Atrial Fibrillation (AF) – Persistent

Digoxin dosing guidance

Digoxin has a limited role as first-line treatment for rate control. It is usually used second-line in combination with a beta-blocker or calcium-channel blocker.

In frail elderly patients or patients with very low body weight, lower loading and maintenance doses are recommended. If further advice is required then contact your clinical pharmacist or Medicines Advice (see Appendix 6 for contact details) or, out-of-hours, the on-call pharmacist.

Loading dose – normal renal function and age <80 years:

• Digoxin oral (preferred route) 500micrograms followed 6 hours later by 500–1000micrograms in divided doses >6 hours apart or
• Digoxin IV 500micrograms followed 6 hours later by 250–500micrograms in divided doses 4–6 hours apart.

Loading dose – renal impairment (creatinine clearance <30ml/minute) or age ≥80 years:

• Digoxin oral (preferred route) 500micrograms followed 6 hours later by 250–375micrograms in divided doses >6 hours apart or
• Digoxin IV 250–500micrograms.

N.B. Digoxin injection: 25micrograms = 0.1ml. Additional loading doses may be required; give according to ventricular (heart rate) response.

Maintenance daily dose: The tables below outline digoxin daily maintenance dosing for patients <60kg or ≥80 years (see table 1) and patients ≥60kg and <80 years (see table 2).

Table 1 – Digoxin daily maintenance dose if <60kg or ≥80 years

Table 2 – Digoxin daily maintenance dose if ≥60kg and <80 years

Target concentration range: 0.5–2micrograms/L (6–24 hours after the dose)

Time to steady state: 5–10 days

Concentration increased by amiodarone, azithromycin, clarithromycin, diltiazem, quinine, verapamil. This list is not exhaustive; see BNF or Stockley's Interactions Checker for more details.

Key Considerations

A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

See the GGC Polypharmacy Review in Adults Living with Moderate to Severe Frailty Guideline for guidance on how to assess frailty and manage medicines for cardiovascular disease in frailty.