Unusually large digitalis requirements. A study of altered digoxin metabolism

Gut microbiota in reductive drug metabolism

Gut bacteria are predominant microorganisms in the gut microbiota and have been recognized to mediate a variety of biotransformations of xenobiotic compounds in the gut. This review is focused on one of the gut bacterial xenobiotic metabolisms, reduction. Xenobiotics undergo different types of reductive metabolisms depending on chemically distinct groups: azo (-NN-), nitro (-NO₂), alkene (-CC-), ketone (-CO), N-oxide (-NO), and sulfoxide (-SO). In this review, we have provided select examples of drugs in six chemically distinct groups that are known or suspected to be subjected to the reduction by gut bacteria. For some drugs, responsible enzymes in specific gut bacteria have been identified and characterized, but for many drugs, only circumstantial evidence is available that indicates gut bacteria-mediated reductive metabolism. The physiological roles of even known gut bacterial enzymes have not been well defined.

Digoxin and its related endogenous factors

The digitalis drugs are plant-derived cardenolide compounds used medicinally for several hundred years. These drugs elicit inotropic and chronotropic effects on the heart, but they also affect many other tissues. The mechanism of action involves inhibition of the ion-transport activity of a membrane-associated protein called Na, K-ATPase (sodium pump). Present theory holds that the sodium pump is the principal molecular receptor for the digitalis drugs. Recent evidence indicates the presence of naturally occurring digitalis-like compounds in mammals. It is believed these compounds, collectively known as either digitalis-like (DLF) or ouabain-like (OLF) factors, may be endogenous hormones regulating the biological activity of the sodium pump and its isoforms. The presence of deglycosylated and other congeners of one specific DLF, the digoxin-like immunoreactive factor (DLIF), has very recently been described in humans. Digoxin as a drug is the most widely prescribed digitalis in the U.S., and its measurement in serum has established a model for present-day therapeutic drug monitoring (TDM). Historically, the accurate measurement of digoxin in blood has been difficult. This article focuses on the present understanding of the clinical use of digoxin, factors that affect the accuracy of measuring digoxin, the principle of measuring metabolically active species of digoxin, and the effects of DLIF and other interfering substances in digoxin immunoassay.

Familial distal renal tubular acidosis is associated with mutations in the red cell anion exchanger (Band 3, AE1) gene

All affected patients in four families with autosomal dominant familial renal tubular acidosis (dRTA) were heterozygous for mutations in their red cell HCO3-/Cl- exchanger, band 3 (AE1, SLC4A1) genes, and these mutations were not found in any of the nine normal family members studied. The mutation Arg589--> His was present in two families, while Arg589--> Cys and Ser613--> Phe changes were found in the other families. Linkage studies confirmed the co-segregation of the disease with a genetic marker close to AE1. The affected individuals with the Arg589 mutations had reduced red cell sulfate transport and altered glycosylation of the red cell band 3 N-glycan chain. The red cells of individuals with the Ser613--> Phe mutation had markedly increased red cell sulfate transport but almost normal red cell iodide transport. The erythroid and kidney isoforms of the mutant band 3 proteins were expressed in Xenopus oocytes and all showed significant chloride transport activity. We conclude that dominantly inherited dRTA is associated with mutations in band 3; but both the disease and its autosomal dominant inheritance are not related simply to the anion transport activity of the mutant proteins.

Clarithromycin-induced digoxin intoxication

OBJECTIVE

To report a case of clarithromycin-induced digoxin intoxication.

CASE SUMMARY

A 78-year-old white man with ischemic cardiomyopathy and chronic renal insufficiency was admitted 4 days after being prescribed clarithromycin for a suspected episode of bronchitis. He reported weakness, asthenia, and gastrointestinal symptoms; the digoxin serum concentration was measured at 3.89 ng/mL. The patient recovered uneventfully after digoxin and clarithromycin were discontinued.

DISCUSSION

Erythromycin frequently interacts with other drugs that are also metabolized by the CYP3A4 isoenzyme. However, erythromycin is hypothesized to interact with digoxin by inhibiting Eubacterium lentum, which is a normal inhabitant of the human gut and is responsible for intestinal metabolism of digoxin in 10% of patients. Since clarithromycin shares a comparable antibacterial spectrum with erythromycin, the possibility of a drug interaction with digoxin remains. Only four cases of clarithromycin interacting with digoxin have been reported to date. Clinically, this interaction may have been more obvious because of our patient's moderate renal dysfunction and serum digoxin concentrations in the upper therapeutic range prior to clarithromycin initiation. Other causes for digoxin intoxication could not be identified.

