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Sessa M, Mascolo A, Andersen MP, Rosano G, Rossi F, Capuano A, Torp-Pedersen C. Effect of Chronic Kidney Diseases on Mortality among Digoxin Users Treated for Non-Valvular Atrial Fibrillation: A Nationwide Register-Based Retrospective Cohort Study. PLoS One 2016; 11:e0160337. [PMID: 27467520 PMCID: PMC4965154 DOI: 10.1371/journal.pone.0160337] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/18/2016] [Indexed: 12/20/2022] Open
Abstract
PURPOSE This study investigated the impact of chronic kidney disease on all-causes and cardiovascular mortality in patients with atrial fibrillation treated with digoxin. METHODS All patients with non-valvular atrial fibrillation and/or atrial flutter as hospitalization diagnosis from January 1, 1997 to December 31, 2012 were identified in Danish nationwide administrative registries. Cox proportional hazard model was used to compare the adjusted risk of all-causes and cardiovascular mortality among patients with and without chronic kidney disease and among patients with different chronic kidney disease stages within 180 days and 2 years from the first digoxin prescription. RESULTS We identified 37,981 patients receiving digoxin; 1884 patients had the diagnosis of chronic kidney disease. Cox regression analysis showed no statistically significant differences in all-causes (Hazard Ratio, HR 0.89; 95% confident interval, CI 0.78-1.03) and cardiovascular mortality (HR 0.88; 95%CI 0.74-1.05) among patients with and without chronic kidney disease within 180 days of follow-up period. No statistically significant differences was found using a 2 years follow-up period neither for all causes mortality (HR 0.90; 95%CI 0.79-1.03), nor for cardiovascular mortality (HR 0.87; 95%CI 0.74-1.02). No statistically significant differences was found comparing patients with and without estimated Glomerular Filtration Rate <30ml/min/1.73m2 and patients with different stages of chronic kidney disease, for all-causes and cardiovascular mortality within 180 days and 2 years from the first digoxin prescription. CONCLUSIONS This study suggest no direct effect of chronic kidney disease and chronic kidney disease stages on all-causes and cardiovascular mortality within both 180 days and 2 years from the first digoxin prescription in patients treatment-naïve with digoxin for non-valvular atrial fibrillation.
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Affiliation(s)
- Maurizio Sessa
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, Second University of Naples, Naples, Italy
- * E-mail:
| | - Annamaria Mascolo
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, Second University of Naples, Naples, Italy
| | | | - Giuseppe Rosano
- IRCCS San Raffaele Pisana, Rome, Italy
- Cardiovascular and Cell Sciences Research Institute, St. George's University of London, London, United Kingdom
| | - Francesco Rossi
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, Second University of Naples, Naples, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, Second University of Naples, Naples, Italy
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The role of digitalis pharmacokinetics in converting atrial fibrillation and flutter to regular sinus rhythm. Clin Pharmacokinet 2014; 53:397-407. [PMID: 24671885 DOI: 10.1007/s40262-014-0141-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This report examined the role of digitalis pharmacokinetics in helping to guide therapy with digitalis glycosides with regard to converting atrial fibrillation (AF) or flutter to regular sinus rhythm (RSR). Pharmacokinetic models of digitoxin and digoxin, containing a peripheral non-serum effect compartment, were used to analyze outcomes in a non-systematic literature review of five clinical studies, using the computed concentrations of digitoxin and digoxin in the effect compartment of these models in an analysis of their outcomes. Four cases treated by the author were similarly examined. Three literature studies showed results no different from placebo. Dosage regimens achieved ≤11 ng/g in the model's peripheral compartment. However, two other studies achieved significant conversion to RSR. Their peripheral concentrations were 9-14 ng/g. In the four patients treated by the author, three converted using classical clinical titration with incremental doses, plus therapeutic drug monitoring and pharmacokinetic guidance from the models for maintenance dosage. They converted at peripheral concentrations of 9-18 ng/g, similar to the two studies above. No toxicity was seen. Successful maintenance was achieved, using the models and their pharmacokinetic guidance, by giving somewhat larger than average recommended dosage regimens in order to maintain peripheral concentrations present at conversion. The fourth patient did not convert, but only reached peripheral concentrations of 6-7 ng/g, similar to the studies in which conversion was no better than placebo. Pharmacokinetic analysis and guidance play a highly significant role in converting AF to RSR. To the author's knowledge, this has not been specifically described before. In my experience, conversion of AF or flutter to RSR does not occur until peripheral concentrations of 9-18 ng/g are reached. Results in the four cases correlated well with the literature findings. More work is needed to further evaluate these provocative findings.
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Adams KF, Ghali JK, Herbert Patterson J, Stough WG, Butler J, Bauman JL, Ventura HO, Sabbah H, Mackowiak JI, van Veldhuisen DJ. A perspective on re-evaluating digoxin's role in the current management of patients with chronic systolic heart failure: targeting serum concentration to reduce hospitalization and improve safety profile. Eur J Heart Fail 2014; 16:483-93. [DOI: 10.1002/ejhf.64] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/07/2013] [Accepted: 01/20/2014] [Indexed: 01/11/2023] Open
Affiliation(s)
- Kirkwood F. Adams
- Departments of Medicine and Radiology, School of Medicine, Division of Cardiology; University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - Jalal K. Ghali
- Division of Cardiology; Mercer University School of Medicine; Macon GA USA
| | - J. Herbert Patterson
- Division of Pharmacotherapy and Experimental Therapeutics; University of North Carolina at Chapel Hill Eshelman School of Pharmacy; Chapel Hill NC USA
| | - Wendy Gattis Stough
- Department of Clinical Research; Campbell University College of Pharmacy and Health Sciences; Buies Creek NC USA
| | - Javed Butler
- Department of Medicine, Division of Cardiology; Emory University; Atlanta GA USA
| | - Jerry L. Bauman
- Departments of Pharmacy Practice and Medicine, Section of Cardiology, Colleges of Pharmacy and Medicine; University of Illinois at Chicago; Chicago IL USA
| | - Hector O. Ventura
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School; The University of Queensland School of Medicine; New Orleans LA USA
| | - Hani Sabbah
- Division of Cardiology; Wayne State University, Henry Ford Health System; Detroit MI USA
| | | | - Dirk J. van Veldhuisen
- Department of Cardiology; University of Groningen, University Medical Center Groningen; Groningen the Netherlands
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Abstract
Most antiarrhythmic drugs fulfil the formal requirements for rational use of therapeutic drug monitoring, as they show highly variable plasma concentration profiles at a given dose and a direct concentration-effect relationship. Therapeutic ranges for antiarrhythmic drugs are, however, often very poorly defined. Effective drug concentrations are based on small studies or studies not designed to establish a therapeutic range, with varying dosage regimens and unstandardised sampling procedures. There are large numbers of nonresponders and considerable overlap between therapeutic and toxic concentrations. Furthermore, no study has ever shown that therapeutic drug monitoring makes a significant difference in clinical outcome. Therapeutic concentration ranges for antiarrhythmic drugs as they exist today can give an overall impression about the drug concentrations required in the majority of patients. They may also be helpful for dosage adjustment in patients with renal or hepatic failure or in patients with possible toxicological or compliance problems. Their use in optimising individual antiarrhythmic therapy, however, is very limited.
