Digoxin toxicity
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
acute ingestion, low to moderate toxicity
supportive care
General supportive care includes initial and ongoing assessment of airway, breathing, and circulation, stabilizing as necessary. Supplemental oxygen is given and endotracheal intubation performed if needed.
Patients require continuous cardiac monitoring and pulse oximetry with consideration of end tidal CO 2.[3]Andrews P, Anseeuw K, Kotecha D, et al. Diagnosis and practical management of digoxin toxicity: a narrative review and consensus. Eur J Emerg Med. 2023 Dec 1;30(6):395-401. https://pmc.ncbi.nlm.nih.gov/articles/PMC10599802 http://www.ncbi.nlm.nih.gov/pubmed/37650725?tool=bestpractice.com
Initial treatment of hypotension and volume depletion should be corrected with isotonic intravenous fluids, with caution for patients with congestive heart failure.
activated charcoal
Treatment recommended for ALL patients in selected patient group
Activated charcoal may be administered to decrease gastrointestinal absorption of digoxin. Digoxin (and other cardiac glycosides) undergo enterohepatic and enteroenteric recirculation and use of activated charcoal interrupts this by facilitating gut dialysis and reducing elimination half-life.[7]Hack JB, Wingate S, Zolty R, et al. Expert consensus on the diagnosis and management of digoxin toxicity. Am J Med. 2025 Jan;138(1):25-33.e14. https://www.amjmed.com/article/S0002-9343(24)00543-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/39265879?tool=bestpractice.com [44]Ibanez C, Carcas AJ, Frias J, et al. Activated charcoal increases digoxin elimination in patients. Int J Cardiol. 1995 Jan 27;48(1):27-30. http://www.ncbi.nlm.nih.gov/pubmed/7744534?tool=bestpractice.com It is effective in the first 6-8 hours post-ingestion. Multiple doses may be required.[45]American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. J Toxicol Clin Toxicol. 1999;37(6):731-51. http://www.clintox.org/wp-content/uploads/2016/04/Position-Statement-Multi-Dose-Activated-Charcoal-1.pdf http://www.ncbi.nlm.nih.gov/pubmed/10584586?tool=bestpractice.com
Caution should be taken in patients who vomit or those with altered mental status; they are at risk of pulmonary aspiration when drinking the charcoal solution.
Primary options
charcoal, activated: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
charcoal, activated: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
charcoal, activated
digoxin immune Fab
Treatment recommended for SOME patients in selected patient group
Digoxin-specific antibody fragments (digoxin immune Fab) are indicated in patients with: symptomatic bradyarrhythmias; ventricular dysrhythmias; suspected digoxin toxicity and hyperkalemia (potassium concentrations >5.5 mEq/L to >6 mEq/L; indication for digoxin immune Fab varies depending on source, consult local guidance); acute ingestion of >4 mg digoxin in a healthy child (or 0.1 mg/kg); acute ingestion of >10 mg digoxin in a healthy adult; serum digoxin concentration of ≥10 nanograms/mL 4-6 hours after ingestion (steady state); and serum digoxin concentration of >4 nanograms/mL at any time.[3]Andrews P, Anseeuw K, Kotecha D, et al. Diagnosis and practical management of digoxin toxicity: a narrative review and consensus. Eur J Emerg Med. 2023 Dec 1;30(6):395-401. https://pmc.ncbi.nlm.nih.gov/articles/PMC10599802 http://www.ncbi.nlm.nih.gov/pubmed/37650725?tool=bestpractice.com [7]Hack JB, Wingate S, Zolty R, et al. Expert consensus on the diagnosis and management of digoxin toxicity. Am J Med. 2025 Jan;138(1):25-33.e14. https://www.amjmed.com/article/S0002-9343(24)00543-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/39265879?tool=bestpractice.com
