Digoxin clearance is significantly reduced in severe renal impairment, leading to potential accumulation and toxicity if dosage is not adjusted.
Adjust initial dose by estimated CrCl using Cockcroft-Gault formula.
Therapeutic drug monitoring is essential to avoid supratherapeutic levels.
Hypokalemia exacerbates toxicity; maintain normal potassium levels.
Elderly patients with renal impairment are at higher risk.
Digoxin is primarily eliminated unchanged by the kidneys through glomerular filtration and tubular secretion. Severe renal impairment (e.g., CrCl <30 mL/min) decreases renal excretion, resulting in prolonged half-life and increased serum concentrations.
Elevated risk of digoxin toxicity, including gastrointestinal symptoms (nausea, vomiting), neurological effects (confusion, dizziness), visual disturbances, and cardiac arrhythmias (e.g., bradycardia, AV block, ventricular ectopy), which can be life-threatening.
Initiate with reduced loading and maintenance doses (e.g., 50-75% reduction based on CrCl); monitor serum digoxin levels (target 0.5-2 ng/mL), electrolytes (especially potassium), renal function, and ECG regularly; consider alternative agents if renal function worsens.
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