Digoxin-specific antibodies

Use of digoxin-specific Fab fragments in the treatment of digitalis intoxication

The narrow margin between therapeutic and toxic effects of digitalis glycosides renders patients taking these drugs particularly susceptible to serious consequences of accidental or deliberate overdosage, including life-threatening arrhythmias. Until recently, the treatment of digitalis intoxication has been largely supportive. In the past decade, however, digoxin-specific antibodies have been developed and have proven to be effective in rapidly reversing the electrophysiologic and metabolic manifestations of digitalis intoxication, both in vitro and in vivo. Enzymatic cleavage of the intact antibody population into Fab fragments results in a more rapidly effective and less immunogenic antidote to digitalis excess. More recently, monoclonal antibodies with high affinity and specificity for digoxin have been produced by the technique of somatic cell fusion; application of this technique to the production of antidigoxin antibodies has potential implications for the production of a highly purified homogeneous product, but this approach has not yet been tested clinically.

Polyacrolein microspheres as a new solid phase for radioimmunoassay

Polyacrolein (PA) microspheres contain reactive aldehyde groups through which ligands containing primary amino groups such as proteins and drugs can be covalently bound in a single step at physiological pH. Antibodies against cyclic-AMP, digoxin and rabbit serum were thus coupled to PA microspheres. The immuno-microspheres were kept in suspension or freeze-dried, with insignificant decrease in their binding capacity. The conjugates were used in the respective radioimmunoassay (RIA) systems to facilitate the separation of the free and the antibody-bound 125I ligands, in comparison with precipitation of Protein A of Staphylococcus aureus. Cyclic-AMP was assayed using PA microspheres coupled either with the primary antibody or with anti-rabbit serum as a secondary antibody, in a buffer system, in chick plasma, in urine and in media in which avian dispersed kidney cells had been stimulated by various agents. The results obtained using the immuno-microspheres and the bacterial separation methods were indistinguishable. Other 125I-ligands, such as digoxin in buffer system or thyroxine and triiodothyronine in chick plasma, were assayed in the picogram range. Owing to the solubility of non crosslinked microspheres conjugates in toluene-based scintillation fluids, both the free and the bound fractions could be counted when using 3H-ligands. Corticosterone was assayed using this technique.

Immunotherapy in the poisoned patient. Overview of present applications and future trends

Immunotherapy for reversal of toxicity due to poisons and drugs is not new. However, refinements in antibody isolation and purification as well as the advancement of hybridoma technology and recombinant DNA biotechnology has led to a new generation of immunotherapeutic and diagnostic agents. The advent of monoclonal antibody technology in 1975 heralded the new age of immunopharmacology and immunotoxicology. Monoclonal antibodies designed for a specific antigen resolved the problem of polyclonality and cross-reactivity of traditional antibodies. Along with the production and isolation of active antibody fragments from both polyclonal and human monoclonal sources, as well as the ability to tailor-make chimeric antibodies by recombinant biotechnology, the development of novel immunotherapeutic agents has taken place. Two immunotherapeutic modalities, digoxin-specific antibody fragments (Fab) and snake antivenin, have been available for the clinician's armamentarium for years. Along the same lines of anti-digoxin Fab development, application of newer antibody isolation technology has led to a purified IgG(T) antibody for snake venom poisoning which is still in the developmental stages. Potential future developments in immunotherapeutics must overcome the clinical problems of immunogenicity and adverse reactions to the antibodies. Human monoclonal sources, active antibody fragments, and chimeric antibodies from transfectomas are all potential resolutions to these problems.

New advances in the assessment and treatment of digitalis toxicity

The narrow margin between the therapeutic and toxic doses and serum levels of cardiac glycosides results in a high incidence of digitalis toxicity. This common problem has led to the development of methods for determining serum glycosides concentrations. It is clear that overlap of serum digoxin levels occurs between groups of patients with and without evidence of toxicity. In spite of these difficulties, use of serum digoxin measurement has been reported to be associated with a lower incidence of digitalis intoxication in clinical practice. When digitalis toxicity does develop, it is generally of two types: disturbances of impulse formation and disturbances of conduction. Therapeutic interventions may include antiarrhythmic drugs, pacemaker placement, and, in the most severe cases, administration of cardiac glycosides-specific antibodies. Recent studies have shown that monoclonal digoxin-specific antibodies and Fab fragments obtained by somatic cell fusion are effective in reversing advanced and otherwise lethal digoxin intoxication. The homogeneity of this antibody offers attractive possibilities for improving our ability to treat advanced digitalis intoxication safely and effectively.