There are formulae available within the package insert for calculating the neutralizing dose of digoxin immune Fab, based on total body burden or total dose ingested.[49]Bateman DN. Digoxin-specific antibody fragments: how much and when? Toxicol Rev. 2004;23(3):135-43. http://www.ncbi.nlm.nih.gov/pubmed/15862081?tool=bestpractice.com In acute toxicity, 15 vials of digoxin immune Fab is the quantity typically needed to treat one patient.[31]Dart RC, Goldfrank LR, Erstad BL, et al. Expert Consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Ann Emerg Med. 2018 Mar;71(3):314-25.e1. https://www.sciencedirect.com/science/article/pii/S0196064417306571?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/28669553?tool=bestpractice.com One study suggests 1-2 vials administered in a stepwise fashion based on clinical response.[32]Chan BS, Buckley NA. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol (Phila). 2014 Sep-Oct;52(8):824-36. http://www.ncbi.nlm.nih.gov/pubmed/25089630?tool=bestpractice.com
Patients who receive digoxin immune Fab have a drop in the serum potassium as it moves intracellularly.[33]Antman EM, Wenger TL, Butler VP Jr, et al. Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments: final report of a multicenter study. Circulation. 1990 Jun;81(6):1744-52. http://www.ncbi.nlm.nih.gov/pubmed/2188752?tool=bestpractice.com [34]Smith TW, Haber E, Yeatman L, et al. Reversal of advanced digoxin intoxication with Fab fragments of digoxin-specific antibodies. N Engl J Med. 1976 Apr 8;294(15):797-800. http://www.ncbi.nlm.nih.gov/pubmed/943040?tool=bestpractice.com [35]Smith TW, Butler VP Jr, Haber E, et al. Treatment of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments: experience in 26 cases. N Engl J Med. 1982 Nov 25;307(22):1357-62. http://www.ncbi.nlm.nih.gov/pubmed/6752715?tool=bestpractice.com Some patients who have been treated for hyperkalemia and who have also received digoxin immune Fab develop profound hypokalemia. Therefore, serial potassium measurements are made when patients receive both digoxin immune Fab and other therapies to decrease potassium.[36]Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol.2019 Aug 20;74(7):e51-156. https://www.jacc.org/doi/10.1016/j.jacc.2018.10.044 http://www.ncbi.nlm.nih.gov/pubmed/30412709?tool=bestpractice.com
After administration of digoxin immune Fab, serum digoxin concentrations are usually falsely elevated (10- to 30-fold). Serum digoxin concentration can be measured again 3-4 days after dose is given, but has been reported to be elevated for up to 10 days, especially in patients with renal insufficiency.[37]Lemon M, Andrews DJ, Binks AM, et al. Concentrations of free serum digoxin after treatment with antibody fragments. Br Med J (Clin Res Ed). 1987 Dec 12;295(6612):1520-1. https://pmc.ncbi.nlm.nih.gov/articles/PMC1248668 http://www.ncbi.nlm.nih.gov/pubmed/3122885?tool=bestpractice.com [38]Miller JJ, Straub RW Jr, Valdes R Jr. Analytical performance of a monoclonal digoxin assay with increased specificity on the ACS:180. Ther Drug Monit. 1996 Feb;18(1):65-72. http://www.ncbi.nlm.nih.gov/pubmed/8848824?tool=bestpractice.com [39]Rainey PM. Effects of digoxin immune Fab (ovine) on digoxin immunoassays. Am J Clin Pathol. 1989 Dec;92(6):779-86. http://www.ncbi.nlm.nih.gov/pubmed/2686397?tool=bestpractice.com
Patients may rarely develop a rate-related infusion reaction, in which case the infusion should be stopped and restarted at a slower infusion rate. There is a higher risk for a reaction if no filter is used when giving digoxin immune Fab.
After administration, serum total digoxin concentrations are no longer useful because elevated levels reflect both free digoxin and digoxin bound to digoxin immune Fab.[37]Lemon M, Andrews DJ, Binks AM, et al. Concentrations of free serum digoxin after treatment with antibody fragments. Br Med J (Clin Res Ed). 1987 Dec 12;295(6612):1520-1. https://pmc.ncbi.nlm.nih.gov/articles/PMC1248668 http://www.ncbi.nlm.nih.gov/pubmed/3122885?tool=bestpractice.com There are assays that are able to determine free digoxin serum concentrations, but they are not always routinely available.
