Effect of preperfusion of lead and aminophylline on digoxin cardiotoxicity

An attempt has been made to investigate the cardiotoxicity of an interaction of Lead acetate (LA), Aminophylline (APH) and Digoxin (DGN), employing an isolated frog heart preparation. While DGN-Cardiotoxicity was potentiated by LA-preperfusion, it was antagonized by APH-preperfusion as revealed by data reflecting the mean DGN perfusion time (Sec) and mean DGN exposure (microgram/10 mg heart weight) for cardiac arrest. In an experimental group involving interaction of LA, DGN and APH, preperfusion of APH has significantly diminished but not fully abolished LA-induced potentiation of DGN-cardiotoxicity. On the other hand, perfusion of APH after LA resulted not only in annulment of LA-induced potentiation but also in an eventual residual protective effect of APH. It was striking that simultaneous preperfusion of APH and LA led to exacerbation of LA-induced potentiation. The results of this interaction study involving two widely prescribed cardioactive drugs, are considered to be of immense pharmaco-toxicological interest.

Digoxin-specific Fab fragments in the treatment of oleander toxicity in a canine model

STUDY OBJECTIVE

To examine the efficacy of digoxin-specific Fab fragments (dsFab) in the treatment of experimentally induced Nerium oleander cardiac glycoside toxicity in a dog model.

DESIGN

A nonblined, placebo-controlled experiment.

SUBJECTS

Ten adult greyhound dogs of either sex divided into treatment and control groups of five dogs each.

INTERVENTIONS

A tincture of oleander was prepared and administered intravenously to each animal. After the onset of cardiotoxicity, the treatment group received 60 mg/kg dsFab IV.

MEASUREMENTS AND MAIN RESULTS

All dogs exhibited dysrhythmias meeting our criteria for cardiac glycoside cardiotoxicity within 27 minutes of beginning the infusion. Three of five control dogs had lethal dysrhythmias during the three-hour observation period. The remaining two control dogs exhibited dysrhythmias throughout the three-hour experiment. All five of the dsFab-treated dogs survived and converted to normal sinus rhythm within eight minutes of dsFab infusion. Three treatment animals reverted back to nonlethal and hemodynamically stable dysrhythmias after a mean of 107 minutes.

CONCLUSION

Large doses of dsFab are efficacious in the treatment of dysrhythmias in this canine model of N oleander cardiac glycoside poisoning.

GABA/BZ-and NMDA-receptor interaction in digoxin-induced convulsions in rats

Digoxin (7.5 micrograms icv) induced 'pop-corn' type of convulsions and 100% mortality. The GABA-ergic agents produced varying degree of protection against digoxin-induced neurotoxicity. Diazepam (4 mg/kg) offered significant protection whereas pentobarbital (5 mg/kg) and baclofen (5 mg/kg) markedly reduced per cent mortality, but ethanol (2 g/kg), progabide (50 mg/kg) and muscimol (0.5 mg/kg) as well as GABA (50 mg/kg) could not offer significant protection in doses used. GABA-ergic agonists; GABA, baclofen, diazepam and pentobarbital when administered along with MK-801 (0.5 mg/kg) a non-competitive NMDA antagonist, a potentiation of anticonvulsant action of MK-801 was observed. MK-801 showed potent anticonvulsant profile in dose range (0.25-1 mg/kg) studied. A synergistic influence of Mg2+ and K+ ions on NMDA receptor antagonism was also observed. A role of GABA-ergic facilitation and NMDA antagonism as a potential anticonvulsant approach in digoxin-induced convulsions in rats has been suggested.

[A comparative study of the toxic and therapeutic effects of digoxin and its immobilized form]

It was shown on different species of laboratory animals (frogs, mice, rats) that digoxin immobilized on the copolymer was 8-15 times less toxic that its usual preparation. In this case glycoside fixed on the copolymer preserves completely its specific cardiotonic effect, i.e., possesses a wider range of the therapeutic action.

Extracellular magnesium and cardiotonic steroid toxicity in isolated myocardial preparations

This study examined effects of extracellular magnesium (Mg++0) on the positive inotropic and toxic actions of cardiotonic steroids in cardiac muscle isolated from guinea pig heart. Increasing concentrations of Mg++0 produced a negative inotropic effect in electrically paced, left atrial muscle and decreased the sensitivity to arrhythmogenic actions of digoxin without affecting the maximum developed tension observed before dysrhythmic activity. Other signs of toxicity such as contracture were less sensitive to the antagonistic effects of Mg++0. Estimates of fractional occupancy suggested that the increased tolerance to digoxin-induced arrhythmias was mediated by an altered responsiveness to given levels of receptor binding. Experiments in partially purified membrane preparations demonstrated that elevations in Mg++ increased affinity for [3H]ouabain without affecting binding site density. Na+,K+-adenosine triphosphatase activity in these membrane preparations was also enhanced by Mg++; however, increases in buffer Mg++ concentration had no effect on the Na+-pump in intact tissue. In summary, these results indicate that elevations in Mg++0 act directly on myocardium to diminish the sensitivity to cardiotonic steroid-induced arrhythmias. Furthermore, data suggest that this antagonistic action of Mg++0 is not mediated by alterations in receptor binding or Na+-pump reserve capacity.

The cardiac glycoside digoxin disrupts host defense in experimental pneumococcal pneumonia by impairing neutrophil mobilization

Normal CD-1 mice were administered digoxin (4 micrograms/kg/24 h) and infected with type 3 Streptococcus pneumoniae in order to assess the effects of the cardiac glycoside on the chemotactic responsiveness of peripheral blood neutrophils and the mobilization of granulocytes from storage pools. The chemotactic responses to autologous zymosan-activated serum (C5a) by neutrophils obtained from uninfected digoxin-treated and control animals were similar; comparable observations were made with circulating granulocytes isolated from animals at 24 or 48 h after intratracheal challenge with 5 x 10(5) colony-forming units (cfu) of bacteria. However, at 4 and 6 h after intratracheal pneumococcal challenge, the number of immature neutrophils in the peripheral blood was significantly lower in the glycoside-treated animals versus controls; at 24 and 48 h, these differences were not apparent. Following the intravenous inoculation of pneumococci, the number of circulating immature neutrophils was also found to be significantly lower at 4 and 24 h in animals given the cardiac glycoside versus controls. We conclude that digoxin disrupts host defense in experimental pneumococcal pneumonia and bacteremia by impairing the mobilization of neutrophils.