CONCLUSIONS

Clarithromycin may inhibit the growth of E. lentum, which can lead to an increase in digoxin bioavailability and blood concentrations in patients in whom this intestinal metabolic pathway is present. Patients at risk include those with renal dysfunction, with serum concentrations in the upper therapeutic range, or with measured digoxin concentrations that are much lower than predicted by pharmacokinetic calculations. For these patients, appropriate therapy includes the selection of an alternative, noninteracting antibiotic or, if this is not possible, a temporary reduction of digoxin dosage.

Digoxin-macrolide drug interaction

Macrolide antibiotics appear to be able to enhance the oral bioavailability of digoxin by altering the gastrointestinal flora that metabolize digoxin to less active dihydro metabolites, thus leading to increased serum digoxin concentrations and possible digoxin toxicity in select patients stabilized on digoxin therapy. This interaction may be of clinical importance in up to 10% of the population. Currently, the orally administered erythromycin, clarithromycin, and roxithromycin have been implicated. Although realistically this interaction may be encountered rarely, when it does occur, it can be of clinical significance.

Effects of acarbose on fecal nutrients, colonic pH, and short-chain fatty acids and rectal proliferative indices

Acarbose, an alpha-glycosidase inhibitor, treats diabetes mellitus by delaying the digestion and intestinal absorption of dietary carbohydrates. In effective doses, acarbose induces some passage of carbohydrates into the colon. The effect of such chronic carbohydrate transfer on colonic structure and function is unknown. We studied the effects of 1 year of acarbose administration in diabetes mellitus on fecal energy, protein, and fat, including short-chain fatty acids (SCFA) output, fecal pH, and several metabolizing bacterial species. Changes in colonic histology and epithelial cell proliferation were investigated in rectal biopsies. Fecal macronutrient output was unaffected by acarbose, but pH decreased and total SCFA, butyrate, and acetate output were markedly greater. Breath hydrogen output increased after acarbose, but digoxin-metabolizing bacteria and diacylglycerol (DAG) production were unaltered. Compared with the control, acarbose did not induce hyperplasia or change rectal proliferation. However, total fecal SCFA and butyrate output correlated inversely with proliferation in the rectal upper crypt-a biomarker of risk for colonic neoplasia. In conclusion, long-term acarbose administration does not adversely affect colonic function or fecal nutrient output. If increased fecal SCFA and butyrate reduces upper-crypt proliferation, then acarbose may reduce the risk of colonic neoplasia.

Comparison of digoxin analysis by high-performance liquid chromatography/post-column derivatization and fluorescence polarization immunoassay

1. This study compared the analysis of digoxin using a high-performance liquid chromatographic post-column derivatization (HPLC-PC) assay and the TDx fluorescence polarization immunoassay (FPIA). 2. Serum obtained from 15 digitalized patients showed higher mean digoxin levels with the FPIA method as compared to the HPLC-PC procedure such that the mean HPLC-PC/FPIA ratio was 0.91 +/- 0.14 (mean +/- SD). Demonstrated cross-reactivity of digoxin metabolites with the FPIA is probably responsible for this observation. 3. Cross-reactivity of the immunoassay towards endogenous material present in serum samples from certain patient groups was an even greater problem, with apparent 'digoxin' serum concentrations in untreated hepatic failure patients being within the therapeutic range for digoxin. 4. The HPLC-PC method did not suffer from such interference and would therefore provide more accurate values for patients where high levels of interference could contribute to false digoxin levels.

Electrochemical detection of the 3,5-dinitrobenzoyl derivative of digoxin by high-performance liquid chromatography

Electrochemical detection of 3,5-dinitrobenzoyl derivatives of digoxin and its metabolites following high-performance liquid chromatography is reported. Partial resolution of derivatized digoxin and dihydrodigoxin was obtained using a Spherisorb ODS II analytical column. Both single- and dual-electrode detection were investigated and a maximum sensitivity equivalent to 0.39 ng of digoxin was found with the dual-electrode method. This system has the necessary sensitivity and selectivity for development into a therapeutic monitoring assay method.

