Extracorporeal treatment for digoxin toxicity: just say no
January 28, 2016, 3:42 pm
Extracorporeal treatment for digoxin poisoning: systematic review and recommendations from the EXTRIP Workgroup. Mowry JB et al. Clin Toxicol 2016 Feb;54:103-14.
“Forced diuresis, and hemodialysis are ineffective in enhancing the elimination of digoxin because of its large volume of distribution (4-10 L/kg), which makes it relatively inaccessible to these techniques.” Goldfrank’s Toxicologic Emergencies (Tenth Edition, 2015)
That one sentence from the latest edition of Goldfrank’s tells you all you need to know about the use of extracorporeal treatment (ECTR) in digoxin poisoning, and makes this current paper from the EXTRIP workgroup somewhat superfluous. To cut to the chase (no spoiler alert needed), the conclusions here agree completely:
ECTR, in any form, is not indicated for either suspected or proven digoxin toxicity, regardless of the clinical context, and is not indicated for removal of digoxin-Fab complex.
As usual with the EXTRIP papers, the discussion is worth reading as a review of the topic. Some points made by the authors:
- less than 0.5% of body burden of digoxin is in the blood
- it is important not to confuse the short-term plasma clearance effected by hemodialysis with significant reduction in total body burden of digoxin
- hemodialysis in patients with digoxin poisoning may still be indicated for reasons other than drug removal, such as renal failure, hyperkalemia that does not reverse with administration of Fab fragments, or fluid overload