Measurement of potato steroidal alkaloids in human serum and saliva by radioimmunoassay

Radioimmunoassay methods are described for measuring potentially toxic potato glycoalkaloids and the aglycone solanidine in human serum and saliva. Solanidine and total alkaloid concentrations in serum and saliva during the summer are given for a group of subjects from the UK and a group from Sweden. Serum concentrations ranged from 3.2 to greater than 125 nmol/l for total alkaloid and 2.5 to 92.5 nmol/l for solanidine and were comparable in the two populations. Salivary total alkaloid concentrations were only about 10% of serum values. Salivary solanidine concentrations did not exceed 20% of the serum levels. Good correlation was found between serum and salivary alkaloid concentrations (r = 0.734, for solanidine; r = 0.892 for total alkaloid). Serum and salivary alkaloid concentrations were significantly raised in a group of Swedish subjects eating potatoes containing unusually high concentrations of alkaloids when compared with those in a group of subjects eating their normal diets.

Treatment of 63 severely digitalis-toxic patients with digoxin-specific antibody fragments

Sixty-three patients with life-threatening digitalis intoxication were treated with purified fragments of digoxin-specific antibodies (Fab) obtained from sheep. Twenty-eight patients developed toxicity as the result of digitalis ingestion in a suicide attempt, 5 ingested a large amount of digoxin accidentally and 30 developed toxicity in the course of treatment for underlying heart disease. The dosage of digoxin-specific Fab was calculated to be equimolar to the amount of cardiac glycoside in the patient's body. Digitalis toxicity was completely reversed in most cases, with onset of effect usually within 30 minutes of administration of Fab fragments. Unbound and, therefore, active digoxin serum concentrations decreased to undetectable levels within minutes after administration of the fragments. In all patients who had elevated serum potassium concentrations caused by massive digitalis toxicity, treatment with the Fab fragments reversed the hyperkalemia. There were no obvious adverse reactions to treatment. Potentially life-threatening digitalis intoxication can be rapidly and safely reversed by treatment with purified digoxin-specific Fab fragments.

Antibodies and digitalis: the modern revolution in the use of an ancient drug

Although digitalis glycosides have been widely used in clinical medicine since the classic description by William Withering in 1785, it was not until the advent of a specific immunoassay that their clinical pharmacology could be examined intensively under a wide variety of circumstances. The insights gained into the relations among dosage, plasma concentration, bioavailability, distribution, metabolism, excretion and interactions with other drugs and the manifestations of toxicity certainly have reduced the frequency of adverse reactions to this highly toxic but useful group of drugs. More recently, antibodies have also been utilized as specific antidotes for digitalis toxicity, with dramatic life-saving effect.

Digoxin specific antibody (Fab) fragments in 34 cases of severe digitalis intoxication

34 patients aged between 2 and 80 years were treated with digoxin specific antibody (Fab) fragments for severe digitalis poisoning. In 27 cases, the glycoside was taken with suicidal intent; in 3 cases accidentally and 4 were iatrogenic. The following criteria were considered to be indications for use of Fab fragments: the appearance of life-threatening arrhythmias such as high-grade atrioventricular conduction disorders (grade 2 and 3 A-V block), multifocal ectopic beats, ventricular tachycardia, and relapsing ventricular fibrillation. Serum digoxin concentrations were between 3.4 and 29ng/ml before the start of treatment. Between 240 and 800mg of Fab were administered; the majority of patients received 480mg. Regression of arrhythmias was seen between 0.5 and 8 hours after Fab infusion. There was a rapid fall in the free digoxin in the serum to concentrations that were no longer measurable and a marked rise in bound digoxin with a simultaneous increase of excretion of bound digoxin in the urine. Fab therapy is considered to be a major advance in the treatment of severe, previously fatal, glycoside poisoning. No notable side effects or allergic reactions were observed.

