Patient handout

Digoxin toxicity

PRODUCTION

1. Your condition

This handout is for digoxin toxicity. Your care team identified this based on: deliberate or accidental digoxin tablet/elixir overdose (acute) (acmt/extrip).

Other reasons your team may use this plan: chronic digoxin + new renal impairment / interacting drug / electrolyte derangement (acmt/extrip); elevated serum digoxin level (≥2.0 ng/ml) on routine or symptomatic draw (acmt/extrip); oleander / foxglove / lily-of-the-valley / toad-venom (bufadienolide) ingestion (case-series tox reviews).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
digoxin immune Fab (ovine, DigiFab)	ACUTE known amount: vials = (mg ingested × 0.8) / 0.5, round up. STEADY-STATE level: vials = (serum digoxin ng/mL × weight kg) / 100. EMPIRIC: acute unknown / arrest 10–20 vials; chronic toxicity 3–6 vials (often 1–2 vials titrated in elderly chronic to avoid AF/HF rebound)	IV	infuse over 30 min (IV push if cardiac arrest); GIVE AND REASSESS — redose for recrudescent/incompletely reversed toxicity	ACMT/EXTRIP + Antman 1990 multicenter trial — DigiFab binds free digoxin (and cross-reacts with most plant cardenolides/bufadienolides) → renal clearance of inactive complex; reverses dysrhythmia + hyperK within 30–60 min. Plant glycosides cross-react variably so dose empirically/clinically (assay does NOT quantify them). Each vial (40 mg) binds ~0.5 mg digoxin. Watch for hypoK rebound + loss of rate control / HF in AF/HFrEF patients

Plan: Cardiac glycoside toxicity — DigiFab-first (antidote → hyperK → bradydysrhythmia → tachydysrhythmia → electrolyte correction)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Acute glycoside ingestion with K+ >5.0–5.5 mEq/L (Bismuth 1973 — pre-Fab mortality ~0% if K+ <5.0, ~50% if 5.0–5.5, ~100% if >5.5)(life-threatening)
Bidirectional VT, VT/VF, or other life-threatening glycoside dysrhythmia (ACMT)(life-threatening)
High-grade/complete AV block or symptomatic bradycardia / junctional escape with hypoperfusion (ACMT)
Hemodynamic instability / shock attributable to glycoside toxicity regardless of digoxin level (ACMT)(life-threatening)
Massive acute ingestion: >10 mg adult / >0.1 mg/kg child, OR acute level >10 ng/mL, OR known cardiotoxic plant/herbal glycoside ingestion (ACMT)
Cardiac arrest in known/suspected cardiac glycoside (digoxin or plant) toxicity (ACMT)(life-threatening)

5. Follow-up

Reconcile/withhold or dose-adjust chronic digoxin (re-evaluate indication — narrow therapeutic index, deprescribe in HFrEF if alternatives); review interacting drugs + renal dosing; patient/caregiver education on toxicity signs (visual halos, GI, confusion); psychiatry follow-up if intentional; plant-source removal counseling (ACMT)

6. Sources

Guideline: 2024-2025 critical-care toxicology reviews; ACMT/EXTRIP digoxin position (Mowry/EXTRIP 2016); Antman 1990 multicenter digoxin-specific Fab trial; Bismuth 1973 hyperkalemia prognosis in acute digitalis poisoning