Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
Case ReportPractice

Digoxin toxicity

Case for retiring its use in elderly patients?

Nora MacLeod-Glover, Matthew Mink, Mark Yarema and Ryan Chuang
Canadian Family Physician March 2016, 62 (3) 223-228;
Nora MacLeod-Glover
Clinical Information Resource Specialist in the Poison and Drug Information Service at Alberta Health Services in Calgary.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: nora.macleod-glover@albertahealthservices.ca
Matthew Mink
Educator and Clinical Information Resource Specialist II in the Poison and Drug Information Service.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Mark Yarema
Medical Director in the Poison and Drug Information Service and Clinical Associate Professor in the Department of Emergency Medicine at the University of Calgary.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ryan Chuang
Associate Medical Director of the Poison and Drug Information Service and Clinical Lecturer in the Division of Pharmacology and Toxicology in the Department of Emergency Medicine at the University of Calgary.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF
Loading

Digoxin is one of the oldest cardiac medications still in use. Both the current Canadian guidelines for heart failure and atrial fibrillation and the American College of Cardiology Foundation–American Heart Association guideline for the management of heart failure include digoxin as a treatment option.1–3 However, it does not have the most favourable efficacy and safety profiles.4,5 Digoxin has a complex pharmacokinetic profile, a narrow therapeutic range, and multiple drug interactions. In 2013, there were 334 referrals to Canadian poison centres related to digoxin toxicity (personal communication with certified specialists in poison information: Ray Li, Deb Kent [BC], Heather Hudson [Ont], Anne Letarte [QC], MaryAnne Carew, and Kim Sheppard [NS]; 2014). Budnitz et al reported that digoxin was the seventh most common cause of adverse drug event–related emergency hospitalizations in older American adults from 2007 to 2009.6 We present a case that illustrates an inadvertent adverse drug event related to digoxin use in an elderly patient and review the influences on and manifestations of digoxin toxicity.

Case

Emergency medical services responded to a call from the husband of a 69-year-old woman. He was concerned about her increasing confusion, vomiting, and reduced level of consciousness. On emergency medical services’ arrival, the patient’s vital signs included a blood pressure of 85/60 mm Hg and heart rate of 30 beats/min. The patient’s medical history included atrial fibrillation, congestive heart failure, osteoarthritis (affecting hips and knees), hypothyroidism, peptic ulcer disease, and bipolar disorder. Her medications at the time of admission are listed in Table 1.

Laboratory investigations revealed a serum digoxin concentration (SDC) of 7.5 nmol/L (therapeutic range 1.0 to 2.6 nmol/L according to Calgary Laboratory Services), a potassium level of 7.3 mmol/L, and a creatinine level of 186 µmol/L. The patient received intravenous fluids, norepinephrine, and digoxin antibody fragments (5 vials). Four hours later the patient’s vital signs improved to a blood pressure of 110/80 mm Hg and a heart rate of 58 beats/min. Seventy-two hours later, the patient’s vital signs remained stable and her creatinine level was 93 µmol/L. All her medications were restarted, and she was prepared for discharge home.

View this table:
  • View inline
  • View popup
Table 1.

Patient’s medications on admission

Discussion

We searched MEDLINE, EMBASE, and the International Pharmaceutical Abstracts using the key words digoxin and toxicity, limiting the search to studies of oral formulations in adults, published in English.

Digoxin dosing, mechanism of action, pharmacokinetics, and monitoring

Oral digoxin is available as a solution (0.05 mg/mL) or as tablets (0.0625 mg, 0.125 mg, and 0.25 mg).7 Dosing should be initiated and maintained at doses of 0.125 to 0.25 mg daily, with lower doses considered in patients 70 years of age or older.3 Historically, the upper therapeutic range for SDC was 2.0 nmol/L.8 However, this upper limit has been adjusted in light of evidence demonstrating that, compared with higher SDCs, patients who were dosed to lower SDCs experienced improved symptom control, fewer hospitalizations, and a decrease in all-cause mortality with fewer safety concerns, particularly in women and frail elderly patients taking doses that achieve an SDC of 1.0 nmol/L or greater.9–13 The recommended therapeutic SDC is 0.5 to 0.9 nmol/L in patients with congestive heart failure.3