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.

Digoxin-specific antibody fragments and a calcium antagonist for reversal of digoxin-induced mesenteric vasoconstriction

The effect of digoxin-specific antibody fragments on glycoside-induced mesenteric vasoconstriction were investigated. Digoxin caused a sustained contraction of strips of isolated feline mesenteric artery lasting for several hours, while in anaesthetized cats it produced a significant decrease in blood flow and increase in resistance in the mesenteric artery. In-vitro, digoxin's contractile effect was inhibited by 'prophylactic' addition of antibody to the organ bath, but the clinical use for prophylaxis is not a practical proposition. When the antibodies were added with the contraction of the arterial strip in response to digoxin already established, the tone of the preparation decreased significantly over 3 h, but the effect of the glycoside was not fully reversible. In-vivo, control animals not treated with antibodies developed arrhythmias, mesenteric blood flow fell by more than 50% and resistance increased by more than 80% relative to the initial values. These animals died of ventricular fibrillation before the end of the experiment. Animals treated with digoxin-specific antibody fragments after receiving digoxin injections showed no further decrease in mesenteric blood flow and 90 min after the last dose of digoxin, the flow was recovering and mesenteric resistance decreasing. Furthermore, all the animals that had received antibodies remained in sinus rhythm to the end of the experiment. In view of the latent period to onset of action of the antibodies, valuable time may be lost in impaired mesenteric blood flow. To bridge the gap or, indeed, as primary treatment, calcium antagonists merit consideration; in our experiments mesenteric vasoconstriction was abolished within a few minutes by application of the dihydropyridine calcium antagonist 4-(2,1,3-benzo-oxadiazol-4-yl)-2,6-dimethyl-1,4-dihydropyridine-3,5-dicarboxylic aid, diethyl ester (PY 108-068).

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.

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.

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.

A radioimmunoassay for VP16-213 in plasma

A radioimmunoassay for the semi-synthetic podophyllotoxin VP16-213 has been developed which is suitable for pharmacokinetic studies of the drug. A high titre antiserum was produced in a sheep in response to a VP16-213-BSA conjugate prepared using sodium periodate. Podophyllotoxin does not cross-react with the antiserum and VM26 cross-reacts to only a small extent (less than 0.6%). In the absence of a high specific activity tritium label, a radioiodinated histamine ligand was produced which was only partially displaced from antibody by native drug. VP16-213 can be measured in plasma without prior drug extraction with a theoretical limit of detection of 5-10 micrograms/l. VP16-213 cis (picro) hydroxy acid is recognised by the antiserum to a greater extent than the drug itself. Thus, in order to eliminate any interference from the trans hydroxy acid metabolite chloroform extraction of plasma samples was carried out.

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.

Acute, massive poisoning with digitoxin: report of seven cases and discussion of treatment

Severe digitoxin poisoning in seven patients is reported. Doses taken varied from 2 to 20 mg, and maximal plasma concentrations of digitoxin from 50 to 237 nmol/L. One patient died from ventricular fibrillation, and the course in another was considerably protracted due to severe complications. The course in all patients was more dependent on underlying heart disease than on the plasma digitoxin concentration. Based on our own experiences and survey of the literature the following treatment is proposed: Gastric aspiration and lavage followed by instillation of activated charcoal should even be performed many hours after drug intake. In order to interrupt the enterohepatic circulation of digitoxin, repeated doses of charcoal should be given. Charcoal is preferable to cholestyramine because of its better tolerability. Ventricular arrhythmias should not be treated unless they are serious, because most antiarrhythmic drugs may further impede the AV-conduction. Phenytoin is the drug of choice, because the AV-conduction is less affected or even improved, and because the metabolism of digitoxin is accelerated. Conduction disturbances with bradycardia are frequently seen and may occur suddenly. Prophylactic introduction of a transvenous pacing catheter is therefore recommended as a routine procedure.

