Expert consensus on the diagnosis and management of digoxin toxicity

Although there has been a decline in the use of digoxin in patients with heart failure and atrial fibrillation, acute and chronic digoxin toxicity remains a significant clinical problem. Digoxin's narrow therapeutic window and non-specific signs and symptoms of toxicity create clinical challenges and uncertainty regarding diagnostic criteria for toxicity and responsive treatment choices for the bedside clinician.

A systematic review of the published literature on digoxin toxicity (34,587 publications over 6 decades, of which 114 met the inclusion criteria) was conducted to develop 33 consensus statements on diagnostic and therapeutic approaches which were then evaluated through a modified Delphi process involving a panel of experts in cardiology, nursing, emergency medicine and medical toxicology.

The results demonstrate the need to agree on the need to consider the timing of ingestion and the nature of exposure (i.e. acute, acute over chronic, chronic) and the use of immune Fab digoxin for life-threatening exposure in order to reduce the risk of death. Although several areas of persistent uncertainty have been identified, this work offers formal guidance that may help providers to better manage this persistent clinical challenge.