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Affiliation(s)
- Gesche Jürgens
- Department of Clinical Pharmacology, Copenhagen University Hospital, Copenhagen, Denmark.
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Hornestam B, Jerling M, Karlsson MO, Held P. Intravenously administered digoxin in patients with acute atrial fibrillation: a population pharmacokinetic/pharmacodynamic analysis based on the Digitalis in Acute Atrial Fibrillation trial. Eur J Clin Pharmacol 2003; 58:747-55. [PMID: 12634981 DOI: 10.1007/s00228-002-0553-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2002] [Accepted: 12/04/2002] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Atrial fibrillation is commonly treated with intravenously administered digoxin. The main objective of this study was to investigate the relationship between plasma concentration of digoxin and heart rate. SUBJECTS AND METHODS Plasma concentrations of digoxin were analysed in 105 patients allocated to digoxin therapy in the Digitalis in Acute Atrial Fibrillation (DAAF) trial. A pharmacokinetic/pharmacodynamic (PK/PD) model for the relationship among digoxin dose, plasma concentration and heart rate in patients remaining in atrial fibrillation was constructed using non-linear, mixed-effect modelling. One hundred and twenty-two placebo-treated patients were included as a control group. In 56 patients, one late sample at 16 h after the first dose of digoxin was obtained while in 49 patients an early sample at 0.25-0.5 h and a late sample 16 h after the first dose were obtained. Heart rate was measured at 0, 2, 6, 12 and 16 h after inclusion, with data from 98, 89, 67, 56 and 53 patients available at each time point, respectively. RESULTS A two-compartment model best described the time course of digoxin concentrations in plasma. Digoxin and creatinine clearance correlated strongly and mean plasma concentration of digoxin at 16 h was within recommended levels (1.6+/-1.0 nM). The decrease in heart rate in placebo-treated patients was, on average, 0.5 beats/min (bpm) per hour. In patients on digoxin, a linear relationship between the estimated digoxin concentration at the effect site and the drop-in heart rate was found. The half-life for the digoxin distribution to the effect compartment was approximately 3.8 h. The degree of reduction was related to the initial heart rate and patients with higher heart rate had a more pronounced decrease. The model predicted that a digoxin concentration of 1 nM at the effect site reduces heart rate by 9.4%. CONCLUSION A PK/PD model for the relationship between the plasma concentration of digoxin, the estimated concentration at the effect site and the reduction in heart rate during atrial fibrillation could be defined using a population pharmacokinetic approach. Our data indicate that a more aggressive dosing regimen of digoxin may be more effective in terms of heart rate reduction.
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Affiliation(s)
- Björn Hornestam
- Division of Cardiology, Department of Internal Medicine, Sahlgrenska University Hospital/Ostra, 416 85, Sweden.
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Adams KF, Gheorghiade M, Uretsky BF, Patterson JH, Schwartz TA, Young JB. Clinical benefits of low serum digoxin concentrations in heart failure. J Am Coll Cardiol 2002; 39:946-53. [PMID: 11897434 DOI: 10.1016/s0735-1097(02)01708-4] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We sought to determine whether there was a relationship between serum digoxin concentration (SDC), including SDCs typically regarded as low, and clinical efficacy related to digoxin in patients with symptomatic left ventricular dysfunction. BACKGROUND Digitalis glycosides have been used for 200 years in the treatment of heart failure (HF), but the SDC required for optimal clinical efficacy and acceptable toxicity remains controversial. METHODS This relationship was investigated by utilizing data from two randomized, double-blinded, placebo-controlled, digoxin-withdrawal trials: the Prospective Randomized study Of Ventricular failure and Efficacy of Digoxin (PROVED) and the Randomized Assessment of Digoxin on Inhibitors of Angiotensin-Converting Enzyme (RADIANCE). Major end points were worsening HF, change in left ventricular ejection fraction and treadmill time after randomization. The primary analysis investigated the relationship between SDC at randomization and these end points. A secondary categorical analysis compared these end points in patients who discontinued digoxin versus patients who continued digoxin and had low (0.5 to 0.9 ng/ml), moderate (0.9 to 1.2 ng/ml) or high (>1.2 ng/ml) SDCs at randomization. RESULTS Multiple regression analysis failed to find a relationship between randomization SDC, considered as a continuous variable, and any study end point (all p > 0.236). Multivariable Cox analysis found that the risk of worsening HF was significantly less (all p < 0.02) for patients in any category of SDC who continued digoxin, as compared with patients withdrawn from digoxin. Specifically, patients in the low SDC category were significantly less likely than placebo patients to experience worsening HF during follow-up (p = 0.018). CONCLUSIONS The beneficial effects of digoxin on common clinical end points in patients with HF were similar, regardless of SDC.
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Affiliation(s)
- Kirkwood F Adams
- Departments of Medicine and Radiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina 27599-7075, USA.
