title: Emergency step-by-step specific immunotherapy in severe digoxin poisoning: an observational cohort study.
abstract: OBJECTIVE
  To evaluate the efficacy and safety of a step-by-step fixed dose of specific immunotherapy protocol in case of severe digoxin poisoning in an open uncontrolled prospective study.
  
  
  METHODS
  Twenty consecutive patients were admitted because of severe digoxin poisoning. The inclusion criteria were: digoxin overdose and either life-threatening arrhythmia; high-degree atrioventricular block, ventricular arrhythmia, or bradycardia less than 50 bpm and hyperkalaemia (>5.5 mmol/l). A two-step protocol of antidigoxin antibodies treatment was carried out. At admission, every patient received two vials of specific Fab-fragments. If after 1 h following infusion ECG signs regressed, no more treatment was given. If ECG signs did not regress, patients were given two more vials. At inclusion and 6 h after immunotherapy, clinical (cardiac rhythm, ECG records) and biological (serum digoxin concentration, potassium) findings were recorded.
  
  
  RESULTS
  Patients had a median (interquartile range) age of 83 (75-90) years. Four patients had acute poisoning and 16 chronic overdoses. Eleven patients showed ventricular arrhythmia, and five had high-degree atrioventricular block. Seventy percent of the patients needed only the first step. Significant decreases were observed in the number of cardiac dysrhythmia (16 vs. three patients), in the median (interquartile range) of serum digoxin concentration [5 microg/l (3.8-6.2) vs. 0.4 microg/l (0.3-2.2)] and in serum potassium [4.6 mmol/l (4.1-5.5) vs. 3.85 mmol/l (3.7-4.55)] before and after immunotherapy. The digoxin-related mortality was 5%.
  
  
  CONCLUSIONS
  This protocol of step-by-step digoxin-specific immunotherapy seems to be as effective as the equimolar treatment, and there was significant cost reduction in case of acute poisoning.
authors.affiliation: Division of Emergency and Intensive Care, School of Medicine, Hôpital de Hautepierre, Strasbourg, France. pascal.bilbault@chru-strasbourg.fr
authors.forename: Pascal
authors.initials: P
authors.lastname: Bilbault
authors.forename: Rachid
authors.initials: R
authors.lastname: Oubaassine
authors.forename: Hassene
authors.initials: H
authors.lastname: Rahmani
authors.forename: Thomas
authors.initials: T
authors.lastname: Lavaux
authors.forename: Vincent
authors.initials: V
authors.lastname: Castelain
authors.forename: Philippe
authors.initials: P
authors.lastname: Sauder
authors.forename: Francis
authors.initials: F
authors.lastname: Schneider
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000889:Anti-Arrhythmia Agents / Q000276:immunology / Q000506:poisoning*; D001145:Arrhythmias, Cardiac / Q000139:chemically induced* / Q000628:therapy; D002985:Clinical Protocols; D004077:Digoxin / Q000276:immunology / Q000506:poisoning*; D062787:Drug Overdose / Q000628:therapy; D004562:Electrocardiography; D004630:Emergencies; D005260:Female; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000008:administration & dosage / Q000627:therapeutic use*; D007155:Immunologic Factors / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D011446:Prospective Studies
chemical_list: D000889:Anti-Arrhythmia Agents; D007140:Immunoglobulin Fab Fragments; D007155:Immunologic Factors; D004077:Digoxin