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Hirai T, Kasai H, Shiga T. Population pharmacokinetic analysis of the interaction of digoxin with N-desethylamiodarone in patients with atrial fibrillation and heart failure. Br J Clin Pharmacol 2025. [PMID: 40289268 DOI: 10.1002/bcp.70075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2024] [Revised: 03/09/2025] [Accepted: 04/02/2025] [Indexed: 04/30/2025] Open
Abstract
AIMS To evaluate the effects of amiodarone and/or N-desethylamiodarone concentrations on digoxin pharmacokinetics and determine the optimal dose of digoxin combined with amiodarone in Japanese patients with atrial fibrillation and heart failure. METHODS A population pharmacokinetic analysis of 3288 points from 368 patients receiving oral digoxin, including 48 (13%) who were coadministered amiodarone, was performed. A 1-compartment model with first-order absorption with amiodarone or N-desethylamiodarone as time-varying covariates for apparent digoxin clearance was constructed using stepwise forward inclusion and backward elimination approaches. The percentage of patients with digoxin values in the toxic range (≥0.9 ng/mL) was evaluated with Monte Carlo simulation. RESULTS The median serum digoxin concentration was 0.75 ng/mL; the median plasma concentrations of amiodarone and N-desethylamiodarone were 610 and 644 ng/mL, respectively. The final model for oral clearance of digoxin was explained by creatinine clearance (CLcr) and the N-desethylamiodarone concentration. Digoxin clearance increased by 21% when CLcr was doubled and decreased by 3% when the N-desethylamiodarone concentration increased by 100 ng/mL. In the simulation, the proportion of patients with values in the toxic range was high at 0.125 mg daily among patients taking amiodarone. A daily dose of 0.0625 mg is recommended for patients with a CLcr >30 mL/min. For patients with a CLcr ≤30 mL/min and an N-desethylamiodarone concentration >600 ng/mL, a daily dose of 0.03125 mg is recommended because of reduced digoxin clearance. CONCLUSIONS This study revealed that renal impairment and high plasma N-desethylamiodarone concentrations reduce digoxin clearance in patients with atrial fibrillation and heart failure.
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Affiliation(s)
- Toshinori Hirai
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine, Tokyo, Japan
- Department of Pharmacy, Institute of Science Tokyo Hospital, Tokyo, Japan
| | - Hidefumi Kasai
- Keio University, Keio Frontier Research & Education Collaborative Square (K-FRECS) at Tonomachi, Kanagawa, Japan
| | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine, Tokyo, Japan
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
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Khandelwal R, Vagha JD, Meshram RJ, Patel A. A Comprehensive Review on Unveiling the Journey of Digoxin: Past, Present, and Future Perspectives. Cureus 2024; 16:e56755. [PMID: 38650769 PMCID: PMC11033962 DOI: 10.7759/cureus.56755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 03/22/2024] [Indexed: 04/25/2024] Open
Abstract
Digoxin, a cardiac glycoside derived from the foxglove plant (Digitalis spp.), has been utilized for centuries in managing various cardiac conditions due to its ability to increase myocardial contractility and regulate heart rate. This comprehensive review explores the historical context, pharmacological properties, clinical applications, efficacy, safety profile, challenges, and future perspectives of digoxin. Tracing its journey from traditional medicine to modern cardiovascular therapeutics, we delve into its mechanism of action, therapeutic indications, and clinical guidelines. While digoxin remains a cornerstone therapy for heart failure and atrial fibrillation, its narrow therapeutic index and individual variability in response pose challenges in clinical practice. Nevertheless, ongoing research efforts aim to elucidate its role in emerging therapeutic areas and technological advancements in drug delivery. Despite the advent of newer pharmacological agents, digoxin's enduring relevance lies in its established efficacy, affordability, and global accessibility. This review underscores the symbiotic relationship between tradition and progress in cardiovascular medicine, highlighting the timeless pursuit of medical innovation to optimize patient care.