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Manunta P, Stella P, Rivera R, Ciurlino D, Cusi D, Ferrandi M, Hamlyn JM, Bianchi G. Left ventricular mass, stroke volume, and ouabain-like factor in essential hypertension. Hypertension 1999; 34:450-6. [PMID: 10489392 DOI: 10.1161/01.hyp.34.3.450] [Citation(s) in RCA: 133] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many patients with essential hypertension (EH) exhibit increased left ventricular mass. Similarly, elevated circulating levels of an endogenous ouabainlike factor (OLF) have been described in some but not all patients with EH. Moreover, ouabain has a hypertrophic influence on isolated cardiac myocytes. Accordingly, we investigated relationships among plasma OLF, left ventricular mass, and cardiac function in patients with EH. Plasma OLF was determined in 110 normotensive subjects and 128 patients with EH. Echocardiographic parameters and humoral determinants were measured in EH. Plasma OLF levels were increased (P<0.0001) in patients with EH (377+/-19 pmol/L) versus normotensive (253+/-53 pmol/L) subjects. The distribution of plasma OLF was unimodal in normotensives, whereas it was bimodal in EH. Twenty-four-hour diastolic ambulatory blood pressure was slighter higher in EH with high OLF compared with EH with normal OLF (93.2+/-1.14 versus 89.4+/-1.33 mm Hg, P=0.03). Left ventricular mass index and stroke volume in EH with high OLF were greater than in EH with normal OLF (101.9+/-3.3 versus 86.1+/-2.5 g/m(2), P=0.0003, and 57.10+/-1.48 versus 52.30+/-1.14 mL/m(2), P=0. 02, respectively), although heart rate was slower (74.2+/-1.3 versus 80.5+/-1.3 bpm, P=0.005). Multiple regression analysis that tested the influence of body mass index, age, gender, 24-hour blood pressure, and OLF on left ventricular mass revealed independent contributions of systolic (13.2%) and diastolic (12.4%) blood pressure and plasma OLF (11.6%) to left ventricular mass. We conclude that approximately 50% of patients with uncomplicated EH have elevated-high circulating OLF levels, higher diastolic blood pressure, greater left ventricular mass and stroke volume, and reduced heart rate. We propose that the OLF affects cardiovascular function and structure and should be considered as a factor that contributes to the risk of morbid events.
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Affiliation(s)
- P Manunta
- University of Milan and Division of Nephrology, Dialysis and Hypertension, IRCCS San Raffaele Hospital, Milan, Italy.
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Affiliation(s)
- M Gheorghiade
- Department of Medicine, Northwestern University Medical School, Chicago, Ill. 60611, USA
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Slatton ML, Irani WN, Hall SA, Marcoux LG, Page RL, Grayburn PA, Eichhorn EJ. Does digoxin provide additional hemodynamic and autonomic benefit at higher doses in patients with mild to moderate heart failure and normal sinus rhythm? J Am Coll Cardiol 1997; 29:1206-13. [PMID: 9137214 DOI: 10.1016/s0735-1097(97)00057-0] [Citation(s) in RCA: 147] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This study sought to examine the hemodynamic and autonomic dose response to digoxin. BACKGROUND Previous studies have demonstrated an increase in contractility and heart rate variability with digitalis preparations. However, little is known about the dose-response to digoxin, which has a narrow therapeutic window. METHODS Nineteen patients with moderate heart failure and a left ventricular ejection fraction < 0.45 were studied hemodynamically using echocardiography and blood pressure at baseline and after 2 weeks of low dose (0.125 mg daily) and 2 weeks of moderate dose digoxin (0.25 mg daily). Loading conditions were altered with nitroprusside at each study. Autonomic function was studied by assessing heart rate variability on 24-h Holter monitoring and plasma norepinephrine levels during supine rest. RESULTS Low dose digoxin provided a significant increase in ventricular performance, but no further increase was seen with the moderate dose. Low dose digoxin reduced heart rate and increased heart rate variability. Moderate dose digoxin produced no additional increase in heart rate variability or reduction in sympathetic activity, as manifested by heart rate, plasma norepinephrine or low frequency/high frequency power ratio. In addition, we did not find that either low or moderate dose digoxin increased parasympathetic activity. CONCLUSIONS We conclude that moderate dose digoxin provides no additional hemodynamic or autonomic benefit for patients with mild to moderate heart failure over low dose digoxin. Because higher doses of digoxin may predispose to arrhythmogenesis, lower dose digoxin should be considered in patients with mild to moderate heart failure.
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Affiliation(s)
- M L Slatton
- Echocardiography and Cardiac Catheterization Laboratories, Dallas Veterans Administration Hospital, Texas 75216, USA
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10
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van Veldhuisen DJ, de Graeff PA, Remme WJ, Lie KI. Value of digoxin in heart failure and sinus rhythm: new features of an old drug? J Am Coll Cardiol 1996; 28:813-9. [PMID: 8837553 DOI: 10.1016/s0735-1097(96)00247-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Digoxin has been a controversial drug since its introduction >200 years ago. Although its efficacy in patients with heart failure and atrial fibrillation is clear, its value in patients with heart failure and sinus rhythm has often been questioned. In the 1980s, reports of some large-scale trials indicated that digoxin, with or without vasodilators or angiotensin-converting enzyme inhibitors, reduced signs and symptoms of congestive heart failure and improved exercise tolerance. This beneficial influence was mainly found in patients with more advanced heart failure and dilated ventricles, whereas the effect in those with mild disease appeared to be less pronounced. In the last few years, new data have shown that digoxin may also have clinical value in mild heart failure, either when used in combination with other drugs or when administered alone. As neurohumoral activation has increasingly been recognized to be a contributing factor in the disease progression of chronic heart failure, the modulating effects of digoxin on neurohumoral and autonomic status have received more attention. Also, there is evidence that relatively low doses of digoxin may be at least as effective as higher doses and have a lower incidence of side effects. Further, the recognition that the use of digoxin too early after myocardial infarction may be harmful and the development of other drugs, in particular angiotensin-converting enzyme inhibitors, have obviously changed the place of digoxin in the treatment of chronic heart failure. The large-scale survival trial by the Digitalis Investigators Group (DIG), whose preliminary results have recently been presented, has shown that although digoxin has a neutral effect on total mortality during long-term treatment, it reduces the number of hospital admissions and deaths due to worsening heart failure. The potentially new features of the old drug digoxin are discussed in this review.