The history of a comprehensive pharmacokinetic service

This paper reviews the 10 years of providing a Clinical Pharmacokinetic Service (CPS) at the Ottawa General Hospital. The history of the service is followed from the early days of selective monitoring of two drugs to the present comprehensive level of monitoring of essentially all drug concentrations analyzed in the hospital. The administrative development is presented, including that of the Subcommittee on Pharmacokinetics. A justification study is described, the results of which indicated 92 percent acceptance of the CPS' recommendations. An effort to withdraw service for digoxin was unsuccessful in that a concurrent study indicated a deterioration in the appropriateness of digoxin prescribing. Several quality assurance techniques are discussed, including a recent audit on predictability. Finally, the education and research links are summarized. Based on the experience of the authors, it is concluded that a comprehensive CPS is an indispensable clinical service.

Quinidine enhancement of digoxin toxicity in rats and minipigs

The combined use of digoxin and quinidine has been associated with potentially fatal toxic reactions. The mechanisms involved in this drug interaction were investigated in Wistar rats and Hormel miniature pigs (minipigs). Infusions of digoxin alone (0.013 mg/min) and in combination with quinidine (0.051 mg/min) demonstrated that quinidine pretreatment significantly decreases the time of onset of arrhythmias and death in these animals as compared with digoxin alone. Similarly, when administered as a slow, bolus intravenous (i.v.) injection to either anesthetized or unanesthetized minipigs, quinidine pretreatment (10 mg/kg, i.v.) led to the rapid development of arrhythmias and death. Quinidine administration in both species also causes a dramatic reduction in blood pressure, and it appears that this hypotension may trigger the irregular rhythms of the heart once digoxin is administered. Electrocardiographic (ECG) evidence showed that the toxicity associated with digoxin administration alone was characterized by bradyarrhythmias and death was attributed to cardiac arrest. In contrast, quinidine pretreatment led to severe tachyarrhythmias and earlier death by ventricular fibrillation. These studies demonstrate the usefulness of these two species, particularly the minipigs, in assessing the magnitude of this drug interaction and also confirm the risks involved when these two drugs are combined.

Coronary vascular lesions in dogs treated with phosphodiesterase III inhibitors

A treatment-related coronary arteriopathy has been observed in the dog following the oral or intravenous administration of 4 potent phosphodiesterase type III inhibiting inodilators at high multiples of their ED50 for periods from 1 day to 6 months. A fifth compound of a similar pharmacological class exhibited limiting toxicity at low multiples of its ED50 and this compound failed to induce coronary arterial lesions. The earliest treatment-related findings observed were medial hemorrhage and necrosis with focal breaks in the internal elastic lamina. Later changes, observed from day 9 onwards, included intimal thickening consisting of smooth muscle proliferation with a mucoid ground substance, variable and inconsistent inflammatory changes involving one or more arterial tunics and adventitial hemorrhage, fibrosis and neovascularization. The changes were restricted to the coronary arteries including the extramural and intramural branches. The distribution of lesions varied from widespread, multifocal involvement of both coronary arterial systems to focal lesions with no obvious site of predilection. Induction of this lesion may involve changes in coronary flow and pressure as a result of an exaggerated pharmacological response to this class of compound. The susceptibility of other species (rat, cynomolgus monkey, or pig) to this effect has been investigated with no treatment-related arteriopathy being observed.

Endogenous digoxin-like factor raises blood pressure and protects against digitalis toxicity

Digoxin-like immunoreactive factor (DLIF) is an endogenous natriuretic material which causes diuresis and natriuresis after salt or fluid loading and which may play a pathogenetic role in various hypertensive states. In order to study the cardiovascular effects of DLIF, we administered partially purified material (500 ng/kg) iv to normal rats. DLIF administration caused a significant rise in blood pressure, induced a brisk diuresis, and slowed the heart rate. In addition, DLIF protected against digitalis toxicity. While iv digoxin, 1 mg/kg, uniformly produced lethal arrhythmias, administration of DLIF 15 min prior to digoxin infusion consistently protected against arrhythmias. These findings support the theory that DLIF may play a role in hypertension. In addition, DLIF may compete with digoxin for cardiac receptors.

Human and primate monoclonal antibodies for in vivo therapy

Human monoclonal antibodies, owing to their decreased immunogenicity, are expected to be an improvement over mouse monoclonal antibodies for in vivo therapy. Human and primate monoclonal antibodies are best produced with a human x mouse heteromyeloma. Several human chromosomes are stable in the human x (human x mouse) hybrids. Chimpanzee anti-digoxin monoclonal antibodies were prepared and characterized. Because they are structurally very similar to human antibodies, they should be well tolerated in humans. The anti-digoxin antibodies can be used for therapy of extreme overdoses or as an in vivo diagnostic tool for slight overdoses. Because the advantage of using human monoclonal antibodies is their lack of immunogenicity, preparation of the antibody must be scrupulous so as not to introduce extraneous immunogens. Analysis to ensure the purity of the preparation can be complicated by the presence of high concentrations of the antibody and the low levels of contamination that must be detected. We describe a Western blot assay for Protein A that is sensitive even in the presence of human IgG.

