Hi all, My dad had paroxysmal AF but since the beginning of June he has persistent AF. Holter monitor heart rate was between 65 and 149 for 24 hour monitoring. He also had an echo and has got a diagnosis of heart failure. On average his heart rate is over 100 most of the time. He was on flecanide but he was asked to stop that and start Digoxin. His heart rate is staying above 100 even after 5 days of taking Digoxin 125mcg.
Pharmacist told us Digoxin can take 2 to 3 weeks to work. Does anyone have a similar experience to share and is it better to wait for 2 weeks or should I be concerned?
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priya_uk
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I agree with your pharmacist. Digoxin is an excellent drug if used correctly.. It’s origins go back hundreds of year's since it’s identification in the Digitalis plant and until recent decades in the list of top ten medications used worldwide.
Your dad has not been loaded, he is on the maintenance dose, so it will take time to accumulate which in time will show it’s effect.
You must take him to see his GP since monitoring will be required especially in the early stages of treatment. Digoxin is not free of side effects and can cause poisoning, particularly in the face of renal impairment when it will accumulate.
Periodic measurement of a blood level 6 hours after last dose is mandatory in the elderly.
Thank you. Good to know. The blood tests have been booked for 3 weeks after first dose. Gp said that according to guidelines there was no need to monitor initially as he was not given a loading dose. However due to my concerns the test was booked after 3 weeks.
I had a loading dose and am now on the maintenance dose plus 5mg of Bisoprolol bd. Further to your reply to my question regarding pace and ablate, I contacted my GP and suggested that I should have a blood test. GP came back and said not necessary unless I had adverse side effects, which I haven't. She mentioned NICE guidelines so I did some follow up on the web and it seems she's correct. Just mentioning this as I was initially quite worried by your reply.
You feel perhaps I have misled you Borderterriorist about the need for Digoxin levels.
Whatever the NICE guidelines may say, what I say remains correct in my opinion and has for decades been good practice.
It’s important to understand that NICE guidelines are as they suggest guidance and not indicative. They are there to give GPs protection. When a patient does not report side effects and dies in hospital with digoxin poisoning the GP is protected from prosecution. They are widely ignored by doctors who are confident that they are acting in the patient’s best interest.
If it were my elderly relative I would insist on a level 4 weeks after initiation. That will not be refused.
Thanks for this. Even cardiac nurse at BHF advised monitoring with Digoxin. Gp said no monitoring needed as per Nice guidelines. I believe you and cardiac nurse over the GP.
Jim987 I didn't think you misled me but your comment worried me, however, I had already taken the loading dose and been on the maintenance level for nearly two weeks and was feeling so much better (reading the information slip that comes in the box is pretty worrying!) so it concerned me less than it might have done. My HR is stable, I am much less tired and I have had absolutely none of the side effects that would suggest any level of toxicity. I'd had a long chat with an arrhythmia nurse as part of my consultation with my consultant and we had discussed taking digoxin, the loading process, what unwanted side effects to look out for and she's also given me her direct line phone number and email should I need to contact her if I was worried about anything. I have been seeing the same consultant for four years both at the NHS and privately and feel he knows me well and I trust him. I also have an excellent GP surgery, when I contacted them online to ask about monitoring they got back to me in 20 minutes with an answer. My daughter is a consultant anaesthetist and she also keeps tabs on my treatment although she's not a cardiac specialist she can interpret NICE guidelines.
I'm aware people will search through posts looking for information so I feel it's important to add to the range of experiences that they encounter. We all will have different journeys AFib or flutter, it's causes, what we respond well to, how successful an ablation or a cardioversion will be different for everyone. I am aware how lucky I am with the medical support I have but I'm also very aware of how anxious a condition like AF can make people even with good support and treatment. I have a regular blood test, know when my next one is due and am happy not to be monitored further as the level of digoxin I'm on is unlikely to cause toxicity in me, that might not be true for others though.
Hi, I had the loading dose of digoxin but it still took a few days for me to start seeing the benefit. We are all different in how we respond to these drugs and I don't know how old your father is. I'm nearly 76 but generally very fit apart from this problem with my electrics. I can honestly say I haven't have any adverse side effects and my heart rate has settled well but if you are worried about him I'd contact the GP. I know my GP wouldn't mind in the slightest even if I made an unnecessary call.
Thanks that's reassuring. My dad is 72. He has other issues. However in relation to the heart, apart from the high heart rate he is not complaining of any new symptoms since he started taking Digoxin. We will give it until next week and follow up with GP.
Did you mention to your GP that your father's heart rate was generally over 100? If you haven't I think I'd contact your surgery tomorrow just to run it past them especially as it's a bank holiday on Monday. Perhaps it would put your and your father's mind at rest? I think one of the most difficult things to manage with AF is knowing when to contact a doctor and it can cause a lot of anxiety which, of course is totally counter productive. Your father is lucky to have you caring for him but you need to also take care of yourself so try not to worry.