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Affiliation(s)
- D J van Veldhuisen
- Department of Cardiology/Thoraxcenter, University Hospital Groningen, The Netherlands
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Gheorghiade M, Hall VB, Jacobsen G, Alam M, Rosman H, Goldstein S. Effects of increasing maintenance dose of digoxin on left ventricular function and neurohormones in patients with chronic heart failure treated with diuretics and angiotensin-converting enzyme inhibitors. Circulation 1995; 92:1801-7. [PMID: 7671364 DOI: 10.1161/01.cir.92.7.1801] [Citation(s) in RCA: 124] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Despite almost three centuries of use, the appropriate dosage of digitalis in patients with chronic heart failure and normal sinus rhythm has not been well studied. METHODS AND RESULTS We studied 22 patients with heart failure who were receiving constant daily doses of digoxin, diuretics, and angiotensin-converting enzyme (ACE) inhibitors. In 18 patients, the oral daily dose of digoxin was increased from a mean of 0.20 +/- 0.07 to 0.39 +/- 0.11 mg/day corresponding to an increase in the serum digoxin concentration from 0.67 +/- 0.22 to 1.22 +/- 0.35 ng/mL. Radionuclide and echocardiographic left ventricular ejection fraction; maximal treadmill time; heart failure score; serum concentrations of norepinephrine, aldosterone, atrial natriuretic factor, and antidiuretic hormone; and plasma renin activity were obtained before and after the increase in digoxin dose. Subsequently, 9 patients were randomized to receive digoxin and 9 to receive placebo and radionuclide ejection fraction measured after 12 weeks. With the higher dose of digoxin compared with the lower dose, there was a significant increase in radionuclide ejection fraction from 23.7 +/- 9.6% to 27.1 +/- 11.8% (P = .007). No significant changes were noted in heart failure score; exercise tolerance; serum concentrations of norepinephrine, atrial natriuretic factor, and antidiuretic hormone; and plasma renin activity. There was, however, an increase in serum aldosterone concentration. Twelve weeks after the patients were randomized to receive digoxin or placebo, there was a significant decrease in ejection fraction (from 29.4 +/- 10.4% to 23.7 +/- 8.9%) in the placebo group but not in patients who continued to receive digoxin (P = .002). CONCLUSIONS The increase in maintenance digoxin dose, while maintaining serum concentrations within therapeutic range, resulted in a significant increase in left ventricular ejection fraction that was not associated with significant changes in heart failure score, exercise tolerance, and neurohumoral profile.
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Affiliation(s)
- M Gheorghiade
- Division of Biostatistics, Henry Ford Heart and Vascular Institute, Detroit, Mich, USA
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Dobbs RJ, O'Neill CJ, Deshmukh AA, Nicholson PW, Dobbs SM. Serum concentration monitoring of cardiac glycosides. How helpful is it for adjusting dosage regimens? Clin Pharmacokinet 1991; 20:175-93. [PMID: 2025980 DOI: 10.2165/00003088-199120030-00001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- R J Dobbs
- Clinical Research Centre, Northwick Park Hospital, Harrow, Middlesex, England
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Chatterjee K. Phosphodiesterase inhibitors: alterations in systemic and coronary hemodynamics. Basic Res Cardiol 1989; 84 Suppl 1:213-24. [PMID: 2684145 DOI: 10.1007/bf02650361] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This paper reviews the effect on myocardial contractility, left ventricular afterload and left ventricular distensibility induced by the following phosphodiesterase inhibitors: Enoximone, piroximone, RO 13-6438, amrinone and milrinone. For all these compounds, direct positive inotropic effects have been shown in experimental studies. For amrinone and milrinone, a direct stimulating effect on myocardial contractility has been demonstrated by an increase in dP/dtmax when intracoronary applications of the compounds were performed. A direct stimulating effect on the myocardium was also demonstrated for enoximone and piroximone by analyzing the systolic pressure versus end-systolic volume ratio. For all of the phosphodiesterase inhibitors, a marked decrease of systemic vascular resistance has been observed indicating direct peripheral vasodilation. Although it has been demonstrated that phosphodiesterase inhibition increases left ventricular distensibility, the nature of this effect is not clear. For most of the phosphodiesterase inhibitors an increase in myocardial oxygen requirements was demonstrated due to overall contractility increase. However, these phosphodiesterase inhibitors induce increased coronary blood flow in excess so that a direct effect of these compounds on the coronary vasculature has been postulated. The clinical significance of such changes, however, remains unclear.
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Kolibash AJ, Lewis RP, Bourne DW, Kramer WG, Reuning RH. Extension of the serum digoxin concentration--response relationship to patient management. J Clin Pharmacol 1989; 29:300-6. [PMID: 2723118 DOI: 10.1002/j.1552-4604.1989.tb03331.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The purposes of this investigation were to demonstrate how computer simulations may be employed to extrapolate data obtained from a single intravenous digoxin dose to multiple oral dosing patterns and how these simulations may apply to clinical situations. The intravenous data were obtained from a previous study of the pharmacokinetics of serum digoxin and its inotropic response (derived from systolic intervals) in 12 normal male volunteers. The simulations were applied to various clinical situations including variations in oral dosing, alternate loading doses, no loading versus loading dose, and intravenous versus oral dosing. A nonlinear relationship was found between response and the post-distribution serum digoxin concentration in the therapeutic range. Thus, the increase in inotropic response is less than proportional to the increase in digoxin concentration in serum. This nonlinear relationship has several important clinical implications for loading and maintenance dosing protocols. Such concepts may be important relative to more rational clinical use of digoxin and to decreasing digoxin toxicity.
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Affiliation(s)
- A J Kolibash
- Department of Internal Medicine, Ohio State University Hospitals, Columbus 43210
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16
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Abstract
Surgical patients frequently require drug treatments that can be assessed with serum drug concentrations. Of the agents for which serum drug concentrations are routinely available, the aminoglycosides theophylline, vancomycin, digoxin, and phenytoin are used most frequently in surgical patients. When using serum drug concentrations, the clinician should have an understanding of the relationships (or lack of) between drug concentrations and therapeutic or toxic effects. When blood is collected for serum concentration determinations, the exact timing of the sample in relation to the dose must be considered. For some drugs, (such as the aminoglycosides, it is necessary to determine peak and trough concentrations, whereas for other agents, like theophylline, the average or mid-dose level may be more important to consider. There are many factors that affect serum drug concentrations. Among these are various disease states, obesity, fluid imbalances, the drug dosage form used, and concurrent drug use. Not all patients require serum drug concentration monitoring; however, with each drug there are high-risk patients who may benefit. When used properly, serum drug concentrations may be helpful in maximizing therapeutic benefits, minimizing or diagnosing drug toxicity, and assessing patient compliance with drug regimens.
