Buy Lanoxin Online

Lanoxin Injection (digoxin)

THERAPEUTIC CLASS

Cardiac glycoside

DEA CLASS

RX

INDICATIONS

Treatment of mild to moderate heart failure (HF) in adults; where possible, use in combination with a diuretic and an ACE inhibitor. Increases myocardial contractility in pediatric patients with HF. Control of ventricular response rate in adult patients with chronic atrial fibrillation (A-fib).

ADULT DOSAGE

Heart Failure

Initiate w/ LD followed by maint dosing if rapid titration is desired, or initiate w/ maint dosing w/o LD
LD: 8-12mcg/kg
Give 1/2 the total LD, then 1/4 the LD every 6-8 hrs, twice
Initial Maint: 2.4-3.6mcg/kg/day qd
Titrate: May be increased every 2 weeks according to clinical response, serum drug levels, and toxicity
Max: 500mcg in a single site

Atrial Fibrillation

Initiate w/ LD followed by maint dosing if rapid titration is desired, or initiate w/ maint dosing w/o LD

LD: 8-12mcg/kg
Give 1/2 the total LD, then 1/4 the LD every 6-8 hrs, twice
Initial Maint: 2.4-3.6mcg/kg/day qd
Titrate: May be increased every 2 weeks according to clinical response, serum drug levels, and toxicity
Max: 500mcg in a single site

Conversions

IV to PO Conversion:
50mcg inj = 62.5mcg tab
100mcg inj = 125mcg tab
200mcg inj = 250mcg tab
400mcg inj = 500mcg tab

PEDIATRIC DOSAGE

Heart Failure

Initiate w/ LD followed by maint dosing if rapid titration is desired, or initiate w/ maint dosing without LD

LD:
Give 1/2 the total LD, then 1/4 the LD every 6-8 hrs, twice
Premature Infants: 15-25mcg/kg
Full-Term Infants: 20-30mcg/kg
1-24 Months: 30-50mcg/kg
2-5 Years: 25-35mcg/kg
5-10 Years: 15-30mcg/kg
>10 Years: 8-12mcg/kg

Starting Maint:
Premature Infants: 1.9-3.1mcg/kg/dose bid
Full-Term: 3.0-4.5mcg/kg/dose bid
1-24 Months: 4.5-7.5mcg/kg/dose bid
2-5 Years: 3.8-5.3mcg/kg/dose bid
5-10 Years: 2.3-4.5mcg/kg/dose bid
>10 Years: 2.4-3.6mcg/kg/day qd; may be increased every 2 weeks according to clinical response, serum drug levels, and toxicity

Max: 200mcg in a single site

Conversions

IV to PO Conversion:
50mcg inj = 62.5mcg tab
100mcg inj = 125mcg tab
200mcg inj = 250mcg tab
400mcg inj = 500mcg tab

DOSING CONSIDERATIONS

Renal Impairment
Refer to PI for recommended maint dose according to lean body weight and renal function

ADMINISTRATION

IV/IM route

IV route is preferred because IM inj may lead to severe pain at the inj site
Inject deep into the muscle followed by massage if administered IM
Administer over a period of ≥5 min
May be administered undiluted or diluted w/ a 4-fold or greater volume of sterile water for inj, 0.9% NaCl, or 5% dextrose inj
Use of less than 4-fold volume of diluent could lead to precipitation of digoxin

Refer to PI for detailed instructions

HOW SUPPLIED

Inj: (Lanoxin) 0.25mg/mL, (Lanoxin Pediatric) 0.1mg/mL

CONTRAINDICATIONS

Ventricular fibrillation.

WARNINGS/PRECAUTIONS

Increased risk of ventricular fibrillation in patients with Wolff-Parkinson-White syndrome who develop A-fib. May cause severe sinus bradycardia or sinoatrial block, particularly with preexisting sinus node disease, and may cause advanced or complete heart block with preexisting incomplete atrioventricular (AV) block; consider insertion of a pacemaker before treatment. Signs and symptoms of digoxin toxicity include anorexia, N/V, visual changes, and cardiac arrhythmias. Low body weight, advanced age or impaired renal function, hypokalemia, hypercalcemia, or hypomagnesemia may predispose to digoxin toxicity; assess serum electrolytes and renal function periodically. Reduce dose or d/c therapy 1-2 days prior to electrical cardioversion of A-fib; if digitalis toxicity is suspected, delay elective cardioversion, and if it is not prudent to delay cardioversion, select the lowest possible energy level to avoid provoking ventricular arrhythmias. Not recommended with acute myocardial infarction. Avoid in patients with HF associated with preserved left ventricular ejection fraction (eg, restrictive cardiomyopathy, constrictive pericarditis, amyloid heart disease, acute cor pulmonale), idiopathic hypertrophic subaortic stenosis, and myocarditis. Hypocalcemia may nullify the effects of treatment. Hypothyroidism may reduce the requirements for therapy. HF and/or atrial arrhythmias resulting from hypermetabolic or hyperdynamic states (eg, hyperthyroidism, hypoxia, or arteriovenous shunt) are best treated by addressing the underlying condition. Caution with impaired renal function and in elderly. Should be used only when the need for rapid digitalization is urgent or when the drug cannot be taken orally. Avoid bolus inj.

