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Antiarrhythmic Pregnancy: Use in pregnancy is not contraindicated, although dosage may be less predictable and some women require increased dosage. Use only when expected clinical benefit to the mother outweighs possible risk to the foetus. No significant adverse foetal/neonatal effects when maternal serum digoxin is kept within the normal range. Breast-feeding is not contraindicated (quantities in milk are minute).

Digoxin

Brand names: Lanoxin

Used in: Atrial Fibrillation

Digoxin is a cardiac glycoside used mainly for rate control in atrial fibrillation (especially with heart failure or sedentary patients) and as add-on therapy in some heart failure.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Adults and children over 10 years: Rapid oral loading 750 to 1500 micrograms (0.75-1.5 mg) as a single dose; maintenance most heart-failure patients 125 to 250 micrograms (0.125-0.25 mg) daily
Route: Oral
Frequency: Loading as single dose or divided six hours apart; maintenance once daily
Max: Rapid oral loading up to 1500 micrograms (1.5 mg) as a single dose
Dose must be tailored individually to age, lean body weight and renal function; suggested doses are only an initial guide. Where there is less urgency or greater risk of toxicity (e.g. in the elderly), give the oral loading dose in divided doses six hours apart with approximately half the total dose as the first dose, assessing clinical response before each additional dose. Slow oral loading: 250 to 750 micrograms (0.25-0.75 mg) daily for one week followed by an appropriate maintenance dose (e.g. in mild heart failure). Maintenance dose is based on percentage of peak body stores lost daily (daily loss % = 14 + creatinine clearance/5). In patients with increased sensitivity, 62.5 micrograms (0.0625 mg) daily or less may suffice; some patients may need a higher dose. If cardiac glycosides taken in preceding two weeks, reconsider and reduce initial dose. When switching from oral to IV, reduce the dose by approximately 33%.

Paediatric dose

Route: Oral
Frequency: Loading dose in divided doses; maintenance as % of 24h loading dose
Neonates, infants and children up to 10 years — oral LOADING dose per 24 h: preterm neonates <1.5 kg 25 micrograms/kg; preterm neonates 1.5-2.5 kg 30 micrograms/kg; term neonates to 2 years 45 micrograms/kg; 2-5 years 35 micrograms/kg; 5-10 years 25 micrograms/kg. Loading dose given in divided doses (~half as first dose, further fractions at 4-8 h intervals, assessing response). MAINTENANCE dose: preterm neonates = 20% of 24 h loading dose; term neonates and children up to 10 years = 25% of 24 h loading dose. Children over 10 years require adult dosages in proportion to body weight. Guidelines only — use serum digoxin levels to adjust. Clinician to verify against a children's formulary.

Dose adjustments

Renal

Reconsider dosing if renal clearance of digoxin is reduced (e.g. elderly); consider reduction in both initial and maintenance doses.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

US labelling (FDA)

Reference — US labelling, may differ from UK

2 DOSAGE & ADMINISTRATION Digoxin dose is based on patient-specific factors (age, lean body weight, renal function, etc.). See full prescribing information. Monitor for toxicity and therapeutic effect. 2.1 Important Dosing and Administration Information In selecting a digoxin dosing regimen, it is important to consider factors that affect digoxin blood levels (e.g., body weight, age, renal function, concomitant drugs) since toxic levels of digoxin are only slightly higher than therapeutic levels. Dosing can be either initiated with a loading dose followed by maintenance dosing if rapid titration is desired or initiated with maintenance dosing without a loading dose. Consider interruption or …

Source: US FDA prescribing information (openFDA / DailyMed), label dated 2024-09-04. Accessed 2026-06-12. US dosing and indications can differ from UK practice — use UK sources for prescribing decisions.

Contraindications

  • Intermittent complete heart block or second degree AV block, especially with history of Stokes-Adams attacks
  • Arrhythmias caused by cardiac glycoside intoxication
  • Supraventricular arrhythmias associated with an accessory AV pathway (e.g. Wolff-Parkinson-White syndrome)
  • Ventricular tachycardia or ventricular fibrillation
  • Hypertrophic obstructive cardiomyopathy (unless concomitant atrial fibrillation and heart failure, with caution)
  • Hypersensitivity to the active substance, other digitalis glycosides or any excipient

Side effects

  • Cardiac: arrhythmia, conduction disorder, bigeminy, trigeminy, PR prolongation, sinus bradycardia (common)
  • Gastrointestinal: nausea, vomiting, diarrhoea (common)
  • Nervous system: dizziness (common); headache (very rare)
  • Eye: visual impairment - blurred vision or xanthopsia (common)
  • Skin rash (common); gynaecomastia with long-term use (very rare)

Interactions

  • P-glycoprotein inducers/inhibitors (alter digoxin pharmacokinetics)
  • Amiodarone (digoxin serum concentration increased ~70%; reduce digoxin dose ~30-50%)
  • Captopril (digoxin serum concentration increased ~58%)
  • Clarithromycin (digoxin AUC increased ~70%)
  • Drugs affecting serum electrolytes/potassium (hypokalaemia predisposes to toxicity)

Clinical monograph

How it works

Digoxin inhibits the myocardial Na-K-ATPase, indirectly raising intracellular calcium to increase contractility, and enhances vagal tone to slow AV-node conduction and heart rate.

Prescribing in practice

  • It has a narrow therapeutic index; toxicity is more likely with renal impairment, low potassium or magnesium, and in older patients.
  • Many interactions raise digoxin levels (e.g. amiodarone, verapamil, some macrolides) — review co-medication and consider dose adjustment.
  • Suspect toxicity with nausea, visual disturbance, confusion or new arrhythmia, and check levels and electrolytes.

Monitoring

Monitor renal function and electrolytes; check digoxin levels when toxicity is suspected, at steady state, or after interacting-drug or renal changes (sampling at least 6 hours post-dose).

Counselling the patient

  • Report nausea, visual changes (such as yellow-green tinge), palpitations or confusion.
  • Do not change other medicines without checking, as several affect digoxin.

Evidence & guidelines

Digoxin is an option for rate control in AF per NICE NG196, particularly in non-active patients or where beta-blockers are unsuitable.

Reference: NICE NG106 Chronic HF; DIG Trial NEJM 1997; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

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