Digoxin Pharmacokinetics and Pharmacodynamics

Questions provided by Nicholas C. Schwier, Pharm.D.

Question 1. HOE is a 62 year-old female with a past medical history of Hypertension, Chronic Heart Failure (EF < 30 %), Ischemic Heart Disease, and Dyslipidemia. Currently, HOE is taking atorvastatin 80 mg once daily, carvedilol 25 mg twice daily, lisinopril 40 mg once daily, and eplerenone 25 mg once daily. HOE is still having heart failure exacerbations and is now admitted to your unit. Your attending would like to start HOE on digoxin (oral tablets). HOE is 65 inches tall and weight 132 lbs. her serum creatinine over the past six months is 1.24 mg/dL. HOE's heart rate today is 135 bpm and his blood pressure is 138/78 mmHg. Using the appropriate digoxin concentration range for heart failure, please calculate a daily dose for HOE, for the low and high ends of this range. Round to the nearest half tablet (0.125 mg/2).

Assume that: Total Cl_Digoxin (mL/min)= (0.33 mL/kg/min).(wt in kg) + (0.9).(CLcr mL/min)

Reference: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3646412/
For heart failure: Lexi-Comp^®, UpToDate^® and Epocrates^® suggest 0.5 - 0.8 ng/mL.

Question 2. VP is a 58 year-old female who comes to your unit in atrial fibrillation with a heart rate of 125 bpm. Her only past medical history is Hypertension. Your attending would like to use digoxin for rate control. VP's blood pressure is 118/73 mmHg, her weight is 233 lbs., and she is 74 inches tall. Her potassium today is 3.9 mEq/L and her serum creatinine is 1.77 mg/dL. Your attending would like to administer a loading dose. Please calculate an IV loading dose for VP using the Jusko-Koup method and the Jelliffe method. Assume VD (L/Kg) = 4.5 + 0.028 (CLcr in mL/min/1.73m²) and target digoxin Css = 0.9 ng/mL

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Some Equations:

Equation 27.2.1 IBW for Male Patients

Equation 27.2.2 IBW for Female Patients

Creatine Clearance C-G Equation
Equation 27.2.3 Creatinine Clearance (Cockcroft-Gault Equation)

Steady State Concentration Equation
Equation 27.2.4 Steady State Concentration

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