Studies of monoclonal and polyclonal anti-digoxin antibodies for serum digoxin radioimmunoassay

We compared the advantages of monoclonal antibodies (produced by plasma cell-myeloma cell hybrid lines) and those of conventional antibodies in the radioimmunoassay of digoxin. It was found that antibodies produced by some hybrid cell lines (hybridomas) were highly specific for the digoxin structure; this way the cross-reactions to related structures (e.g. spironolactone) could be avoided. When the hybridoma lines were grown in ascites, the resulting fluid could have as high or higher titre than the serum of a hyperimmunized rabbit. The high titre, the specificity and the permanent growth of the hybridoma lines make them an optimal source of the specific antibody in clinical radioimmunoassays for the measurement of drug or hormone levels.

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.

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.

Current considerations in digoxin usage

Basic considerations in biotransformation and pharmacodynamics are presented as a basis for understanding clinical usage. The role of polarity in determining a given glycoside's duration of action and extent of biotransformation is emphasized. The pharmacokinetics are summarized emphasizing the fact that digoxin is not completely absorbed by oral administration. The important relationship of serum digoxin levels to myocardial content and apparently to myocardial response is reviewed. This relationship and the development of precise methods for measurement of digoxin in serum provide the clinician with accurate means to assess myocardial tolerance for digoxin under diverse clinical circumstances. This review includes discussion of methods of digitalization, appropriate use of serum levels, apparent and real resistance to digoxin, and apparent and real sensitivity to digoxin. The limitations of serum levels as a precise guide to toxicity are analyzed. Finally, new developments in use of immunologic therapy for digoxin intoxication are presented.

Reversal of advanced digitoxin toxicity and modification of pharmacokinetics by specific antibodies and Fab fragments

The effects of Fab fragments of high-affinity specific antibodies have been studied in a canine experimental model of lethal digitoxin toxicity. Selected antiserum from sheep immunized and boosted with a digoxin-serum albumin conjugate contained antibodies that cross-reacted with digitoxin with an average intrinsic association constant of 1.4 x 10(10) M(-1) as determined by equilibrium dialysis. Rapid second-order association kinetics (k(f) = 3.7 x 10(6) M(-1) per s) and slow dissociation kinetics (k(r) = 1.9 x 10(-4) per s) were documented for the antibody-digitoxin complex. Eight dogs given 0.5 mg/kg digitoxin intravenously developed ventricular tachycardia after 23+/-4 (SEM) min. Control nonspecific Fab fragments were then given. All animals died an average of 101+/-36 min after digitoxin administration. Another eight dogs given the same digitoxin dose similarly developed ventricular tachycardia after 28+/-3 min. This group then received a molar equivalent dose of specific Fab fragments intravenously over 3 min, followed by a 30-min infusion of one-third of the initial dose. All dogs survived. Conducted sinus beats reappeared 18+/-4 min after initial Fab infusion, and stable normal sinus rhythm was present at 54+/-16 min. Plasma total digitoxin concentrations increased threefold during the hour after initial Fab infusion, while plasma free digitoxin concentration decreased to less than 0.1 ng/ml. Effects on digitoxin pharmacokinetics of these Fab fragments and the antibody population from which they were derived were further investigated in a primate species. Unlike common laboratory animals previously studied, the rhesus monkey was found to have a prolonged elimination half-life, estimated at 135 and 118 h by radioimmunoassay and [(3)H]digitoxin measurements, respectively, similar to man and thus providing a clinically relevant experimental model. Intravenous administration of 2 mol of specific Fab fragments per mole of digitoxin 6 h after 0.2 mg of digitoxin produced a rapid 4.3-fold increase in plasma total digitoxin concentration followed by a rapid fall (t((1/2)) 4 h) accompanied by a 14-fold enhancement of urinary digitoxin excretion over control values during the 6-h period after Fab was given. Analytical studies were consistent with increased excretion of native digitoxin rather than metabolites, and the glycoside was found in equilibrium dialysis studies to be excreted in the urine in Fab-bound form. Administration of 2 mol of specific antibody binding sites per mole of digitoxin as intact IgG caused a greater and more prolonged increase in plasma total digitoxin concentration, peaking 13-fold above control levels. In contrast to the effects of Fab, however, specific IgG reduced the rate of urinary digitoxin excretion substantially below control values. We conclude that Fab fragments of antibodies with high affinity for digitoxin are capable of rapid reversal of advanced, otherwise lethal digitoxin toxicity, and are capable of reducing the plasma half-life and accelerating urinary excretion of digitoxin.

