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Physicians should consider using digoxin to improve the symptoms and clinical status of patients with HF, in conjunction with diuretics, an ACE inhibitor, and a beta-blocker.

Digoxin may be used early to reduce symptoms in patients who have been started on, but have not yet responded symptomatically to, treatment with an ACE inhibitor or a beta- blocker.

Alternatively, treatment with digoxin may be delayed until the patient’s response to ACE inhibitors and beta-blockers has been defined and used only in patients who remain symptomatic despite therapy with the neurohormonal antagonists.

If a patient is taking digoxin but not an ACE inhibitor or a beta-blocker, treatment with digoxin should not be withdrawn, but appropriate therapy with the neurohormonal antagonists should be instituted.

Digoxin is prescribed routinely in patients with HF who have chronic atrial fibrillation, but beta-blockers may be more effective in controlling the ventricular response, especially during exercise83.

Digoxin is not indicated as primary therapy for the stabilization of patients with acutely decompensated HF. Such patients should first receive appropriate treatment for HF (usually with intravenous medications); therapy with digoxin may be initiated at the same time as part of an effort to establish a long-term treatment strategy.

Patients should not be given digoxin if they have significant sinus or atrioventricular block, unless the block has been treated with a permanent pacemaker. The drug should be used cautiously in patients taking other drugs that can depress sinus or atrioventricular nodal function (e.g., amiodarone or a beta-blocker), even though such patients usually tolerate digoxin without difficulty.

Initiation and maintenance

Although a variety of glycosides have been used, digoxin is the most commonly used formulation in the United States and it is the only glycoside that has been evaluated in placebo-controlled trials. There is little reason to prescribe other cardiac glycosides for the management of HF.

Therapy with digoxin is commonly initiated and maintained at a dose of 0.125 to 0.25 mg daily. Low doses (0.125 mg daily or every other day) should be used if the patient is over 70 years old, has impaired renal function, or has a low lean body mass. Higher doses (e.g., digoxin 0.375 to 0.50 mg daily) are rarely used or needed in the management of patients with HF.

83 Farshi R, Kistner D, Sarma JS, Longmate JA, Singh BN. Ventricular rate control in chronic atrial fibrillation during daily activity and programmed exercise: a crossover open-label study of five drug regimens. J Am Coll Cardiol 1999;33:304-10.

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