My wife was paroxysmal then persistent (plus flutter too). She had first full load of digoxin (3x500mg) in ED during a prolonged episode in April which did nothing, another full load a week later again in ED, then a third one about a month later in May and then they also suggested maintenance dose (125mg daily) after that one. Her heart finally "permanently" returned to NSR about 3 weeks after that BUT we put that down to her starting bisoprolol about a week prior to the NSR. She's still on the digoxin too though, so impossible to know which drug brought it under control.
I'm worried now about the digoxin poisoning comments on this thread - non of our ED doctors, specialist cardiologists or GPs here in the UK has ever suggested that her blood levels will need to be monitored re. digoxin. She is very averse and distrusting of meds anyway so If I mention this now she's likely to stop it immediately ☹️ My only comfort now is the mention of NICE guidelines saying testing isn't needed. Need to research digoxin poisoning symptoms now...
I first had digoxin in A&E following a similar episode to your wife, it didn't resolve it but giving me large doses of bisoprolol did initially, unfortunately 7.5mg of bisolprolol morning and evening didn't settle it permanently so I now take digoxin and 5mg of bisoprolol in the morning and 5mg of bisoprolol in the evening and it's made a massive difference to me. I always think if you are worried it's worth having a chat with your GP or someone at the hospital is she is on their books and you have a contact there (I can contact an arrhythmia nurse). Please don't let her stop taking any of her meds I think the 125 is micrograms? It's what I take and it normally doesn't cause toxicity according to the info I've found on the internet so I hope that reassures you a little.
Sorry, yes, probably micrograms, I know it was 125 and it was a "standard" maintenance dose. She's been badly let down many times by local hospital. She's only just had her first referral to cardiac nurses (after over 3y in and out of ED with AF and other heart related issues, and having seen NHS cardiologist only once for a scheduled appointment) and they said they'll put her on their list to book into their clinic some time in the next 6-12 months. We had to use BUPA to get some of of the investigations done.
That's awful, I know waiting lists are long as there is a shortage of cardiac consultants and it's frustrating when you do get to see one as the appointment can feel very rushed. Purely by chance my NHS consultant is also the guy I saw privately whilst waiting for my first clinic appointment following an emergency admission. I've seen him three times privately and three times in an NHS clinic and I feel he really knows me as a person as well as a clinical patient. If you afford to spend the money, I think it's well worth doing that. It doesn't buy you any extra privilege or shorten your wait times but it does build a relationship.
I fund digoxin worked immediately and worked well, keeping my heart rate down until my ablation. You don't say how old your father is, or how severe his HF is, but I would have thought that should be more aggressively treated. Flecainide can only be given when the heart is in sound shape, so maybe the HF is being caused by other issues? I would ask his GP for more explanation and prognosis, myself.
I was stuck with BBs at first with rapid and persistent AF. Metoprolol 186 and pauses at might during my normally low Heart Rate of 47bpm 1 year 5 mths the 24hr Heart Monitor showed this. Then changed to Bisoprolol (better for AF) but stil no control in heart rate. No breathlessness or pauses with less fatigue. 156bpm Day.
10 months later the new locum referred me to private Heart Specialist.
Introduced 1/2 dose Diltiazem and I dropped from 156 to 51 in 2 hours! It doesn't affect BP much.
So last 2.5 years on:
AM Diltiazem 120mg CD to control Heart Rate - now 60s Day 47avg Night.
PM Bisoprolol 2.5mg to control BP especially Systolic 110/69. 79 late afternoon.
Bingo.
110mg PRADAXA x twice daily.
Why do heart specialist forget Diltiazem the CCB which is safe and doesn't make too low BP.
Unless Lower Chambers have a structural damage. Yes, and separate CCB AM and BB PM.
Digoxin is an antiarrhymic old type med.
Diltiazem also works as a anti-arrhymic med but is a more natural and safer med. Diltiazem CD can be taken as one daily dose.
JOY2THEWORLD49 that's amazing information, thanks for sharing. Diltiazem sounds like a wonder drug in your case.
My dad has a diagnosis of heart failure. One of the side effects of Diltiazem is that it can worsen symptoms in patients with pre-existing heart failure. Also my dad has Asthma and Diltiazem can exacerbate asthma symptoms.
However will definitely discuss this option with cardiologist.
I think everyone is different. My dad has paoriatic arthritis which is an autoimmune condition so monitoring may be necessary for any change in renal function.This is an old BHF article but I found it helpful.
If you read into Digoxin. You must have a 3-month blood test to see any change in kidney or liver.
I would insist.
Why so forgetful your Dr.
But interesting that the patient should be reminding Dr of this. Same in the fact of that you are on anti-co.agulants for pain killers. Just the state of systems. But in UK etc Drs can be sued for not keeping up with patients 'caution' 'allergies' etc. We have ACC so we go through this government Agency for damage.
Just a quick update. We met with EP today and my dad has been asked to continue with Digoxin and also take Bisoprolol everyday. To help with Apixaban bleeding, he has been asked to try omeprazole as he may be experiencing bleeding due to weak stomach lining. In the meantime his qrisk2 score was above 45% so he has been put on statin.
He will be on the list to have cardioversion to get him back to sinus rythm and then we will see if he needs ablation.
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