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Signs and symptoms of life-threatening or potentially life-threatening digoxin (also known as digitalis) toxicity include, but are not limited to, severe ventricular arrhythmias (including ventricular tachycardia or fibrillation), progressive bradycardia, second- or third-degree heart block not responsive to atropine, serum potassium levels exceeding 5.5 mEq/L in adults or 6 mEq/L in children with rapidly progressive signs and symptoms of digoxin toxicity, and neurologic symptoms (eg, visual disturbances, disorientation, and confusion).1,2
Risk factors for digoxin toxicity include advanced age (>80 years); a decrease in renal clearance or loss of renal function due to chronic disease, hypokalemia, hypomagnesemia, and hypothyroidism; and use of multiple concomitant prescription drugs like macrolide antibiotics or drugs that impair renal function or cause hypokalemia.2,4
DigiFab® Digoxin Immune Fab (Ovine) is a treatment for patients with life-threatening or potentially life-threatening digoxin toxicity or overdose and is clinically proven to effectively clear digoxin from the body. Digoxin toxicity can be difficult to recognize in patients whose health may already be compromised.
Since the signs and symptoms are non-specific, knowing what to look for is important in order to effectively treat digoxin toxicity.
DigiFab® is indicated for the treatment of patients with life-threatening or potentially life-threatening digoxin toxicity or overdose, including:
Known suicidal or accidental consumption of fatal doses of digoxin: 10 mg or more of digoxin in healthy adults, or 4 mg (or more than 0.1 mg/kg) in healthy children, or ingestion of an amount that can cause steady state serum concentrations of ≥10 ng/mL;
Chronic ingestions causing steady-state serum digoxin concentrations >6 ng/mL in adults or 4 ng/mL in children;
Manifestations of life-threatening toxicity of digoxin overdose such as severe ventricular arrhythmias, progressive bradycardia, and second or third degree heart block not responsive to atropine, serum potassium levels exceeding 5.5 mEq/L in adults or 6 mEq/L in children with rapidly progressive signs and symptoms of digoxin toxicity.
General: Suicidal ingestion may result from more than one drug. Consider toxic effects of other drugs or poisons in cases where signs and symptoms of digitalis toxicity are not relieved by administration of DigiFab®.
Rapid drop in serum potassium concentration may occur after treatment. Monitor frequently.
Patients with poor cardiac function may deteriorate secondary to the withdrawal of the inotropic action of digoxin by DigiFab®. Monitor frequently and provide additional inotropic support if needed. Postpone re-digitalization, if possible, until the Fab fragments have been eliminated; this may require several days or a week or longer in patients with impaired renal function.
Hypersensitivity Reactions: Anaphylaxis and hypersensitivity reactions are possible. Carefully monitor patients for signs and symptoms of an acute allergic reaction and if one occurs, stop the infusion and treat immediately with appropriate emergency medical care.
Patients with known allergies to sheep protein or those who have previously received intact ovine antibodies or Fab are particularly at risk for an anaphylactic reaction.
Do not administer DigiFab® to patients with a known history of hypersensitivity to papaya or papain unless the benefits outweigh the risks and appropriate management for anaphylactic reactions is readily available.
Use of DigiFab® in Renal Failure: The elimination half-life of DigiFab® in renal failure has not been clearly defined. Monitor patients with severe renal failure who receive DigFab® for a prolonged period for possible recurrence of toxicity. Monitoring of free (unbound) digoxin concentrations after the administration may be appropriate
Laboratory Tests: DigiFab® may interfere with digitalis immunoassay measurements. Thus, standard serum digoxin concentration measurements may be clinically misleading until the Fab fragments are eliminated from the body. This may take several days or a week or more in patients with markedly impaired renal function. If possible, obtain serum digoxin samples before DigiFab® administration to establish the level of serum digoxin at the time of diagnosis.
The total serum digoxin concentration may rise precipitously following administration of DigiFab®, but this will be almost entirely bound to the Fab fragment and not able to react with receptors in the body.
The most common adverse reactions (>7%) related to DigiFab® administration are worsening congestive heart failure (13%), hypokalemia (13%) and worsening atrial fibrillation (7%).
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