Digoxin exerts its positive inotropic effects by reversibly inhibiting the cellular membrane sodium-potassium pump. As a result, there is an increase in intracellular sodium concentration, a reduction in cytoplasmic potassium, and ultimately an increase in cytoplasmic calcium that promotes myocardial contractility.14 When taken orally, digoxin is incompletely absorbed. Distribution follows a 2-compartment model: the first compartment being plasma and other rapidly equilibrating tissues and the second being more slowly equilibrating tissues— including the myocardium—with a final volume of distribution of 6.3 to 7.3 L/kg.15,16 Digoxin metabolism occurs via hydrolysis, oxidation, and conjugation in the liver and does not involve the cytochrome P450 system.17 Up to 70% of an oral dose is cleared unchanged by the kidneys.15,17 In patients with normal renal function, the half-life of digoxin is about 36 hours; however, this can be prolonged in patients with renal dysfunction.15

Manifestations of toxicity

Clinical manifestations of toxicity include gastrointestinal and neurologic symptoms, as well as cardiac dysrhythmia (Table 2).17,18

View this table:
  • View inline
  • View popup
Table 2.

Clinical and laboratory manifestations of digoxin toxicity

Considerations if using digoxin

Assess patient-specific factors that can influence the dose-effect relationship such as age, renal function, body habitus, comorbid conditions, and medications.10,17–19 Specifically, prescribers should keep in mind the following:

  • Functional decline of the liver and especially the kidneys can alter digoxin metabolism and clearance, and is more likely in the elderly.15,18

  • Digoxin is highly hydrophilic and the dose-effect relationship is dependent on lean body mass; dosage should be based on ideal body weight.16,20

  • Electrolyte imbalances such as hypomagnesemia, hypercalcemia, hypernatremia, and hypokalemia can alter the effects of digoxin on the myocardium, even when blood concentrations are within the therapeutic range.21

  • Exacerbations of chronic heart failure can lead to a reduced clearance of digoxin.19

  • Hypoxia and alkalosis related to chronic pulmonary disease can lead to toxic effects in patients receiving digoxin.19

  • Thyroid abnormalities alter digoxin kinetics; a hypothyroid state reduces both volume of distribution and clearance while a hyperthyroid state increases both.16

  • A previous hospital admission for digoxin toxicity is a predictor of subsequent events.22

Evaluate a patient’s drug profile for any recently started or stopped medications or dosage changes to existing medications. Medication changes can result in pharmacokinetic or pharmacodynamic interactions. Drug interactions might result in rapid increases in digoxin blood concentrations and related toxic symptoms. Commonly reported clinically meaningful drug interactions are listed in Table 3.15–18,22–27 Pharmacodynamic interactions leading to digoxin toxicity might occur without changes in SDC.

View this table:
  • View inline
  • View popup
Table 3

Drug interactions

Digoxin has a unique interaction with macrolide antibiotics. In 10% to 15% of patients, digoxin is inactivated in the gut by enteric bacteria (primarily Eubacterium lentum); inhibition of these bacteria by macrolide antibiotics, in particular clarithromycin, can increase bioavailability.10,21,23

Case review

Patient factors potentially influencing digoxin concentrations in this case include hypothyroidism, congestive heart failure, and an acute episode of renal impairment, which might have been exacerbated by the use of celecoxib. Drug interactions with digoxin in this case include celecoxib, furosemide, levothyroxine, and spironolactone. The decision to continue digoxin in this patient is controversial. Two large randomized trials demonstrated worsening heart failure in patients who stopped taking digoxin compared with those who took it to maintain an SDC of 1.2 nmol/L.28,29 However, neither study included the use of β-blockers, currently considered the criterion standard of care.2,3 If this patient continues to take digoxin, she is at an increased risk of future episodes of digoxin toxicity and requires close monitoring (both symptomatic and laboratory). Based on the Beers criteria, which strongly recommend against taking more than 0.125 mg daily of digoxin in heart failure, a dose reduction is recommended.30

This patient’s toxicity management included digoxin antibody fragment. Digoxin antibody fragment use should be considered in the context of life-threatening dysrhythmias, a potassium level greater than 5.0 mmol/L (in acute overdose), an SDC greater than 12 nmol/L, acute adult ingestion of digoxin greater than 10 mg or acute pediatric ingestion of digoxin greater than 4 mg, or undiagnosed or unstable bradycardia. Patients who receive digoxin antibody fragment should be monitored for changes in serum potassium level, creatinine level, vital signs, heart failure symptoms, and electrocardiography findings. Serum digoxin levels will appear to rise immediately following administration of digoxin antibody fragment owing to the presence of inactive Fabdigoxin complex; obtaining a free digoxin concentration (which might not be readily available) is clinically useful.31