Some factors affecting a commercial kit for radioimmunoassay of digoxin using tritiated digoxin

Some factors affecting results of digoxin determinations using one commercially available radioimmunoassay kit are described and discussed. Serum of pregnant women, cord blood, amniotic fluid and serum of patients taking spironolactone may show erroneously high digoxin activity due to lack of specificity of the antiserum. Cross-reaction with digitoxin was found to vary substantially with antibody-lot. Haemaccel (5 g/1) in the sample leads to too low results. When ethanol (100 g/1) is present results are too high. The need for testing the specifity of every new lot of antiserum before use is stressed.

Pharmacokinetics of beta-methyldigoxin in healthy humans II: Oral studies and bioavailability

The pharmacokinetics of orally administered aqueous 3H-beta-methyldigoxin solutions were studied at two dose levels, 0.3 and 0.6 mg, in healthy human subjects. The drug and its metabolites were specifically assayed in biological fluids and compared with results after intravenous doses to the same subjects. No significant dose dependency was observed. The apparent half-life of absorption was 16+/-6 min (SEM). Digoxin was the only metabolite observed in the plasma and comprised 28.6+/-3.7% of the dose in the urine. 3H-beta-Methyldigoxin, renally excreted unchanged, comprised 25.7+/-1.7% (SEM). Water-soluble metabolites in the urine comprised 9.0+/-1.8%. Fecal and urinary excretion accounted for 85% of the dose at 144 hr. The oral absorption of unchanged 3H-beta-methyldigoxin from solution was 59+/-6% by area under the curve methods and 60+/-4% by renal excretion. A total of 73% of the dose in the solution was absorbed as beta-methyldigoxin and digoxin. First-pass metabolism prior to absorption was largely prehepatic and assignable to GI degradation; 21.9+/-2.8% was degraded with 12.8+/-4.0% to digoxin and 9.1+/-4.0% to water-soluble metabolites. From 14 to 18% of the administered oral dose did not reach the systemic circulation. Analog computer fitting of plasma and urine levels of drug and digoxin was consistent with the first-pass premise with a delayed absorption of GI-generated digoxin and other metabolites. There were no significant differences between the oral absorption of a tablet formulation and the solution. Orally administered beta-methyldigoxin solution delivered 97% cardioactivity as itself and digoxin with respect to an equivalent amount of intravenously administered digoxin. This value contrasts to the 140% delivered by intravenously administered beta-methyldigoxin on the premise of pharmacodynamic equivalence of systemically appearing digoxin and beta-methyl-digoxin. Literature reports on the oral bioavailability of solutions and solid dosage forms of digoxin were critically reviewed, but no reliable comparison of the extent and reproducibility of oral absorption of cardioactive agents from administered digoxin or beta-methyldigoxin could be made from the widely variable digoxin studies with nonspecific assays.

Effects of sheep digoxin-specific antibodies and their Fab fragments on digoxin pharmacokinetics in dogs

Intact sheep antidigoxin antibodies and their Fab fragments have both been found to exert profound effects on digoxin pharmacokinetics in [3H] digoxin-treated dogs. Both classes of molecule remove digoxin from the extravascular space and sequester it in the circulation in protein-bound form, a form in which the digoxin is presumably inactive. These two classes of molecule differ, however, in that the intact antibody molecules interfere with digoxin excretion, thereby promoting the retention of the glycoside; this retained digoxin is eventually released in free, active form when the administered antibody is metabolically degraded. In contrast, urinary excretion of digoxin continues in Fab-treated dogs, with significant quantities of digoxin being excreted promptly in the urine in complex with Fab fragments. These differences in urinary excretion, together with the probable decreased immunogenicity of sheep antidigoxin Fab fragments, suggest that such fragments possess potential advantages over intact antibody molecules for use in the therapy of life-threatening digoxin intoxication in man.