Metabolism of drugs and other xenobiotics in the gut lumen and wall

Metabolism in the gut lumen and wall can decrease the bioavailability and the pharmacological effects of a wide variety of drugs. Bacterial flora in the gut, the environmental pH and oxidative or conjugative enzymes present in the intestinal epithelial cells can all contribute to the process. Bacterial biotransformation is greatest in the colon, while gut wall metabolism is generally highest in the jejunum and decreases distally. Gut wall metabolism may be induced or inhibited by dietary or environmental xenobiotics or by co-administered drugs. Recent evidence suggests that some drugs, food-derived mutagens and other xenobiotics can be metabolized by gut flora and/or gut wall enzymes to reactive species which may cause tumors.

Erythromycin-induced digoxin toxicity

The potential interaction between certain antibiotics and digoxin has been discussed in the literature; however, few cases of actual erythromycin-induced digoxin toxicity have been reported. We present a case in which an 86-year-old woman who was taking digoxin 0.25 mg/d developed probably digoxin toxicity after the administration of erythromycin for the treatment of otitis media and streptococcal pharyngitis. Her digoxin concentration increased from a trough of 1.9 to 5.1 nmol/L six days after the erythromycin was started. Digoxin was discontinued and restarted approximately six weeks later when the patient's atrial fibrillation and congestive heart failure recurred. Her digoxin dose at this time was 0.125 mg/d and resulted in steady-state concentrations of 1.2, 1.4, and 1.2 nmol/L over the next year. Erythromycin inhibition of Eubacterium lentum, which converts digoxin into digoxin-reduction products in the gut, is the proposed mechanism of this interaction.

Geographic differences in digoxin inactivation, a metabolic activity of the human anaerobic gut flora

The inactivation of digoxin by conversion to reduced metabolites (digoxin reduction products, or DRP), a function of the anaerobic gut flora, was studied in normal volunteers from southern India and the United States. Digoxin was metabolised to DRP by 28 (13.7%) of 204 healthy south Indians in contrast to 67 (36.0%) of 186 New Yorkers (p less than 1 X 10(-6)). Only 1.0% of Indians compared with 14.0% of Americans excreted large amounts of metabolites (greater than 40% DRP) in the urine (p less than 1 X 10(-5)). Of 104 urban Indians, 23 (22.1%) were metabolisers, in contrast with five of 100 rural villagers (p less than 0.001). Within the urban group, digoxin metabolism correlated with education, frequency of animal protein intake, and most significantly, personal income. Organisms capable of reducing digoxin in vitro were found with similar frequencies in stool cultures from Indians and Americans. In the cultures of some subjects, DRP production was inhibited at lower dilutions but expressed at higher dilutions. We conclude that variations in drug metabolism between population groups may result from differences in the metabolic activity of the anaerobic gut flora probably mediated by environmentally determined factors.

Interethnic variation in the metabolic inactivation of digoxin by the gut flora

Digoxin is metabolized to cardioinactive reduced metabolites (digoxin reduction products) in some patients by anaerobic bacteria present in the gut flora. We compared the tendencies of Americans and Bangladeshis to reduce digoxin by this pathway. Of 97 normal Americans in New York City, 34 (35.1%) were metabolizers in contrast to 14 of 100 Bangladeshis in Dhaka (p less than 0.002). Forty-three (35.8%) of 120 American patients in New York City receiving digoxin reduced the drug compared with 4 (13.8%) of 29 Bangladeshi patients in Dhaka (p less than 0.05). In Americans who emigrated to Dhaka or Bengali immigrants to New York City, the frequency of digoxin reduction product excretion was that of their country of origin. Fourteen Bengali immigrants who were nonmetabolizers when first studied in New York did not metabolize digoxin when restudied 4 yr later. In the Bangladeshis studied in Dhaka, income, education, and most strongly, urban residence during childhood correlated positively with digoxin inactivation. The findings are consistent with the hypothesis that the metabolic functions of the anaerobic gut flora may be determined by environmental factors operative early in life and tend to remain stable in adulthood. Interethnic variations in drug metabolism may be the consequence of differences in the intestinal microflora.