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Affiliation(s)
- J E Connors
- University of Georgia College of Pharmacy, Athens
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17
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Murphy AM, Gaum WE, Lathrop DA, Hussain AS, Ritschel WA, Kaplan S. Age-related digoxin effects in an intact canine model. Am Heart J 1987; 114:583-8. [PMID: 3630899 DOI: 10.1016/0002-8703(87)90756-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The inotropic and electrophysiologic effects of digoxin were studied in anesthetized neonatal and adult dogs to test the hypothesis that digoxin had comparable effects in these groups. Recordings of the ECG and central arterial pressure were made starting at 5.75 hours after an intravenous injection of 50 micrograms/kg of the drug. Parameters measured were heart rate (HR); PR interval; mean, systolic, and diastolic blood pressure; preejection period (PEP); and ejection time (ET). Two indices of systolic function were calculated, the systolic time interval (STI = PEP/ET) and total electromechanical systole (TMS = PEP + ET), which was indexed for HR. There was no significant difference from control animals in either the adult or neonatal groups in the PR interval or blood pressure. In the neonatal dogs, HR and STI were also not significantly different from control. However, in the neonatal dogs, there was a significant decrease in the indexed TMS, 288 +/- 7 vs 270 +/- 11 msec (p less than 0.01). In the adult animals, HR decreased from 116 +/- 35 to 66 +/- 25 bpm (p less than 0.01), STI decreased from 0.559 +/- 0.059 to 0.447 +/- 0.069 (p less than 0.01), and indexed TMS decreased from 333 +/- 10 to 291 +/- 13 msec (p less than 0.001). Two-way analysis of variance demonstrated that digoxin differed significantly in its effects on HR (p = 0.005), STI (p = 0.018), and TMS indexed for HR (p = 0.003) in neonatal compared to adult dogs. Pharmacokinetic studies showed a rapid distribution phase and equilibrium conditions at the time of physiologic measurements.(ABSTRACT TRUNCATED AT 250 WORDS)
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Chatterjee K, Kereiakes D, Viquerat C, Podolin R. Potential mechanisms of improved left ventricular function with enoximone in severe congestive heart failure. Am J Cardiol 1987; 60:37C-41C. [PMID: 2956866 DOI: 10.1016/0002-9149(87)90523-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Enoximone, a phosphodiesterase inhibitor, is a potent inotropic vasodilator agent that causes a marked improvement in systemic hemodynamics in patients with severe chronic congestive heart failure. Cardiac index, stroke volume index and stroke work index increase, and there is a significant decrease in pulmonary capillary wedge pressure. Left ventricular dP/dt increases, despite a decrease in arterial pressure and systemic vascular resistance and without any significant change in heart rate, indicating a positive inotropic effect. A marked decrease in systemic vascular resistance indicates that decreased left ventricular outflow resistance resulting from peripheral vasodilation also contributes to improvement in left ventricular function. In some patients, left ventricular end-diastolic volume increases despite a marked decrease in pulmonary capillary wedge pressure, suggesting an improvement in apparent left ventricular compliance, which may also be contributory to improved left ventricular function.
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Rousson D, Piolat C, Galleyrand J, Ferry S, Boissel JP. Systolic time intervals in evaluation of the negative inotropic effect after single oral doses of mexiletine and disopyramide. Eur J Clin Pharmacol 1986; 30:263-8. [PMID: 3732360 DOI: 10.1007/bf00541525] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A placebo-controlled, single blind, crossover study was done to evaluate the inotropic effects of single oral doses of mexiletine and disopyramide assessed by the measurement of Systolic Time Intervals (STI). Each of 8 healthy volunteers received five treatments in random order: 200 and 400 mg mexiletine, 100 and 200 mg disopyramide, and placebo. There was a significant increase in cumulated PEP after 400 mg mexiletine and 200 mg disopyramide. There was no significant change in LVET and QS2. Peak plasma levels were in the lower range of the reputed antiarrythmic levels. Plasma concentration-effect relationships are discussed. Although the study revealed large inter- and intrasubject variability in the measured STIs, it is concluded that a negative inotropic effect was detected despite the low plasma levels of the minor negative inotropic drugs.
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20
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Kereiakes DJ, Viquerat C, Lanzer P, Botvinick EH, Spangenberg R, Buckingham M, Parmley WW, Chatterjee K. Mechanisms of improved left ventricular function following intravenous MDL 17,043 in patients with severe chronic heart failure. Am Heart J 1984; 108:1278-84. [PMID: 6238512 DOI: 10.1016/0002-8703(84)90754-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To evaluate the mechanisms for improved left ventricular function with MDL 17,043 in patients with severe chronic heart failure, 24 patients were evaluated by simultaneous determination of hemodynamics by right heart catheterization and ejection fraction by computerized nuclear probe before and following intravenous administration of MDL 17,043 (mean cumulative dose 3.6 mg/kg). Following MDL 17,043, there was an increase in cardiac index (+62%), stroke volume index (+42%), and stroke work index (+68%), together with a decrease in pulmonary capillary wedge pressure (-46%), indicating improved left ventricular pump function. There was a marked reduction in systemic vascular resistance (-40%) and a modest reduction in arterial pressure, indicating decreased left ventricular outflow resistance. The ratio of peak systolic blood pressure to calculated left ventricular end-systolic volume tended to increase, but the change was not statistically significant. Despite a marked increment in stroke volume index, left ventricular ejection time corrected for heart rate was shortened, suggesting enhanced contractility. In the group as a whole, the calculated left ventricular end-diastolic volume remained unchanged, but it increased in 14 patients. Since pulmonary capillary wedge pressure fell in each patient, this suggests improved overall left ventricular distensibility. Thus, decreased left ventricular outflow resistance, and possibly increased contractile function, and improved left ventricular diastolic compliance may all contribute to improved left ventricular pump function with MDL 17,043 in patients with severe heart failure.
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21
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Ware JA, Snow E, Luchi JM, Luchi RJ. Effect of digoxin on ejection fraction in elderly patients with congestive heart failure. J Am Geriatr Soc 1984; 32:631-5. [PMID: 6236251 DOI: 10.1111/j.1532-5415.1984.tb02249.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To assess the effect of oral digoxin on left ventricular systolic function in elderly patients, radionuclide angiography was performed on 20 patients 74 years old or older before and after several weeks of oral digoxin. The mean age was 83.8 years. All had congestive heart failure or cardiomegaly, and all were in sinus rhythm. The ejection fraction was 0.36 +/- 0.10 (mean +/- SD) before digoxin; 0.45 +/- 0.09 after digoxin (P less than 0.01). A comparison group that did not receive digoxin had no significant improvement in ejection fraction. In ten patients serial radionuclide angiograms were repeated after increasing serum digoxin concentrations. Six demonstrated maximal improvement in ejection fraction at serum digoxin concentrations of 0.4-1.0 ng/ml. It is concluded that oral digoxin improves left ventricular ejection fraction in elderly patients with congestive heart failure or cardiomegaly who are in sinus rhythm. Some of these patients achieve maximal improvement in ejection fraction at serum digoxin concentrations of less than 1.0 ng/ml.
