3%, P = 0.010) but fatiguability was unchanged. During LC, in DIG (main effects), time to fatigue and [K⁺]_a were unchanged, whilst [K⁺]_v was lower (P = 0.042) and [K⁺]_a‐v greater (P = 0.004) than in CON; with exercise (main effects), muscle OB‐F_ab was increased at 67% VO2peak (per wet‐weight, P = 0.005; per protein P = 0.001) and at fatigue (per protein, P = 0.003), whilst [K⁺]_a, [K⁺]_v and [K⁺]_a‐v were each increased at fatigue (P = 0.001). During FF, in DIG (main effects), time to fatigue, [K⁺]_a, [K⁺]_v and [K⁺]_a‐v were unchanged; with exercise (main effects), plasma [K⁺]_a, [K⁺]_v, [K⁺]_a‐v and muscle K⁺ efflux were all increased at fatigue (P = 0.001). Thus, muscle strength declined, but functional muscle NKA content was preserved during DIG, despite elevated plasma digoxin and muscle NKA–digoxin occupancy, with K⁺ disturbances and fatiguability unchanged.

Key points

The Na⁺,K⁺‐ATPase (NKA) is vital in regulating skeletal muscle extracellular potassium concentration ([K⁺]), excitability and plasma [K⁺] and thereby also in modulating fatigue during intense contractions.

NKA is inhibited by digoxin, which in cardiac patients lowers muscle functional NKA content ([³H]‐ouabain binding) and exacerbates K⁺ disturbances during exercise.

In healthy adults, we found that digoxin at clinical levels surprisingly did not reduce functional muscle NKA content, whilst digoxin removal by Digibind antibody revealed an ∼8% increased muscle total NKA content.

Accordingly, digoxin did not exacerbate arterial plasma [K⁺] disturbances or worsen fatigue during intense exercise, although quadriceps muscle strength was reduced.

Thus, digoxin treatment in healthy participants elevated serum digoxin, but muscle functional NKA content was preserved, whilst K⁺ disturbances and fatigue with intense exercise were unchanged. This resilience to digoxin NKA inhibition is consistent with the importance of NKA in preserving K⁺ regulation and muscle function.