Comparative in vivo evaluation of a radioimmunoassay and a chromatographic assay for the measurement of digoxin in biological fluids

The concentrations of digoxin in plasma and urine samples obtained from three healthy male volunteers, who received 1.2 mg of labeled digoxin perorally and intravenously, were simultaneously measured by a commercially available radioimmunoassay (RIA) and by a combined column thin-layer chromatographic assay (CA). The CA method, previously shown to assay digoxin specifically, was also used to monitor the individual digoxin metabolites. The results of this investigation showed that digoxin was significantly metabolized, particularly after peroral administration. The lower level of sensitivity of the RIA in plasma was 0.4 ng/mL. There were highly significant positive linear correlations between the values of the following parameters of digoxin as obtained by the RIA and CA methods: the concentrations in plasma and urine, the AUCs, and the cumulatively excreted amounts in urine. The two assays did not give completely identical results either with plasma or urine; the slopes of the regression lines deviated from unity in a significant number of cases. However, there was no relationship between the magnitude of the slopes of the regression lines and the extent of metabolism. It was concluded that the commercially available RIA evaluated was specific for digoxin and that the presence of digoxin metabolites did not affect the determinations.

Pharmacokinetics, bioavailability and serum levels of cardiac glycosides

Digoxin, the cardiac glycoside most frequently used in clinical practice in the United States, can be given orally or intravenously and has an excretory half-life of 36 to 48 hours in patients with serum creatinine and blood urea nitrogen values in the normal range. Since the drug is excreted predominantly by the kidney, the half-life is prolonged progressively with diminishing renal function, reaching about 5 days on average in patients who are essentially anephric. Serum protein binding of digoxin is only about 20%, and differs markedly in this regard from that of digitoxin, which is 97% bound by serum albumin at usual therapeutic levels. Digitoxin is nearly completely absorbed from the normal gastrointestinal tract and has a half-life averaging 5 to 6 days in patients receiving usual doses irrespective of renal function. The bioavailability of digoxin is appreciably less than that of digitoxin, averaging about two-thirds to three-fourths of the equivalent dose given intravenously in the case of currently available tablet formulations. Recent studies have shown that gut flora of about 10% of patients reduce digoxin to a less bioactive dihydro derivative. This process is sensitive to antibiotic administration, creating the potential for important interactions among drugs. Serum or plasma concentrations of digitalis glycosides can be measured by radioimmunoassay methods that are now widely available, but knowledge of serum levels does not substitute for a sound working knowledge of the clinical pharmacology of the preparation used and careful patient follow-up.

Digoxin and metabolites in urine: a derivatization--high-performance liquid chromatographic method capable of quantitating individual epimers of dihydrodigoxin

A high-performance liquid chromatographic method is described for the determination of digoxigenin, digoxigenin monodigitoxoside, digoxigenin bis-digitoxoside, digoxin, and dihydrodigoxin as the 3,5-dinitrobenzoyl esters. The method is applied to a 10 ml urine sample by adding digitoxigenin as internal standard, extracting with methylene chloride, derivatizing with 3,5-dinitrobenzoyl chloride in pyridine, chromatographing with a normal-phase system and detecting at 254 nm. Derivatized digoxigenin, digoxigenin mono- and bis-digitoxoside, and digoxin each yielded one symmetrical peak with the limit of sensitivity of the method being approximately 100 ng/ml. Analysis of a commercially obtained sample of dihydrodigoxin resulted in two well-separated, symmetrical peaks that represent the two epimers of derivatized dihydrodigoxin. Data indicate rapid and complete esterification of all primary and secondary alcohol moieties in the various molecules and the derivatives are shown to be stable in chloroform for at least four days. The procedure appears to be suitable for metabolic investigations and as a prototype for future analytical developments.

Increased metabolism to dihydrodigoxin after intake of a microencapsulated formulation of digoxin