Conclusion

Digoxin toxicity can be a life-threatening condition. Practitioners involved in monitoring digoxin use need to maintain a high level of suspicion for digoxin toxicity. This includes the ability to recognize toxicity regardless of whether digoxin concentrations fall within the therapeutic range. Digoxin dosing should be based on ideal body weight. Monitoring of blood concentrations should occur at initiation and during times of physiologic change or when adding, adjusting, or removing medications known to interact with digoxin. Digoxin blood concentrations should be measured following the first distribution phase—at least 6 hours after the daily dose.

Notes

EDITOR’S KEY POINTS

  • Digoxin dosing needs to be personalized based on multiple patient-specific considerations, including age, renal function, body habitus, comorbid conditions, and medications.

  • Practitioners should maintain a high level of suspicion for chronic toxicity in patients using digoxin, especially in women, in those with renal impairment, and in older, frail individuals. Symptoms of digoxin toxicity can occur at therapeutic blood concentrations.

  • Digoxin-specific antibodies might be considered in some cases of toxicity; if used, serum digoxin levels after treatment are not useful. Patients who receive digoxin antibody fragment should be monitored for changes in serum potassium level, creatinine level, vital signs, heart failure symptoms, and electrocardiography findings.

POINTS DE REPÈRE DU RÉDACTEUR

  • La posologie de la digoxine doit être personnalisée en tenant compte de nombreux facteurs relatifs au patient, dont l’âge, la fonction rénale, la morphologie, les comorbidités et la médication.

  • Les praticiens doivent toujours maintenir un niveau de suspicion de toxicité chronique chez les patients sous digoxine, particulièrement les femmes, les personnes aux prises avec une atteinte rénale et les patients âgés et frêles. Les symptômes de toxicité à la digoxine peuvent se manifester à des concentrations sanguines thérapeutiques.

  • Dans certains cas de toxicité, on peut envisager le recours aux fragments d’anticorps spécifiques de la digoxine; s’ils sont utilisés, les taux sériques de digoxine après le traitement sont inutiles. Les patients qui reçoivent un fragment d’anticorps anti-digoxine doivent être surveillés pour détecter tout changement dans le taux sérique de potassium et de créatinine, les signes vitaux, les symptômes d’insuffisance cardiaque et les constatations à l’électrocardiogramme.

Footnotes

  • This article has been peer reviewed.

  • Cet article a fait l’objet d’une révision par des pairs.