Primary options
digoxin immune Fab: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
digoxin immune Fab: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
digoxin immune Fab
potassium replacement
Treatment recommended for ALL patients in selected patient group
Potassium should be given via cautious intravenous infusion to restore serum potassium to normal levels.
Replacement should follow local protocols.
The serum potassium should be checked at intervals and therapy adjusted as needed.
observation ± correction of hyperkalemia
Treatment recommended for ALL patients in selected patient group
Hyperkalemia is only further corrected (e.g., with insulin/glucose) if it is considered life-threatening, because of the risk of producing hypokalemia. If required, correction should follow local protocols.
Calcium has historically not been used to treat hyperkalemia in patients with suspected digoxin toxicity as there are concerns that it may induce arrhythmia or cardiac arrest. The risk of harm from calcium in patients with digoxin toxicity has not been quantified; however, there is also no evidence of benefit.[41]Lavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2023 Oct 17;148(16):e149-84. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001161 http://www.ncbi.nlm.nih.gov/pubmed/37721023?tool=bestpractice.com
magnesium replacement
Treatment recommended for ALL patients in selected patient group
Magnesium should be given via cautious intravenous infusion to restore serum magnesium to normal levels.
Replacement should follow local protocols.
The serum magnesium should be checked at intervals and therapy adjusted as needed.
chronic ingestion, low to moderate toxicity
supportive care
Treatment of chronic toxicity is based on clinical signs and symptoms, not the serum digoxin concentration, which might be just above the therapeutic range. Serum digoxin concentrations are unreliable if obtained earlier than 6 hours after a dose of digoxin.[25]Gheorghiade M, van Veldhuisen DJ, Colucci WS. Contemporary use of digoxin in the management of cardiovascular disorders. Circulation. 2006 May 30;113(21):2556-64. http://www.ncbi.nlm.nih.gov/pubmed/16735690?tool=bestpractice.com If a serum digoxin concentration cannot be obtained, patients are managed based on their presentation, ECG findings, and laboratory results.
General supportive care includes initial and ongoing assessment of airway, breathing, and circulation, stabilizing as necessary. Supplemental oxygen is given and endotracheal intubation performed if needed.
Patients require continuous cardiac monitoring and pulse oximetry with consideration of end tidal CO 2.[3]Andrews P, Anseeuw K, Kotecha D, et al. Diagnosis and practical management of digoxin toxicity: a narrative review and consensus. Eur J Emerg Med. 2023 Dec 1;30(6):395-401. https://pmc.ncbi.nlm.nih.gov/articles/PMC10599802 http://www.ncbi.nlm.nih.gov/pubmed/37650725?tool=bestpractice.com
Initial treatment of hypotension and volume depletion should be corrected with isotonic intravenous fluids, with caution for patients with congestive heart failure.
digoxin immune Fab
Treatment recommended for ALL patients in selected patient group
Digoxin-specific antibody fragments (digoxin immune Fab) are indicated in patients with: symptomatic bradyarrhythmias; ventricular dysrhythmias; suspected digoxin toxicity and hyperkalemia (potassium concentrations >5.5 mEq/L to >6 mEq/L; indication for digoxin immune Fab varies depending on source, consult local guidance); serum digoxin concentration of ≥10 nanograms/mL 4-6 hours after ingestion (steady state); and serum digoxin concentration of >4 nanograms/mL at any time.[3]Andrews P, Anseeuw K, Kotecha D, et al. Diagnosis and practical management of digoxin toxicity: a narrative review and consensus. Eur J Emerg Med. 2023 Dec 1;30(6):395-401. https://pmc.ncbi.nlm.nih.gov/articles/PMC10599802 http://www.ncbi.nlm.nih.gov/pubmed/37650725?tool=bestpractice.com [7]Hack JB, Wingate S, Zolty R, et al. Expert consensus on the diagnosis and management of digoxin toxicity. Am J Med. 2025 Jan;138(1):25-33.e14. https://www.amjmed.com/article/S0002-9343(24)00543-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/39265879?tool=bestpractice.com
There are formulae available within the package insert for calculating the neutralizing dose of digoxin immune Fab, based on total body burden or total dose ingested.[49]Bateman DN. Digoxin-specific antibody fragments: how much and when? Toxicol Rev. 2004;23(3):135-43. http://www.ncbi.nlm.nih.gov/pubmed/15862081?tool=bestpractice.com One study suggests 1-2 vials administered in a stepwise fashion based on clinical response.[32]Chan BS, Buckley NA. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol (Phila). 2014 Sep-Oct;52(8):824-36. http://www.ncbi.nlm.nih.gov/pubmed/25089630?tool=bestpractice.com For patients with chronic digitalis poisoning, therapy may require only a few digoxin immune Fab vials.