A capsule preparation containing small, enteric-coated granules of digoxin was developed to prevent acid hydrolysis of the drug in the stomach and to diminish the variation in plasma glycoside concentration during the intervals between doses. The absorption and metabolism of tritiated digoxin after a single oral loading dose of this formulation (Formulation C) were compared to those after ingestion of a digoxin solution (Formulation S) by 8 healthy men. Drug concentrations were measured by radioimmunoassay (RIA) and liquid chromatography (LC). The percentage of the digoxin dose excreted in the urine during 72 h, as measured by RIA, was significantly lower after the capsule (20.5 +/- 2.0% vs 36.2 +/- 3.0% after S, mean +/- SEM) but total urinary radioactivity after the two treatments was similar (C 35.3 +/- 5.2 and S 41.2 +/- 2.6%; p greater than 0.05). The discrepancy was mainly due to significantly greater excretion of dihydrodigoxin after the capsule (m 12.8%, range 0-28.6% of the dose) than after the digoxin solution (m 5.4%, range 0-14.5%). Dihydrodigoxin was not measured by the RIA. The recovery of hydrolysis metabolites (LC) was greater during the first 24 h after S (2.3 +/- 0.6% vs 0.9 +/- 0.3% after C; p less than 0.05). The peak plasma concentration of digoxin (RIA) was significantly reduced and delayed after intake of C (2.5 +/- 0.4 nmol/l at 3.8 +/- 0.3 h vs. 8.3 +/- 0.8 nmol/l at 0.9 +/- 0.1 h after S), and so was the shortening of electromechanical systole at 1.5 h, 2.5 h, and 3 h.(ABSTRACT TRUNCATED AT 250 WORDS)

Digoxin-inactivating bacteria: identification in human gut flora

Digoxin, the most widely used cardiac glycoside, undergoes significant metabolic conversion in many patients to cardioinactive metabolites in which the lactone ring is reduced. This appears to occur within the gastrointestinal tract. An attempt was made to isolate and identify the organisms capable of reducing digoxin from stool cultures obtained from human volunteers. Of hundreds of isolates studied, only Eubacterium lentum, a common anaerobe of the human colonic flora, converted digoxin to reduced derivatives. Such organisms were also isolated in high concentrations from the stools of individuals who did not excrete these metabolites when given digoxin in vivo. When the growth of E. lentum was stimulated by arginine, inactivation of digoxin was inhibited. Neither the presence of these organisms alone nor their concentration within the gut flora appeared to determine whether digoxin would be inactivated by this pathway in vivo.

Spectral analysis of the configuration and solution conformation of dihydrodigoxigenin epimers

The C20 configuration and solution conformation of each epimer of dihydrodigoxigenin has been studied by circular dichroism (CD) and NMR spectroscopy. Results from the CD spectra indicate that the two epimers have opposite orientations of the beta-carbon in the lactone ring. This finding, together with X-ray crystallographic data from a separate study on the minor epimer, establishes the C20 configuration of the minor epimer as S and of the major epimer as R. NMR evidence indicates that the average lactone rotamer for the minor epimer has the C22 position located on the C12 side of the steroid nucleus, whereas the average lactone rotamer for the major epimer has the C21 position located on the C12 side of the steroid nucleus. Molecular models indicate that these are the least-hindered positions for the respective rotamers. Physical data characterizing the two epimers are provided.

Excretion of digoxin and its metabolites in urine after a single oral dose in healthy subjects

The 3-day urinary excretion of digoxin, its conjugated and unconjugated hydrolytic metabolites and dihydrodigoxin, was studied in 8 healthy men after oral administration of tritiated digoxin. Analysis was performed by high pressure liquid chromatography (HPLC). The total radioactivity corresponded to 45.4 +/- 2.0 per cent (mean +/- S.E.M.) of the dose. By HPLC 42.4 +/- 2.7 per cent was recovered before and 44.0 +/- 2.7 per cent after deconjugation of the samples. Digoxin and dihydrodigoxin constituted 40.3 +/- 2.9 per cent; of this 0.7 +/- 0.4 per cent was dihydrodigoxin. The sum of the hydrolytic metabolites was 2.1 +/- 0.3 per cent before and 3.4 +/- 0.5 per cent after deconjugation. No correlation was found between gastric pH and the production of hydrolytic metabolites. The relative amount of these metabolites was maximal (mean 13.4 per cent of the excretion) in the 4-8 h sampling period. During the first 8 h an average of 8.6 per cent of the radioactivity was not recovered by HPLC. The metabolism of digoxin as judged by urinary excretion was limited and showed great variation during the early hours after treatment. The excretion of unchanged digoxin in some individuals constituted as little as 60 per cent over the first 12 h after dosing.

