Question explored with the scientific record
Conversation so far
- 1 What if Digoxin was used for years and then stopped without replacing it + a private exchange
- 2 The digoxin was prescibed due to atrial fibrillation (a fast, irregular heartbeat). + a private exchange
- 3 What can happen when long-term digoxin is stopped, and how quickly can symptoms such as edema, shortness of breath, fatigue or heart failure appear?
- 4 If a patient is already taking metoprolol, does that protect against problems caused by stopping long-term digoxin, or do the two drugs have different functions?
- 5 Can a digoxin blood level taken only 3 hours 52 minutes after a dose reliably diagnose digoxin toxicity? What is the proper timing for the test?
- 6 If one digoxin result is 2.65 nmol/L at 3 hours 52 minutes after a dose and another is 1.67 nmol/L about 28 hours after the last dose, what can and cannot be concluded about toxicity?
- 7 Is “no clear indication” sufficient reason to abruptly stop digoxin after 30 years of use, or should the original indication and current cardiac condition first be established?
- 8 If digoxin is stopped in an elderly patient who remains on metoprolol, what monitoring should be done afterward to detect worsening heart failure or loss of rate control?
- 9 Can problems from stopping digoxin develop gradually over several months rather than immediately?
- 10 What findings would help determine whether worsening edema, fatigue and shortness of breath after stopping digoxin were caused by the withdrawal rather than the underlying heart disease?
- 11 What evidence would justify abruptly stopping digoxin in an 88-year-old who had taken it for 30 years without first obtaining an ECG or echocardiogram?
Answered on this page ↓
What evidence would justify abruptly stopping digoxin in an 88-year-old who had taken it for 30 years without first obtaining an ECG or echocardiogram?
The burden of proof is on the person who wants to stop the drug, not on the person who has taken it for three decades.
Abruptly stopping digoxin in an 88-year-old who has been on it for 30 years, without first getting an ECG or echocardiogram, is not supported by any clinical evidence I know of. The question is backwards. The evidence would need to show that stopping the drug is safer than continuing it, and that the risks of stopping are lower than the risks of the underlying condition the digoxin was treating. No such evidence exists for this scenario. The default in geriatric medicine, when a drug has been stable for decades, is to ask why change anything now. The burden is on the intervention, and here the intervention is withdrawal.
Digoxin is used for two main things: atrial fibrillation with a fast ventricular rate, and heart failure with reduced ejection fraction. In an 88-year-old, both conditions are common, and both can be unstable. If the drug is holding the heart rate down or supporting the pump, stopping it abruptly can cause the heart rate to spike, the failure to decompensate, or both. That can land the person in the hospital with pulmonary edema or a stroke from rapid AF. The withdrawal syndrome is real, and it is not rare. The studies on digoxin withdrawal, like the PROVED and RADIANCE trials from the early 1990s, showed that patients with heart failure who were randomized to placebo instead of digoxin had more worsening of symptoms, more hospitalizations, and worse exercise tolerance. Those were patients in stable condition, not 88-year-olds with 30 years of cumulative exposure. The risk is higher, not lower, in this population.
Now, the counterargument. Maybe the digoxin is no longer needed. Maybe the atrial fibrillation has converted to sinus rhythm on its own, or the heart failure has improved with other drugs. Maybe the person has developed digoxin toxicity, which is more common in the elderly due to reduced renal clearance and lower body mass. Symptoms like nausea, confusion, visual disturbances, or bradycardia could point to toxicity. But that is exactly why you get an ECG and an echocardiogram first. The ECG shows the rhythm and the rate, and it can show digoxin effect, like the classic scooping of the ST segment. The echo shows the ejection fraction and whether the heart is still failing. Without those two tests, you are flying blind. You do not know if the drug is still needed, and you do not know if it is toxic. Stopping it blindly could either remove a necessary support or leave a toxic drug in place. Both are bad.
The evidence for the safety of abrupt withdrawal in this specific scenario is essentially absent. I have not seen a trial randomizing 88-year-olds on 30 years of digoxin to abrupt stop versus slow taper versus continue, with ECG and echo done only after the stop. That study does not exist. What exists are the withdrawal trials in younger, stable heart failure patients, and they showed harm. What exists are case reports of withdrawal precipitating decompensation. What exists is the basic physiology of the drug, which says the heart has adapted to its presence, and removing it suddenly forces a rapid re-adaptation that the elderly heart handles poorly.
