Brand name:Lanoxin
Drug class: Cardiotonic Agents

Medically reviewed by Drugs.com on Nov 10, 2025. Written byASHP.

Introduction

Digoxin is a cardiac glycoside with positive inotropic and antiarrhythmic effects.

Uses for Digoxin

Heart Failure

Used in the treatment of mild to moderate heart failure in adults and to increase myocardial contractility in pediatric patients with heart failure.

Current guidelines for the management of heart failure in adults recommend guideline-directed medical therapy with a combination of drug therapies to reduce morbidity and mortality, including angiotensin converting enzyme inhibitors, sodium-glucose cotransporter 2 inhibitors, angiotensin II receptor antagonists, angiotensin receptor-neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists.

There is a lack of contemporary data for the use of digoxin in heart failure with reduced ejection fraction; most use focuses on rate control.

Benefits of digoxin in patients currently treated with guideline-directed medical therapy is unclear. Its use is generally reserved for adult patients remaining symptomatic despite optimal guideline recommended therapies.

A statement from the American Heart Association (AHA) on management of chronic heart failure in pediatric patients discusses the use of several agents for medical management and notes that digoxin has been used empirically for pediatric patients with a single ventricle who are at risk for heart failure.

Atrial Fibrillation

Used for control of ventricular response rate in adults with chronic atrial fibrillation.

May be used in combination with recommended standard of care agents (i.e., beta-blockers or nondihydropyridine calcium-channel blocking agents) for patients with atrial fibrillation and heart failure, or as monotherapy if first-line agents cannot be tolerated.

Supraventricular Tachycardia

Used in the management of sustained fetal tachyarrhythmias^{† [off-label]}.

Initial therapy for fetal supraventricular tachyarrhythmias (SVT) and atrial fibrillation^{† [off-label]} includes transplacental monotherapy with either flecainide, sotalol, or digoxin, with addition of a second agent (i.e., either flecainide, sotalol, or digoxin) if cessation of arrhythmia is not achieved. Monotherapy with amiodarone is a third-line option if arrhythmia persists despite dual therapy.

Has been used in the management of SVT of unknown mechanism^{† [off-label]} in adults without pre-excitation and who are not candidates for catheter ablation. Beta-blockers, diltiazem, and verapamil, in absence of pre-excitation, have a stronger level of recommendation from the AHA compared to digoxin.

Has been used in the management of SVTs due to AV nodal reentry tachycardia or AV reentry tachycardia^{† [off-label]} in adults without pre-excitation and who are not candidates for catheter ablation. Beta-blockers, diltiazem, and verapamil have a stronger level of recommendation from the AHA, compared to digoxin.

Digoxin Dosage and Administration

General

Patient Monitoring

• Because digoxin has a narrow therapeutic window, increased monitoring of serum digoxin concentrations and for possible clinical manifestations of digoxin toxicity is necessary when initiating, adjusting, or discontinuing therapy with any drugs that may interact with digoxin.

• Determine serum concentrations by obtaining blood samples at least 6–8 hours after the daily dose and preferably just prior to the next scheduled daily dose.

• Interpret serum concentrations in the overall clinical context; do not use an isolated measurement alone as the basis for adjusting dosage.

• Serum electrolytes and renal function should be periodically assessed during digoxin therapy. Potassium concentrations should be closely monitored in patients at high risk for hypokalemia (e.g., receiving diuretics, corticosteroids, or other drugs that cause potassium loss, those with GI losses from diarrhea, vomiting, or nasogastric suction, or those with endocrinopathies or nephropathies).

Dispensing and Administration Precautions

• The Institute for Safe Medication Practices (ISMP) includes Lanoxin, levothyroxine, and naloxone on their List of Confused Drug Names, and recommends using special safeguards to ensure the accuracy of prescriptions for these drugs.