Separation of digoxin, digitoxin and their potential metabolites, impurities or degradation products by high-performance liquid chromatography

A rapid and versatile series of high-performance liquid chromatographic systems are described for the resolution of digoxin, digitoxin and their potential metabolites or degradation products and impurities. These systems consist of isocratic, single-step gradient and linear gradient modes that provide resolution of the glycosides in 25, 17 and 14 min respectively. Digoxin, its mono- and bisdigitoxosides, digoxigenin and gitoxin, a potential impurity, may be isocratically separated in 11 min. The two semi-synthetic glycosides alpha- and beta-acetyldigoxin are resolved and separated from digoxin and its metabolites in a chromatographic time of 23 min. Digitoxin and its metabolites or degradation products may be separated in as little as 9 min using an isocratic system. The solvent systems employ varying proportions of methanol, water, isopropanol and dichloromethane and a conventional 5 micrometers bonded, octadecyl phase. Detection was accompanied using a variable wavelength detector set at 220 nm.

Inactivation of digoxin by the gut flora: reversal by antibiotic therapy

In approximately 10 per cent of patients given digoxin, substantial conversion of the drug to cardioinactive, reduced metabolites (digoxin reduction products, or DRPs) occurs. The site and clinical importance of this conversion is unknown. In four normal volunteers taking digoxin daily for four weeks, urinary excretion of DRPs was greatest after a poorly absorbed tablet was ingested, and least after intravenous administration, Stool cultures from subjects known to make DRPs in vivo ("excretors") converted digoxin to DRPs; cultures from nonexcretors did not. Three excretors were given tablets for 22 to 29 days. A five-day course of erythromycin or tetracycline, administered after a base-line period of 10 to 17 days, markedly reduced or eliminated DRP excretion in urine and stool. Serum digoxin concentrations rose as much as twofold after antibiotics were given. We conclude that in some persons digoxin is inactivated by gastrointestinal bacteria. Changes in the enteric flora may markedly alter the state of digitalization.

Urinary excretion of reduced metabolites of digoxin

The urinary excretion of the relatively cardioinactive reduced metabolites of digoxin, dihydrodigoxin and related compounds was measured by radioimmunoassay in 131 normal subjects during studies of the bioavailability of digoxin preparations. Digoxin reduction products (DRP) constitute more than 5 percent of the excretion of digoxin and its metabolites in one-third of the volunteers after the administration of single or multiple doses of digoxin. There was little or no output of DRP during the first 8 hours after a single dose, with maximal excretion usually occurring on the second day. Most subjects who excreted more than 5 percent DRP on one occasion did so with each subsequent exposure to digoxin. Six volunteers, however, in whom substantial amounts of DRP had previously been found, failed to excrete detectable quantities after subsequent doses. In two, this change occurred shortly after they took erythromycin. Urinary DRP were less after the intravenous administration compared to the oral administration of digoxin. After oral doses, DRP excretion tended to vary inversely with the bioavailability of the preparation. The findings are consistent with the hypothesis that DRP are formed as the result of the activity of a variable component of the intestinal flora. Prospective studies will be necessary to prove this hypothesis.

Determination of tritiated digoxin and metabolites in urine by liquid chromatography

A liquid chromatographic method for the determination of digoxin, digoxigenin, its mono- and bisdigitoxoside and dihydrodigoxin in urine is described. Doses of 100 muCi of [12 alpha-3H]digoxin and 0.5 mg (640 nmol) of digoxin were administered orally to eight healthy volunteers. The compounds were extracted from urine with methylene chloride containing 3% of heptafluorobutanol. After separation, fractions corresponding to digoxin and the metabolites were measured by liquid scintillation counting. Conjugates of the glycoside metabolites were determined indirectly after pre-treatment of the samples with beta-glucuronidase-arylsulphatase. The detection limit was 0.1 nmol/l. Metabolites amounting to 0.5% of digoxin were assayed with a relative standard deviation of 5%. The advantages of the method are a high recovery in the extraction step, short separation times and the possibility of separate assay of dihydrodigoxin.