The honest answer is that the evidence would justify abrupt discontinuation only if you had a documented reason to believe the drug was causing more harm than benefit, and that reason would come from the ECG and echo. If the ECG showed a normal sinus rhythm with a normal rate, and the echo showed a normal ejection fraction, then you could argue the drug is no longer needed, and you might taper it slowly under observation. But even then, abrupt is not the word. You would taper. You would monitor. You would have a plan for what to do if the rate spikes or the breathing worsens. That is not what the question describes. The question describes stopping without any of that, and that is not supported by evidence. It is supported by nothing except a guess that the drug is unnecessary.
The deeper issue is that this is a common pattern in geriatric medicine: polypharmacy reduction done hastily, without the diagnostic workup that would tell you which drugs are still needed. Deprescribing is a real and important practice, but it is not a race. The evidence on deprescribing digoxin specifically is thin, and what exists points to caution. The 2014 American Geriatrics Society Beers Criteria list digoxin as potentially inappropriate in older adults, but that is about avoiding it as a first-line drug for heart failure, not about abruptly stopping it in someone who has been stable on it for decades. The criteria do not say stop it cold. They say use with caution. The caution includes checking renal function, checking drug levels, and monitoring for toxicity. None of that is happening in the scenario you describe.
So here is the call. The evidence does not justify abrupt discontinuation without ECG and echo. The evidence justifies the opposite: keep the drug, get the tests, and only then decide. If the tests show the drug is no longer needed, taper it slowly and watch. If the tests show toxicity, reduce the dose or stop it under monitoring, but that is a different situation from stopping it because you assume it is unnecessary. The confidence here is high on the physiology and the withdrawal trials. The confidence is high that the absence of evidence for harm from abrupt withdrawal is not evidence of safety. It is absence of evidence, and in an 88-year-old, the default should be to avoid the intervention that carries the known risk of decompensation. The system that pushes deprescribing without diagnostics is the same system that pushes prescribing without diagnostics. Both are shortcuts. Neither serves the patient.
Sources used 32
-
Can Medications be Safely Withdrawn in Patients With Stable Chronic Heart Failure? Systematic Review and Meta-analysis
This systematic review and meta-analysis investigates the safety and outcomes of medication withdrawal in patients with stable chronic heart failure, revealing that discontinuation of RAAS inhibitors and beta-blockers is discouraged due to increased hospitalizations without mort…
DOI: 10.1016/j.cardfail.2014.04.013 -
The use of digitalis in heart failure
A comprehensive review of digitalis/digoxin in heart failure, detailing pharmacology, hemodynamic and neurohormonal effects, and a synthesis of randomized and observational studies showing symptomatic/hemodynamic benefits and reduced hospitalizations, but with inconsistent morta…
DOI: 10.1016/s0146-2806(96)80001-6 -
Economic outcomes of withdrawal of digoxin therapy in adult patients with stable congestive heart failure
This study analyzes the health and economic outcomes of continuing versus withdrawing digoxin therapy in U.S. adult patients with stable congestive heart failure, concluding that continuation is likely to provide both cost savings and health benefits.
DOI: 10.1016/0735-1097(95)00140-u -
Letter by Uzun et al Regarding Article, “Comparison of Transplacental Treatment of Fetal Supraventricular Tachyarrhythmias With Digoxin, Flecainide, and Sotalol: Results of a Nonrandomized Multicenter Study”
This study evaluates the efficacy and safety of a combination treatment of digoxin and flecainide for fetal supraventricular tachyarrhythmias, reporting a high response rate and survival among treated fetuses.
DOI: 10.1161/circulationaha.111.071456 -
Clinical and pharmacologic study of fetal supraventricular tachyarrhythmias
A retrospective and prospective study evaluating maternal digoxin as a first-line prenatal therapy for fetal supraventricular tachyarrhythmias with normal cardiac anatomy, demonstrating high fetal conversion to sinus rhythm using intravenous digoxin, supplemented by amiodarone o…
DOI: 10.1016/s0022-3476(05)81156-4 -
Incidence, Predictive Factors, and Prognostic Significance of Supraventricular Tachyarrhythmias in Congestive Heart Failure
In a large, multicenter DIG trial of congestive heart failure patients in sinus rhythm, the study quantified the incidence and baseline predictors of supraventricular tachyarrhythmias (SVT), demonstrated that SVT independently predicts higher all-cause mortality, stroke, and hos…
DOI: 10.1378/chest.118.4.914 -
Transplacental digoxin therapy for fetal tachyarrhythmia with multiple evaluation systems
This study evaluates the effectiveness of transplacental digoxin therapy in treating fetal tachyarrhythmia, demonstrating significant improvements in cardiac function and favorable neonatal outcomes.
