Digitoxin intoxication with severe thrombocytopenia: reversal by digoxin-specific antibodies

As a result of overdosage a 77-year-old patient with heart disease developed digitoxin intoxication, associated with arrhythmias, extracardiac symptoms of intoxication and severe thrombocytopenia. Treatment with digoxin-specific antibody fragments relieved the signs and symptoms of intoxication within a few hours. The rise in platelet count from the pretreatment value of 26 000/mm3 to 47 000 within 12 h and to over 60 000/mm3 within 16 h of starting the antibody infusion may also be attributed to the treatment with antibodies. Such a rapid recovery from digitoxin-induced thrombocytopenia has not hitherto been described. Digoxin-specific antibodies, obtained by immunization of sheep with a digoxin-albumin conjugate, were used to treat intoxication with digitoxin, since cross-reaction had been demonstrated in vitro and in animal experiments. The present paper briefly discusses the mode of action and the general problems relating to the antibody therapy of digitalis poisoning.

Amino acid sequence of the light chain variable region from a mouse anti-digoxin hybridoma antibody

A hybridoma cell line (26-10) derived from the A/J strain of mice secretes an immunoglobulin (IgG2a-k) which binds digoxin with an association constant of 1.2 nM. Such high-affinity antibodies have been utilized in clinical radioimmunoassays as well as in the reversal of toxicity due to excess digoxin. The amino acid sequence of the light chain variable region of this antibody was derived by automated sequencing of the following: the intact chain; a fragment beginning C terminal to the tryptophan residue 40, obtained by cleavage with iodosobenzoic acid; a fragment beginning C terminal to arginine residue 82, obtained by trypsin cleavage on the completely reduced, alkylated, and succinylated chain. Difficulties which had previously prevented the automated Edman sequencing of this chain (and, presumably, similar ones of the same subgroup) were overcome by increasing the duration of the cleavage step at proline residues 8 and 12. The sequences of the first two hypervariable and framework regions of this chain are virtually identical with those of the dinitrophenol- and menadione-binding myeloma light chain MOPC 460 (95% homology). This anti-digoxin hybridoma from the A/J strain makes use of a Vk gene which is similar to that utilized by some BALB/c 2,4-dinitrophenol-binding myelomas.

Monoclonal antibodies to drugs--digoxin

A number of monoclonal antibodies to digoxin, two of which have been further characterized, were produced by somatic cell fusion. No cross reactivity with chemically related drugs was detected. Preliminary in vivo studies showed altered digoxin pharmacokinetics in antibody treated mice. These monoclonal antibodies could be used for a standardized radioimmunoassay and in the treatment of digoxin toxicity.

[Digitoxin poisoning: reversing ventricular fibrillation with Fab fragments of anti-digoxin antibody]

Purified Fab fragments of ovine anti-digoxin antibodies (Wellcome Foundation) were used to treat a patient who attempted suicide by absorbing 10 mg of digitoxin (serum concentration 265 micrograms/l). The poor prognosis, as assessed clinically and from serum potassium levels (7.5 mEq/l), seemed to warrant such a treatment. The weak (6.85%) cross-reactivity elicited in vitro between the anti-digoxin antibodies and digitoxin was compensated by increasing the doses, but improvement was observed with 3.6 g, i.e. about half the effective dosage initially considered. The criteria of effectiveness were clinical, electrocardiographic (reversal of the ventricular fibrillation), biochemical (simultaneous and opposite changes in extra- and intracellular potassium levels, suggesting that ATPase inhibition by digitalis is a reversible process) and toxicological: there was an increase in digitoxin serum levels suggesting displacement of the drug from tissue sites to plasma and other extracellular compartments where the Fab fragments are distributed, and Fab-bound digitoxin appeared fairly rapidly in the urine, which suggested shunting of the normal hepatic metabolic pathway.