Antiarrhythmic actions of left stellectomy in digitalis-mediated malignant ventricular arrhythmias in the postinfarcted canine heart

Recently, this laboratory has demonstrated an enhanced susceptibility toward the development of ischemia-related lethal ventricular arrhythmias in the presence of therapeutic serum concentrations of digoxin in conscious dogs after myocardial infarction. The present study was performed to assess the effect of the interruption of cardiac sympathetic influences, via subacute left stellate ganglionectomy (LSGX), on digitalis-mediated ischemic ventricular arrhythmias. Commencing 4-5 days after anterior myocardial infarction, 11 dogs with LSGX and 14 sham controls were administered digoxin (0.0125 mg/kg/day i.v.) for 5-7 consecutive days. At baseline testing, programmed ventricular stimulation failed to initiate ventricular tachycardia in any postinfarction dog entered into this evaluation. After treatment, 11/11 digoxin + LSGX (1.33 +/- 0.10 ng/ml serum digoxin) and 14/14 digoxin-treated sham (1.23 +/- 0.14 ng/ml serum digoxin) dogs remained nonresponsive to programmed stimulation testing. The incidence of arrhythmic mortality in response to subsequent ischemia at a site remote from the infarcted anterior region was greater in the digoxin-treated sham group (1.22 +/- 0.21 ng/ml serum digoxin) than in the digoxin + LSGX group (1.33 +/- 0.10 ng/ml serum digoxin); mortality was 6/10 (60%) digoxin sham vs. 1/10 (10%) digoxin + LSGX, p less than 0.005. The underlying anterior myocardial infarct sizes (% of left ventricle: 6.8 +/- 2.3 vs. 6.6 +/- 1.1) did not differ between the digoxin sham and digoxin + LSGX groups. However, the digoxin sham controls developed larger posterolateral myocardial infarctions than did the digoxin + LSGX animals (% of left ventricle: 27.4 +/- 3.0 vs. 16.7 +/- 2.7, p less than 0.05). Norepinephrine concentrations in posterolateral through posteroseptal ventricular sections were not altered by LSGX in a separate group of digoxin-treated postinfarct dogs. The results suggest that left stellate ganglionectomy may reduce the incidence of digitalis-mediated malignant ventricular arrhythmias during ischemia, possibly due to a reduction in the severity of ischemic injury.

Increase in experimental infarct size with digoxin in a canine model of myocardial ischemia-reperfusion injury

In the present study, dogs were pretreated with intravenous digoxin, 0.0125 mg/kg/day, for 6 to 7 consecutive days to achieve clinically relevant serum concentrations; untreated animals were used as control subjects. After pretreatment, nine digoxin-pretreated dogs and nine control dogs were anesthetized and subjected to a 60-minute occlusion of the left circumflex coronary artery, followed by 6 hours of reperfusion. Anatomic myocardial infarct size, expressed as a percentage of the areas at risk of infarction and as a percentage of the total left ventricle were: 20.2 +/- 3.3% control vs 35.4 +/- 6.2% digoxin-pretreated (p less than 0.05) and 8.6 +/- 1.3% control vs 14.7 +/- 2.5% digoxin-pretreated (p less than 0.05), respectively (2.04 +/- 0.37 ng/ml serum digoxin). Regional myocardial blood flow in the nonischemic and ischemic zones tended to be lower in digoxin-pretreated than in control animals at baseline testing and were significantly reduced in the anterior subendocardial sites of digoxin-pretreated dogs during ischemia and reperfusion. These data suggest that an exacerbation or enhancement of myocardial ischemia-reperfusion injury may occur in the presence of clinically observable serum digoxin concentrations.

Effect of digoxin on the extent of injury and the severity of arrhythmias during acute myocardial ischemia and infarction in the dog

Recently, this laboratory has demonstrated an enhanced susceptibility toward the development of lethal ventricular arrhythmias occurring in response to acute posterolateral ischemia in dogs with previous anterior myocardial infarction in the presence of therapeutic serum concentrations of digoxin. In the present study, acute posterolateral myocardial ischemia was produced in the absence of previous myocardial infarction in 15 digoxin-pretreated (1.19 +/- 0.21 ng/ml serum digoxin, 5-7 days pretreatment) and 11 vehicle-pretreated dogs. The incidences of sudden ventricular fibrillation and of 24 h arrhythmic mortality in response to posterolateral ischemia were 4/15 (27%) vs. 1/11 (9%) (p = 0.23) and 7/15 (47%) vs. 4/11 (36%) (p = 0.27) for digoxin- vs. vehicle-pretreated dogs, respectively. Ventricular ectopic activity at 24 and 48 h after the onset of posterolateral ischemia was reduced significantly by both intravenous lidocaine (1.0-5.0 mg/kg) and verapamil (50.0-500.0 micrograms/kg) in the vehicle-pretreated dogs, whereas neither antiarrhythmic agent significantly suppressed ventricular ectopy in the digoxin-pretreated dogs. The mean sizes for developing posterolateral myocardial infarctions (percentage of left ventricle) were greater for the digoxin-pretreatment group (31.9 +/- 2.8%) vs. vehicle-pretreatment group (14.8 +/- 2.0%, p less than 0.001). These findings suggest that uncomplicated acute myocardial ischemia in the presence of serum concentrations of digoxin that are considered clinically therapeutic may result in the development of larger areas of developing myocardial infarction and in the occurrence of ventricular arrhythmias that are less sensitive to suppression with conventional antiarrhythmic agents.

(Pyridoxylated hemoglobin)-(polyoxyethylene) conjugate solution as blood substitute for normothermic whole body rinse-out

In order to investigate a new possibility for artificial blood with oxygen-carrying capability to be applied to other than mere supplementation, normothermic whole body rinse-out in which artificial blood deriving from perfluorochemical emulsion, Fluosol-DA 20% (Green Cross Co., Ltd., Osaka, Japan) or stabilized hemoglobin solution, (pyridoxylated hemoglobin)-(polyoxyethylene) conjugate solution (Ajinomoto Co., Ltd., Tokyo, Japan) were used as rinsing fluid for a blood purification experiment. Replacement either with approximately 150 ml/kg of Fluosol-DA or stabilized hemoglobin solution showed effective removal of digoxin at a reduction rate of 96.3% or 92.2%, respectively. However, when Fluosol-DA was used, a certain amount of perfluorochemical should be retrieved by centrifugation to avoid a possible toxic effect on the reticulo-endothelial system. Even though 3 out of 6, and 3 out of 8 dogs, respectively, survived for a long period after the procedure, the experimental dogs were very susceptible to infection.

