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Atrial fibrillation - Management
What key drug interactions should I be aware of for digoxin?

  • Beta-blockers
    • Concomitant administration of a beta-blocker and digoxin can reduce heart rate and prolong atrioventricular (AV) conduction time, increasing the risk of AV block and bradycardia — monitor pulse carefully.
    • An increase in plasma digoxin levels has been noted with carvedilol — monitor for signs of digoxin toxicity (confusion, anorexia, nausea, and disturbance of colour vision) when starting, adjusting, or stopping carvedilol.
  • Calcium-channel blockers
    • The plasma concentration of digoxin is increased by diltiazem and verapamil and possibly by nifedipine — monitor for signs and symptoms of toxicity.
    • There is an increased risk of AV block and bradycardia with verapamil.
  • Amiodarone
    • The plasma concentration of digoxin is increased by amiodarone — halve the dose of digoxin and monitor for signs and symptoms of toxicity.
  • Antimicrobials
    • The plasma concentration of digoxin is increased by itraconazole, macrolide antibiotics, tetracycline, and trimethoprim — monitor for signs and symptoms of toxicity.
  • St John's wort
    • The plasma concentration of digoxin may be reduced by St John's wort — advise people taking digoxin that they should not use St John's wort, and that they should check with their pharmacist before using any other over-the-counter medications.
Basis for recommendation
  • These recommendations are based on guidance on heart failure published by the National Institute for Health and Clinical Excellence [NICE, 2003]; the manufacturer's Summary of Product Characteristics [ABPI Medicines Compendium, 2009c]; and Stockley's drug interactions: a source book of interactions, their mechanisms, clinical importance and management [Baxter, 2008].

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