DOI: 10.3109/14767058.2011.554924 -
Quantification of rate-dependent effects of verapamil, diltiazem, and digoxin on atrioventricular conduction
This study investigates the rate-dependent effects of verapamil, diltiazem, and digoxin on atrioventricular conduction time in isolated guinea pig hearts, revealing drug-specific differences in binding kinetics and their implications for clinical use in supraventricular tachyarr…
DOI: 10.1016/s1056-8719(96)00127-x -
Fetal supraventricular tachycardia, treating the baby by targeting the mother
This case study presents the diagnosis and treatment of fetal supraventricular tachycardia (SVT) in a 26-year-old woman, highlighting the use of transplacental digoxin therapy and the decision for premature delivery due to persistent tachycardia.
DOI: 10.1136/bcr-2012-008515 -
Atrial flutter with exit block.
A case report of a 76-year-old woman with chronic atrial flutter and exit block, documenting spontaneous 2:1 exit block from flutter with a slower rhythm that resembled digoxin-related atrial tachycardia, and discussing the underlying mechanisms and management with pacing and di…
DOI: 10.1161/01.CIR.60.3.711 -
Mitochondrial toxicity of cardiac drugs and its relevance to mitochondrial disorders
A comprehensive review outlining how a wide range of cardiac drugs can impair mitochondrial function, the mechanisms underlying this toxicity, its variable relevance to mitochondrial disorders, and the clinical implications for treating patients with mitochondrial disease.
DOI: 10.1517/17425255.2015.973401 -
Junctional Bradycardia as Early Sign of Digoxin Toxicity in a Premature Infant with Congestive Heart Failure due to a Left to Right Shunt
This case report describes a premature infant with congestive heart failure who exhibited junctional bradycardia as an early sign of digoxin toxicity, highlighting the importance of monitoring electrolyte levels and considering aldosterone antagonists in treatment.
DOI: 10.1055/s-0035-1567858 -
Serum digoxin concentrations and clinical signs and symptoms of digoxin toxicity in the paediatric population
Retrospective paediatric study examining whether serum digoxin concentrations relate to signs and symptoms of digoxin toxicity in children, finding little overall association but noting female gender and electrolyte associations with higher concentrations and questioning routine…
DOI: 10.1017/S1047951115000505 -
Cost-effectiveness analysis of the use of digoxin immune Fab(ovine) for treatment of digoxin toxicity
This study conducts a cost-effectiveness analysis of using Digoxin Immune Fab (Ovine) for treating digoxin toxicity, revealing that while it increases survival rates, it also raises medical costs for severely toxic patients.
DOI: 10.1016/0002-9149(91)90334-h -
Clinical Toxicology of Cardiovascular Drugs
A comprehensive veterinary toxicology review detailing cardiovascular drug toxicities (digitalis/digoxin, antiarrhythmics, doxorubicin Adriamycin) in dogs and other species, with pharmacokinetic considerations, monitoring strategies, and implications for clinical management.
DOI: 10.1016/S0195-5616(90)50039-X -
Extracardiac and coronary vascular effects of digitalis
This review synthesizes how digitalis glycosides produce extracardiac vascular and systemic effects—including arteriolar vasoconstriction, altered coronary flow, renal and GI actions, CNS involvement, and baroreceptor reflexes—across normal physiology and heart failure, highligh…
DOI: 10.1016/s0735-1097(85)80468-x -
Dronedarone-digoxin interaction in PALLAS: A foxglove connection?
A critical analysis of the PALLAS trial data showing that dronedarone markedly increases digoxin serum levels via P-glycoprotein inhibition, leading to higher cardiovascular and arrhythmic deaths among patients on digoxin, with no such effect in patients not on digoxin, and urgi…
DOI: 10.5339/gcsp.2015.4 -
Clinical value of serum digoxin assays in outpatients: Improvement by the standardization of blood sampling
Standardized rest in the supine position before outpatient blood sampling for serum digoxin assays improves the correlation between measured levels and clinical status, increases diagnostic specificity, and identifies an optimal therapeutic range (1.0–2.1 nmol/L) for digoxin in …
DOI: 10.1016/0002-8703(89)90865-x -
Comparison of the immunogenicity and safety of polysaccharide and protein-conjugated pneumococcal vaccines among the elderly aged 80 years or older in Japan: An open-labeled randomized study
This study compares the immunogenicity and safety of polysaccharide and protein-conjugated pneumococcal vaccines in elderly individuals aged 80 years or older, finding that the protein-conjugated vaccine (PCV7) elicits a stronger immune response than the polysaccharide vaccine (…
DOI: 10.1016/j.vaccine.2014.11.023 -
Is Robot-Assisted Radical Cystectomy Justified in the Elderly? A Comparison of Robotic Versus Open Radical Cystectomy for Bladder Cancer in Elderly ≥75 Years Old