• The 2023 American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults includes digoxin on the list of PIMs that are best avoided by older adults in most circumstances or under specific situations, such as certain diseases, conditions, or care settings. The criteria are intended to apply to adults 65 years of age and older in all ambulatory, acute, and institutional settings of care, except hospice and end-of-life care settings. For digoxin, the Beers Criteria Expert Panel specifically recommends avoiding digoxin as a first-line agent for atrial fibrillation and heart failure. If digoxin is used for atrial fibrillation or heart failure, the Beers Criteria Expert Panel recommends avoiding dosages that exceed 0.125 mg per day.

Other General Considerations

• Narrow therapeutic index; therefore, cautious dosage determination is essential. Serum digoxin concentrations can be used to guide dosing.

• When selecting an appropriate dosage, consider patient's renal function, body weight, age, concomitant disease states, concurrent drugs, and other factors likely to alter serum concentrations of digoxin.

• Since digoxin is largely distributed into tissues, use lean body weight for dosage calculations.

• Since digoxin can induce ventricular arrhythmias, consider reducing or interrupting the dosage of the drug for 1–2 days before elective cardioversion in patients with atrial fibrillation.

• Rapid infusion of calcium in patients receiving digoxin can produce serious arrhythmias and should be avoided.

Administration

Administer orally or IV (when oral therapy not feasible or rapid therapeutic effect necessary).

Although IM route also has been used, IM injections can cause severe local irritation and pain at the site of injection; IV route is therefore preferred. If IM administration is necessary, inject no more than 2 mL deep into the muscle and massage injection site after administration.

Oral Administration

Administer once daily (as tablets or oral solution) in adults and children >10 years of age; divided daily dosing generally recommended in infants and young children <10 years of age.

The manufacturer recommends that the oral solution be used to obtain appropriate dose in infants, young children, or patients with very low body weights. Use calibrated oral dosing syringe supplied by the manufacturer to measure doses of the oral solution; use a separate measuring device to accurately measure doses <0.1 mL.

IV Administration

May administer IV when oral therapy is not feasible or when rapid therapeutic effect is necessary.

Donot mix with other drugs in the same container or administer simultaneously in the same IV line.

Dilution

May administer digoxin injection either undiluted or diluted with a 4-fold or greater volume of sterile water for injection, 5% dextrose injection, or 0.9% sodium chloride injection; use of a smaller volume of diluent may cause precipitation of digoxin.

Use diluted IV solutions immediately.

Rate of Administration

Administer by slow (over at least 5 minutes) IV infusion; avoid rapid (i.e., bolus) IV administration since systemic and coronary vasoconstriction may occur.

Dosage

Dosage guidelines provided are based upon average patient response; substantial patient variation can be expected.

Dosage may be initiated with or without a loading dose depending on whether rapid titration or more gradual titration is desired.

Administer loading dose in divided doses, with about 50% of the total dose given as the first (i.e., initial) dose and additional fractions (usually 25%) usually every 6–8 hours; carefully assess patient's clinical response (including possible toxicity) before each additional dose. If a change from the calculated loading dose is required, then calculate maintenance dosage based upon the amount (i.e., total loading dose) actually administered.

Since daily maintenance dosage is a replacement of daily digoxin loss from the body, an alternative dosing method has been used where maintenance dosage isestimated by multiplying daily percentage loss by peak body stores (i.e., loading dose). The percentage of digoxin eliminated from the body daily can beestimated by the following equation:

daily % loss = 14 + [creatinine clearance (in mL/minute) / 5]

Pediatric Patients

Titrate dosage carefully in neonates, especially premature infants, because renal clearance of digoxin is reduced.

Infants and young children (≤10 years of age) generally require proportionally larger doses than children >10 years of age and adults when calculated on the basis of lean or ideal body weight or body surface area.

Children >10 years of age require adult dosages in proportion to the child’s body weight.

Heart Failure

Loading and Maintenance Dosages

Loading doses and maintenance dosages recommended by the manufacturers in pediatric patients are given in the tables that follow based on the dosage form administered.