Patients who receive digoxin immune Fab have a drop in the serum potassium as it moves intracellularly.[33]Antman EM, Wenger TL, Butler VP Jr, et al. Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments: final report of a multicenter study. Circulation. 1990 Jun;81(6):1744-52. http://www.ncbi.nlm.nih.gov/pubmed/2188752?tool=bestpractice.com [34]Smith TW, Haber E, Yeatman L, et al. Reversal of advanced digoxin intoxication with Fab fragments of digoxin-specific antibodies. N Engl J Med. 1976 Apr 8;294(15):797-800. http://www.ncbi.nlm.nih.gov/pubmed/943040?tool=bestpractice.com [35]Smith TW, Butler VP Jr, Haber E, et al. Treatment of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments: experience in 26 cases. N Engl J Med. 1982 Nov 25;307(22):1357-62. http://www.ncbi.nlm.nih.gov/pubmed/6752715?tool=bestpractice.com Some patients who have been treated for hyperkalemia and who have also received digoxin immune Fab develop profound hypokalemia. Therefore, serial potassium measurements are made when patients receive both digoxin immune Fab and other therapies to decrease potassium.[36]Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol.2019 Aug 20;74(7):e51-156. https://www.jacc.org/doi/10.1016/j.jacc.2018.10.044 http://www.ncbi.nlm.nih.gov/pubmed/30412709?tool=bestpractice.com
After administration of digoxin immune Fab, serum digoxin concentrations are usually falsely elevated (10- to 30-fold). Serum digoxin concentration can be measured again 3-4 days after dose is given, but has been reported to be elevated for up to 10 days, especially in patients with renal insufficiency.[37]Lemon M, Andrews DJ, Binks AM, et al. Concentrations of free serum digoxin after treatment with antibody fragments. Br Med J (Clin Res Ed). 1987 Dec 12;295(6612):1520-1. https://pmc.ncbi.nlm.nih.gov/articles/PMC1248668 http://www.ncbi.nlm.nih.gov/pubmed/3122885?tool=bestpractice.com [38]Miller JJ, Straub RW Jr, Valdes R Jr. Analytical performance of a monoclonal digoxin assay with increased specificity on the ACS:180. Ther Drug Monit. 1996 Feb;18(1):65-72. http://www.ncbi.nlm.nih.gov/pubmed/8848824?tool=bestpractice.com [39]Rainey PM. Effects of digoxin immune Fab (ovine) on digoxin immunoassays. Am J Clin Pathol. 1989 Dec;92(6):779-86. http://www.ncbi.nlm.nih.gov/pubmed/2686397?tool=bestpractice.com
Patients may rarely develop a rate-related infusion reaction, in which case the infusion should be stopped and restarted at a slower infusion rate. There is a higher risk for a reaction if no filter is used when giving digoxin immune Fab.
After administration, serum total digoxin concentrations are no longer useful because elevated levels reflect both free digoxin and digoxin bound to digoxin immune Fab.[37]Lemon M, Andrews DJ, Binks AM, et al. Concentrations of free serum digoxin after treatment with antibody fragments. Br Med J (Clin Res Ed). 1987 Dec 12;295(6612):1520-1. https://pmc.ncbi.nlm.nih.gov/articles/PMC1248668 http://www.ncbi.nlm.nih.gov/pubmed/3122885?tool=bestpractice.com There are assays that are able to determine free digoxin serum concentrations, but they are not always routinely available.