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Affiliation(s)
- Rahul Khandelwal
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Jayant D Vagha
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Revat J Meshram
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ankita Patel
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Lin ZQ, Guo L, Zhang LM, Lu JJ, Jiang X. Dosage Optimization of Digoxin in Older Patients with Heart Failure and Chronic Kidney Disease: A Population Pharmacokinetic Analysis. Drugs Aging 2023; 40:539-549. [PMID: 37157010 DOI: 10.1007/s40266-023-01026-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Renal function is an important index for digoxin dose adjustment, especially in patients with chronic kidney disease (CKD). Decreased glomerular filtration rate is common in older patients with cardiovascular disease. OBJECTIVE The aim of this study was to establish a digoxin population pharmacokinetic model in older patients with heart failure and CKD and to optimize the digoxin dose strategy. METHODS Older patients with heart failure and CKD aged > 60 years from January 2020 to January 2021 and who had an estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m2 or urine protein production were enrolled in this retrospective study. Population pharmacokinetic analysis and Monte Carlo simulations (n = 1000) were performed using NONMEN software. The precision and stability of the final model were analyzed by graphical and statistical methods. RESULTS Overall, 269 older patients with heart failure were enrolled. A total of 306 digoxin concentrations were collected, with a median value of 0.98 ng/mL (interquartile range [IQR] 0.62-1.61, range 0.04-4.24). The median age was 68 years (IQR 64-71, range 60-94) and eGFR was 53.6 mL/min/1.73 m2 (IQR 38.1-65.2, range 11.4-89.8). A one-compartment model with first-order elimination was developed to describe the digoxin pharmacokinetics. Typical values for clearance and volume of distribution were 2.67 L/h and 36.9 L, respectively. Dosage simulations were stratified by eGFR and metoprolol. Doses of 62.5 and 125 μg were recommended for older patients with eGFR < 60 mL/min/1.73 m2. CONCLUSIONS A population pharmacokinetic model of digoxin in older patients with heart failure and CKD was established in this study. A novel digoxin dosage strategy was recommended in this vulnerable population.
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Affiliation(s)
- Zhong-Qiu Lin
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Ling Guo
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Li-Min Zhang
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Jie-Jiu Lu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China.
| | - Xia Jiang
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, People's Republic of China.
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Asai Y, Tashiro T, Kondo Y, Hayashi M, Arihara H, Omote S, Tanio E, Yamashita S, Higuchi T, Hashimoto E, Yamada M, Tsuji H, Hayakawa Y, Suzuki R, Muro H, Yamamoto Y. Machine Learning-Based Prediction of Digoxin Toxicity in Heart Failure: A Multicenter Retrospective Study. Biol Pharm Bull 2023; 46:614-620. [PMID: 37005306 DOI: 10.1248/bpb.b22-00823] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Digoxin toxicity (plasma digoxin concentration ≥0.9 ng/mL) is associated with worsening heart failure (HF). Decision tree (DT) analysis, a machine learning method, has a flowchart-like model where users can easily predict the risk of adverse drug reactions. The present study aimed to construct a flowchart using DT analysis that can be used by medical staff to predict digoxin toxicity. We conducted a multicenter retrospective study involving 333 adult patients with HF who received oral digoxin treatment. In this study, we employed a chi-squared automatic interaction detection algorithm to construct DT models. The dependent variable was set as the plasma digoxin concentration (≥ 0.9 ng/mL) in the trough during the steady state, and factors with p < 0.2 in the univariate analysis were set as the explanatory variables. Multivariate logistic regression analysis was conducted to validate the DT model. The accuracy and misclassification rates of the model were evaluated. In the DT analysis, patients with creatinine clearance <32 mL/min, daily digoxin dose ≥1.6 µg/kg, and left ventricular ejection fraction ≥50% showed a high incidence of digoxin toxicity (91.8%; 45/49). Multivariate logistic regression analysis revealed that creatinine clearance <32 mL/min and daily digoxin dose ≥1.6 µg/kg were independent risk factors. The accuracy and misclassification rates of the DT model were 88.2 and 46.2 ± 2.7%, respectively. Although the flowchart created in this study needs further validation, it is straightforward and potentially useful for medical staff in determining the initial dose of digoxin in patients with HF.