Digoxin-induced cardiac toxicity in the anaesthetized guinea-pigs and effect of heparin infusion

We have examined the effects of heparin infusion on the arrhythmias induced by digoxin. Digoxin treatment consisted of 0.6 mg kg-1 given i.v. 15 min after the beginning of heparin infusion. Heparin infusions (1.7 IU, 3.4 IU and 6.8 IU kg-1 min-1) were begun 15 min before digoxin injection and continued for another 30 min. ECG, blood pressure, heart rate and arrhythmias were recorded starting 15 min before and continuing for 60 min after the digoxin injection. Heparin at the infusion rates of 3.4 IU and 6.8 IU kg-1.min-1 reduced significantly the arrhythmia scores. On the other hand, heparin did not significantly alter the arterial blood pressure and heart rate values affected by digoxin.

Triggered activity induced by pacing during digitalis intoxication: observations during programmed electrical stimulation in the conscious dog with chronic complete atrioventricular block

In isolated Purkinje fibers, digitalis intoxication induces triggered activity, which is based upon delayed afterdepolarizations. The characteristics of delayed afterdepolarizations have been studied systematically by programmed electrical stimulation. The present investigations were done to study the role of triggered activity during digitalis intoxication in the intact heart. For this purpose, a pacing protocol, similar to that used in experiments of isolated Purkinje fibers, was used. The experiments were done on conscious dogs with chronic complete atrioventricular block. Ventricular tachycardia was induced with digoxin IV 0.1 mg/kg/1-1 1/2 hr. The effect of programmed electrical stimulation on the first post-pacing interval was determined during sustained ventricular tachycardia and, following its spontaneous termination during an episode when ectopic activity could only be induced by pacing. During sustained ventricular tachycardia there was a direct linear relation between the interstimulus interval of regular pacing and the first post-pacing interval. During the episode when ectopic activity could only be induced by pacing, shortening of the post-pacing interval resulted in biphasic behavior of the first post-pacing interval. Pacing with interstimulus intervals of more than 400 ms induced a first post-pacing interval equal to the interstimulus interval, whereas shorter interstimulus intervals induced a first post-pacing interval twice the interstimulus interval. When during regular pacing only the last pacing interval was changed, a similar biphasic response resulted. When toxicity had almost subsided, ectopic activity could only be induced following short pacing intervals (200-320 ms). Again, a direct linear relation was found between the pacing interval and the first post-pacing interval. Our findings strongly suggest that at different levels of digitalis intoxication triggered activity is the underlying mechanism for the first post-pacing QRS complex.

[Effect of strophanthin and digoxin on the activity of an experimental epileptogenic focus in the frog hippocampus]

It has been shown on frogs with epileptogenic focus induced by the injection of penicillin (1000 U in 0.4 ml) into the hippocamp that preinjection (or injection on the background of the functioning epileptogenic focus) of strophanthin (1.8 and 0.18 microgram/g) or digoxin (1.2 micrograms/g) into spinal lymphaticus sac led to a sharp increase in interparoxysmal epileptiform discharges and electrographic correlates of fits on the ECG. The influence of cardiac glycosides upon the epileptized cerebral neurons is thought to be associated with the capacity of these drugs to inhibit Na+, K+-ATPase of neurons and their axons resulting in the disturbance of cerebral mediator activity.

Reversal of toxic and non-toxic effects of digoxin by digoxin-specific Fab fragments in isolated human ventricular myocardium

The time course of the reversal of toxic and nontoxic effects of digoxin by digoxin-specific antibody fragments (Fab) was measured in isolated human ventricular myocardium. A concentration of 2 X 10(-6) mol/l digoxin was used to produce positive inotropy followed by mechanical signs of toxicity. After addition of a 1.5-fold higher molar concentration of digoxin-specific Fab, signs of toxicity disappeared within 30 min and digoxin-induced force of contraction decayed with a monoexponential time course with a half-life of 52 min. This rate of decay was almost identical to that observed for the dissociation of the digoxin-(Na+ + K+)-ATPase complex in human heart cell membranes. It is concluded that digoxin-specific Fab are capable of completely removing digoxin from its binding sites, the maximal rate of removal of digitalis glycosides from the (Na+ + K+)-ATPase is limited by the dissociation rate constant, and there is a close correlation between the degree of binding of digitalis glycosides to the (Na+ + K+)-ATPase and the increase in force of contraction.

Toxic neuropsychiatric effects of digoxin at therapeutic serum concentrations

Serum digoxin concentrations can mislead psychiatric consultants. Two patients with therapeutic digoxin concentrations were seen for neuropsychiatric disorders that cleared rapidly once digoxin was discontinued.

Central dopamine receptors and their role in digoxin-induced cardiotoxicity in the dog

The role of the dopaminergic system in digoxin-induced cardiotoxicity has been examined. Specific dopaminergic agonists and antagonists were administered into the ventriculocisternal system of pentobarbitone-anaesthetized dogs before systemic administration of digoxin. Pretreatment with apomorphine, a specific dopamine agonist, did not significantly alter the arrhythmogenic or lethal doses of digoxin. However, the digoxin-induce increase in CSF noradrenaline was decreased significantly in apomorphine-pretreated animals. Pretreatment with pimozide, a specific dopamine antagonist, significantly decreased the arrhythmogenic dose of digoxin but did not alter the lethal dose. As with apomorphine, pimozide-pretreated animals accumulated significantly less noradrenaline in CSF compared with control dogs. These results suggest that dopamine receptors are not directly related to the cardiotoxic actions of digoxin. However, dopaminergic receptors may influence the balance of central catecholaminergic systems that influence the peripheral cardiovascular system.