[Determination of glycoside concentrations in human tissue by means of radioimmunoassay (author's transl)]

After extraction of myocardial and skeletal muscle biopsy and autopsy specimens tissue glycoside concentrations can be determined by radioimmunoassay. Total tissue extraction of digoxin and beta-methyl-digoxin varies between 87 and 95%, the variation coefficient for repeated determinations is 10.2%. Glycoside concentrations of left ventricular papillary muscle obtained after mitral valve replacement were 69.0 +/- 25.05 ng/g with a tissue to serum relation of 46.6 +/- 8.96:1 and a correlation coefficient of r = 0.8442. In autopsy left ventricular papillary muscle glycoside concentrations were 105.2 +/- 27.35 ng/g with an almost identical tissue to serum relation of 46.2 +/- 9.57:1 and a corresponding serum concentration of 2.3 +/- 0.63 ng/ml. In adults glycoside concentrations of autopsy specimens of the right ventricle were significantly lower by 28 to 30% than those of the left ventricle. Glycoside concentrations of skeletal muscle specimens (m. pectorialis major) were 14.7 +/- 10.35 ng/g with a tissue to serum relation of 9.7 +/- 3.00:1 (r = 0.8377), which corresponds to approximately 1/5 to 1/4 of the concentrations of the left ventricular myocardium.

Decreased bioavailability of digoxin due to antacids and kaolin-pectin

Employing a Latin-square design and single-dose studies of bioavailability in 10 normal human volunteers, we tested the hypothesis that antacids and kaolin-pectin might interfere with the bioavailability of orally administered digoxin. Cumulative six-day urinary digoxin excretion (expressed as the percentage of a 0.75-mg dose recovered) was: control, 40.1+/-3.0 (S.E.); aluminum hydroxide, 30.7+/-2.9; magnesium hydroxide, 27.1+/-2.4; magnesium trisilicate, 29.1+/-1.7; and kaolin-pectin 23.4+/-2.0. The differences in means were highly significant (F = 10.47, P less than 0.005). Further analysis (multiple comparison test) revealed that control differed significantly from each of the other treatments (alpha = 0.05), but there was no such difference between any of the other treatment groups. The decreased cumulative excretion produced by antacids and kaolin-pectin reflected a striking reduction in digoxin absorption associated with these compounds that was not related to alteration of gut transit time or to adsorption of digoxin to these gastrointestinal medications.

Reversal of advanced digoxin intoxication with Fab fragments of digoxin-specific antibodies

Purified Fab fragments of ovine digoxin-specific antibodies reversed severe digoxin intoxication in a patient who had taken 22.5 mg of the drug with suicidal intent. Atrioventricular block with extreme bradycardia was temporarily managed by pacing, but progressive, intractable hyperkalemia (serum potassium of 8.7 meq per liter) with increasing pacing threshold and progressive intraventricular conduction delay was controlled only after infusion of 1100 mg of Fab. Sinus rhythm returned 10 minutes after completion of Fab infusion. Within five hours, the serum potassium concentration fell to 4.0 meq per liter. Free digoxin concentrations in serum fell sharply to undetectable levels, whereas total serum digoxin concentration concomitantly increased 12-fold. Renal excretion of digoxin bound to Fab was documented. Reversal of toxicity was not accompanied by hemodynamic instability, and antibodies to sheep Fab fragments were not detected in the patient's serum after treatment. Thus, purified digoxin-specific Fab fragments are capable of rapid reversal of advanced digoxin toxicity.

A solid phase radioimmunoassay for digoxin and its acylated derivatives

A solid phase radioimmunoassay (RIA) is presented for the determination of digoxin and its acylated derivatives. In the procedure the antiserum is covalently bound to bromacetylcellulose. Therefore the free and the immunologically bound digoxin fractions can easily be separated by centrifuging. The radioactivity in the supernatant representing the unbound digoxin is proportional to the digoxin concentration in the sample. This modification of the RIA for digoxin is far more time saving than the separation procedure using dextran-coated charcoal as an absorbent; nevertheless both methods are equally sensitive, specific and reliable. The use of the solid phase assay is demonstrated comparing the bioavailability of various digoxin derivatives.