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22
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Smith TW, Antman EM, Friedman PL, Blatt CM, Marsh JD. Digitalis glycosides: mechanisms and manifestations of toxicity. Part III. Prog Cardiovasc Dis 1984; 27:21-56. [PMID: 6146162 DOI: 10.1016/0033-0620(84)90018-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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23
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Smith TW, Antman EM, Friedman PL, Blatt CM, Marsh JD. Digitalis glycosides: mechanisms and manifestations of toxicity. Part II. Prog Cardiovasc Dis 1984; 26:495-540. [PMID: 6326196 DOI: 10.1016/0033-0620(84)90014-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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24
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Smith TW, Antman EM, Friedman PL, Blatt CM, Marsh JD. Digitalis glycosides: mechanisms and manifestations of toxicity. Part I. Prog Cardiovasc Dis 1984; 26:413-58. [PMID: 6371896 DOI: 10.1016/0033-0620(84)90012-4] [Citation(s) in RCA: 94] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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25
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Abstract
Cardiac glycosides exert an acute positive inotropic effect on the normal and failing heart. Recent evidence establishes that the positive inotropic effect is maintained over several months in many patients. The effectiveness of long-term treatment with cardiac glycosides in relieving symptoms is less certain; only a small subset of patients benefits. An effect on mortality is not established. The use of digoxin in the treatment of mild heart failure is questionable since the drug has serious side-effects and the efficacy in patients already taking diuretics has not been established. The use of glycosides in the treatment of severe chronic heart failure is being challenged because of the availability of powerful diuretics, new vasodilators and alternative positive inotropes.
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Pedersen KE, Thayssen P, Klitgaard NA, Christiansen BD, Nielsen-Kudsk F. Influence of verapamil on the inotropism and pharmacokinetics of digoxin. Eur J Clin Pharmacol 1983; 25:199-206. [PMID: 6628501 DOI: 10.1007/bf00543791] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Verapamil has been demonstrated to inhibit the elimination of digoxin and to increase its steady state plasma level by 60-80%. Animal studies suggest that verapamil abolishes the intropic action of other drugs such as ouabain and dopamine. The clinical consequences of this drug interaction were investigated by examining the inotropic activity of single doses of digoxin (assessed from systolic time intervals), with and without coadministration of verapamil. Verapamil decreased total-body clearance of digoxin from 4.68 +/- 0.41 to 3.29 +/- 0.26 ml/min/kg (p less than 0.001) and increased the plasma half-life of the drug from 33.50 +/- 2.38 to 41.31 +/- 2.27 h (p less than 0.01). Verapamil had no influence on the base-line values of the systolic time intervals. Both in the absence and presence of verapamil, digoxin caused significant shortening of the total electromechanical systole and the left ventricular ejection time. However, compared to control conditions, the decay of these changes was slower in the presence of verapamil, in parallel with the prolongation of the plasma half-life of digoxin. A linear relationship was established between reductions in the systolic time intervals and the computer-derived concentration of digoxin in the deep compartment. These regression lines, which represent the concentration-effect relationships of the inotropism of digoxin, were not affected by verapamil. Thus, verapamil per se had no measurable effect either on base-line contractile function of the heart or on digoxin-induced inotropism. The elevated plasma digoxin concentration induced by verapamil appears cardioactive in terms of inotropism.
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27
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Maskin CS, Forman R, Sonnenblick EH, Frishman WH, LeJemtel TH. Failure of dobutamine to increase exercise capacity despite hemodynamic improvement in severe chronic heart failure. Am J Cardiol 1983; 51:177-82. [PMID: 6849256 DOI: 10.1016/s0002-9149(83)80032-0] [Citation(s) in RCA: 136] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The acute hemodynamic and metabolic effects of dobutamine administered during exercise were studied in 8 patients with severe chronic heart failure. Exercise was performed on an upright bicycle ergometer using a graded protocol. During exercise performed without administration of dobutamine, exhaustion occurred after 4.5 +/- 1.2 minutes of exercise. The cardiac index increased from 1.61 +/- 0.25 to 2.67 +/- 0.59 liters/min/m2 (p less than 0.001), the arteriovenous oxygen difference from 7.8 +/- 1.7 to 12.5 +/- 2.4 ml/100 ml (p less than 0.001), and oxygen uptake from 7.9 +/- 3.0 to 41.2 +/- 15.7 mg/100 ml (p less than 0.001). During exercise performed with the administration of dobutamine, the cardiac index was significantly greater than during the control state, 3.23 +/- 0.78 versus 2.67 +/- 0.59 liters/min/m2 (p less than 0.001), while the arteriovenous oxygen difference was significantly lower, 11.2 +/- 2.1 vs 12.5 +/- 2.4 ml/100 ml (p less than 0.01). The arterial lactate level was not significantly changed, 45.3 +/- 17.6 versus 41.2 +/- 15.7 mg/100 ml. Although the dobutamine level tended to increase maximal oxygen uptake compared with the control period of exercise, 9.1 +/- 1.2 versus 8.5 +/- 1.4 ml/kg/min (p less than 0.05), it did not significantly increase exercise capacity, 4.8 +/- 1.5 versus 4.5 +/- 1.2 min. Thus administration of dobutamine in patients with severe chronic heart failure increased the cardiac index during maximal exercise but failed to increase exercise capacity. Since arteriovenous oxygen difference is reduced, dobutamine probably increases blood flow to the nonexercising tissues and not to the actively metabolizing muscles.
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28
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Jogestrand T, Sundqvist K. Skeletal muscle digoxin concentration and its relation to serum digoxin concentration and cardiac effect in healthy man. Eur J Clin Pharmacol 1981; 19:89-95. [PMID: 7202476 DOI: 10.1007/bf00568394] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Blood samples and skeletal muscle biopsies (m. quadriceps femoris, vastus lateralis) were taken from seven healthy subjects for analysis of serum and skeletal muscle digoxin concentrations by radioimmunoassay using a percutaneous needle biopsy technique for muscle sampling. The subjects were investigated on two digoxin dose levels and on the third day after withdrawal of digoxin. It was found that the skeletal muscle/serum digoxin ratio was significantly higher than the corresponding ratio obtained in a previous study with muscle sampling (m. rectus abdominis) from patients during open heart surgery. The present study indicates a significant correlation between the digoxin concentrations in serum and skeletal muscle as well as between cardiac effect, measured by changes in QS2I, and skeletal muscle digoxin concentration. A doubling of the digoxin dose gave a proportional increase in skeletal muscle digoxin concentration. The magnitude of the estimated half-life of skeletal muscle digoxin was the same as previously reported for serum or plasma digoxin.