Antiarrhythmic effect of amperozide, a novel psychotropic compound with class III antiarrhythmic properties, on digoxin-induced arrhythmias in the guinea-pig

Amperozide is a novel psychotropic compound with specific effect in limbic brain areas. Preliminary findings have also indicated an antiarrhythmic effect in-vitro. Injections of saline, amperozide, melperone, thioridazine, bretylium or lignocaine, were given i.p. to anaesthetized guinea-pigs, which 10 min later were given digoxin s.c. to induce arrhythmia. In a series of control experiments none of these compounds caused arrhythmia in combination with the vehicle of digoxin. The time to arrhythmia was significantly prolonged after treatment with amperozide, melperone and bretylium compared with saline, but there were no differences between the treatments. The digoxin concentrations in plasma at death varied considerably within the groups and no statistical significance was found.

The effect of digoxin-specific active immunization on digoxin toxicity and distribution in the guinea-pig

In guinea-pigs intravenously infused with digoxin, prior immunization using a digoxin-human serum albumin conjugate increased by 3- and 2.4-fold, respectively, the digoxin doses causing the first signs of cardiotoxicity and death. At death, serum digoxin concentration was four times higher in immunized than in control animals. In the immunized guinea-pigs 50% of the serum digoxin was protein bound, presumably mainly to digoxin-specific antibodies, since in the controls the bound fraction was only 1-2%. Generally, tissue digoxin concentrations were not increased to the same extent as the lethal dose, and in the heart and lungs the increase was not significant. With cardiac (ventricle) subcellular fractions, there was no difference between control and immunized animals in the digoxin concentration of the 'microsomal' pellet. This subfraction contains the plasma membrane and the associated sodium pumps which are considered to be the sites at which the pharmacologically active digoxin binds. It seems likely, therefore, that the greater digoxin resistance in the immunized animals can be explained on the basis of reduced drug access to the site of action within the heart.

Facilitation of lethal ventricular arrhythmias by therapeutic digoxin in conscious post infarction dogs

The proarrhythmic potential of digoxin, administered in a therapeutic dosage regimen, was evaluated in conscious dogs in the subacute phase of myocardial infarction. In this evaluation, digoxin (0.0125 mg/kg/day intravenously) or vehicle were administered to conscious dogs for periods of 5 to 7 days, commencing 4 to 5 days after anterior myocardial infarction. Before treatment, programmed ventricular stimulation failed to initiate ventricular tachycardia in 26 post infarction dogs. After treatment, programmed stimulation initiated ventricular tachyarrhythmias in only 1 of 13 digoxin-treated dogs (1.36 +/- 0.17 ng/ml serum digoxin) and in 0 of 13 vehicle-treated dogs. However, the incidences of early ventricular fibrilation (4 of 10 digoxin vs 0 of 12 vehicle; p less than 0.05) and of 24-hour mortality (6 of 10 digoxin vs 2 of 12 vehicle; p less than 0.05) occurring in response to the development of posterolateral ischemia in the presence of previous anterior myocardial infarction was significantly greater in digoxin-treated (1.47 +/- 0.19 ng/ml serum digoxin) than in vehicle-treated animals. These findings suggest an enhanced susceptibility toward the development of ischemia-related lethal arrhythmias in the presence of therapeutic digoxin serum concentrations early after myocardial infarction, which is not predicted by programmed ventricular stimulation testing.

Digitalis and other positive catecholamine-like inotropic agents in the management of congestive heart failure

Positive inotropic agents are used to improve the impaired cardiac contractility that characterizes chronic heart failure. Digitalis is the traditional drug given for this purpose. However, there is controversy about the effectiveness of digitalis in chronic heart failure. Analysis of the available data indicates the efficacy of digoxin in mild heart failure (i.e., New York Heart Association functional classes I and II) and the relative lack of efficacy in advanced heart failure (i.e., NYHA functional class IV). Further, digoxin can be stopped in a substantial number of patients without recurrence of congestive heart failure. In selected patients whose condition no longer responds to digoxin, the long-term administration of dobutamine may be an effective alternative approach.

In vivo diagnostic and therapeutic uses of monoclonal antibodies in cardiology

Antibodies, long used as discriminating tools in immunoassay, are now being used in vivo, both in diagnosis and therapy. In cardiovascular medicine, applications that have reached the stage of clinical trial include the reversal of digitalis intoxication by digoxin-specific antibodies and the imaging of cardiac necrosis with monoclonal myosin-specific antibodies. An exciting future prospect, still in an early experimental stage, is the application of fibrin-specific monoclonal antibodies to both the visualization of thrombi and emboli and the targeting of fibrinolytic agents.

Effect of acute and chronic exposure to heat on pharmacokinetic parameters of digoxin in rats

Digoxin pharmacokinetic parameters in acute heat-exposed male rats (AHE) maintained for 3 hours at 35 degrees C, and chronic heat-exposed rats (CHE) maintained at 35 degrees C for 4 weeks, were compared to control rats (C) maintained at 22 degrees C. Digoxin concentration in the plasma was measured by radioimmunoassay which gave values similar to thin layer chromatography method. The half life time of digoxin during the elimination phase of the drug (t 1/2 beta) was similar in all three experimental groups (2.8; 2.7; 3.0 hrs) while the values obtained by extrapolation of digoxin plasma concentration to zero time (CpO) was 40% higher in AHE rats and 375% higher in CHE rats than in C rats. The apparent distribution volume of the drug (Vapr) was 40% lower in AHE rats and 80% lower in CHE rats as compared to C rats.