ADVERSE REACTIONS

Cardiac arrhythmias, N/V, abdominal pain, intestinal ischemia, hemorrhagic necrosis of the intestines, headache, weakness, dizziness, apathy, mental disturbances.

DRUG INTERACTIONS

Drugs that induce/inhibit P-glycoprotein in intestine/kidney may alter digoxin pharmacokinetics. Increased levels with quinidine, ritonavir, amiodarone, propafenone, quinine, spironolactone, and verapamil; refer to PI for recommendations to reduce digoxin concentrations. Drugs that affect renal function (eg, ACE inhibitors, ARBs, NSAIDs, COX-2 inhibitors) may impair excretion. Higher rate of torsades de pointes with dofetilide. Proarrhythmic events were more common with concomitant sotalol. Sudden death was more common with concomitant dronedarone. Teriparatide transiently increases serum calcium. Thyroid supplements may increase digoxin dose requirement. Increased risk of arrhythmias with epinephrine, norepinephrine, dopamine, and succinylcholine. Rapid IV calcium administration can produce serious arrhythmias in digitalized patients. Additive effects on AV node conduction with β-adrenergic blockers and calcium channel blockers.

PREGNANCY AND LACTATION

Category C, caution in nursing.

MECHANISM OF ACTION

Cardiac glycoside; inhibits Na+-K+ ATPase, which is responsible for maintaining the intracellular milieu throughout the body by moving Na+ ions out of and K+ ions into cells.

PHARMACOKINETICS

Absorption: Absolute bioavailability (100%). Distribution: Vd=475-500L. Plasma protein binding (25%); crosses placenta; found in breast milk. Metabolism: dihydrodigoxin, digoxigenin bisdigitoxoside, glucuronide, sulfate conjugates (metabolites); hydrolysis, oxidation, and conjugation. Elimination: (Healthy, IV) Urine (50-70%, unchanged); T1/2=(healthy) 1.5-2 days, (anuric patients) 3.5-5 days.

ASSESSMENT

Assess for known hypersensitivity to the drug or other digitalis preparations, ventricular fibrillation, myocarditis, hypermetabolic or hyperdynamic states, sinus node disease, AV block, pregnancy/nursing status, possible drug interactions, and any other conditions where treatment is cautioned. Assess serum electrolytes and renal function. Obtain a baseline digoxin level; serum digoxin concentrations may be falsely elevated by endogenous digoxin-like substances.

MONITORING

Monitor for signs/symptoms of severe sinus bradycardia, sinoatrial block, advanced or complete heart block, digoxin toxicity, vasoconstriction, and other adverse reactions. Monitor serum electrolytes and renal function periodically. Obtain serum digoxin concentrations just before the next dose or at least 6 hrs after the last dose. Monitor for clinical response.

PATIENT COUNSELING

Advise that digoxin is a cardiac glycoside used to treat HF and heart arrhythmias. Advise to inform physician if taking any OTC medications, including herbal medication, or if started on a new prescription. Inform that blood tests will be necessary to ensure the appropriate digoxin dose. Instruct to contact physician if N/V, persistent diarrhea, confusion, weakness, or visual disturbances occur. Advise parents or caregivers that symptoms of having too high doses may be difficult to recognize in infants and pediatric patients; symptoms such as weight loss, failure to thrive in infants, abdominal pain, and behavioral disturbances may be indications of digoxin toxicity. Suggest to monitor and record HR and BP daily. Instruct women of childbearing potential who become or are planning to become pregnant to consult physician prior to initiation or continuing therapy with digoxin.

STORAGE

25°C (77°F); excursions permitted to 15-30°C (59-86°F). Protect from light. Diluted Sol: Use immediately.

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