Oral

Loading doses are administered in divided doses, with about 50% of the total dose given as the first (i.e., initial) dose; additional 25% fractions are administered every 6–8 hours

Loading doses are administered in divided doses, with about 50% of the total dose given as the first (i.e., initial) dose; additional fractions may be administered every 4–8 hours

IV

Loading doses are administered in divided doses, with 50% of the total dose given as the first (i.e., initial) dose; additional 25% fractions are administered every 6–8 hours

Adults

Heart Failure

Loading Dose

Oral

Loading doses generally not required in patients with heart failure. If a loading dose is given, manufacturers recommend an oral loading dose of 10–15 mcg/kg administered in divided doses.

IV

Loading doses generally not required in patients with heart failure. If a loading dose is given, manufacturers recommend an IV loading dose of 8–12 mcg/kg administered in divided doses.

Maintenance Dosage

Oral

Experts state that digoxin is commonly initiated and maintained at a dosage of 125–250 mcg (0.125–0.25 mg) daily for heart failure in adults.

Manufacturers recommend an initial oral maintenance dosage of 3.4–5.1 mcg/kg once daily as tablets or 3–4.5 mcg/kg once daily as the oral solution in adults with normal renal function; may increase dosage every 2 weeks according to clinical response, serum digoxin concentrations, and toxicity.

IV

If IV administration is necessary, manufacturer recommends an initial IV maintenance dosage of 2.4–3.6 mcg/kg once daily in adults with normal renal function; may increase dosage every 2 weeks according to clinical response, serum digoxin concentrations, and toxicity.

Atrial Fibrillation

Loading Dose

Oral

If a loading dose is given for rate control in patients with atrial fibrillation, manufacturers recommend an oral loading dose of 10–15 mcg/kg, administered in divided doses.

IV

If a loading dose is given for rate control in patients with atrial fibrillation, manufacturers recommend an IV loading dose of 8–12 mcg/kg, administered in divided doses. Some experts recommend an initial IV dose of 250–500 mcg (0.25–0.5 mg) with repeat dosing to a maximum of 1500 mcg (1.5 mg) over 24 hours.

Maintenance Dosage

Oral

Experts state that usual oral maintenance dosage for ventricular rate control in adults with atrial fibrillation is 125–250 mcg (0.125–0.25 mg) daily.

Special Populations

Hepatic Impairment

No dosage adjustment is necessary in patients with hepatic impairment; however, serum digoxin concentrations may be used to guide dosing.

Renal Impairment

Must adjust dosage in patients with renal impairment. Reduce and titrate dosage carefully based on clinical response and serum digoxin concentrations.

Consult manufacturer's prescribing information for recommended maintenance dosages based on renal function.

Lower dosages (125 mcg [0.125 mg] daily or every other day) are recommended for management of heart failure in adult patients with renal impairment.

Geriatric Patients

Select dosage carefully since geriatric patients may have impaired renal function.

Lower dosages (125 mcg [0.125 mg] daily or every other day) are recommended for management of heart failure in geriatric patients >70 years of age.

Patients with Hypothyroidism

Lower dosages may be warranted in hypothyroidism.

Patients with Malabsorptive Disorders

Although specific dosage adjustments are not provided, the absorption of digoxin may be reduced in patients with certain malabsorptive conditions such as chronic diarrhea.

Cautions for Digoxin

Contraindications

• Ventricular fibrillation.

• Known hypersensitivity to digoxin or other digitalis preparations.

Warnings/Precautions

Ventricular Fibrillation in Patients with Accessory AV Pathway (WPW Syndrome)

Use with caution in patients with Wolff-Parkinson-White (WPW) syndrome and atrial fibrillation since the drug may enhance conduction via the accessory pathway and result in extremely rapid ventricular rates and ventricular fibrillation.

Sinus Bradycardia and Sino-atrial Block

Digoxin can cause severe sinus bradycardia or sinoatrial block, particularly in patients with pre-existing sinus node disease. May also cause advanced or complete heart block in patients with pre-existing incomplete AV block. Consider pacemaker insertion prior to use of digoxin.