Treatment of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments: experience in 26 cases

Purified Fab fragments of digoxin-specific antibodies obtained from sheep were used to treat 26 patients with advanced, life-threatening digoxin (23 cases) or digitoxin (3 cases) toxicity. These patients had advanced cardiac arrhythmias, and in some cases hyperkalemia, which were resistant to conventional treatment. All patients had an initial favorable response to doses of Fab fragments calculated (in most cases) to be equivalent, on a molar basis, to the amount of cardiac glycoside in the patient's body. In four patients treated after prolonged hypotension and low cardiac output, death ensued from cerebral or myocardial hypoperfusion. In one case the available Fab fragment supply was inadequate to reverse a massive suicidal ingestion of digoxin, and the patient died after recurrent ventricular arrhythmias. In the remaining 21 patients, cardiac rhythm disturbances and hyperkalemia were rapidly reversed, and full recovery ensued. There were no adverse reactions to the treatment. We conclude that the use of purified digoxin-specific Fab fragments is a safe and effective means to reverse advanced, life-threatening digitalis intoxication.

Digoxin-like natriuretic activity in the urine of salt loaded healthy subjects

In previous studies we have demonstrated a natriuretic factor of small molecular weight (less than 1,000 Daltons) in the serum and urine of salt loaded subjects. This factor isolated from salt loaded animals inhibits the Na-K-ATPase enzyme system. In addition, the natriuretic material isolated from plasma of salt-loaded dogs was shown to bind to specific digoxin antibodies. It was therefore suggested that a digitalis-like endogenous natriuretic factor (endoxin) is released in response to saline loading. In the present study we therefore investigated the presence of such an endogenous natriuretic digitalis-like activity in the urine of healthy volunteers during high salt intake. Using Sephadex G-25 for chromatographic separation of urine a material elutes as a single peak in the natriuretic post-salt fraction IV which is specifically bound to digoxin antiserum complex. Mean peak activity amounted to 1.55 +/- 0.48 ng/ml digoxin equivalents. We further purified the natriuretic material by immunoprecipitation with the digoxin antiserum complex. This purification procedure resulted in a more than 10-fold increase in specific natriuretic activity from 2.7 +/- 0.4 to 30.4 +/- 5.8 muEq Na+ x min-1 x mg-1. Thus the digitalis-like natriuretic activity previously observed in the plasma of saline loaded dogs is also present in the urine of healthy subjects during high dietary salt intake. Immunoprecipitation may offer a meaningful tool for further isolation and identification of the natriuretic hormone(s).

Fab fragments of digoxin-specific antibodies used to reverse ventricular fibrillation induced by digoxin ingestion in a child

Digitalis poisoning is a rare problem in children, but it may be life threatening. A case of massive overdose of digoxin in a 2 1/2-year-old boy that produced prolonged ventricular fibrillation refractory to conventional therapy is reported. After two hours the boy was given digoxin-specific Fab fragments of antibody in sufficient quantity to bind his estimated dose of 10 mg. By completion of the treatment minutes later, normal rhythm and circulation were restored. The serum free digoxin level before antibody administration was greater than 100 ng/ml, and it rapidly fell to undetectable levels after antibody was given. Digoxin bound to the antibody had a clearance half-life of approximately 48 hours. The child had no apparent neurologic damage and his intellectual function was normal on discharge. He had a transient hematuria and a residual incomplete right bundle branch block. Administration of purified Fab fragments of digoxin-specific antibodies can be life saving in children with digitalis poisoning, and prolonged cardiopulmonary resuscitation in children is justified when the cause of cardiac arrest is potentially reversible.

Radial partition immunoassay

In radial partition immunoassay, radial chromatography is used for performing an immunoassay. We describe the application of this technology to the measurement of digoxin in serum by enzyme immunoassay, with the entire testing procedure carried out on glass-fiber filter paper. A sample is applied to a small central area of the filter paper, where it reacts with the antibody to digoxin immobilized there. Subsequently, enzyme-labeled digoxin is applied to react with remaining antibody sites. After incubation, substrate for the enzyme is applied to the center of the reaction area and washes out any unbound label to the periphery of the paper. This step also initiates the enzyme reaction, which is quantified by front-surface fluorescence. A microprocessor-controlled automated instrument has been developed to process the filter paper matrix through the above sequence, and calculate the final result. Total testing time for digoxin is less than 7 min.

