DIGOXIN Lippincott Williams Wilkins（地高辛威廉姆斯Lippincott 威尔金斯）.pdfVIP

3 DIGOXIN Maureen S. Boro and Michael E. Winter Digoxin is an inotropic agent primarily used to treat congestive heart failure (CHF) and atrial fibrillation. It is incompletely absorbed and once ab- sorbed, a substantial fraction is cleared by the kidneys. In the acute care set- ting, historically digoxin loading doses of L 1 mg/70 kg were administered before the initiation of the usual maintenance dose of 0.125 to 0.25 mg/day. These loading and maintenance doses were from an era when target levels were 1 to 2 mcg/L and probably today doses of approximately one-half would be more common in patients with heart failure (see Therapeutic Plasma Concentrations, this chapter). Because it has a relatively long elimination half-life in adults, digoxin is given once daily. Dosage adjust- ments can be important for patients who are being converted from par- enteral to oral therapy or vice versa; patients with renal impairment, CHF, or thyroid abnormalities; or patients who take amiodarone concurrently. THERAPEUTIC PLASMA CONCENTRATIONS Although there is considerable variation between patients, histori- cally plasma digoxin concentrations of L 1 to 2 mcg/L (ng/mL) were gen- erally considered to be within the therapeutic range.1,2 Data now indicate that a therapeutic range of 0.5 to 0.9 mcg/L is indicated for patients with CHF.3–6 This lower target range is based on the fact that most patients with left ventricular dysfunction do not demonstrate additional therapeutic benefits from higher digoxin concentrations and are at greater risk for toxicity with digoxin concentrations Ú 1.2 mcg/L.7–9 For patients on digoxin for atrial fibrillation, the goal for digoxin is rate control.10 Rate con- trol is achieved by atrioventricular (AV) nodal blockade and may require higher digoxin concentrations. The use of pharmacokinetics to adjust the dosing regimen can reduce the incid