Digoxin Monitoring

Obtain blood samples at least 6–8 hours after the daily dose and preferably just prior to the next scheduled daily dose. Therapeutic plasma concentrations of digoxin in adults generally are 0.5–2 ng/mL. Some experts suggest that plasma concentrations of 0.5–0.9 ng/mL are sufficient for treatment of heart failure in adults.

Interpret serum concentrations of digoxin in the overall clinical context; thus, an isolated serum concentration measurement should not be used alone as the basis for adjusting dosage.

Digoxin Toxicity

It often is difficult to distinguish toxic cardiac effects caused by underlying heart failure or digoxin.

In adults, toxicity is usually, but not always, associated with steady-state plasma digoxin concentrations >2 ng/mL. The potential for adverse reactions increases with digoxin concentrations >1.2 ng/mL.

Toxicity can occur at lower digoxin levels, especially in the presence of advanced age, impaired renal function, hypokalemia, hypomagnesemia, or hypothyroidism.

Discontinue digoxin immediately if signs of toxicity appear; obtain serum digoxin concentrations, place patient on a cardiac monitor, and address possible contributing factors (e.g., electrolyte and thyroid abnormalities, concomitant drugs).

In patients with hypokalemia, administer potassium supplementation to maintain serum concentrations between 4–5.5 mEq/L.

Do not administer calcium infusions rapidly in patients receiving digoxin, as rapid infusion may produce serious arrhythmias. Activated charcoal may be administered if acute ingestion (intentionally or accidentally) of a potentially toxic amount of digoxin occurs. Digoxin Immune Fab (DigiFab) may be administered if life-threatening arrhythmias (ventricular tachycardia, ventricular fibrillation, high-degree AV block, bradyarrhythmia, sinus arrest) or hyperkalemia occur.

In the event of chronic overdosage with digoxin, DigiFab may be used in patients with symptomatic arrhythmia.

Risk of Ventricular Arrhythmias During Elective Cardioversion

Reduce dosage or withhold digoxin therapy for 1–2 days before elective cardioversion in patients with atrial fibrillation; consider consequences of increasing the ventricular response.

Postpone elective cardioversion in patients with manifestations of digoxin toxicity.

If it is not possible to delay cardioversion, use lowest possible energy level to avoid provoking ventricular arrhythmias.

Risk of Ischemia in Acute MI

Use in acute MI may result in an undesirable increase in oxygen demand and associated ischemia. Use of digoxin not recommended in acute MI.

Vasoconstriction in Myocarditis

Avoid use of digoxin in patients with myocarditis, as the drug can precipitate vasoconstriction and may promote the production of pro-inflammatory cytokines.

Decreased Cardiac Output in Preserved Left Ventricular Systolic Function

Patients with heart failure associated with preserved left ventricular ejection fraction (e.g., restrictive cardiomyopathy, constrictive pericarditis, amyloid heart disease, acute cor pulmonale) may experience decreased cardiac output with digoxin.

Worsening of outflow obstruction may occur in patients with idiopathic hypertrophic subaortic stenosis as a result of the inotropic effects of digoxin.

Avoidance of digoxin recommended, although the drug has been used for ventricular rate control in the subpopulation of patients with atrial fibrillation.

Use in Patients with Electrolyte Abnormalities

Electrolyte imbalances, especially hypokalemia, hypomagnesemia, or hypercalcemia, may predispose to cardiotoxic effects. Conversely, digoxin may be rendered ineffective in the presence of hypocalcemia.

Periodically assess serum electrolytes. Closely monitor serum potassium levels in patients at high risk for hypokalemia (e.g., receiving diuretics, corticosteroids, other drugs that cause potassium loss, those with GI losses from diarrhea, vomiting, nasogastric suction, or those with endocrinopathies or nephropathies).

Altered Response in Thyroid Disorders and Hypermetabolic States

Certain conditions (e.g., hypo- or hyperthyroidism) can alter response to digoxin if the underlying condition is not treated appropriately.