Primary options
digoxin immune Fab: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
digoxin immune Fab: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
digoxin immune Fab
potassium replacement
Treatment recommended for ALL patients in selected patient group
Potassium should be given via cautious intravenous infusion to restore serum potassium to normal levels.
Replacement should follow local protocols.
The serum potassium should be checked at intervals and therapy adjusted as needed.
observation ± correction of hyperkalemia
Treatment recommended for ALL patients in selected patient group
Hyperkalemia is only further corrected (e.g., with insulin/glucose) if it is considered life-threatening, because of the risk of producing hypokalemia. If required, correction should follow local protocols.
Calcium has historically not been used to treat hyperkalemia in patients with suspected digoxin toxicity as there are concerns it may induce arrhythmia or cardiac arrest. The risk of harm from calcium in patients with digoxin toxicity has not been quantified; however, there is also no evidence of benefit.[41]Lavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2023 Oct 17;148(16):e149-84. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001161 http://www.ncbi.nlm.nih.gov/pubmed/37721023?tool=bestpractice.com
magnesium replacement
Treatment recommended for ALL patients in selected patient group
Magnesium should be given via cautious intravenous infusion to restore serum magnesium to normal levels.
Replacement should follow local protocols.
The serum magnesium should be checked at intervals and therapy adjusted as needed.
severe toxicity or hemodynamic compromise (acute or chronic toxicity)
supportive care
General supportive care includes initial and ongoing assessment of airway, breathing, and circulation, stabilizing as necessary. Supplemental oxygen is given and endotracheal intubation performed if needed.
Patients require continuous cardiac monitoring and pulse oximetry with consideration of end tidal CO 2.[3]Andrews P, Anseeuw K, Kotecha D, et al. Diagnosis and practical management of digoxin toxicity: a narrative review and consensus. Eur J Emerg Med. 2023 Dec 1;30(6):395-401. https://pmc.ncbi.nlm.nih.gov/articles/PMC10599802 http://www.ncbi.nlm.nih.gov/pubmed/37650725?tool=bestpractice.com
Initial treatment of hypotension and volume depletion should be corrected with isotonic intravenous fluids, with caution for patients with congestive heart failure.
In patients with signs of hemodynamic insufficiency and/or compromise (e.g., hypotension, altered consciousness), digoxin immune Fab is given as primary management. As a bridge to the administration of digoxin immune Fab, intravenous fluids and direct-acting vasopressors (e.g., phenylephrine, norepinephrine [noradrenaline]) are used.
digoxin immune Fab
Treatment recommended for ALL patients in selected patient group
Digoxin-specific antibody fragments (digoxin immune Fab) are used in patients with: severe toxicity or hemodynamic compromise; symptomatic bradyarrhythmias; ventricular dysrhythmias; suspected digoxin toxicity and hyperkalemia (potassium concentrations >5.5 mEq/L to >6 mEq/L; indication for digoxin immune Fab varies depending on source, consult local guidance); acute ingestion of >4 mg digoxin in a healthy child (or 0.1 mg/kg); acute ingestion of >10 mg digoxin in a healthy adult; serum digoxin concentration of ≥10 nanograms/mL 4-6 hours after ingestion (steady state); and serum digoxin concentration of >4 nanograms/mL at any time.[3]Andrews P, Anseeuw K, Kotecha D, et al. Diagnosis and practical management of digoxin toxicity: a narrative review and consensus. Eur J Emerg Med. 2023 Dec 1;30(6):395-401. https://pmc.ncbi.nlm.nih.gov/articles/PMC10599802 http://www.ncbi.nlm.nih.gov/pubmed/37650725?tool=bestpractice.com [7]Hack JB, Wingate S, Zolty R, et al. Expert consensus on the diagnosis and management of digoxin toxicity. Am J Med. 2025 Jan;138(1):25-33.e14. https://www.amjmed.com/article/S0002-9343(24)00543-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/39265879?tool=bestpractice.com [30]Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. Circulation. 2018 Sep 25;138(13):e272-391. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000549 http://www.ncbi.nlm.nih.gov/pubmed/29084731?tool=bestpractice.com
There are formulae available within the package insert for calculating the neutralizing dose of digoxin immune Fab, based on total body burden or total dose ingested.[49]Bateman DN. Digoxin-specific antibody fragments: how much and when? Toxicol Rev. 2004;23(3):135-43. http://www.ncbi.nlm.nih.gov/pubmed/15862081?tool=bestpractice.com In acute toxicity, 15 vials of digoxin immune Fab is the quantity typically needed to treat one patient.[31]Dart RC, Goldfrank LR, Erstad BL, et al. Expert Consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Ann Emerg Med. 2018 Mar;71(3):314-25.e1. https://www.sciencedirect.com/science/article/pii/S0196064417306571?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/28669553?tool=bestpractice.com One study suggests 1-2 vials administered in a stepwise fashion based on clinical response.[32]Chan BS, Buckley NA. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol (Phila). 2014 Sep-Oct;52(8):824-36. http://www.ncbi.nlm.nih.gov/pubmed/25089630?tool=bestpractice.com For patients with chronic digitalis poisoning, therapy may require only a few digoxin immune Fab vials.
