Retrospective evaluation of patients with elevated digoxin levels at an emergency department

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Abstract

Objectives

We investigated the demographic characteristics, clinical and laboratory findings, treatment strategies and clinical outcomes of patients presenting at emergency department (ED) with digoxin levels at or above 1.2 ng/ml.

Materials and methods

The demographic and clinical characteristics of patients with serum digoxin levels at or above 1.2 ng/ml admitted to an ED between January 2010 and July 2011 were investigated in this cross-sectional descriptive study. Patients with ECG and clinical findings consistent with digoxin toxicity and no additional explanation of their symptoms were evaluated for digoxin toxicity.

Results

In this study 137 patients were included, and 68.6% of patients were women with mean age 76.1 ± 12.2. There was no significant difference between gender and digoxin intoxication. The mean age of intoxicated group was significantly higher than the non-intoxicated group (P = 0.03). The most common comorbidities were congestive heart failure (n = 91) and atrial fibrillation (n = 74). The most common symptoms were nausea, vomiting and abdominal pain. The levels of hospitalization and mortality in this group were significantly higher.

Conclusion

Digoxin intoxication must be suspected in patients present in the ED, particularly those with complaints that include nausea and vomiting, as well as new ECG changes; serum digoxin levels must be determined.

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Most cited references 24

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National surveillance of emergency department visits for outpatient adverse drug events.

Daniel S Budnitz, Daniel A Pollock, Kelly Weidenbach … (2006)

Adverse drug events are common and often preventable causes of medical injuries. However, timely, nationally representative information on outpatient adverse drug events is limited. To describe the frequency and characteristics of adverse drug events that lead to emergency department visits in the United States. Active surveillance from January 1, 2004, through December 31, 2005, through the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project. National estimates of the numbers, population rates, and severity (measured by hospitalization) of individuals with adverse drug events treated in emergency departments. Over the 2-year study period, 21,298 adverse drug event cases were reported, producing weighted annual estimates of 701,547 individuals (95% confidence interval [CI], 509,642-893,452) or 2.4 individuals per 1000 population (95% CI, 1.7-3.0) treated in emergency departments. Of these cases, 3487 individuals required hospitalization (annual estimate, 117,318 [16.7%]; 95% CI, 13.1%-20.3%). Adverse drug events accounted for 2.5% (95% CI, 2.0%-3.1%) of estimated emergency department visits for all unintentional injuries and 6.7% (95% CI, 4.7%-8.7%) of those leading to hospitalization and accounted for 0.6% of estimated emergency department visits for all causes. Individuals aged 65 years or older were more likely than younger individuals to sustain adverse drug events (annual estimate, 4.9 vs 2.0 per 1000; rate ratio [RR], 2.4; 95% CI, 1.8-3.0) and more likely to require hospitalization (annual estimate, 1.6 vs 0.23 per 1000; RR, 6.8; 95% CI, 4.3-9.2). Drugs for which regular outpatient monitoring is used to prevent acute toxicity accounted for 41.5% of estimated hospitalizations overall (1381 cases; 95% CI, 30.9%-52.1%) and 54.4% of estimated hospitalizations among individuals aged 65 years or older (829 cases; 95% CI, 45.0%-63.7%). Adverse drug events among outpatients that lead to emergency department visits are an important cause of morbidity in the United States, particularly among individuals aged 65 years or older. Ongoing, population-based surveillance can help monitor these events and target prevention strategies.

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Medication use leading to emergency department visits for adverse drug events in older adults.

Daniel S Budnitz, Scott Kegler, Alexander L. Richards … (2007)

The Beers criteria identify inappropriate use of medications in older adults. The number of and risk for adverse events from these medications are unknown. To estimate the number of and risk for emergency department visits for adverse events involving Beers criteria medications compared with other medications. Nationally representative, public health surveillance of adverse drug events and a cross-sectional survey of outpatient medical visits. National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance System, 2004-2005; National Ambulatory Medical Care Survey, 2004; and National Hospital Ambulatory Medical Care Survey, 2004. Persons 65 years of age or older seeking emergency department and outpatient care. Estimated number of and risks for emergency department visits for adverse drug events involving Beers criteria medications and other medications. Among U.S. patients 65 years of age or older, an estimated 177,504 emergency department visits (95% CI, 100,155 to 254,854 visits) for adverse drug events occurred both years. An estimated 3.6% (CI, 2.8% to 4.5%) of these visits were for adverse events medications considered to be always potentially inappropriate, according to the Beers criteria, and 33.3% (CI, 27.8% to 38.7%) of visits were for adverse events from 3 other medications (warfarin [17.3%], insulin [13.0%], and digoxin [3.2%]). Accounting for outpatient prescription frequency, the risk for emergency department visits for adverse events due to these 3 medications was 35 times (CI, 9.6 to 61) greater than that for medications considered to be always potentially inappropriate. Adverse events were identified only in emergency departments. Compared with other medications, Beers criteria medications caused low numbers of and few risks for emergency department visits for adverse events. Performance measures and interventions targeting warfarin, insulin, and digoxin use could prevent more emergency department visits for adverse events.

