title: Management of digoxin therapy using pharmacokinetics in a patient undergoing continuous venovenous hemofiltration.
abstract: OBJECTIVE
  The management of digoxin therapy using pharmacokinetics in a patient undergoing continuous venovenous hemofiltration (CVVH) is reported.
  
  
  CONCLUSIONS
  A 46-year-old African-American woman with New York Heart Association class IV, American College of Cardiology- American Heart Association stage D heart failure arrived from an outside facility with complaints of dyspnea after minimal exertion, orthopnea, and lower-extremity edema. A transthoracic echocardiogram revealed an estimated left ventricular ejection fraction of 15%. The patient subsequently required left ventricular assist device placement on hospital day 5 as a potential bridge to transplantation. A total digoxin loading dose of 500 μg i.v. (8.2 μg/kg) was given in two divided doses six hours apart. The next morning, the serum digoxin concentration was 1.9 ng/mL, and the patient was started on a maintenance digoxin dosage of 125 μg i.v. daily. On postoperative day (POD) 20, the patient developed acute kidney injury, and CVVH was initiated. The sieving coefficient (Sc), transmembrane clearance (CLtm), digoxin concentration in ultrafiltration fluid (Cuf), and need for supplemental digoxin were determined to account for CVVH- associated digoxin loss. After 14 days of CVVH, the patient's clinical condition improved, and CVVH was transitioned to intermittent hemodialysis. On POD 66, the patient was discharged to an extended-care facility without adverse reactions related to digoxin therapy.
  
  
  CONCLUSIONS
  Analysis of serum digoxin concentration and digoxin Cuf values suggested that digoxin was cleared by CVVH, allowed calculation of Sc and CLtm values, and facilitated determination of digoxin requirements in a critically ill patient requiring CVVH.
authors.affiliation: Scott T. Benken, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Cardiothoracic Surgery, Department of Pharmacy, University of Chicago Medicine, Chicago, IL. Bryan D. Lizza, Pharm.D., BCPS, is Clinical Pharmacy Specialist-Critical Care, Department of Pharmacy, Northwestern Memorial Hospital, Chicago. Hala Yamout, M.D., is Nephrology Fellow; and Cybele Ghossein, M.D., is Associate Professor of Medicine, Division of Nephrology and Hypertension, Feinberg School of Medicine, Northwestern University, Chicago.
authors.forename: Scott T
authors.initials: ST
authors.lastname: Benken
authors.forename: Bryan D
authors.initials: BD
authors.lastname: Lizza
authors.forename: Hala
authors.initials: H
authors.lastname: Yamout
authors.forename: Cybele
authors.initials: C
authors.lastname: Ghossein
mesh_terms: D058186:Acute Kidney Injury / Q000628:therapy; D002316:Cardiotonic Agents / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use*; D016638:Critical Illness; D004077:Digoxin / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use*; D004305:Dose-Response Relationship, Drug; D004452:Echocardiography; D005260:Female; D006333:Heart Failure / Q000188:drug therapy* / Q000601:surgery; D006353:Heart-Assist Devices; D006440:Hemofiltration / Q000379:methods*; D006801:Humans; D008875:Middle Aged
chemical_list: D002316:Cardiotonic Agents; D004077:Digoxin