Suicidal digoxin poisoning: conventional treatment and antibody therapy

A 66-year-old mand suffering from severe coronary heart disease took digoxin with suicidal intent an was treated for the ensuing complete atrioventricular block with digoxin-specific antibody fragments. Two and a half hours after intravenous infusion of the antibody fragments, the signs of intoxication passed off, and atrial fibrillation with a normal ventricular rate was reinstated. Antibody therapy is capable of permanently abolishing the signs of symptoms of digitalis poisoning after a matter of hours. Such a rapid or complete response cannot be achieved by any conventional form of treatment. This advantage must be weighed against the risks (immunologic reactions, loss of the therapeutic effect of the cardiac glycoside if an overdose of antibody is given). Moreover, antibody therapy does not take effect immediately, as is understandable in view of the mechanism of action. It should therefore be instituted in good time in potentially life-threatening cases of intoxication.

The development and application of a radioimmunoassay for dihydrodigoxin, a digoxin metabolite

The cardioinactive digoxin metabolite, dihydrodigoxin, has been conjugated to bovine serum albumin and to bovine pancreatic ribonuclease by the periodate oxidation method. Rabbits immunized with the dihydrodigoxin-bovine serum albumin conjugate formed antibodies which bound a radioiodinated dihydrodigoxin-ribonuclease conjugate. This binding was inhibited by dihydrodigoxin. After affinity chromatography on a digoxin-ribonuclease-Sephacryl immunoadsorbent to remove antibodies which cross-reacted with digoxin, dihydrodigoxin was 300 times more effective than digoxin in inhibiting the binding of tracer by antibody. Digoxin-absorbed antidihydrodigoxin antibodies were coupled to Sephacryl and were used to develop a solid-phase radioimmunoassay capable of detecting 250 to 500 pg of dihydrodigoxin in 1 ml of human serum or urine. This radioimmunoassay has been used to define the pharmacokinetics of the metabolite in four normal human volunteers who ingested 125 to 500 micrograms of dihydrodigoxin by mouth. Dihydrodigoxin was quickly absorbed, with maximal serum concentrations achieved within 45 to 105 min, followed by a rapid fall in serum immunoreactivity over 2 to 4 hr and then by a slower, more gradual decline. The terminal half-life (beta) in serum varied from 4.24 to 11.9 hr (mean +/- S.E. = 8.1 +/- 1.3 hr). Most of the administered dose was excreted in the urine, with cumulative urinary recovery varying inversely with the dose. Urinary half-lives averaged 13.8 +/- 2.1 hr, and renal clearance rates were similar to those of creatinine. Dihydrodigoxin is rapidly absorbed and excreted in man and appears to be eliminated from the body at a faster rate than digoxin.

Oleander interference in the digoxin radioimmunoassay in a fatal ingestion

An elderly woman allegedly ingested oleander leaves and died. Ventricular arrhythmias and asystole were unresponsive to cardiopulmonary resuscitation, pharmacologic agents, and cardioversion. The patient, who had no access to digoxin, had an initial serum digoxin concentration of 5.8 ng/mL. Cross-reactivities between oleander extract and pure oleandrin and digoxin in the digoxin radioimmunoassay were 100:1 and 29,000:1, respectively. We postulate that glycosides in oleander leaves produced the elevated serum digoxin concentration. Based on an assumed volume of distribution of the oleander glycosides of 1 L/kg, the calculated lethal dose absorbed by our patient was 200 times greater than lethal doses in several animal species and corresponded to the absorption of 4 g of oleander leaves.