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29
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Jogestrand T, Ericsson F, Sundqvist K. Skeletal muscle digoxin concentration during digitalization and during withdrawal of digoxin treatment. Eur J Clin Pharmacol 1981; 19:97-105. [PMID: 7202477 DOI: 10.1007/bf00568395] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Blood samples and skeletal muscle biopsies (m. quadriceps femoris, vastus lateralis) were taken from 15 patients during digitalization or during withdrawal of digoxin treatment for analysis of serum and skeletal muscle digoxin concentrations. A percutaneous needle biopsy technique was used for muscle sampling and digoxin was analysed by radioimmunoassay. During "slow" digitalization with 0.25 mg digoxin daily the skeletal muscle digoxin concentrations after 2 and 4 days were 45% (range 19%--62%; n = 3) and 78% (range 56%--92%; n= 3) respectively, of the steady state concentration (defined as the digoxin concentration after 25--40 days of treatment). After 9 and 11 days of treatment the skeletal muscle digoxin concentrations were 106% (range 84%--133%; n = 5) and 116% (range 72%--164%; n = 3) respectively, of the steady state concentration. A doubling of the digoxin dose gave a proportional increase in skeletal muscle digoxin concentration (three patients). The magnitude of the estimated half-life of skeletal muscle digoxin was the same as previously reportedly in healthy subjects. No significant correlations were found between changes in systolic time intervals and steady state serum or skeletal muscle digoxin concentrations.
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30
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Arnold SB, Byrd RC, Meister W, Melmon K, Cheitlin MD, Bristow JD, Parmley WW, Chatterjee K. Long-term digitalis therapy improves left ventricular function in heart failure. N Engl J Med 1980; 303:1443-8. [PMID: 6776403 DOI: 10.1056/nejm198012183032503] [Citation(s) in RCA: 288] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
To clarify the controversy regarding the benefits of long-term oral digoxin in the treatment of heart failure, we evaluated hemodynamics at rest and during exercise in nine patients in sinus rhythm with symptomatic heart failure. Patients were studied during long-term digoxin therapy, after withdrawal of the drug, and six hours after readministration. Upon withdrawal of digoxin, pulmonary capillary-wedge pressure increased from 21 +/- 8 to 29 +/- 10 mm Hg, and cardiac index decreased from 2.4 +/- 0.7 to 2.1 +/- 0.6 liters per minute per square meter of body-surface area, suggesting a deterioration in left ventricular function. In addition, heart rate tended to increase and stroke-work index, stroke-volume index, and radioangiographic ejection fraction decreased. Acute readministration restored the hemodynamic values to those observed during long-term digoxin therapy. The improvement in hemodynamics during long-term digoxin administration was also observed during exercise. This improvement demonstrated the value of long-term oral digoxin therapy in congestive heart failure.
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31
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Cokkinos DV, Tsartsalis GD, Heimonas ET, Gardikas CD. Comparison of the inotropic action of digitalis and isoproterenol in younger and older individuals. Am Heart J 1980; 100:802-6. [PMID: 7446382 DOI: 10.1016/0002-8703(80)90059-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The positive inotropic effects of digitalis (deslanoside C, 1.2 mg. intravenously) and isoproterenol (2 microgram/minute intravenously) were compared in two groups of younger and older individuals using the systolic time interval method. Both groups responded in a completely comparable way to deslanoside C. However, after isoproterenol administration, the LVET of the older group was significantly shortened. Consequently, the PEP/LVET ratio did not change significantly. This difference is attributed to a lesser increase of the stroke volume in the older group.
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32
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Berman W, Musselman J, Shortencarrier R. The physiologic effects of digoxin under steady-state drug conditions in newborn and adult sheep. Circulation 1980; 62:1165-71. [PMID: 7438352 DOI: 10.1161/01.cir.62.6.1165] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The physiologic response to the chronic administration of digoxin was studied in 12 adult and 13 newborn sheep. Vascular pressures, cardiac output, isovolumic contraction phase indexes and systolic time intervals were measured before and after 2 weeks of digoxin therapy. Physiologic measurements were correlated with drug levels in plasma and myocardium. Resting myocardial function in newborns exceeded that in ewes. In ewes, the heart rate decreased from 98 to 74 beats/min, the preejection period (PEP) decreased from 76 to 57 msec, the ratio of PEP to left ventricular ejection time (LVET) decreased from 0.323 to 0.223 and dP/dt max increased from 2415 to 3460 mm Hg . sec-1 as plasma concentrations of digoxin increased to a mean of 1.8 ng/ml. Although the final steady-state plasma concentration of digoxin in newborn lambs averaged 1.7 ng/ml, cardiac output, PEP, PEP/LVET and dP/dt max did not change significantly from baseline values. These studies suggest that developmental differences in the physiologic response to digoxin are due either to a limited capacity for improvement in myocardial contractility shortly after birth or to an age-related difference in the effect of digoxin on myocardial tissue.
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33
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Hirsh PD, Weiner HJ, North RL. Further insights into digoxin-quinidine interaction: lack of correlation between serum digoxin concentration and inotropic state of the heart. Am J Cardiol 1980; 46:863-8. [PMID: 7435398 DOI: 10.1016/0002-9149(80)90441-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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34
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Keller F, Molzahn M, Ingerowski R. Digoxin dosage in renal insufficiency: impracticality of basing it on the creatinine clearance, body weight and volume of distribution. Eur J Clin Pharmacol 1980; 18:433-41. [PMID: 7439268 DOI: 10.1007/bf00636799] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Previous dosing schedules for digoxin in renal failure have considered the decrease in the elimination rate constant but not the decrease in the volume of distribution. A dosing schedule based on the creatinine clearance, body weight and volume of distribution has been developed from pharmacokinetic data taken from the literature. Its validity was tested in a clinical study of 35 patients with chronic renal insufficiency not requiring dialysis. The dosing schedule resulted in correct digitalization expressed as a steady state plasma digoxin concentration in the therapeutic range (0.5-2.0 ng/ml) in 25 out of 27 patients (93%). However, of 82 possible candidates for the study, it could not be performed in 47 (57%). The high drop-out rate was mainly due to the complicated dosing schedule and to the difficulty of repeatedly measuring creatinine clearance on a routine basis. Therefore, safe dosing of digoxin in renal insufficiency does not seem to be feasible in practice. Digitoxin may be a better alternative.