Digitalis toxicity at Duke Hospital, 1973 to 1984

In a review of the records of 81 patients with the discharge diagnosis of digitalis toxicity, I found a preponderance of very old patients, many of whom had anorexia, nausea, and prerenal azotemia. Arrhythmias were common (93%) and reflected enhanced automaticity, enhanced AV block, or both. Atrial fibrillation with complete heart block and a regular junctional rhythm should particularly elicit suspicion of digitalis toxicity. Atrial tachycardia with block is less specific and less frequent.

The effects of central beta-receptor antagonism on digoxin cardiotoxicity

Pentobarbital-anesthetized dogs were pretreated centrally with either metoprolol, a selective beta1 antagonist, or ICI 118,551, a selective beta2 antagonist, prior to a continuous digoxin infusion (2.5 micrograms/kg/min, i.v.). Both agents produced depressant effects on hemodynamic parameters upon central administration. Metoprolol (1, 3 and 5 mg, i.c.v.) significantly increased the lethal dose of digoxin in a non-dose dependent manner, but these protective effects were not evident upon peripheral administration of the drug (5 mg). This protective effect was not due to local anesthetic properties of metoprolol since pretreatment with lidocaine did not alter the toxicity of digoxin. Central beta2 blockade by ICI 118,551 did not alter the doses of digoxin to ventricular arrhythmias or death. These results suggest that beta receptors are not directly involved in the cardiotoxic actions of digoxin. Metoprolol's effects may be attributed to non-specific central depressant activity.

Digoxin and the susceptibility of the canine heart to countershock-induced arrhythmia

This study investigated the effects of therapeutic and subtoxic doses of digoxin on the risk of ventricular tachycardia (VT) after graded, transthoracic shocks in anesthetized dogs. A series of direct current shocks (5, 10, 25, 50, 75, 100, 150 and 200 J) was delivered to 33 normal dogs and 6 dogs with a healed (32 +/- 7 days) myocardial infarct (MI). In 10 untreated dogs, the duration of post-shock VT was highly reproducible when 3 separate series of shocks were delivered at 2-hour intervals. In 6 normal dogs treated with oral digoxin (0.5 mg/day for 5 to 7 days), a series of shocks delivered before and during treatment (serum levels 1.5 +/- 0.5 ng/ml) resulted in the same duration of post-shock VT. In 18 normal and 6 dogs with MI, a series of shocks was given before and 90 minutes after a therapeutic dose of digoxin (0.05 mg/kg intravenously). At this dose of digitalis (serum level 2.5 +/- 1.0 ng/ml), there was no difference in the duration of post-shock VT in either normal dogs or dogs with MI. A third series of shocks was given after achieving subtoxic digitalization with additional intravenous digoxin (0.01 mg/kg) every 30 minutes until a premature ventricular stimulus evoked a repetitive ventricular response. The subtoxic doses of digitalis (serum levels 13.9 +/- 4.7 ng/ml) increased the duration of post-shock VT in both normal dogs (100%) and dogs with MI (700%) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Tests for local toxicity of intramuscular drug preparations: comparison of in vivo and in vitro methods

Different concentrations of aqueous preparations of metoclopramide, gaboxadol, cis(Z)-clopenthixol, digoxin and chlorpromazine and of cis(Z)-clopenthixol acetate in Viscoleo have been tested for local toxicity after intramuscular injection in rabbits. The weight of macroscopically changed muscle tissue isolated 3 days after injection was determined. In addition, homogenized injection site muscle tissue was analysed for creatine kinase (CK) activity and by comparison with the CK activity of contralateral muscle tissue, the amount of injection site muscle tissue totally depleted for CK activity was calculated. The substances have also been tested for in vitro toxicity. The concentrations of the substances which caused 100% haemolysis of human erythrocytes or minimal cytotoxicity in cell culture assays using MRC-5 fibroblasts were estimated. Metoclopramide and gaboxadol caused no or only minimal local muscle damage in the rabbits. Metoclopramide caused local bleeding. The four other substances caused concentration-dependent muscle damage. Although there was some deviations, the two in vitro tests reflected reasonably well the in vivo findings. The results of this study suggest that the in vitro tests employed can be useful as screening tests for local toxic effect of intramuscular drug preparations. However, further studies are required before conclusion as to predictability can be drawn. The in vitro methods are inexpensive and quick, especially the haemolysis test.

The influence of digoxin antibodies on digoxin disposition and effect: studies in guinea-pigs and HeLa cells

Pretreatment of guinea-pigs with digoxin-specific Fab (fragment antigen binding) fragments reduced the cardiotoxicity of intravenously infused digoxin (the lethal doses in Fab-treated and control animals were 1.0 and 0.6 mgkg-1, respectively). At death the serum digoxin concentration was elevated 2 fold in the Fab-treated animals, while the tissue concentrations were generally lower. The 30-40% lower cardiac digoxin concentration (seen in whole homogenate and throughout the subcellular fractions examined) was surprising; presumably this reflects a difference from the controls in the proportion of pharmacologically active/inactive digoxin in this organ. Adding digoxin-specific immunoglobulin G or the Fab fragments to HeLa cells before incubation with digoxin, reduced specific digoxin binding (Na pump-bound) slightly more than the non-specific binding. Adding specific antibody after digoxin, however, did not reduce digoxin binding or effect a recovery in Na pump activity. It seems that the protective effect of digoxin-specific antibodies seen in the guinea-pig can to some extent be simulated using HeLa cells. However, this is apparently not so regarding the widely-reported ability of these antibodies to reverse the action of digoxin.