Fluoroimmunoassay of digoxin in serum

A heterogeneous (solid-phase separation) fluoroimmunoassay for digoxin in serum was developed employing antibodies coupled to magnetisable cellulose/iron oxide particles and a fluorescein-labelled digoxin derivative as tracer. Intrinsic fluorophores and other potentially interfering components of serum samples were reliably and completely removed at the separation and wash steps of the assay procedure which were facilitated by magnetic sedimentation. In order to attain adequate sensitivity (detection limit 0.2 micrograms/l (0.26 nmol/l) serum digoxin), a sample volume of 500 microliters was necessary. Assay results for patients' specimens correlated well with those obtained using established charcoal--separation (r = 0.96) and magnetisable solid-phase (r = 0.95) radioimmunoassays. The feasibility of a "stat" adaptation of the fluoroimmunoassay that involved only two standards (0.5 and 4 micrograms/l digoxin) was demonstrated. The stat method would be suitable for the assay of urgent or single specimens.

Extracellular versus intracellular digoxin action on bovine myocardium, using a digoxin antibody and intracellular glycoside application

1. The actions of externally and internally applied digoxin in heart ventricular muscle have been compared. 2. External application of digoxin (5 x 10(-8)--10(-7) M) had an inotropic effect, a steady level of twitch tension being reached at the end of about 3 hr. 3. Addition of an anti-digoxin antibody to the bathing solution prevented or reversed the digoxin effect, depending on the time of application. 4. The efflux of the antibody-[3H]digoxin-complex could be fitted by a single exponential with a half-time of 18 min. 5. In the absence of antibody, [3H]digoxin washout was two-compartmental with half-times of 4 and 72 min respectively. It is thought that the fast process signifies efflux from the extracellular space while the slow process reflects the washout of initially membrane bound glycoside. 6. When digoxin was applied by a cut end method, there was no effect on contractile strength. 7. The profile of radioactivity several hours following exposure to [3H]digoxin clearly indicated movement from cell to cell, the concentration of [3H]digoxin being above 10(-7) M in half the preparation at the end of 6 hr. Longitudinal diffusivity averaged 8.6 x 10(-8) cm-2 sec-1. 8. We conclude that digoxin has an inotropic effect when reaching the surface membrane of cardiac cells from the outside but is ineffective when applied from the inside.

Anti-digoxin antibody in digoxin intoxication

This study was conducted to investigate the action of anti-digoxin antibody in digoxin intoxication. Anti-digoxin antibody was raised in sheep and administered to six dogs following intravenous infusion of digoxin (0.04 or 0.16 mg/kg body weight), either as whole serum or as partially purified gamma globulin. Plasma and urine digoxin levels, both bound and free, were determined on serial samples. Myocardial samples were analysed for digoxin content. Comparisons were made with six dogs given digoxin but no antibody. The results indicate that anti-digoxin antibody is effective through inactivation of digoxin in myocardium and removal of digoxin from myocardium into plasma. Loss of digoxin in urine is not responsible for toxicity reversal.

Digoxin sensitivity in amyloid cardiomyopathy

Digoxin (5 mg/ml) was added to 10-mg and 20-mg pellets of purified primary and secondary amyloid fibrils, a normal human liver and heart homogenate and a homogenate from the heart of a patient with amyloid cardiomyopathy who had not received digitalis. After centrifugation, the supernatants were recovered and assayed for digoxin concentrations. Aliquots from the sediments were studied for the presence of digoxin, using rabbits antidigoxin antiserum and an indirect immunofluorescent technique. The results showed that 0.11--0.13 ng/ml of digoxin bound per milligram of fibrils and could not be separated by repeated washings. Elution with citrate or changes in the pH of the buffer. Immunofluorescent studies demonstrated diffusely bright immunofluorescence with the fibril preparation and amyloid heart homogenate when reacted with digoxin and digoxin-specific antiserum. These studies demonstrate that isolated amyloid fibrils bind digoxin and suggest that this interaction may play some role in the sensitivity to digitalis that has been observed in some patients with amyloid cardiomyopathy.

[Immunological treatment of digitalis poisoning with heterologous antibodies]

Our own experience with the production of digoxin-specific antibody preparations from the sheep and the results of the experimental and clinical use are briefly reviewed. Advantages, risks and unsolved problems of therapy with glycoside-specific antibodies are discussed.

