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Digoxin Monitoring in CKD — EECC MCQ

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ModerateCardiac PharmacologyDigoxin Monitoring in CKDEECC

A 62-year-old man with HFrEF on optimal GDMT develops atrial fibrillation with a fast ventricular response. IV digoxin is given for rate control. His renal function is CKD stage 3b (eGFR 28 mL/min). What monitoring is required with digoxin in renal impairment?

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Correct answer: C — Renal dose reduction and biochemical monitoring

Digoxin is 70-80% renally cleared; renal impairment significantly reduces clearance and increases the risk of toxicity. The ESC HF Guidelines recommend: (1) dose reduction in CKD (typically 62.5-125 micrograms daily, or every other day in severe CKD); (2) serum digoxin level monitoring — target 0.5-0.9 ng/mL for HF (levels >1.0 ng/mL are associated with increased mortality in the DIG trial post-hoc analysis); (3) potassium monitoring — hypokalaemia increases digoxin binding to Na⁺/K⁺-ATPase, potentiating toxicity (arrhythmias, nausea, visual disturbance) even at 'therapeutic' digoxin levels; (4) monitor for drug interactions: amiodarone, verapamil, and quinidine increase digoxin levels; (5) reduce dose in elderly and low body weight. Digoxin-specific antibodies (Fab fragments) are the treatment for severe digoxin toxicity.

Reference: ESC (2023): HF Guidelines; BNF: https://bnf.nice.org.uk/