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Digoxin (and Other Cardiac Glycoside) Overdose

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General Information

Description

  • intentional or unintentional digitalis overdose or toxicity resulting in a range of adverse effects that may be life-threatening1,2,3
  • cardiac glycoside overdose or cardiac glycoside toxicity may result from other cardiac glycosides derived from several plant species other than Digitalis lanata

Also called

  • digitalis overdose
  • digitoxin overdose
  • cardiac glycoside overdose
  • digitalis toxicity
  • digitoxin toxicity
  • cardiac glycoside toxicity

Definitions

  • digitalis cardiac glycosides (such as digoxin and digitoxin) are used therapeutically for conditions such as heart failure and atrial fibrillation and are derived from Digitalis lanata4
    • digoxin - only commercially available cardiac glycoside in United States
    • digitoxin - cardiac glycoside available in many countries outside United States

References

General references used

  1. Chan BS, Buckley NA. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol (Phila). 2014 Sep-Oct;52(8):824-36OpenInNew
  2. Bauman JL, Didomenico RJ, Galanter WL. Mechanisms, manifestations, and management of digoxin toxicity in the modern era. Am J Cardiovasc Drugs. 2006;6(2):77-86OpenInNew
  3. Marraffa JM, Cohen V, Howland MA. Antidotes for toxicological emergencies: a practical review. Am J Health Syst Pharm. 2012 Feb 1;69(3):199-212OpenInNew
  4. Kanji S, MacLean RD. Cardiac glycoside toxicity: more than 200 years and counting. Crit Care Clin. 2012 Oct;28(4):527-35OpenInNew

Recommendation grading systems used

  • Extracorporeal Treatments in Poisoning (EXTRIP) workgroup uses Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) system for recommendations
    • strength of recommendations
      • Strong recommendation - certainty about balance of desirable and undesirable consequences of an intervention
      • Weak recommendation - less certainty, or balance of desirable and undesirable consequences was finely balanced
    • quality of evidence
      • High - further research unlikely to change confidence in estimate of effect
      • Moderate - further research likely to have important impact on confidence in estimate of effect and may change estimate
      • Low - further research very likely to have important impact on confidence in estimate of effect and is likely to change estimate
      • Very low - estimate of effect very uncertain
    • Reference - EXTRIP recommendations on extracorporeal treatment for digoxin poisoning (mnh26795743paph112453049pa9h112453049pbyh112453049pafh112453049phch112453049pcxh112453049pmdc26795743pClin Toxicol (Phila) 2016;54(2):103OpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • Panagiotis Papageorgiou, MD, PhD (Assistant Professor of Medicine, Harvard Medical School; Massachusetts, United States)
  • Dr. Papageorgeiou declares no relevant financial conflicts of interest.
  • Eddy Lang, MDCM, CCFP(EM), CSPQ (Zone Clinical and Academic Department Head for Emergency Medicine and Professor of Emergency Medicine, University of Calgary; Senior Researcher, Alberta Health Services; Alberta, Canada)
  • Dr. Lang declares his position as Chair of the Canadian Association of Emergency Physicians Stroke Practice Committee.
  • Dr. Lang declares no relevant financial conflicts of interest.
  • Zbys Fedorowicz, MSc, DPH, BDS, LDSRCS (Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain)
  • Dr. Fedorowicz declares no relevant financial conflicts of interest.
  • Peter Oettgen MD, FACC, FAHA, FACP (Editor in Chief; Cardiologist, Beth Israel Deaconess Medical Center; Associate Professor of Medicine, Harvard Medical School, Massachusetts, United States)
  • Dr. Oettgen declares no relevant financial conflicts of interest.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T116792, Digoxin (and Other Cardiac Glycoside) Overdose; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T116792. Registration and login required.
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    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • For poison emergency

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    General Information

    • Description

    • Also called

    • Definitions

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    Epidemiology

    • Incidence/Prevalence

    • Likely risk factors

    • Possible risk factors

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    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

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    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

    • KeyboardArrowRight

      Physical

      • General physical

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • KeyboardArrowRight

      Blood tests

      • Serum digoxin levels

      • Serum potassium

      • Additional blood tests

    • Electrocardiography (ECG)

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    Management

    • Management overview

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      Medications

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        Digoxin immune Fab

        • General information

        • Indication and uses

        • Dosing for digoxin overdose/digoxin toxicity

        • Dosing for digiTOXIN overdose/digiTOXIN toxicity

        • Efficacy evidence

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        Gastrointestinal decontamination medications

        • Activated charcoal

        • Ipecac syrup

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        Other medications for supportive care

        • Treatment of hyperkalemia

        • Treatment of hypokalemia/hypomagnesemia

        • Treatment of hemodynamically unstable dysrhythmias

        • Treatment of other dysrhythmias

    • Consultation and referral

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      Other management

      • Gastric lavage

      • Whole bowel irrigation

      • Extracorporeal treatments

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    Complications and Prognosis

    • Complications

    • Prognosis

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

    • Screening

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

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    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Panagiotis Papageorgiou MD, PhD
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Affiliations

Assistant Professor of Medicine, Harvard Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Papageorgeiou declares no relevant financial conflicts of interest.

Recommendations Editors
Eddy Lang MDCM, CCFP(EM), CSPQ
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Affiliations

Zone Clinical and Academic Department Head for Emergency Medicine and Professor of Emergency Medicine, University of Calgary; Alberta, Canada; Senior Researcher, Alberta Health Services; Alberta, Canada

Conflicts of Interest

Dr. Lang declares no relevant financial conflicts of interest.

Recommendations Editors
Zbys Fedorowicz MSc, DPH, BDS, LDSRCS
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Affiliations

Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain

Conflicts of Interest

Dr. Fedorowicz declares no relevant financial conflicts of interest.

Deputy Editor
Peter Oettgen MD
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Affiliations

Editor in Chief, DynaMed; Cardiologist, Beth Israel Deaconess Medical Center; Massachusetts, United States; Associate Professor of Medicine, Harvard Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Oettgen declares no relevant financial conflicts of interest.

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