ECG Changes During Exercise

Potential for false-positive ST-T changes during exercise testing.

Specific Populations

Pregnancy

Available data and clinical experience over several decades have not identified a drug-associated risk of adverse maternal or fetal outcomes with digoxin.

Underlying maternal condition (e.g., heart failure, atrial fibrillation) may increase risk of adverse pregnancy outcomes.

Dosage requirements may increase during pregnancy and decrease during postpartum period; monitor serum digoxin concentrations. Because the risk of arrhythmias can increase during labor and delivery, patients should receive continuous monitoring.

Lactation

Distributed into human milk; however, quantities present unlikely to be clinically important. Effects of digoxin on the breast-fed infant or on milk production not known.

Pediatric Use

Safety and efficacy not established in pediatric patients with atrial fibrillation.

Manufacturer states safety and efficacy in pediatric patients with heart failure not established in adequate and well-controlled studies; however, improvements in hemodynamics and clinical manifestations reported in published literature.

Neonates exhibit considerable variability in their tolerance to digoxin.

Premature and immature infants are particularly sensitive to digoxin, and dosage must be reduced and individualized according to maturity.

Adverse effect profile differs in infants and children, particularly the initial signs of toxicity. Cardiac arrhythmias, including sinus bradycardia, usually occur earliest and most frequently. In children, any arrhythmia can occur.

Any arrhythmia or alteration in cardiac conduction in a child should be considered a sign of toxicity.

Geriatric Use

Most experience is in geriatric patients, and response and adverse effects do not appear to differ from those in younger patients; however, use with caution because of increased toxicity risk secondary to decreased renal function in the elderly.

Monitor renal function.

Hepatic Impairment

Hepatic impairment does not appear to alter serum digoxin concentrations.

Renal Impairment

Eliminated renally; therefore, patients with renal impairment are at higher risk of toxicity. Must reduce dosage.

Common Adverse Effects

Overall, adverse effects have been reported in 5−20% of patients; 15−20% of these considered serious. Cardiac toxicity accounted for about 50% of reactions, GI disturbances for 25%, and CNS and other toxicities for 25%.

Drug Interactions

Digoxin has a narrow therapeutic window; increase monitoring of serum digoxin concentrations and for possible digoxin toxicity when initiating, adjusting, or discontinuing therapy with any drugs that may interact with digoxin. Consult the prescribing information for any concurrently administered drugs for potential drug interaction information.

Drugs Affecting P-glycoprotein (P-gp) Transport

Digoxin is a substrate of P-gp at the level of intestinal absorption, renal tubular secretion, and biliary-intestinal secretion. Clinically important interactions may occur when digoxin is used concomitantly with drugs that induce or inhibit P-gp.

Drugs Affecting Renal Function

Drugs that affect renal function may impair elimination of digoxin, and thus predispose patients to digoxin toxicity.

Specific Drugs

Digoxin Pharmacokinetics

Absorption

Bioavailability

Peak plasma concentrations occur 1–3 hours following administration of the tablets, and 30–90 minutes following administration of the oral solution.

Absolute bioavailability is 60–80% for the tablets and 70–85% for the oral solution.

Substrate of P-gp, a transport protein involved in absorption.

Onset

Following oral administration, onset of action occurs in approximately 0.5–2 hours and maximal effect occurs in 2–6 hours.

Following IV administration, onset of action occurs in 5–30 minutes depending on the rate of infusion and maximal effect occurs in 1–4 hours.

Food

Presence of food in the GI tract may slow rate but not extent of absorption.

Plasma Concentrations

Determine plasma concentrations by obtaining blood samples at least 6–8 hours after the daily dose and preferably just prior to next scheduled daily dose.

Therapeutic plasma concentrations in adults are generally 0.5–2 ng/mL.

In adults, toxicity is usually, but not always, associated with steady-state plasma digoxin concentrations >2 ng/mL.