Renal tubular secretion of digoxin

To study the mechanism of the renal handling of digoxin, simultaneous measurements of digoxin and inulin clearances were performed in 13 digitalized patients with congestive heart disease. The renal digoxin clearances exceeded inulin clearances, indicating an active tubular secretion of digoxin. No evidence of tubular backward diffusion was disclosed. Treatment with spironolactone (Aldactone) decreased the digoxin clearances, suggesting an inhibition of the tubular secretion of digoxin in the distal segment of the renal tubulus. After blocking the tubular secretion, the calculated renal clearances of nonproteinbound digoxin in plasma were similar to that of inulin, suggesting a glomerular filtration of free plasma digoxin. Plasma digoxin level rose during treatment with spironolactone.

A rapid, simple assay for digoxin

An extremely rapid radioimmunoassay for digoxin is described which is precise over the range of concentrations required to determine whether, or not, a patient has digoxin toxicity. The assay is based on the use of (125)-iodine-labelled digoxin and of a gel equilibration technique for the separation of antibody-bound and free digoxin. The results obtained compare closely with those by a conventional radioimmunoassay and the technique is sufficiently simple to enable its performance by relatively inexperienced laboratory staff.

Reversal of ouabain and acetyl strophanthidin effects in normal and failing cardiac muscle by specific antibody

Isolated cat right ventricular papillary muscles were used to study the effects of antibodies with high affinity for ouabain and acetyl strophanthidin on myocardium exposed to these cardioactive steroids. Antibodies with average intrinsic affinity constants for ouabain and acetyl strophanthidin of the order of 10(8) M(-1) were raised in rabbits challenged by repeated injection of a conjugate of ouabain covalently linked to a poly D,L-alanyl derivative of human serum albumin. Effects were assessed in terms of time-course and extent of inotropy reversal, influence of experimentally induced ventricular failure, digitalis-antibody concentration relations, influence of digitalis-antibody complex on response to additionally added digitalis, and relation of antibody effects on digitalis-induced automaticity and contracture to reversal of inotropy. Specific antibody (but not control antibody) in 1.1-1.5-fold molar excess over cardioactive steroid concentrations blocked positive inotropic effects of ouabain and acetyl strophanthidin, and gradually reversed established contractile effects of these agents with a mean time for half-reversal of ouabain-induced inotropy of 124+/-6 (SEM) min and 37+/-3 min for half-reversal of acetyl strophanthidin-induced inotropy. Papillary muscles from cats with right ventricular failure induced by chronic pulmonary artery constriction responded similarly. Both normal and failing muscles returned to but not below levels of contractility existing before cardioactive steroid exposure, and time for half-reversal of inotropy by antibody was significantly shorter than time for half-reversal after removal of ouabain or acetyl strophanthidin by muscle bath washout alone. Presence of ouabain- or acetyl strophanthidin-antibody complex did not alter the myocardial contractile response to subsequently added cardioactive steroids. Spontaneous automaticity occurring as a toxic response to ouabain or acetyl strophanthidin in eight muscles was rapidly reversed by specific antibody at a time when positive inotropic effects were still fully manifest. Early contracture was also reversed by specific antibody. These studies provide further support for the concept that cardiac glycoside-specific antibodies are capable of reversing established cellular effects of cardioactive steroids.

Comparison of serum digoxin level measurement with acetyl strophanthidin tolerance testing

Serum digoxin levels (SDL) were compared with tolerance for the rapidly acting cardiac aglycone, acetyl strophanthidin (AS). AS titration tests were performed on 133 patients with diverse cardiac disorders. All were receiving maintenance digoxin. Both exquisite AS sensitivity and tolerance for a 1.0 mg AS were associated with a wide range of SDL values. Concordance and discordance between the two methods in assessing degree of digitalization were evaluated by considering SDL of 1.4 ng/ml to be the mean value for patients without glycoside-induced cardiac arrhythmia. An SDL of < 1.5 ng/ml with tolerance for 1.0 mg AS and an SDL of > 1.4 ng/ml with sensitivity to 1.0 mg AS or less constituted concordant responses. An SDL of < 1.5 ng/ml with intolerance for 1.0 mg or less AS and an SDL of > 1.4 ng/ml with tolerance for 1.0 mg AS comprised discordant responses. In 60 of 144 (42%) AS titrations discordant results were observed. Severe pulmonic, coronary, and aortic valvular heart disease, as well as old age, contributed to unusual AS sensitivity. Titration with AS clarified pharmacologic quantification of SDL by providing insight into optimum therapeutic glycoside dose.