The effectiveness of digoxin-specific F(ab')2-antibody fragments in the treatment of digitoxin poisoning: experimental investigations in the cat

In animal experiments heterologous digoxin-specific F(ab')2 antibody fragments have been found to be effective for the treatment of arrhythmias induced by toxic doses of digoxin. So far they have been successfully employed in three patients suffering from digoxin poisoning. The present study was undertaken to test whether these antibodies are also effective in the treatment of digitoxin poisoning. Ventricular tachycardia, induced in digitalized cats by intravenous injections of digitoxin, was fatal in four out of five controls. However, sinus rhythm was reinstated in all the animals treated with digoxin-specific F(ab')2 after onset of the arrhythmia. Cross-reactivity between the antibodies used and digitoxin, while slight in vitro, is, nevertheless, sufficient to justify their clinical use in cases of digitoxin poisoning.

Treatment of a case of lanatoside C intoxication with digoxin-specific F(ab')2 antibody fragments

In animal experiments arrhythmias induced by cardiac glycosides which prove fatal if untreated can be terminated by administration of glycoside-specific antibodies. Immunotherapy with digoxin-specific antibody fragments had hitherto only been employed on one occasion, namely in a person who had taken a massive overdose of digoxin with suicidal intent and who had failed to respond to symptomatic treatment. The present paper describes the use of F(ab')2 fragments of digoxin-specific antibodies in a female patient with lanatoside C intoxication to treat the associated life-threatening cardiac arrhythmia. The arrhythmia was rapidly terminated and normal sinus rhythm was restored. Treatment with the heterologous antibodies did not cause any side-effects.

Immunogenicity and kinetics of distribution and elimination of sheep digoxin-specific IgG and Fab fragments in the rabbit and baboon

To evaluate the relative merits of purified IgG and Fab preparations of defined specificity for potential clinical use, immunogenicity studies were carried out in baboon and rabbit experimental models. Distribution and elimination kinetics of purified sheep digoxin-specific IgG and Fab fragments were also studied following intravenous administration to baboons. Serial plasma and urine Fab concentrations were determined from trichloroacetic acid-precipitable 125I counts from pre-labelled preparations and also by measurement of the antibody's functional 3H-digoxin binding capacity. Results were compared with data obtained from IgG by 3H-digoxin binding. Kinetic data analysed by computer-fitted functions demonstrated that plasma Fab disappearance was best described by a tri-exponential function, whereas a bi-exponential function best described the IgG data. Initial distribution half-life (t 1/2) of Fab (0.28-0.32 hr) was considerably shorter than that of IgG (4.0 hr) and contributed a greater proportion of the total fall in plasma level over 24 hr. Fab elimination t 1/2 (9-13 hr) was also shorter than IgG (61 hr), but appreciably longer than earlier estimates in rabbits, guinea-pigs, rats and mice. The total volume of distribution of Fab was 8.7 times greater than that of IgG measured by the same method. Over the first 24 hr after administration 30-45% of administered Fab was recoverable in active form in urine, while 93% of total administered 125I counts from 125I-Fab preparations (bound and free) could be recovered. Less than 1% of administered IgG binding activity was recovered in urine during the initial 24 hr. The relative immunogenicities of sheep digoxin-specific IgG and Fab fragments were studied in six baboons. Both IgG and Fab elicited prompt immune responses when injected intramuscularly with Freund's complete adjuvant. Intravenous injection of soluble sheep IgG resulted in a prompt immune response in one baboon while repeated injections caused only a late, weak response in a second animal. Soluble sheep Fab fragments elicited only delayed and weak responses in the two baboons thus challenged. Further immunogenicity studies in ninteen rabbits showed significantly earlier and greater antibody responses to intravenously administered sheep IgG antigen than to Fab fragments derived from the same IgG population. These studies demonstrate that digoxin-specific Fab fragments undergo more rapid and extensive distribution to the extra vascular compartment and also more rapid renal excretion than IgG. Furthermore, Fab fragments are significantly less immunogenic than the parent IgG population. These data indicate potentially important therapeutic advantages for digoxin-specific Fab compared with IgG when administered for the reversal of life-threatening digitlis toxicity.