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Sex-based differences in the effect of digoxin for the treatment of heart failure.

Saurabh Rathore, Yongfei Wang, Harlan M. Krumholz (2002)

The Digitalis Investigation Group trial reported that treatment with digoxin did not decrease overall mortality among patients with heart failure and depressed left ventricular systolic function, although it did reduce hospitalizations slightly. Even though the epidemiologic features, causes, and prognosis of heart failure vary between men and women, sex-based differences in the effect of digoxin were not evaluated. We conducted a post hoc subgroup analysis to assess whether there were sex-based differences in the effect of digoxin therapy among the 6800 patients in the Digitalis Investigation Group study. The presence of an interaction between sex and digoxin therapy with respect to the primary end point of death from any cause was evaluated with the use of Mantel-Haenszel tests of heterogeneity and a multivariable Cox proportional-hazards model, adjusted for demographic and clinical variables. There was an absolute difference of 5.8 percent (95 percent confidence interval, 0.5 to 11.1) between men and women in the effect of digoxin on the rate of death from any cause (P=0.034 for the interaction). Specifically, women who were randomly assigned to digoxin had a higher rate of death than women who were randomly assigned to placebo (33.1 percent vs. 28.9 percent; absolute difference, 4.2 percent, 95 percent confidence interval, -0.5 to 8.8). In contrast, the rate of death was similar among men randomly assigned to digoxin and men randomly assigned to placebo (35.2 percent vs. 36.9 percent; absolute difference, -1.6 percent; 95 percent confidence interval, -4.2 to 1.0). In the multivariable analysis, digoxin was associated with a significantly higher risk of death among women (adjusted hazard ratio for the comparison with placebo, 1.23; 95 percent confidence interval, 1.02 to 1.47), but it had no significant effect among men (adjusted hazard ratio, 0.93; 95 percent confidence interval, 0.85 to 1.02; P=0.014 for the interaction). The effect of digoxin therapy differs between men and women. Digoxin therapy is associated with an increased risk of death from any cause among women, but not men, with heart failure and depressed left ventricular systolic function. Copyright 2002 Massachusetts Medical Society

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Author and article information

Contributors

Onder Limon

Journal

Journal ID (nlm-ta): Turk J Emerg Med

Journal ID (iso-abbrev): Turk J Emerg Med

Title: Turkish Journal of Emergency Medicine

Publisher: Elsevier

ISSN (Electronic): 2452-2473

Publication date PMC-release: 14 March 2016

Publication date Collection: March 2016

Publication date (Electronic): 14 March 2016

Volume: 16

Issue: 1

Pages: 17-21

Affiliations

[a ]Izmir University School of Health Sciences, First Aid and Emergency Care Program, Izmir, Turkey

[b ]Dokuz Eylul University, Faculty of Medicine, Department of Emergency Medicine, Izmir, Turkey

[c ]Izmir University, Faculty of Medicine, Department of Emergency Medicine, Izmir, Turkey

Author notes

[∗ ]Corresponding author. Tel.: +90 0505 525 26 52, 905055252652 (mobile). dronderlimon@ 123456yahoo.com

Article

Publisher ID: S2452-2473(16)00005-4

DOI: 10.1016/j.tjem.2015.10.001

PMC ID: 4882205

PubMed ID: 27239633

SO-VID: 53bb05d0-5af5-4f7e-b42b-ebaf90242392

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

History

Date received : 21 August 2015

Date revision received : 5 October 2015

Date accepted : 14 October 2015

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Retrospective evaluation of patients with elevated digoxin levels at an emergency department

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Abstract

Objectives

Materials and methods

Results

Conclusion

Related collections

Preventive and Emergency Medicine Insights

Most cited references 24

National surveillance of emergency department visits for outpatient adverse drug events.

Medication use leading to emergency department visits for adverse drug events in older adults.

Sex-based differences in the effect of digoxin for the treatment of heart failure.

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