A standard approach to compiling clinical pharmacokinetic data

A standard format for a Clinical Pharmacokinetic Summary is proposed. It consists of a heading, tables, notes, and references for each drug reviewed. The table presents a unified and logical set of clinically useful population pharmacokinetic parameters. They concern four major areas: absorption, distribution, elimination, and the relationship of concentration to effect. Within each major group, parameters dealing with extents and rates of processes are given. Each such parameter is really two: a population mea value (for example, average volume of distribution) and the standard deviation of individual values about this mean. The first value allows individual predictions of dosage or drug level to be made; the second allows computation of the likely proximity of subsequently observed quantities to those predictions. The table presents single consensus values for each population parameter, rather than a list of values. A procedure for computing these consensus values, and for revising them in the light of new data, or reinterpreted old data, is given. Examples of Summaries are given. The method appears applicable to a variety of drugs. We suggest our approach as a standard one for preparing Clinical Pharmacokinetic Summaries, and urge our colleagues to consider it for that purpose.

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.

Extraction of digoxin and its metabolites from urine and their separation by Sephadex LH-20 column chromatography

The efficiency with which serveral solvent systems extract digoxin and its metabolites from urine has been studied and column chromatography using Sephadex LH-20 has been used to separate digoxin and its metabolites. These procedures have been evaluated and used to study the excretion of 3H-digoxin-12alpha and its metabolites in urines collected serially in 7 patients and in bile in one. The percentage of the radioactivity excreted as metabolites in urine and bile was found to reach a peak within the first day and then to gradualy decline to minimal amounts in patients with advanced renal failure as well as those with good renal function. The maximum percentage measured as metabolites in 4 patients with the most advanced renal failure was 10%.

The measurement of urinary digoxin and dihydrodigoxin by radioimmunoassay and by mass spectroscopy

A radioimmunoassay for urinary digoxin is described which includes an initial solvent extraction to remove factors in urine which cause non-specific interference in the assay. The recoveries obtained using different solvents are compared and the non-specific factors influencing the assay investigated further. These effects were overcome by the use of a small urine volume (10 mul) in a direct, unextracted, urine assay and the results obtained correlated closely with those from the assay using prior extraction (r=0.99). No false positive results were obtained with unextracted urine samples from hospitalised patients not receiving digoxin. The specificity was also determined with regard to the natural steroids, spironolactone and the metabolites of digoxin including dihydrodigoxin. The metabolite dihydrodigoxin, with a saturated lactone ring, was not detected whereas the mono-, and bis-digitoxo-sides and digoxigenin metabolites did cross react in the assay. It was not possible to separate dihydrodigoxin and digoxin by thin-layer chromatography or solvent extraction due to their similar structures, however, mass spectroscopy was successful in this respect and was employed to obtain the ratio of dihydrodigoxin to digoxin in extracted urine samples. Levels of urinary digoxin excreted by patients maintained on different oral doses of the drug were measured. The percentage excreted in the urine as digoxin correlated closely with the oral dose (r = 0.96) but was found to be lower than that reported in most previous studies. Mass spectroscopy measurements showed that an average of 16.4% (range 12.2-19.7%) of the total oral dose was excreted as dihydrodigoxin in the urine of nine patients investigated.

Serum digitalis measurements in the assessment of digitalis resistance and sensitivity

Antibodies to digitalis glycosides have been elicited in experimental animals and have been utilized in the development of rapid, sensitive, specific and convenient radioimmunoassay methods for the clinical measurement of digoxin and other cardiac glycosides in man. The use of these assay methods has supplemented earlier studies with radiolabeled digitalis preparations and has made it possible to obtain much new information concerning factors which may contribute to the well known patient to patient variability in digitalis dosage requirements and in sensitivity to the toxic effects of cardiac glycosides. In some patients with a poor clinical response to digitalis, the finding of a serum concentration which is relatively low for the dose prescribed may suggest that true digitalis resistance is not present and may raise questions of poor patient compliance, tablet inadequacies, intestinal malabsorption, increased metabolic degradation or hyperthyroidism; if the cause of the low serum level cannot be identified or corrected, serial serum measurements should enable safe and rational upward adjustment of dosage. In some patients with digitalis toxicity, the finding of a serum level which is relativity high for the dose prescribed may suggest that the patient is not sensitive to digitalis but rather is excreting it slowly; in such instances in elderly patients (with decreased glomerular filtration rates) and in patients with renal disease, serial digitalis measurements are useful adjuncts to clinical observation in determining optimal digitalis dosage schedules. A knowledge of serum digitalis concentrations should enable us to develop sound principles for a more rational approach to the clinical administration of cardiac glycosides, especially in patients with unusually high dosage requirements or with unusual sensitivity to relatively small doses of digitalis.