Thank you Hans - Digoxin warning

I want to express my appreciation to Hans and the contributors to this forum. When I started on this afib journey over 4 years ago, three different doctors (emergency room doctor, cardiologist, and EP tried to put me on digoxin). Based primarily on the studies posted here about digoxin, I refused all three times.

Thank you - I will probably take this article to my next appointment with my EP.

Doreen


Digoxin May Raise Death Risk in Afib

By Crystal Phend, Senior Staff Writer, MedPage Today
Published: November 27, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco


Action Points

The heart rate control drug digoxin may independently raise risk of death in atrial fibrillation.
Point out that the exact mechanism for a mortality effect of digoxin wasn't clear from the study, which didn't record digoxin levels routinely monitored as part of standard clinical care or the exact duration of or adherence to digoxin treatment.


The heart rate control drug digoxin may independently raise risk of death in atrial fibrillation, a clinical trial subanalysis suggested.

After adjustment for clinical characteristics and comorbidities, the drug was associated with 41% elevated all-cause mortality (P<0.001), reported Claude Elayi, MD, of the Gill Heart Institute at the University of Kentucky in Lexington, and colleagues.

Cardiovascular mortality and arrhythmic mortality were similarly elevated with digoxin in the post-hoc AF Follow-Up Investigation of Rhythm Management (AFFIRM) trial analysis, they wrote in the European Heart Journal online.

"These findings call into question the widespread use of digoxin in patients with atrial fibrillation," Elayi's group stated, recommending that the drug's role be reassessed.

The drug, which comes from the foxglove plant, has been used for centuries in heart failure but is controversial today "due to its narrow therapeutic index and a potential to contribute to life-threatening ventricular tachyarrhythmias and severe bradyarrhythmias," the researchers explained.

Randomized trials with strict monitoring of serum levels of digoxin have shown no negative effect of the drug on mortality in heart failure without atrial fibrillation, whereas large observational studies have shown an impact on all-cause and cardiovascular mortality.

To help sort out the role of residual potential confounding versus inherent drug toxicity, Elayi's group examined nonrandomized use of digoxin among the 4,060 patients in the AF Follow-Up Investigation of Rhythm AFFIRM trial.

That trial was designed to compare rate- versus rhythm-control in an atrial fibrillation population considered at high risk for stroke.

The 69% of patients who took digoxin within 6 months of randomization, during the study, or both were more likely to die during the mean 3.5 years of follow-up.

Along with the overall survival difference, cardiovascular mortality remained 35% elevated after controlling for clinical and demographic variables and propensity scores (P=0.016).

Arrhythmic deaths were 61% more common among digoxin-treated patients in the adjusted analysis as well (P=0.009).

The effect didn't appear to differ by sex, and was elevated both among patients without heart failure and those with it (estimated hazard ratios 1.37 and 1.41, P=0.019 and P=0.010, respectively).

"Patients without congestive heart failure or low ejection fraction lack the neurohormonal and inotropic derangements that may improve with digoxin, while remaining exposed to its potential deleterious effects such as pro-arrhythmia and bradycardia," Elayi's group noted.

Even for those with heart failure, "it may be hypothesized that potential benefits are offset by deleterious effects," they added.

A step-wise regression analysis looking for explanatory variables showed the biggest attenuation in the all-cause survival link with adjustment for NYHA functional class, which dropped the mortality excess from 66% to 49%, though still statistically significant.

The lowest estimate for the excess risk was 36%.

The researchers cautioned that their findings may still have overestimated the association due to unknown or unmeasured potential confounders.

"However, given the large observed magnitude of effect and directionally consistent main and sensitivity analyses, invalidation of these results by residual confounding appears implausible," they argued.

Cardiac causes of death without evidence of ischemia were more common among the 56% of deaths with digoxin in use as of the last follow-up visit (37% versus 27% of deaths without digoxin, P=0.007).

Cancer, pulmonary, and noncardiovascular causes of death didn't differ by digoxin status.

The exact mechanism for a mortality effect of digoxin wasn't clear from the study, which didn't record digoxin levels routinely monitored as part of standard clinical care or the exact duration of or adherence to digoxin treatment.

"However, it is important to note that real-world patients, including those in AFFIRM, are not routinely subject to the close follow-up and frequent monitoring of serum digoxin concentrations mandated in the DIG study [N Engl J Med 1997; 336: 525–533]," which showed a neutral effect of the drug in heart failure without atrial fibrillation, Elayi's group wrote.

"It is possible that such strict monitoring is required to ensure safety," they added.


The researchers reported no conflicts of interest.




Primary source: European Heart Journal
Source reference:
Whitbeck MG, et al "Increased mortality among patients taking digoxin-analysis from the AFFIRM study" Eur Heart J 2012; DOI: 10.1093/eurheartj/ehs348.

See also

[www.bbc.co.uk]


Ritze
(The Netherlands)

Thank you Doreen for alerting us to this very important article.

The fact that digoxin (digitalis, Lanoxin) is a highly dangerous drug has been known since at least 1994. In my first book published 10 years ago I labeled it “the medicine from hell” and strongly advised afibbers never to take it.

In 2007 Swedish researchers found that the mortality among afibbers on digoxin was 42% higher than among afibbers not on digoxin; they concluded that digoxin is an independent risk factor for death among AF patients placed on long-term therapy with the drug. They also point out that there is no evidence that digoxin is helpful in speeding up conversion to normal sinus rhythm, nor in preventing recurrence of AF episodes. [www.afibbers.com].

In 2008 a group of Norwegian researchers found a 53% higher mortality rate among afibbers on digoxin therapy as compared to afibbers not on digoxin therapy [www.afibbers.com]

For more on the dangers and many serious adverse effects of digoxin see my report Digoxin: The Medicine from Hell? at [afibbers.org]

One can’t help but wonder how many lives were needlessly cut short by the continued, cavalier, routine dispensing of digoxin by the medical profession over the past 15 years.

Hans

I remember in June and July of 2008 just after I flipped into that very symptomatic persistent AFIB and was in and out of AMC Academisch Medisch Centrum ( Academic Medical Center of University of Amsterdam) in Holland , I had on going battles with their insistance I be on Digoxin injections in addition to mountains of Verapamil (360mg dosings) with the on duty cardiologists including their head of cardiology who all the resident cardios in the ziekenhaus assured me was a true expert in all thing arrhythmia.

I showed him Hans report from this site warning of the unsuitability and out of date-ness of their information on Digoxin and got the typical scoff and dismissal of disbelief, but I still stood my ground and refused to take the digoxin nonetheless.

The only way we got my very extreme swings in rate and rhythm under control was after I called my trusted EP in Hawaii and he said to take only a very low dose of 12.5 mg of Toprol XL along with the large dose of 180mg Verapamil and that combo settled my persistent AFIB/flutter down to a steady 90bpm average HR for the next two months until Dr. Natale could work his magic in Austin.

It would be interesting to have that conversation again now with those cardios in Amsterdam after they have digested this and other more recent studies underscoring the dangers of using this inappropriate drug for AFIB. Hopefully, that have fully moved past all that now and are caught up to speed for the sake of their Dutch patients.

Shannon

more detailed discussion re digoxin study -

[www.theheart.org]