[Determination of digoxin and digitoxin in the blood and their clinical significance]

Magnesium concentration in saliva -- an indicator of digitalis toxicity. ?

In a prospective study salivary magnesium was measured by atomic absorption spectrophotometry in 168 patients on chronic digoxin therapy. Magnesium concentration in saliva was correlated with clinical data and plasma digoxin levels. A significant elevation in salivary magnesium concentration was caused by digoxin therapy (0.58 +/- 0.39 mmol/l, n = 93) in comparison to patients with no digitalis treatment (0.17 +/- 0.07 mmol/l, n = 35). Magnesium concentrations in saliva were significantly higher in toxic patients (1.1 +/- 0.68 mmol/l, n = 32) than in nontoxic patients. Possibly toxic patients showed a magnesium level of saliva of 0.63 +/- 0.39 mmol/l (n = 40). In 89% of the intoxicated patients salivary magnesium concentrations were higher than 1.0 mmol/l. The overlap of magnesium between toxic and nontoxic patients was less as compared to calcium and potassium concentrations in saliva. No changes were noted in serum magnesium levels. Magnesium concentration in saliva was influenced by chronic digoxin therapy only. No significant increase of magnesium in saliva was observed within 24 h after i.v. injection of 1.0 mg digoxin in four healthy volunteers. It is concluded that salivary magnesium concentration is a valid method for monitoring digoxin therapy in addition to plasma digoxin levels.

[Forensic aspects of digoxin-poisoning: toxicological and morphological findings (author's transl)]

Case report. A 82 year old woman died 80 min after accidental ingestion of 5 mg beta-methyl-digoxin. The autopsy and the histological examination revealed non-specific alterations due to shock and preexisting coronary heart disease. Digoxin levels in various fluids and tissues were estimated by radioimmunoassay: bloodplasma 20--25 ng/ml, liquor 10--13 ng/ml, liver 100--110 ng/g, kidney 130--145 ng/g; the gastric fluid contained 0,6 mg. Forensic aspects of glycosid-intoxication, especially of the varying concentrations in different tissues, are discussed.

[Plasma concentrations of digoxin in patients under intensive care conditions and in patients undergoing anesthesia and operation (author' transl)]

Pharmacokinetic behavior of digoxin or beta-acetyldigoxin was examined in 66 patients (27 patiets under intensive care conditions, partially with controlled breathing, 22 patients undergoing extirpation of the uterus and 17 patients treated with radium or chemotherapeutics; 19 males and 47 females) by determining plasma concentrations of digoxin (PDC). After intravenous and oral application with a maintenance dose of 0.20--0.50 mg/day blood was taken daily during a 2 to 3 week period, resulting in 510 determinations. 24 hours after the first application of 0.50 mg digoxin i.v. the mean values of PDC amounted to 0.62 +/- 0.08 ng/ml. After 0.40 or 0.25 mg digoxin per day i.v. therapeutical concentrations could be observed at the third vs fifth day. An equilibrium of PDC was reached on the 6th day after starting digitalization using maintenance doses. Intravenous application of 0.25, 0.40 or 0.50 mg digoxin per day resulted in a mean steady state of 0.68 +/- 0.37, 0.86 +/- 0.33 or 1.27 +/- 0.49 ng/ml PDC, respectively. The results were significantly different (p less than 0.01--0.001). Serial measurements indicated a great variation of PDC. In patients without renal failure the intraindividual variation of the plasma concentrations was maximal 37.4% referring to the mean steady state, interindividual 37.1% and the evaluation of the inter- and intraindividual differences amounted to 54.1%. After oral administration of digoxin (maintenance dose: 0.50 mg/day) or beta-acetyldigoxin (maintenance doses: 0.20--0.40 mg/day) differences in PDC of 38.3% and 29.7% were obtained. Body weight, age and serum creatinine concentration were partly responsible for the variance of PDC. Multiple linear regression between stead state PDC and dose, age, body weight and serum creatinine concentration revealed 62.1% of the variance of the PDC after intravenous administration of digoxin. After oral administration of beta-acetyldigoxin 39.9% were obtained. Thus, 40% of the variance were caused by differences in distribution and elimination of digoxin after i.v. application. After oral application additional 20% of the variance could be attributed to resorption and possible disturbances.

[Determination of digoxin by enzyme immunoassay and radioimmunoassay (author's transl)]

The results of parallel determinations of digoxin in the sera of non selected patients (n = 104) by enzyme immunoassay (EMIT-EIA) and radioimmunoassay (J-125 labeled RIA) were compared with each other. The determinations revealed considerably different concentrations; the values determined by EIA were statistical lower (for EIA 1.09 +/- 0.99 ng/ml, for RIA 1.34 +/- 1.01 ng/ml, p less than 0.01). In sera with hemolysis and in sera of patients with hyperlipidemia and uremia false-negative results were found by EIA. After elimination of these sera an exact concordation of the values of both the methods was obtained (for EIA 1.12 +/- 1.01 ng/ml, for RIA 1.12 +/- 1.02 ng/ml, r = 0.95).

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.

Therapeutic and toxic lanatoside C serum concentrations in hospital patients

Serum lanatoside C concentrations were measured by radioimmunoassay in 56 patients on oral maintenance therapy. Seven patients were judged to have digitalis toxicity and the lanatoside C concentration in this group was 6.99+/-2.00 ng/ml (mean +/-1 SD). 49 patients were non-toxic and the mean serum lanatoside C concentration in this group corresponded to 2.32+/-1.08 ng/ml.

Studies on a plasma cardiac glycoside assay based upon displacement of 3-H-ouabain from Na+-K+-ATPase

We tested an assay system introduced for plasma glycoside measurements, basing on the displacement of 3-H-ouabain from Na+-K+-ATPase by unlabeled glycoside. ATPase preparations from hog, cat and guinea pig were used. Displacements were performed using 20 cardiac glycosides, genins and derivatives with different cardiac activity. Most of the glycosides and derivatives do not induce a continuous 3-H-ouabain displacement from the ATPase, but a very steep increase of unbound 3-H-ouabain between 10-minus 7 and 2 times 10-minus 7 M. Therefore this assay system shows a satisfactory discrimination only in a short concentration range. This behavior and a relatively low sensitivity make the ATPase displacement assay problematic for clinical and pharmacokinetical plasma glycoside measurements.