Digoxin Toxicity and Use of Digoxin Antibody

Study Questions:

What are the patient characteristics, hospital utilization, and outcomes of patients with digoxin toxicity, and outcomes among patients treated with and without digoxin immune fab (DIF)?

Methods:

The Premier Perspective Comparative Hospital Database (Premier Inc., Charlotte, North Carolina) was used to retrospectively identify patients diagnosed with digoxin toxicity and/or who received digoxin immune fab (DIF) over a 5-year period (2007-2011). DIF was evaluated using treatment date, number of vials administered, and total cost. Clinical outcomes included length of stay (total hospitalization; days after DIF), cost of hospitalization, and in-hospital mortality. Exploratory multivariate analyses were conducted to determine predictors of DIF and effect on length of stay, adjusting for patient characteristics and selection bias.

Results:

Digoxin toxicity diagnosis without DIF treatment accounted for 19,543 cases; 5,004 patients received DIF, of whom 3,086 had a diagnosis of toxicity. Most patients were >65 years old (88%). The predictors of DIF use were urgent/emergent admission, hyperkalemia, arrhythmia associated with digoxin toxicity, acute renal failure, or suicidal intent (odds ratios 1.7, 2.4, 3.6, 2.1, and 3.7, respectively; p < 0.0001 for all). The majority (78%) of DIF was administered on days 1 and 2 of the hospitalization; 10% received treatment after day 7. Digoxin was used after DIF administration in 14% of cases. Among patients who received DIF within 2 days of admission, there was no difference for in-hospital mortality or length of stay compared with patients not receiving DIF.

Conclusions:

The authors concluded that opportunities exist for improved diagnosis and post-DIF management of digoxin toxicity.

Perspective:

This study reports that digoxin toxicity was often associated with complex hospitalizations and only a minority of patients, approximately 20%, was treated with DIF. Digoxin was prescribed in 14% of patients following use of DIF, suggesting that opportunities exist for better management. Additional research is indicated to better understand appropriate patient selection, and timing for administration of DIF, with prospective data collection to assess whether early identification and treatment can lead to shorter lengths of stay and improved clinical outcomes.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Acute Kidney Injury, Arrhythmias, Cardiac, Digoxin, Heart Failure, Hospital Mortality, Hyperkalemia, Immunoglobulin Fab Fragments, Length of Stay, Outcome Assessment (Health Care), Suicide, Attempted


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