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Affiliation(s)
- Yuki Asai
- Pharmacy, National Hospital Organization Mie Chuo Medical Center
| | - Takumi Tashiro
- Pharmacy, National Hospital Organization Shizuoka Medical Center
| | - Yoshihiro Kondo
- Pharmacy, National Hospital Organization Nagoya Medical Center
| | - Makoto Hayashi
- Pharmacy, National Hospital Organization Nagoya Medical Center
| | - Hiroki Arihara
- Pharmacy, National Hospital Organization Kanazawa Medical Center
| | - Saki Omote
- Pharmacy, National Hospital Organization Kanazawa Medical Center
| | - Ena Tanio
- Pharmacy, National Hospital Organization Kanazawa Medical Center
| | - Saena Yamashita
- Pharmacy, National Hospital Organization Kanazawa Medical Center
| | - Takashi Higuchi
- Pharmacy, National Hospital Organization Kanazawa Medical Center
| | - Ei Hashimoto
- Pharmacy, National Hospital Organization Kanazawa Medical Center
| | - Momoko Yamada
- Pharmacy, National Hospital Organization Kanazawa Medical Center
| | - Hinako Tsuji
- Pharmacy, National Hospital Organization Kanazawa Medical Center
| | - Yuji Hayakawa
- Pharmacy, National Center for Geriatrics and Gerontology
| | - Ryohei Suzuki
- Pharmacy, National Hospital Organization Higashinagoya National Hospital
| | - Hiroya Muro
- Pharmacy, National Hospital Organization Toyohashi Medical Center
| | - Yoshiaki Yamamoto
- Department of Clinical Research, National Hospital Organization Shizuoka Institute of Epilepsy and Neurological Disorders
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Sakai M, Hirai T, Shitara S, Iwamoto T, Shiga T. Comparison of creatinine-based equations for estimating renal function for digoxin dose adjustment in patients with atrial fibrillation and heart failure. Pharmacol Res Perspect 2023; 11:e01050. [PMID: 36628508 PMCID: PMC9832284 DOI: 10.1002/prp2.1050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/08/2022] [Accepted: 12/23/2022] [Indexed: 01/12/2023] Open
Abstract
The aim of this study was to determine an appropriate equation for estimating renal function to dose regulate the serum digoxin trough concentration to a target of <0.9 ng/ml in patients with atrial fibrillation (AF) and heart failure (HF). All patients received 0.125 mg oral digoxin daily. The estimated glomerular filtration rate by the Modification of Diet in Renal Disease (eGFRMDRD ) equation deindexed based on body surface area had the highest correlation with digoxin trough concentrations (r = -0.450) compared to the Cockcroft-Gault equation (r = -0.415) or deindexed eGFR based on the Chronic Kidney Disease Epidemiology Collaboration (eGFRCKD-EPI ) equation (r = -0.416). The median digoxin trough concentrations were 0.60, 0.77, 0.97 and 1.30 ng/ml in patients with a deindexed eGFRMDRD ≥ 60, 45-59, 30-44 and < 30 ml/min, respectively. The deindexed eGFRMDRD is an appropriate equation for digoxin dose adjustment in patients with AF and HF.