Interpret plasma concentrations in the overall clinical context; thus, do not use an isolated plasma concentration measurement alone as the basis for adjusting dosage.

Special Populations

Renal impairment: Systemic exposure is increased.

Hepatic Impairment: Plasma digoxin concentrations in patients with acute hepatitis generally similar to those with normal hepatic function.

Distribution

Extent

Widely distributed into tissues.

Crosses the placenta.

Distributes into breast milk.

Plasma Protein Binding

Approximately 25%.

Elimination

Metabolism

Usually, only small amounts are metabolized.

Metabolism involves hydrolysis, oxidation, and conjugation. CYP enzymes not involved in metabolism.

Apparently also metabolized by bacteria within the lumen of the large intestine following oral administration and possibly after biliary elimination following parenteral administration.

Elimination Route

Mainly in urine, principally as unchanged drug.

Half-life

Approximately 1.2–2 days in patients with normal renal function. Increased to 3.5–5 days in anuric patients.

Special Populations

Renal impairment: Elimination half-life is prolonged.

Stability

Storage

Oral

Tablets

25°C (excursions permitted to 15–30°C); store in dry place and protect from light.

Oral Solution

20–25°C; protect from light.

Parenteral

Injection

25°C (excursions permitted to 15–30°C); protect from light.

Diluted solutions of digoxin should be used immediately.

Digoxin Mechanism of Action

• Digoxin is a cardiac glycoside.

• Inhibits the activity of sodium-potassium-activated adenosine triphosphatase (Na⁺-K⁺-ATPase), an enzyme required for transport of sodium ions out of and potassium ions into myocardial cells.

• Increased calcium influx to the myocardium and conduction system results in positive inotropy, increased automaticity, and decreased conduction velocity.

• Decreases conduction velocity through the atrioventricular (AV) node through indirect parasympathetic stimulation.

• Reduces catecholamine reuptake, which increases the sensitivity of blood vessels to circulating catecholamines.

• Causes increased baroreceptor sensitization, with subsequent increases in carotid sinus nerve activity and enhanced sympathetic withdrawal with any change in mean arterial pressure (MAP).

• At higher concentrations, increases sympathetic outflow from the CNS to cardiac and peripheral sympathetic nerves.

• At higher concentrations, increases the efflux of intracellular potassium, which increases serum potassium levels.

• The direct and indirect cardiac effects of digoxin increase the force and velocity of systolic contraction (positive inotropy), slow heart rate (negative chronotropy), decrease conduction velocity through the AV node, and decrease activation of the sympathetic nervous system and renin-angiotensin system.

• With therapeutic doses, may cause prolongation of the PR interval and ST segment depression, but these ECG effects are not indicative of toxicity.

Advice to Patients

• Instruct patients to take their medication as directed by their prescriber. The dose of digoxin should not be adjusted by the patient without first consulting their healthcare provider.

• Inform patients that blood tests will be needed to ensure the appropriate digoxin dose is used.

• Explain common signs and symptoms of digoxin toxicity (e.g., nausea, vomiting, persistent diarrhea, confusion, weakness) or visual disturbances, including blurred vision, green-yellow color disturbances, or halo effect, and to contact a clinician if they occur.

• Inform patients or caregivers that signs of digoxin toxicity may be more difficult to recognize in infants and children. Symptoms that may be indicative of digoxin toxicity include weight loss, failure to thrive, abdominal pain, and behavioral disturbances.

• Inform patients to self-monitor and record their heart rate and blood pressure daily.

• Inform patients using digoxin oral solution to avoid less precise measuring tools such as teaspoons, and to use the provided calibrated oral syringe to measure their digoxin dose. For doses that are less than 0.1 mL, an oral syringe that can adequately measure the dose must be provided.

• Stress importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs or herbal supplements, as well as any concomitant illnesses.

• Advise patients to inform clinicians if they are or plan to become pregnant or plan to breast-feed.

• Inform patients of other important precautionary information.

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer’s labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to theASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

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