Patients who receive digoxin immune Fab have a drop in the serum potassium as it moves intracellularly.[33]Antman EM, Wenger TL, Butler VP Jr, et al. Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments: final report of a multicenter study. Circulation. 1990 Jun;81(6):1744-52. http://www.ncbi.nlm.nih.gov/pubmed/2188752?tool=bestpractice.com [34]Smith TW, Haber E, Yeatman L, et al. Reversal of advanced digoxin intoxication with Fab fragments of digoxin-specific antibodies. N Engl J Med. 1976 Apr 8;294(15):797-800. http://www.ncbi.nlm.nih.gov/pubmed/943040?tool=bestpractice.com [35]Smith TW, Butler VP Jr, Haber E, et al. Treatment of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments: experience in 26 cases. N Engl J Med. 1982 Nov 25;307(22):1357-62. http://www.ncbi.nlm.nih.gov/pubmed/6752715?tool=bestpractice.com Some patients who have been treated for hyperkalemia and who have also received digoxin immune Fab develop profound hypokalemia. Therefore, serial potassium measurements are made when patients receive both digoxin immune Fab and other therapies to decrease potassium.[36]Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol.2019 Aug 20;74(7):e51-156. https://www.jacc.org/doi/10.1016/j.jacc.2018.10.044 http://www.ncbi.nlm.nih.gov/pubmed/30412709?tool=bestpractice.com
After administration of digoxin immune Fab, serum digoxin concentrations are usually falsely elevated (10- to 30-fold). Serum digoxin concentration can be measured again 3-4 days after dose is given, but has been reported to be elevated for up to 10 days, especially in patients with renal insufficiency.[37]Lemon M, Andrews DJ, Binks AM, et al. Concentrations of free serum digoxin after treatment with antibody fragments. Br Med J (Clin Res Ed). 1987 Dec 12;295(6612):1520-1. https://pmc.ncbi.nlm.nih.gov/articles/PMC1248668 http://www.ncbi.nlm.nih.gov/pubmed/3122885?tool=bestpractice.com [38]Miller JJ, Straub RW Jr, Valdes R Jr. Analytical performance of a monoclonal digoxin assay with increased specificity on the ACS:180. Ther Drug Monit. 1996 Feb;18(1):65-72. http://www.ncbi.nlm.nih.gov/pubmed/8848824?tool=bestpractice.com [39]Rainey PM. Effects of digoxin immune Fab (ovine) on digoxin immunoassays. Am J Clin Pathol. 1989 Dec;92(6):779-86. http://www.ncbi.nlm.nih.gov/pubmed/2686397?tool=bestpractice.com
Patients may rarely develop a rate-related infusion reaction, in which case the infusion should be stopped and restarted at a slower infusion rate. There is a higher risk for a reaction if no filter is used when giving digoxin immune Fab.
After administration, serum total digoxin concentrations are no longer useful because elevated levels reflect both free digoxin and digoxin bound to digoxin immune Fab.[37]Lemon M, Andrews DJ, Binks AM, et al. Concentrations of free serum digoxin after treatment with antibody fragments. Br Med J (Clin Res Ed). 1987 Dec 12;295(6612):1520-1. https://pmc.ncbi.nlm.nih.gov/articles/PMC1248668 http://www.ncbi.nlm.nih.gov/pubmed/3122885?tool=bestpractice.com There are assays that are able to determine free digoxin serum concentrations, but they are not always routinely available.
