Management of digoxin therapy using pharmacokinetics in a patient undergoing continuous venovenous hemofiltration

• Published in: American journal of health-system pharmacy Vol. 70; no. 23; pp. 2105 - 2109
• Main Authors: BENKEN, SCOTT T, LIZZA, BRYAN D, YAMOUT, HALA, GHOSSEIN, CYBELE
• Format: Journal Article
• Language: English
• Published: Bethesda, MD American Society of Health-System Pharmacists 01-12-2013; Copyright American Society of Health-System Pharmacists, Inc. All rights reserved; American Society of Health Pharmacists; Oxford University Press
• Subjects: Acute Kidney Injury - therapy; Analysis; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Blood; Cardiotonic Agents - administration & dosage; Cardiotonic Agents - pharmacokinetics; Cardiotonic Agents - therapeutic use; Case studies; Critical Illness; Digoxin; Digoxin - administration & dosage; Digoxin - pharmacokinetics; Digoxin - therapeutic use; Dosage and administration; Dose-Response Relationship, Drug; Echocardiography; Emergency and intensive care: renal failure. Dialysis management; Female; Filtration; Heart failure; Heart Failure - drug therapy; Heart Failure - surgery; Heart-Assist Devices; Hemofiltration - methods; Humans; Intensive care medicine; Medical sciences; Middle Aged; United States; Human; Extrarenal dialysis; Cardiotonic agent; Clinical management; Treatment; Digoxin; Continuous; Hemofiltration; Glycoside; Pharmacokinetics; Digitalis drug
• ISSN: 1079-2082; 1535-2900
• DOI: 10.2146/ajhp130171

PURPOSEThe management of digoxin therapy using pharmacokinetics in a patient undergoing continuous venovenous hemofiltration (CVVH) is reported.
SUMMARYA 46-year-old African-American woman with New York Heart Association class IV, American College of Cardiology– American Heart Association stage D heart failure arrived from an outside facility with complaints of dyspnea after minimal exertion, orthopnea, and lower-extremity edema. A transthoracic echocardiogram revealed an estimated left ventricular ejection fraction of 15%. The patient subsequently required left ventricular assist device placement on hospital day 5 as a potential bridge to transplantation. A total digoxin loading dose of 500 μg i.v. (8.2 μg/kg) was given in two divided doses six hours apart. The next morning, the serum digoxin concentration was 1.9 ng/mL, and the patient was started on a maintenance digoxin dosage of 125 μg i.v. daily. On postoperative day (POD) 20, the patient developed acute kidney injury, and CVVH was initiated. The sieving coefficient (Sc), transmembrane clearance (CLtm), digoxin concentration in ultrafiltration fluid (Cuf), and need for supplemental digoxin were determined to account for CVVH-associated digoxin loss. After 14 days of CVVH, the patientʼs clinical condition improved, and CVVH was transitioned to intermittent hemodialysis. On POD 66, the patient was discharged to an extended-care facility without adverse reactions related to digoxin therapy.
CONCLUSIONAnalysis of serum digoxin concentration and digoxin Cuf values suggested that digoxin was cleared by CVVH, allowed calculation of Sc and CLtm values, and facilitated determination of digoxin requirements in a critically ill patient requiring CVVH.