New Review Casts Doubt on Digoxin for Afib
A recent review on the role of digoxin in atrial fibrillation (AF) has concluded that clinicians should avoid using digoxin monotherapy for rate control in patients with AF when other options are available. Findings from the report are published in the Journal of Pharmacy Practice.
Digoxin, one of the oldest medications in use today, is indicated for cardiac conditions including heart failure and supraventricular tachyarrhythmias. But recent data has questioned the safety and efficacy of digoxin in patients with AF; some data suggest digoxin has no benefit on mortality and may actually increase this risk. Some evaluations have suggested an increase in mortality, including high doses in heart failure.
Pharmacists from Auburn University and University of Missouri-Kansas City compiled an overview on digoxin therapy, a review of current literature, and defined the current role of digoxin in the management of AF. They reported that robust data exists in digoxin improving symptoms and reducing hospitalization in the heart failure population with no or minimal effect on mortality. The data in AF patients, however, have been limited to observational studies and post-hoc analyses of larger trials. Guidelines on management of AF offer limited recommendations on approrpriate use of digoxin due to limited amount of large clinical trials. Data from prospective studies have shown inconsistent relationships between digoxin use and mortality.
For rate control, higher priority is still given to beta-blockers and non-dihydropyridine calcium channel blockers due to their rapid onset of action and recorded safety. These agents are first-line therapies as they exhibit a more preferred pharmacokinetics profile, rapid symptomatic relief, and relatively limited side effect profile.
Digoxin's parasympathetic activity makes it a viable option for controlling ventricular rate in AF but its pharmacokinetic properties, electrolyte-dependent effects, and P-glycoprotein drug interactions affect its clinical application. Its delayed onset and narrow therapeutic index can further complicate its use and require serum drug monitoring frequently.
The majority of the reviewed studies were not randomized, which limited the ability to make definitive conclusions. Study authors caution that the possible mortality risk must be weighed against the potential benefits of digoxin in making individualized patient care decisions. Clinicians should reserve digoxin for rate control in AF patients that have specific factors preventing from using safer and more effective alternatives.
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