If hypotension persists after administration of digoxin immune Fab, consider the possibility of mixed overdose, effects of other underlying drugs, or another cause, such as sepsis or cardiogenic shock.
Primary options
digoxin immune Fab: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
digoxin immune Fab: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
digoxin immune Fab
activated charcoal
Treatment recommended for SOME patients in selected patient group
Activated charcoal is administered to decrease gastrointestinal absorption of digoxin. Digoxin (and other cardiac glycosides) undergo enterohepatic and enteroenteric recirculation and use of activated charcoal interrupts this by facilitating gut dialysis and reducing elimination half-life.[7]Hack JB, Wingate S, Zolty R, et al. Expert consensus on the diagnosis and management of digoxin toxicity. Am J Med. 2025 Jan;138(1):25-33.e14. https://www.amjmed.com/article/S0002-9343(24)00543-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/39265879?tool=bestpractice.com [43]Boldy DA, Smart V, Vale JA. Multiple doses of charcoal in digoxin poisoning. Lancet. 1985 Nov 9;2(8463):1076-7. http://www.ncbi.nlm.nih.gov/pubmed/2865561?tool=bestpractice.com [44]Ibanez C, Carcas AJ, Frias J, et al. Activated charcoal increases digoxin elimination in patients. Int J Cardiol. 1995 Jan 27;48(1):27-30. http://www.ncbi.nlm.nih.gov/pubmed/7744534?tool=bestpractice.com It is effective in the first 6-8 hours post-ingestion. Multiple doses may be required.[45]American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. J Toxicol Clin Toxicol. 1999;37(6):731-51. http://www.clintox.org/wp-content/uploads/2016/04/Position-Statement-Multi-Dose-Activated-Charcoal-1.pdf http://www.ncbi.nlm.nih.gov/pubmed/10584586?tool=bestpractice.com
Caution should be taken in patients who vomit or those with altered mental status; they are at risk of pulmonary aspiration when drinking the charcoal solution.
Primary options
charcoal, activated: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
charcoal, activated: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
charcoal, activated
potassium replacement
Treatment recommended for ALL patients in selected patient group
Potassium should be given via cautious intravenous infusion to restore serum potassium to normal levels.
Replacement should follow local protocols.
The serum potassium should be checked at intervals and therapy adjusted as needed.
observation ± correction of hyperkalemia
Treatment recommended for ALL patients in selected patient group
Hyperkalemia is only further corrected (e.g., with insulin/glucose) if it is considered life-threatening, because of the risk of producing hypokalemia. If required, correction should follow local protocols.
Calcium has historically not been used to treat hyperkalemia in patients with suspected digoxin toxicity as there are concerns it may induce arrhythmia or cardiac arrest. The risk of harm from calcium in patients with digoxin toxicity has not been quantified; however, there is also no evidence of benefit.[41]Lavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2023 Oct 17;148(16):e149-84. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001161 http://www.ncbi.nlm.nih.gov/pubmed/37721023?tool=bestpractice.com
magnesium replacement
Treatment recommended for ALL patients in selected patient group
Magnesium should be given via cautious intravenous infusion to restore serum magnesium to normal levels.
Replacement should follow local protocols.
The serum magnesium should be checked at intervals and therapy adjusted as needed.
atropine or temporary pacing wire
Treatment recommended for ALL patients in selected patient group
If the patient does not respond to digoxin immune Fab or it is not immediately available, patients with symptomatic bradycardia can be treated with atropine.[36]Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol.2019 Aug 20;74(7):e51-156. https://www.jacc.org/doi/10.1016/j.jacc.2018.10.044 http://www.ncbi.nlm.nih.gov/pubmed/30412709?tool=bestpractice.com
In adults, atropine can be given every 3-5 minutes until there is a response or the maximum dose is reached. Pediatric patients with symptomatic bradycardia require lower doses of atropine.