[Sensitization to digoxin with demostration of reagini antibodies]

The author presents the case of a male patient, 60 years old, suffering a chronic obstructive bronchopneumopathy with cor pulmonale in a state of cardiorespiratory insuffiency. Without any personal or familial history of allergy, a few minutes after the ingestion of .5mg of Digoxin a picture occurs of urticaria, angioneurotic edema and asthmatic crisis that disappears with sympatheticomimetics. No other medication was used, previously or at the time. The existence of reaginic antibodies is made evident with positive reactions to Digoxin and C Lanatosid in a Leftwich passive transference test and cutaneous tests. No alteration was found in the number of platelets and leucocytes nor in the percentage of eosinophils within 24 hours after the anaphylactic accident. The oral provocation test with the excipient of the commercial preparation was negative; the tolerance to Methyl-Digoxin complete. The literature referring to sensitization to digitalis glycosides is reviewed and some consideration is given to its mechanism.

Reversal of digitalis effects by specific antibodies

Highly digoxin-specific or ouabain-specific antibodies can readily be obtained by immunizing rabbits or sheep with repeated injections of the glycoside coupled to protein carriers. By virtue of their binding capacity digoxin-specific antibodies are capable of removing digoxin concentrations from red blood cells and renal tissue specimens. As evidenced by various experiments with human erythrocytes and isolated cardiac preparations in vitro, digoxin effects are rapidly reversible in the presence of digoxin-specific antibodies. In vivo antidigoxin antibodies can protect animals from digoxin effects and promptly abolish established toxic effects, associated with marked alterations of digoxin pharmacokinetics. However, due to the large molecular weight, complete antibodies cannot be eliminated via the renal route. The use of antigen-binding (Fab) fragments of digoxin-specific antibodies offer the advantage of rapid renal elimination of bound and inactivated digoxin. So far, due to potential immune reactions, the clinical use of purified digoxin-specific antibodies of Fab fragments is restricted to life-threatening accidental or suicidal digoxin or digitoxin poisoning.

Effects of inotropic and arrhythmogenic digoxin doses and of digoxin-specific antibody on myocardial monovalent cation transport in the dog

The effects of digoxin on monovalent cation active transport were determined in cardiac tissue obtained from dogs given inotropic, toxic, or lethal doses of digoxin. In hemodynamically monitored dogs, active uptake of the K+ analogue Rb+ was determined in vitro in a control myocardial biopsy, and then in serial biopsies from the same dog after the infusion of [3H]digoxin in doses sufficient to cause a sustained positive inotropic effect in the absence of toxicity, and finally after additional doses to induce overt toxicity. Nontoxic digoxin doses producing a mean increase of 20% in left ventricular (LV) dP/dt significantly reduced Rb+ active transport by 25% below control values. At the onset of digoxin-induced arrhythmias, maximal LV dP/dt was 53% above control whereas active Rb+ transport was reduced by 60% below baseline values (P less than 0.001). Control dogs given vehicle alone showed no significant change in contractility or in monovalent cation active transport. In another group of dogs given a lethal dose of digoxin, Rb+ active transport was reduced 59% below control levels at the onset of overt toxicity and was further reduced 80% below control at the time of onset of a fatal rhythm disturbance. When dogs were given high affinity digoxin-specific IgG or Fab fragments at the onset of overt toxicity, toxicity was rapidly reversed, and monovalent cation active transport increased to 51% of control at the time of restoration of sinus rhythm. Twenty-four hours after antibody reversal of arrhythmias, monovalent cation transport values approximated normal control levels. These data provide quantitative estimates of the extent of inhibition of monovalent cation transport by digoxin at inotropic, toxic, and lethal endpoints. Similar degrees of transport inhibition were present at the time of onset of digoxin-induced arrhythmias and at the time or arrhythmia reversal by digoxin-specific antibodies.