Effects of myocardial hypoxia on digitalis-induced toxicity in the isolated heart of guinea pigs and cats

The effects of hypoxia on the tolerance of myocardium to the toxic actions of digitalis were studied in isolated heart muscle preparations. Perfusion of Langendorff preparations of guinea-pig heart with a hypoxic solution failed to alter Na, K-ATPase with respect to its activity, its sensitivity to inhibition by dihydrodigoxin, or the number of [3H]ouabain binding sites and their affinity for ouabain, when these activities were estimated in ventricular muscle homogenates obtained after the hypoxic perfusion. Hypoxia potentiated the development of digoxin-induced contracture, as well as digoxin-induced changes in maximal upstroke velocity and the amplitude of action potentials, and the resting transmembrane potential in atrial and ventricular muscle preparations of guinea-pig heart. Under hypoxic conditions, however, digoxin failed to induce arrhythmias. In Purkinje fibers of cat heart, the time to onset of digoxin-induced arrhythmias, or the development of afterdepolarizations, was not affected by hypoxia. These results indicate that hypoxia alters the nature of toxic effects of digitalis in isolated heart muscle preparations, the development of contracture instead of arrhythmias being the primary toxicity in hypoxic muscle.

Reversal of lethal digoxin toxicity in guinea pigs using monoclonal antibodies and Fab fragments

To extend the potential application of digoxin-specific immunoglobulin (Ig) (Fab) fragments for the reversal of advanced digitalis intoxication, monoclonal digoxin-specific antibodies were obtained by fusion of myeloma cell lines with spleen cells from mice immunized with a digoxin-serum albumin conjugate. The monoclonal antibody from the cell line designated Dig 26-10 had high affinity (KA = 5 X 10(9) M-1) and specificity for digoxin and was tested for its efficacy in the reversal of advanced, otherwise lethal digoxin toxicity in guinea pigs given a loading dose of 500 micrograms of digoxin per kg b.wt. i.v. followed by continuous infusion of digoxin at 10 (IgG-treated group) or 50 (Fab-treated group) microgram/kg/min. Control animals given nonspecific rabbit or mouse Igs after the onset of digoxin-toxic ventricular arrhythmias all died. Administration of monoclonal digoxin-specific antibody as intact IgG in doses stoichiometrically equivalent to the digoxin dose fully reversed digoxin toxicity in six of eight animals and prolonged survival somewhat in the remaining two animals. Fab fragments from the Dig 26-10 monoclonal antibody were even more effective, with rapid reversal (mean time 7 min) of all arrhythmias and survival of all animals so treated. We conclude that murine monoclonal antibodies and their Fab fragments are capable of reversing advanced and otherwise lethal digoxin-induced arrhythmias in a guinea-pig experimental model and offer potential advantages over polyclonal antibodies in the management of this clinically important problem.

Role of sympathetic nervous system in ischemia-induced reduction of digoxin tolerance in anesthetized cats

Acute myocardial ischemia reduces tolerance of the heart to arrhythmogenic actions of digitalis glycosides. Because both ischemia and the glycoside produce profound changes in activity of the autonomic nervous system and because sympathetic discharge or catecholamines enhance toxic actions of the cardiac glycosides, the possibility that alterations in digitalis sensitivity of ischemic heart involve changes in sympathetic nerve activity was examined using alpha-chloralose-anesthetized cats. Left anterior descending coronary artery (LAD) was completely occluded by ligation and, 40 min later, a slow i.v. infusion of digoxin was started at a rate of 1 microgram/kg/min. LAD ligation alone did not produce arrhythmias in that condition, but shortened the time to onset of digoxin-induced arrhythmias and thereby reduced the amount of digoxin required to produce the toxic manifestation. Concomitantly, digoxin concentration in plasma and nonischemic areas of the heart were lower in LAD-ligated cats at the onset of arrhythmias than those in sham-operated cats. Myocardial digoxin content in the ischemic area of the LAD-occluded heart was lower than that in nonischemic areas of the same heart. At the onset of digoxin-induced arrhythmias, Na,K-adenosine triphosphatase activity of ischemic myocardium was significantly higher than that in the nonischemic area, reflecting a lower digoxin occupancy of the glycoside binding sites on the sodium pump. Spinal cord (C1) transection or propranolol treatment prolonged the time to arrhythmias in both control and LAD-ligated cats, but failed to abolish the effect of LAD ligation to augment digoxin toxicity. Bilateral vagotomy also did not alter the enhancement of digoxin toxicity caused by ligation of LAD.(ABSTRACT TRUNCATED AT 250 WORDS)

Protective effects of Na salicylate against digoxin- and BaCl2-induced arrhythmias in guinea-pigs

In pentobarbital-anaesthetized (60 mg/kg i.p.) guinea-pigs injections of Na salicylate (50 and 100 mg/kg i.v.) had a protective effect against arrhythmias induced by digoxin or BaCl2. A lower (25 mg/kg) and a higher (200 mg/kg) dose exerted no clearcut antiarrhythmic effect. Plasma concentrations of Na salicylate up to 1 mg/ml influenced neither the heart rate nor the ECG parameters. The antiarrhythmic effect of the drug may be explained by an inhibition of cardiac cyclooxygenase.

Specific removal of digoxin by hemoperfusion through agarose polyacrolein microsphere polyacrolein microsphere beads-antidigoxin antibodies (APAMB-AD)

The efficacy of a new, biocompatible, specific immunosorbent for hemoperfusive removal of digoxin is described. The sorbent contains antidigoxin antibodies covalently bound to polyacrolein microspheres, 0.2 mu diam. Thousands of microspheres are matrix-encapsulated in crosslinked agarose to form beads of 500 to 800 mu diam. Digoxin intoxicated dogs showed heart block, ventricular and atrial tachycardia and extended runs of PVCs. During hemoperfusion the abnormal ECG abated; at 2 h of hemoperfusion the ECG tracings returned to normal. Up to 25% of the total digoxin burden was removed. The numbers of the blood cells and the content of a battery of relevant soluble components of the blood remained constant. Dogs were alive and well after the hemoperfusion. Non hemoperfused dogs, which received antiarrythmic agents, did not survive the intoxication. This is the first report of a practical hemoperfusive system for the specific removal of digoxin from whole blood.