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Affiliation(s)
| | - Toshinori Hirai
- Department of Clinical Pharmacology and TherapeuticsThe Jikei University School of MedicineTokyoJapan
- Department of PharmacyMie University Hospital, Faculty of Medicine, Mie UniversityTsuMieJapan
| | - Satoshi Shitara
- Department of Clinical Pharmacology and TherapeuticsThe Jikei University School of MedicineTokyoJapan
| | - Takuya Iwamoto
- Department of PharmacyMie University Hospital, Faculty of Medicine, Mie UniversityTsuMieJapan
| | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and TherapeuticsThe Jikei University School of MedicineTokyoJapan
- Department of CardiologyTokyo Women's Medical UniversityTokyoJapan
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Suresh MR, Mills AC, Britton GW, Pfeiffer WB, Grant MC, Rizzo JA. Initial treatment strategies in new-onset atrial fibrillation in critically ill burn patients. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2022; 12:251-260. [PMID: 36660265 PMCID: PMC9845808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/05/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Atrial fibrillation is associated with increased morbidity and mortality in critically ill patients. Few studies have specifically examined this arrhythmia in burn patients. Given the significant clinical implications of atrial fibrillation, understanding the optimal management strategy of this arrhythmia in burn patients is important. Consequently, the purpose of this study was to examine rate- and rhythm-control strategies in the management of new onset atrial fibrillation (NOAF) and assess their short term outcomes in critically ill burn patients. METHODS We identified all patients admitted to our institution's burn intensive care unit between January 2007 and May 2018 who developed NOAF. Demographic information and burn injury characteristics were captured. Patients were grouped into two cohorts based on the initial pharmacologic treatment strategy: rate-(metoprolol or diltiazem) or rhythm-control (amiodarone). The primary outcome was conversion to sinus rhythm. Secondary outcomes included relapse or recurrence of atrial fibrillation, drug-related adverse events, and complications and mortality within 30 days of the NOAF episode. RESULTS There were 68 patients that experienced NOAF, and the episodes occurred on median days 8 and 9 in the rate- and rhythm-control groups, respectively. The length of the episodes was not significantly different between the groups. Conversion to sinus rhythm occurred more often in the rhythm-control group (P = 0.04). There were no differences in the incidences of relapse and recurrence of atrial fibrillation, and the complications and mortality between the groups. Hypotension was the most common drug-related adverse event and occurred more frequently in the rate-control group, though this difference was not significant. CONCLUSIONS Conversion to sinus rhythm occurred more often in the rhythm-control group. Outcomes were otherwise similar in terms of mortality, complications, and adverse events. Hypotension occurred less frequently in the rhythm-control group, and although this difference was not significant, episodes of hypotension can have important clinical implications. Given these factors, along with burn patients having unique injury characteristics and a hypermetabolic state that may contribute to the development of NOAF, when choosing between rate- and rhythm control strategies, rhythm-control with amiodarone may be a better choice for managing NOAF in burn patients.
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Affiliation(s)
- Mithun R Suresh
- Department of Medicine, CentraCare-St.Cloud Hospital1406 6th Ave N, St. Cloud 56303, MN, USA
| | - Alexander C Mills
- Department of Surgery, University of Texas Health Science Center at Houston6410 Fannin Street, Houston 77030, TX, USA
| | - Garrett W Britton
- Burn Center, United States Army Institute of Surgical Research3698 Chambers Pass STE B, JBSA Ft. Sam Houston 78234, TX, USA
| | - Wilson B Pfeiffer
- Department of Anesthesiology, Brooke Army Medical Center3551 Roger Brooke Dr, JBSA Ft. Sam Houston 78234, TX, USA
| | - Marissa C Grant
- Department of Anesthesiology, Brooke Army Medical Center3551 Roger Brooke Dr, JBSA Ft. Sam Houston 78234, TX, USA
| | - Julie A Rizzo
- Department of Trauma, Brooke Army Medical Center3551 Roger Brooke Dr, JBSA Ft. Sam Houston 78234, TX, USA,Department of Surgery, Uniformed Services University of The Health Sciences4301 Jones Bridge Rd, Bethesda 20814, MD, USA
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