The prevention and reversal of digoxin intoxication with specific antibodies

The formation of digoxin-specific antibodies was induced in sheep by immunization with a digoxin-albumin conjugate. The efficacy of the antibodies was investigated in anesthetized cats. When the digoxin-specific antibodies were administered prophylactically as a gammaglobulin, IgG or F (ab')2 preparation, the dose of digoxin needed to induce ventricular dysrhythmia was significantly greater (p less than 0.001) for the pretreated animals than for the controls. To investigate therapeutic efficacy, the animals were digitalized with digoxin over a period of three days and were given digoxin injections on the fourth day to provoke ventricular tachycardia. Of the control animals, three died before two hours had elapsed and the arrhythmia persisted in the two remaining animals. By contrast, a stable sinus rhythm was restored in all animals which were treated with F (ab')2 fragment of the digoxin-specific antibodies after onset of ventricular tachycardia. The doses of digoxin required to trigger renewed ventricular dysrhythmia in these animals were greater than those required at the start of the experiment. The potential clinical use of digoxin-specific antibodies is discussed in the light of these results and reports in the literature.

Contrasting rates of reversal of digoxin toxicity by digoxin-specific IgG and Fab fragments

Both heterologous IgG and Fab fragments of appropriate affinity and specificity have been shown capable of reversing advanced cardiac glycoside toxicity. Fab fragments are more rapidly excreted and theoretically have a smaller risk of unwanted immunologic effects, but relative rates of toxicity reversal have not been established. Rates of reversal of advanced digoxin toxicity by digoxin-specific IgG and Fab fragments were therefore compared in a dog model of advanced digoxin intoxication. Initial studies confirmed more rapid distribution of sheep Fab fragments (M.W. 50,000) than of the parent IgG molecule (M.W. 150,000) after intravenous injection. Twenty-five pentobarbital-anesthetized dogs were given 0.3 mg/kg digoxin intravenously, resulting in rapid onset of ventricular tachycardia in all animals. Eight dogs subsequently given nonspecific IgG or Fab died in asystole or ventricular fibrillation an average of 55 minutes after digoxin administration. Ten of 11 dogs given 1.33 moles of binding sites per mole of digoxin as intact IgG returned to sinus rhythm at a mean time of 85 minutes after antibody infusion. In contrast, six of six dogs given an equivalent dose of specific Fab fragments returned to sinus rhythm in a significantly shorter mean time of 36 minutes (P less than 0.01). Variability of time to arrhythmia reversion was less in Fab-treated dogs. These data demonstrate a decisive advantage of specific Fab fragments over intact IgG for potential clinical use in advanced, life-threatening digoxin intoxication.

Antibodies of restricted heterogeneity directed against the cardiac glycoside digoxin

Intravenous injection of New Zealand White rabbits with type III pneumococcal polysaccharide vaccine conjugated with the cardiac glycoside digoxin resulted in the production of both antidigoxin and anti-type III pneumococcal polysacharide antibodies. Among antisera of 12 rabbits examined during their peak antibody production periods, 1 to 20 mg (mean, 5.4 mg) of antidigoxin antibody could be recovered from 1 ml of serum. Antisera from five of these 12 rabbits contained antidigoxin antibodies of restricted heterogeneity as demonstrated by urea-polyacrylamide disc gel electrophoresis of fully reduced and alkylated antibodies. From the antisera of four of these five rabbits, electrophoretically homogeneous antibodies (1 to 5 mg/ml antiserum) could be isolated by affinity chromatography on ouabain-amine-Sepharose columns. The structural homogeneity of two of these antidigoxin antibodies was confirmed by amino acid sequence analysis of purified light chains through the first hypervariable region. These data suggest that the conjugation of small molecules to bacterial polysaccharide vaccines may provide a general method for synthesis of immunogens that can regularly elicit antihapten antibodies of restricted heterogeneity.

Cross reactivity of digitoxin and spironolactone in two radioimmunoassays for serum digoxin

We measured the cross reactivity of two medications--digitoxin and spironolactone--in two digoxin radioimmunoassay (liquid and solid-phase) kit procedures. Both tests showed similar average percentages of cross reactivity with digitoxin (7.2 and 8.9% for intravenous, and 11.9 and 10.9% for oral administration), but no cross reactivity with spironolactone or its metabolites after equal intravenous or oral doses.