  • Competing interests

    None declared

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Skanes AC,
    2. Healey JS,
    3. Cairns JA,
    4. Dorian P,
    5. Gillis AM,
    6. McMurtry MS,
    7. et al
    . Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control. Can J Cardiol 2012;28(2):125-36. Erratum in: Can J Cardiol2012:28(3)396.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Malcom J,
    2. Arnold O,
    3. Howlett JG,
    4. Ducharme A,
    5. Ezekowitz JA,
    6. Gardner M,
    7. et al
    . Canadian Cardiovascular Society Consensus Conference guidelines on heart failure—2008 update: best practices for the transition of care of heart failure patients, and the recognition, investigation and treatment of cardiomyopathies. Can J Cardiol 2008;24(1):21-40.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Yancy CW,
    2. Jessup M,
    3. Bozkurt B,
    4. Butler J,
    5. Casey DE Jr.,
    6. Drazner MH,
    7. et al
    . 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013;128(16):e240-327. Epub 2013 Jun 5.
    OpenUrlFREE Full Text
  4. 4.↵
    1. Digitalis Investigation Group
    . The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997;336(8):525-33.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Turakhia MP,
    2. Santangeli P,
    3. Winkelmayer WC,
    4. Xu X,
    5. Ullal AJ,
    6. Than CT,
    7. et al
    . Increased mortality associated with digoxin in contemporary patients with atrial fibrillation: findings from the TREAT-AF study. J Am Coll Cardiol 2014;64(7):660-8.
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Budnitz DS,
    2. Lovegrove MC,
    3. Shehab N,
    4. Richards CL
    . Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011;365(21):2002-12.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Health Canada
    . Drugs and health products. Drug product database online query. Ottawa, ON: Health Canada; 2015. Available from: http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp [active ingredients: digoxin]. Accessed 2016 Feb 2.
  8. 8.↵
    1. Goldberger ZD,
    2. Goldberger AL
    . Therapeutic ranges of serum digoxin concentrations in patients with heart failure. Am J Cardiol 2012;109(12):1818-21. Epub 2012 Apr 11.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Ahmed A,
    2. Gambassi G,
    3. Weaver MT,
    4. Young JB,
    5. Wehrmacher WH,
    6. Rich MW
    . Effects of discontinuation of digoxin versus continuation at low serum digoxin concentrations in chronic heart failure. Am J Cardiol 2007;100(2):280-4. Epub 2007 Jun 6.
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Chan KE,
    2. Lazarus JM,
    3. Hakim RM
    . Digoxin associates with mortality in ESRD. J Am Soc Nephrol 2010;21(9):1550-9. Epub 2010 Jun 24.
    OpenUrlAbstract/FREE Full Text
  11. 11.
    1. Adams KF Jr.,
    2. Patterson JH,
    3. Gattis WA,
    4. O’Connor CM,
    5. Lee CR,
    6. Schwartz TA,
    7. et al
    . Relationship of serum digoxin concentration to mortality and morbidity in women in the digitalis investigation group trial: a retrospective analysis. J Am Coll Cardiol 2005;46(3):497-504.
    OpenUrlCrossRefPubMed
  12. 12.
    1. Rathore SS,
    2. Curtis JP,
    3. Wang Y,
    4. Bristow MR,
    5. Krumholz HM
    . Association of serum digoxin concentration and outcomes in patients with heart failure. JAMA 2003;289(7):871-8.
    OpenUrlCrossRefPubMed
  13. 13.↵
    1. Hauptman PJ,
    2. McCann P,
    3. Romero JM,
    4. Mayo M
    . Reference laboratory values for digoxin following publication of Digitalis Investigation Group (DIG) trial data. JAMA Intern Med 2013;173(16):1552-4.
    OpenUrlPubMed
  14. 14.↵
    1. Yang EH,
    2. Shah S,
    3. Criley JM
    . Digitalis toxicity: a fading but crucial complication to recognize. Am J Med 2012;125(4):337-43.
    OpenUrlCrossRefPubMed
  15. 15.↵
    1. Winter ME,
    2. Koda-Kimble MA,
    3. Young LY
    . Digoxin. In: Winter ME, editor. Basic clinical pharmacokinetics. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. p. 183-221.
  16. 16.↵
    1. Ritschel WA,
    2. Kearns GL
    . Handbook of basic pharmacokinetics ... including clinical applications. 6th ed. Washington, DC: American Pharmacists Association; 2004.
  17. 17.↵
    1. Ehle M,
    2. Patel C,
    3. Giugliano RP
    . Digoxin: clinical highlights: a review of digoxin and its use in contemporary medicine. Crit Pathw Cardiol 2011;10(2):93-8.
    OpenUrlCrossRefPubMed
  18. 18.↵
    1. Hack JB
    . Cardiac steroids. In: Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE, editors. Goldfrank’s toxicologic emergencies. 9th ed. New York, NY: McGraw-Hill Medical; 2011. p. 936-45.
  19. 19.↵
    1. Wofford JL,
    2. Ettinger WH
    . Risk factors and manifestations of digoxin toxicity in the elderly. Am J Emerg Med 1991;9(2 Suppl 1):11-5.
    OpenUrlPubMed
  20. 20.↵
    1. Spruill WJ,
    2. Wade WE,
    3. DiPiro JT,
    4. Blouin RA,
    5. Pruemer JM
    . Concepts in clinical pharmacokinetics. 6th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014.
  21. 21.↵
    1. Young IS,
    2. Goh EM,
    3. McKillop UH,
    4. Stanford CF,
    5. Nicholls DP,
    6. Trimble ER
    . Magnesium status and digoxin toxicity. Br J Clin Pharmacol 1991;32(6):717-21.
    OpenUrlPubMed
  22. 22.↵
    1. Juurlink DN,
    2. Mamdani M,
    3. Kopp A,
    4. Laupacis A,
    5. Redelmeier DA
    . Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA 2003;289(13):1652-8.
    OpenUrlCrossRefPubMed
  23. 23.↵
    1. Gomes T,
    2. Mamdani MM,
    3. Juurlink DN
    . Macrolide-induced digoxin toxicity: a population-based study. Clin Pharmacol Ther 2009;86(4):383-6. Epub 2009 Jul 15.
    OpenUrlCrossRefPubMed
  24. 24.
    1. Guven H,
    2. Tuncok Y,
    3. Guneri S,
    4. Cavdar C,
    5. Fowler J
    . Age-related digoxin-alprazolam interaction. Clin Pharmacol Ther 1993;54(1):42-4.
    OpenUrlPubMed
  25. 25.
    1. Mathis AS,
    2. Friedman GS
    . Coadministration of digoxin with itraconazole in renal transplant recipients. Am J Kidney Dis 2001;37(2):E18.
    OpenUrlPubMed
  26. 26.
    1. Wang MT,
    2. Li IH,
    3. Lee WJ,
    4. Huang TY,
    5. Leu HB,
    6. Chan AL
    . Exposure to sennosidedigoxin interaction and risk of digoxin toxicity: a population-based nested case-control study. Eur J Heart Fail 2011;13(11):1238-43. Epub 2011 Jul 28.
    OpenUrlCrossRefPubMed
  27. 27.↵
    1. Yang XX,
    2. Hu ZP,
    3. Duan W,
    4. Zhu YZ,
    5. Zhou SF
    . Drug-herb interactions: eliminating toxicity with hard drug design. Curr Pharm Des 2006;12(35):4649-64.
    OpenUrlCrossRefPubMed
  28. 28.↵
    1. Packer M,
    2. Gheorghiade M,
    3. Young JB,
    4. Costantini PJ,
    5. Adams KF,
    6. Cody RJ,
    7. et al
    . Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. RADIANCE study. N Engl J Med 1993;329(1):1-7.
    OpenUrlCrossRefPubMed
  29. 29.↵
    1. Uretsky BF,
    2. Young JB,
    3. Shahidi FE,
    4. Yellen LG,
    5. Harrison MC,
    6. Jolly MK
    . Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. PROVED Investigative Group. J Am Coll Cardiol 1993;22(4):955-62.
    OpenUrlCrossRefPubMed
  30. 30.↵
    1. American Geriatrics Society 2012 Beers Criteria Update Expert Panel
    . American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;60(4):616-31. Epub 2012 Feb 29.
    OpenUrlCrossRefPubMed
  31. 31.↵
    DigiFab [product monograph]. West Conshohocken, PA: BTG International; 2014. Available from: http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp [DIN 02361043]. Accessed 2016 Feb 9.
PreviousNext
Back to top