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35
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36
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Kramer WG, Kolibash AJ, Lewis RP, Bathala MS, Visconti JA, Reuning RH. Pharmacokinetics of digoxin: relationship between response intensity and predicted compartmental drug levels in man. JOURNAL OF PHARMACOKINETICS AND BIOPHARMACEUTICS 1979; 7:47-61. [PMID: 458556 DOI: 10.1007/bf01059440] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A study designed to investigate the relationship between the pharmacokinetics of digoxin and a measure of its pharmacological effect has been conducted. Serum digoxin concentrations and systolic time intervals were measured concurrently in 12 normal male volunteers following a 1.0 mg i.v. bolus injection. The averaged serum digoxin concentration--time and response--time data were analyzed pharmacokinetically using a three-compartment open model and nonlinear least-squares fitting. When only the serum level--time data were analyzed, a close relationship was found between calculated digoxin levels in the slowly distributing (deep) peripheral compartment and response of the heart to digoxin, as measured by changes in the QS2 index (delta QS2I). Although it was not possible to distinguish clearly a linear from a nonlinear relationship between digoxin levels in the deep compartment and delta QS2I, the nonlinear relationship gave the best overall fit when both serum digoxin and delta QS2I data were fitted simultaneously. The simultaneous fit yielded a total body clearance of digoxin of 3.6 ml/min/kg and a terminal t1/2 of 42 hr.
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37
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Okada RD, Hager WD, Graves PE, Mayersohn M, Perrier DG, Marcus FI. Relationship between plasma concentration and dose of digoxin in patients with and without renal impairment. Circulation 1978; 58:1196-203. [PMID: 709776 DOI: 10.1161/01.cir.58.6.1196] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The purpose of this study was to determine if there is a linear relationship between oral doses of digoxin and various measurements of steady-state digoxin plasma concentration and urinary excretion in patients with wide range of renal function. Ten patients (mean age 58 years) with creatinine clearances greater than 50 ml/min/1.73 m2 BSA (mean creatinine clearance 80 ml/min/1.73 m2 BSA) and nine patients mean age 61 years) with creatinine clearances less than 50 ml/min/1.73 m2 BSA (mean creatinine clearance 20 ml/min/1.73 m2 BSA) were given digoxin tablets orally at two or three different dose levels (dose range 0.0313--0.5 mg/day). After a dosing period equal to at least five half-lives, three to four consecutive daily digoxin plasma concentrations were determined. Plasma concentrations and urinary digoxin excretion were measured during one 24-hour dosing interval at each dose level. Digoxin plasma and urine concentrations were determined in triplicate using radioimmunoassay. Individual patient plots provided evidence of linearity for: digoxin 24-hour steady-state plasma concentration vs dose; digoxin 24-hour cumulative urinary excretion versus dose; and area under the digoxin plasma concentration-time curve during a 24-hour dosing interval vs dose. Absolute values for these various parameters indicated substantial interpatient variation probably due to patient differences in both digoxin absorption and digoxin total body clearance. These results indicate that there is a linear relationship between digoxin plasma concentration and dose in patients with normal and decreased renal function. This linearity is support for dose-independent pharmacokinetics of digoxin in man. We conclude from these data that a change in digoxin dose should result in a proportional change in digoxin plasma concentration over the dose range examined.
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38
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Belz GG, Erbel R, Schumann K, Gilfrich HJ. Dose-response relationships and plasma concentrations of digitalis glycosides in man. Eur J Clin Pharmacol 1978; 13:103-11. [PMID: 350590 DOI: 10.1007/bf00609753] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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39
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Kleiman JH, Ingels NB, Daughters G, Stinson EB, Alderman EL, Goldman RH. Left ventricular dynamics during long-term digoxin treatment in patients with stable coronary artery disease. Am J Cardiol 1978; 41:937-42. [PMID: 645604 DOI: 10.1016/0002-9149(78)90737-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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40
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Abstract
Correlative studies of serum digoxin levels, cardiac rhythm and related clinical laboratory data were carried out in 114 patients. Seventy-three patients who presented with 79 episodes of arrhythmias typical of digitalis intoxication could be separated into a normokalemic group of 55 patients whose serum digoxin level was 6.68 +/- 0.17 ng/ml (mean +/- standard error of the mean), and a hypokalemic group of 24 with a mean serum digoxin level of 1.13 +/- 0.04 ng/ml (P less than 0.001). Of 45 consectutive normokalemic patients with a high serum digoxin level (more than 2 mg/ml) who underwent serial studies, 17 had arrhythmias. Serial studies in 10 hypokalemic patients revealed an inconsistent relation between presence of arrhythmia and serum digoxin level. During repletion of serum potassium in seven of these patients with an arrhythmia, the arrhythmia disappeared without a significant change in serum digoxin level in four patients. A group of seven patients had 16 episodes of serum digoxin level greater than 2.2 ng/ml, but an arrhythmia occurred during only 3 of these episodes. A sharp border between toxic and therapeutic serum digoxin values was not found in these groups of study patients. The serum digoxin level at which arrhythmias occurred appeared to be variable for both groups and individual patients. However, correlative studies utilizing serum digoxin levels can define existing thresholds for therapeutic and toxic effects and may often be more useful than isolated observations.
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41
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Shapiro W. Current considerations in digoxin usage. CRC CRITICAL REVIEWS IN CLINICAL LABORATORY SCIENCES 1978; 9:321-46. [PMID: 401374 DOI: 10.3109/10408367809150924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- W Shapiro
- Dallas Veterans Administration Hospital, Texas
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42
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Dobbs RJ, Dobbs SM, Kenyon WI. Maintenance digoxin after an episode of heart failure. BRITISH MEDICAL JOURNAL 1977; 2:522-3. [PMID: 890397 PMCID: PMC1630883 DOI: 10.1136/bmj.2.6085.522-c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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43
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Vogel R, Frischknecht J, Steele P. Short- and long-term effects of digitalis on resting and posthandgrip hemodynamics in patients with coronary artery disease. Am J Cardiol 1977; 40:171-6. [PMID: 879022 DOI: 10.1016/0002-9149(77)90004-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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44
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Aronson JK, Grahame-Smith DG, Hallis KF, Hibble A, Wigley F. Monitoring digoxin therapy: I. Plasma concentrations and an in vitro assay of tissue response. Br J Clin Pharmacol 1977; 4:213-21. [PMID: 861136 PMCID: PMC1429008 DOI: 10.1111/j.1365-2125.1977.tb00697.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
1 An in vitro technique is described for measuring the uptake of 86Rb by human erythrocytes. 2 Fifteen patients were treated with digoxin for atrial fibrillation and other fast arrhythmias. 3 86Rb uptake by the patients' own red cells fell from pre-treatment values during digitalization. 4 The therapeutic response of patients with atrial fibrillation correlated better with the changes in 86Rb uptake than with plasma digoxin concentrations.
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