Alternatively, a temporary pacing wire can be inserted in patients with evidence of significant bradycardia or AV block and hemodynamic compromise if digoxin immune Fab is not adequate or not readily available.
Primary options
atropine: children: 0.02 mg/kg (minimum 0.1 mg, maximum 0.5 mg) intravenously as a single dose, may repeat once only, maximum 1 mg/total dose; adults: 0.5 mg intravenously every 3-5 minutes, maximum 3 mg/total dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
atropine: children: 0.02 mg/kg (minimum 0.1 mg, maximum 0.5 mg) intravenously as a single dose, may repeat once only, maximum 1 mg/total dose; adults: 0.5 mg intravenously every 3-5 minutes, maximum 3 mg/total dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
atropine
defibrillation plus antiarrhythmics
Treatment recommended for ALL patients in selected patient group
Patients with ventricular fibrillation or pulseless ventricular tachycardia require defibrillation along with immunotherapy.
Antiarrhythmics are administered while awaiting digoxin immune Fab. Type IB antiarrhythmics (e.g., lidocaine, phenytoin) have a fast-on, fast-off effect at the Na+ channel, and these drugs depress the enhanced ventricular automaticity without significantly slowing atrioventricular (AV) nodal conduction. Phenytoin may perhaps enhance AV nodal conduction.[50]Helfant RH, Scherlag BJ, Damato AN. Protection from digitalis toxicity with the prophylactic use of diphenylhydantoin sodium. An arrhythmic-inotropic dissociation. Circulation. 1967 Jul;36(4):119-24. http://www.ncbi.nlm.nih.gov/pubmed/6027207?tool=bestpractice.com [51]Rumack BH, Wolfe RR, Gilfrich H. Phenytoin (diphenylhydantoin) treatment of massive digoxin overdose. Br Heart J. 1974 Apr;36(4):405-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1020039/pdf/brheartj00266-0085.pdf http://www.ncbi.nlm.nih.gov/pubmed/4842639?tool=bestpractice.com Phenytoin can terminate digitalis-induced cardiac arrhythmias better than lidocaine.[51]Rumack BH, Wolfe RR, Gilfrich H. Phenytoin (diphenylhydantoin) treatment of massive digoxin overdose. Br Heart J. 1974 Apr;36(4):405-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1020039/pdf/brheartj00266-0085.pdf http://www.ncbi.nlm.nih.gov/pubmed/4842639?tool=bestpractice.com
Type 1A (e.g., quinidine, procainamide) and 1C (e.g., flecainide, propafenone) antiarrhythmics are contraindicated.
Primary options
phenytoin: children: 1.25 mg/kg intravenously every 5 minutes, maximum 15 mg/kg total dose; adults: 50-100 mg intravenously every 10-15 minutes, maximum 15 mg/kg total dose
Secondary options
lidocaine: children: 1 mg/kg intravenous bolus initially, followed by 30-50 micrograms/kg/min infusion; adults: 1 to 1.5 mg/kg intravenous bolus initially, followed by 1-4 mg/min infusion
These drug options and doses relate to a patient with no comorbidities.
Primary options
phenytoin: children: 1.25 mg/kg intravenously every 5 minutes, maximum 15 mg/kg total dose; adults: 50-100 mg intravenously every 10-15 minutes, maximum 15 mg/kg total dose
Secondary options
lidocaine: children: 1 mg/kg intravenous bolus initially, followed by 30-50 micrograms/kg/min infusion; adults: 1 to 1.5 mg/kg intravenous bolus initially, followed by 1-4 mg/min infusion
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
phenytoin
Secondary options
lidocaine
acute or chronic toxicity after initial treatment
1st line – switch to alternative drug and discontinue digoxin
switch to alternative drug and discontinue digoxin
Ideally, digoxin is discontinued and a different medicine for rate control or a different inotrope prescribed (for atrial fibrillation, atrial flutter or congestive heart failure, respectively).
digoxin dose adjustment and regular monitoring
If the patient has to remain on digoxin for some clinical reason, then the dose of digoxin is adjusted for the patient's drug profile. Glomerular filtration rate and serum digoxin concentration is monitored regularly.
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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