Central alpha receptors and their role in digoxin cardiotoxicity

The purpose of this study was to determine the role of alpha receptors in the inotropic and cardiotoxic actions of digoxin. Pentobarbital-anesthetized dogs were pretreated centrally with either prazosin, a selective alpha-1 antagonist, or yohimbine, a selective alpha-2 antagonist. Cardiac rhythm, blood pressure and contractile force were monitored during a 60-min period after pretreatment and during a continuous i.v. infusion of digoxin (2.5 micrograms/kg/min). Both agents, when administered into the lateral ventricle, produced depressant effects on hemodynamic parameters. Yohimbine (100 and 200 micrograms/kg i.c.v.) significantly increased the arrhythmogenic and lethal doses of digoxin in a dose-dependent manner. The protective effects of yohimbine (200 micrograms/kg) were not evident when the drug was given peripherally. Central alpha-1 blockade with prazosin increased the lethal dose of digoxin only at the largest dose (100 micrograms/kg i.c.v.) and its effects may be attributed to nonspecific central activity. BHT-933 (5 micrograms/kg i.c.v.), a selective alpha-2 agonist, enhanced the toxic effects of digoxin by decreasing both the arrhythmogenic and lethal dose of digoxin. These results suggest a central alpha-2 receptor mediation of the cardiotoxic actions of digoxin.

Effect of quinidine on differing sensitivities of Purkinje fibers and myocardium to inhibition of monovalent cation transport by digitalis in dogs

Studies have implicated quinidine in increasing serum digoxin levels, resulting in serious arrhythmias. Arrhythmias caused by digitalis intoxication are thought to originate in Purkinje fibers. Thus, the extent of inhibition of monovalent cation-active transport in Purkinje fibers and myocardium may explain the enhanced toxicity of the combined administration of digoxin and quinidine. Monovalent cation transport was assessed by measuring the uptake of the potassium analog rubidium in samples of myocardium and Purkinje fibers after in vitro exposure to ouabain and after long-term administration of digoxin and quinidine or digoxin alone. A group of dogs received chronic digoxin administration and achieved a steady-stage digoxin administration and achieved a steady-stage digoxin level of 2.1 +/- 0.3 ng/ml. Quinidine administered intravenously caused a 134% increase in the serum digoxin level. The transport in myocardium was unchanged, while it was reduced to 40% of control levels in Purkinje fibers. The difference in sensitivity between Purkinje fibers and myocardium may explain the finding that digitalis-toxic arrhythmias arise in Purkinje fibers and that quinidine, when combined with digitalis, increases the incidence of such arrhythmias.

Comparison of digoxin-induced cardiac toxicity in resistant and sensitive species

We have examined the species-specific arrhythmogenic effects of digoxin in the rat (resistant species) and in the guinea-pig (sensitive species). 26 adult rats and 23 adult guinea-pigs were anaesthetized with pentobarbitone and injected subcutaneously with varying doses of digoxin. Electrocardiograms were monitored continuously for 4 1/2 h following digoxin administration. The arrhythmogenic dose (AD50) and lethal dose 50 under anaesthesia (LD50) were determined using the method of Litchfield & Wilcoxin. AD50 in rats was 13.0 +/- 1.0 mg kg-1 (mean +/- s.d.) compared with 0.60 +/- 0.04 (P less than 0.01) in the guinea-pig and LD50 was 30.0 +/- 1.9 mg kg-1 in the rat compared with 0.60 +/- 0.04 (P less than 0.01) in the guinea-pig. The onset of arrhythmias was not dose-dependent in the rat but was clearly so in the guinea-pig; for example 102 +/- 15 min (mean +/- s.e.m.) following 0.5 mg kg-1, and 43 +/- 2 min following 1 mg kg-1. In the rat the onset of arrhythmias was 54.0 +/- 11.5 min. Supraventricular arrhythmias (paroxysmal atrial tachycardia) appeared in 73% of rats compared with only 18% of guinea-pigs whereas ventricular arrhythmias (ventricular tachycardia), multiple premature ventricular contractions and or multifocal PVC's occurred in 100% of guinea-pigs compared with only 32% of rats. All guinea-pigs that developed arrhythmias died whereas several rats recovered from supraventricular tachycardias. In conclusion, the guinea-pig is much more sensitive to digoxin toxicity than the rat, develops arrhythmias at much lower doses and these arrhythmias are much more likely to be ventricular in origin and cause fatality.

Digoxin-induced toxicity and experimental atrioventricular block in dogs. Relation between ventricular arrhythmias and oscillatory afterpotentials

In anesthetized dogs, digoxin intoxication was performed after and before production of a definitive complete atrioventricular (A-V) block induced by formaldehyde injection in A-V node area, compared to intoxication in dogs in sinus or junctional rhythm. The results showed that digoxin toxicity was decreased in dogs with previous A-V block. This A-V block protective effect was abolished by resetting initial sinus-like frequency with ventricular pacing before digoxin administration. Ventricular arrhythmias were suppressed by production of complete A-V block. The A-V block protective effect can be explained by a lesser myocardial uptake of digoxin because of the low idioventricular frequency. However, ventricular arrhythmias in dogs with A-V block presented similarities both in occurrence and spreading with the development of oscillatory afterpotentials (OAPs) and rhythmical triggered activity demonstrated in isolated digitalis-poisoned Purkinje fibers and ventricular myocardium: the repetitive discharge of toxic foci masked normal idioventricular pacemakers and was interrupted by variable pauses followed by the resumption of either a very slow idioventricular rhythm or a toxic focus. It is suggested that because of the low idioventricular frequency, competition and/or superimposition of slow enhanced diastolic depolarization and OAPs can be electrocardiographically displayed. The terminal event was asystole in dogs with unpaced A-V block, and ventricular fibrillation in dogs with sinus, junctional and paced A-V block rhythms. The asystole (at least 30 seconds of electrical quiescence) may be explained partly as an intense depression of normal idioventricular pacemaker being overdriven by the discharge of toxic pacemakers, and partly as a consequence of the suppression of local autonomic influences in the A-V node area induced by the formaldehyde injection.