This study compares the outcomes of robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC) in elderly patients aged 75 and older, finding that RARC is associated with less blood loss, shorter hospital stays, and fewer complications without compromising pathol…
DOI: 10.1089/end.2012.0035 -
SPINAL MENINGIOMA SURGERY IN ELDERLY PATIENTS WITH PARAPLEGIA OR SEVERE PARAPARESIS
This multicenter retrospective study evaluates the surgical outcomes of 102 elderly patients (aged 70 and older) with severe neurological deficits due to spinal meningiomas, finding that surgery can improve quality of life despite advanced age and significant preoperative defici…
DOI: 10.1227/01.NEU.0000338427.44471.1D -
Pragmatic exercise-oriented prevention of falls among the elderly: A population-based, randomized, controlled trial
This study evaluates the effectiveness of a pragmatic exercise-oriented intervention to prevent falls among elderly individuals aged 85 and older, finding that while it did not significantly reduce fall rates at the population level, it improved balance performance and reduced t…
DOI: 10.1016/j.ypmed.2006.09.011 -
Comparison of different metabolic syndrome definitions and risks of incident cardiovascular events in the elderly
This study compares various definitions of metabolic syndrome and their predictive value for incident cardiovascular events in elderly individuals aged 65 and older, finding that most definitions, except for the EGIR criteria, are significantly associated with increased cardiova…
DOI: 10.1016/j.metabol.2011.07.002 -
Characteristics of Infectious Keratitis in Old and Very Old Patients
This study analyzes the characteristics, risk factors, causative agents, and severity of infectious keratitis in elderly patients aged 75 and older, revealing significant correlations between age, activities of daily living, and visual outcomes.
DOI: 10.1089/jop.2018.0028 -
Association of vitamin D and vitamin B 12 with cognitive impairment in elderly aged 80 years or older: a cross‐sectional study
A cross-sectional study of Brazilians aged 80 and older (n=165) found that vitamin D deficiency (≤18 ng/mL) is associated with higher cognitive decline and that higher vitamin B12 levels (≥496 pg/mL) are associated with higher prevalence of cognitive decline, after adjusting for…
DOI: 10.1111/jhn.12636 -
Ovarian cancer in elderly patients: a difference in treatment based on age?
This study investigates whether treatment strategies for ovarian cancer differ by age in elderly patients, revealing that older patients often receive less optimal treatment despite having worse disease characteristics.
DOI: 10.1007/s00404-012-2486-0 -
RISK FACTORS IN SURGICAL MANAGEMENT OF THORACIC EMPYEMA IN ELDERLY PATIENTS
This study investigates the surgical management and associated risk factors of thoracic empyema in elderly patients aged 70 years and older, revealing a 30-day mortality rate of 11.3% and identifying significant risk factors such as necrotizing pneumonitis and preoperative venti…
DOI: 10.1111/j.1445-2197.2008.04532.x -
Impact of age and comorbidities on colorectal endoscopic submucosal dissection outcomes: Large multicenter study in a Western cohort
This study evaluates the effectiveness and safety of endoscopic submucosal dissection (ESD) for colorectal lesions in elderly patients, particularly those aged 80 and older, compared to those aged 65 to 79, revealing that ESD is feasible and safe, with specific attention to the …
DOI: 10.1055/a-2568-1366 -
Pathologic characteristics of gastric cancer in the elderly: a retrospective study of 994 surgical patients
This study investigates the pathologic characteristics of gastric cancer in elderly patients, particularly those aged 85 and older, revealing a shift towards differentiated-type carcinoma and increased multiplicity with advancing age.
DOI: 10.1007/s10120-004-0285-4 -
Surgical outcomes among elderly women with endometrial cancer treated by laparoscopic hysterectomy: a NRG/Gynecologic Oncology Group study
This study investigates the surgical outcomes and complications of laparoscopic hysterectomy versus laparotomy in elderly women with endometrial cancer, revealing that laparoscopic staging is associated with decreased morbidity in patients aged 60 and older.
DOI: 10.1016/j.ajog.2017.09.026 -
Robotic Surgery in Elderly and Very Elderly Gynecologic Cancer Patients
This study investigates the feasibility, safety, and short-term outcomes of robotic surgery for gynecological cancer in elderly women aged 65-74 compared to those aged 75 and older, finding that robotic surgery is safe and well-tolerated in both age groups.
DOI: 10.1016/j.jmig.2018.01.007 -
The use of adjuvant endocrine breast cancer therapy in the oldest old
This study investigates the patterns of compliance and persistence in adjuvant endocrine therapy among breast cancer patients aged 80 and older compared to younger elderly patients, revealing significant differences in treatment acceptance and completion rates.
DOI: 10.1016/j.breast.2013.03.001