title: Extracorporeal treatment for digoxin poisoning: systematic review and recommendations from the EXTRIP Workgroup.
abstract: BACKGROUND
  The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup was formed to provide recommendations on the use of extracorporeal treatments (ECTR) in poisoning. Here, we present our results for digoxin.
  
  
  METHODS
  After a systematic literature search, clinical and toxicokinetic data were extracted and summarized following a predetermined format. The entire workgroup voted through a two-round modified Delphi method to reach a consensus on voting statements. A RAND/UCLA Appropriateness Method was used to quantify disagreement, and anonymous votes were compiled and discussed in person. A second vote was conducted to determine the final workgroup recommendations.
  
  
  RESULTS
  Out of 435 articles screened, 77 met inclusion criteria. Only in-vitro, animal studies, case reports and case series were identified yielding a very low quality of evidence for all recommendations. Based on data from 84 patients, including six fatalities, it was concluded that digoxin is slightly dialyzable (level of evidence = B), and that ECTR is unlikely to improve the outcome of digoxin-toxic patients whether or not digoxin immune Fab (Fab) is administered. Despite the lack of robust clinical evidence, the workgroup recommended against the use of ECTR in cases of severe digoxin poisoning when Fab was available (1D) and also suggested against the use of ECTR when Fab was unavailable (2D).
  
  
  CONCLUSIONS
  ECTR, in any form, is not indicated for either suspected or proven digoxin toxicity, regardless of the clinical context, and is not indicated for removal of digoxin-Fab complex.
authors.affiliation: a Indiana Poison Center, Indiana University Health , Indianapolis , IN , USA ;
authors.forename: James B
authors.initials: JB
authors.lastname: Mowry
authors.affiliation: b Division of Nephrology , University of Sao Paulo Medical School , Sao Paulo , Brazil ;
authors.forename: Emmanuel A
authors.initials: EA
authors.lastname: Burdmann
authors.affiliation: c Department of Emergency Medicine , ZNA, Campus Stuivenberg , Antwerpen , Belgium ;
authors.forename: Kurt
authors.initials: K
authors.lastname: Anseeuw
authors.affiliation: d Department of Nephrology , Verdun Hospital, University of Montreal , Verdun , Canada ;
authors.forename: Paul
authors.initials: P
authors.lastname: Ayoub
authors.affiliation: d Department of Nephrology , Verdun Hospital, University of Montreal , Verdun , Canada ;
authors.forename: Marc
authors.initials: M
authors.lastname: Ghannoum
authors.affiliation: e Ronald O. Perelman Department of Emergency Medicine, Division of Medical Toxicology , New York University School of Medicine , New York , NY , USA ;
authors.forename: Robert S
authors.initials: RS
authors.lastname: Hoffman
authors.affiliation: f Department of Medical Biology , Sacré-Coeur Hospital, University of Montreal , Montreal , Canada ;
authors.forename: Valery
authors.initials: V
authors.lastname: Lavergne
authors.affiliation: g Department of Pharmacy and Therapeutics , Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy , Pittsburgh , PA , USA ;
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Nolin
authors.affiliation: h Department of Medicine and Emergency Medicine , McGill University Health Centre, McGill University , Montreal , Canada.
authors.forename: Sophie
authors.initials: S
authors.lastname: Gosselin
mesh_terms: D000818:Animals; D002316:Cardiotonic Agents / Q000493:pharmacokinetics / Q000633:toxicity; D032921:Consensus; D003697:Delphi Technique; D004077:Digoxin / Q000097:blood / Q000493:pharmacokinetics / Q000633:toxicity*; D004195:Disease Models, Animal; D062787:Drug Overdose / Q000628:therapy*; D064420:Drug-Related Side Effects and Adverse Reactions / Q000628:therapy*; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D006435:Renal Dialysis
chemical_list: D002316:Cardiotonic Agents; D004077:Digoxin
keywords: Dialysis; dialyzability; digoxin; extracorporeal treatment; poisoning; systematic review