In this issue

Canadian Family Physician: 62 (3)
Canadian Family Physician
Vol. 62, Issue 3
1 Mar 2016
  • Table of Contents
  • About the Cover
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Digoxin toxicity
(Your Name) has sent you a message from The College of Family Physicians of Canada
(Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Digoxin toxicity
Nora MacLeod-Glover, Matthew Mink, Mark Yarema, Ryan Chuang
Canadian Family Physician Mar 2016, 62 (3) 223-228;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Respond to this article
Share
Digoxin toxicity
Nora MacLeod-Glover, Matthew Mink, Mark Yarema, Ryan Chuang
Canadian Family Physician Mar 2016, 62 (3) 223-228;
Reddit logo Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Case
    • Discussion
    • Conclusion
    • Notes
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • eLetters
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • Republished: Symptomatic digoxin toxicity in a patient on haemodialysis
  • Symptomatic digoxin toxicity in a patient on haemodialysis
  • Simultaneous Assessment of Transporter-Mediated Drug-Drug Interactions Using a Probe Drug Cocktail in Cynomolgus Monkey
  • Google Scholar

More in this TOC Section

Practice

  • Determining if and how older patients can safely stay at home with additional services
  • Managing type 2 diabetes in primary care during COVID-19
  • Effectiveness of dermoscopy in skin cancer diagnosis
Show more Practice

Case Report

  • Malnourishment masquerading as dementia
  • Psilocybin mushrooms for psychological and existential distress
  • Substitute decision making and code status at end of life
Show more Case Report

Similar Articles

Navigate

  • Home
  • Current Issue
  • Archive
  • Collections - English
  • Collections - Française

For Authors

  • Authors and Reviewers
  • Submit a Manuscript
  • Permissions
  • Terms of Use

General Information

  • About CFP
  • About the CFPC
  • Advertisers
  • Careers & Locums
  • Editorial Advisory Board
  • Subscribers

Journal Services

  • Email Alerts
  • Twitter
  • RSS Feeds

Copyright © 2023 by The College of Family Physicians of Canada

Powered by HighWire