Digitalis and Hemodialysis Is a Bad Combination

Two centuries after its discovery, digitalis remains perennially controversial, even as it is largely supplanted by newer, safer drugs. For atrial fibrillation, β blockers and calcium channel blockers offer better rate control than digoxin; for congestive heart failure (CHF), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers, β blockers, and aldosterone antagonists have a proven survival advantage. Consensus guidelines have become increasingly cautious: In 2005, the American Heart Association/American College of Cardiology Heart Failure guidelines downgraded digoxin from a class 1 recommendation (in 2001) to class IIa; the 2009 update added special cautions about dosing and levels.1 Overall use has declined from approximately 80% of patients with systolic heart failure to 30%,2 yet no less a scientist and statesman than Eugene Braunwald3 recently urged a large National Institutes of Health–sponsored trial of low-dosage digoxin for acute CHF.The basic clinical facts about digoxin for nondialysis patients come from two venerable randomized trials. In the Randomized Assessment of Digoxin on Inhibitors of Angiotensin-Converting Enzyme (RADIANCE) trial of 178 patients,4 withdrawal of digoxin from patients who had an ejection fraction of ≤35% and were tolerating the drug well (an important caveat—these were survivors already) carried a 5.9-fold relative risk for worsening heart failure. In the Digitalis Investigation Group (DIG) trial of 6801 patients,5 the addition of digoxin (with levels …