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OBJECTIVES FOR CARDIAC

GLYCOSIDES
Explain how digoxin produces a positive inotropic

effect by inhibiting the Na/K pump.


Describe the effect of CHF on the slope and
position of the Frank-Starling relationship, and how
digoxin alters this relationship.
Discuss digoxin's use for controlling the ventricular
rate in patients with atrial tachyarrhythmia's.
Describe the cellular mechanisms by which digoxin
can produce serious cardiac arrhythmias (3rd
degree AV block, bigeminy, ventricular
tachycardia).
Explain how digoxin toxicity can be enhanced by
hypokalemia, hypercalcemia and drug interactions
with antiarrhythmic and diuretics.
List some of the more common non cardiac signs

Cardiac Glycosides
Digitalis glycosides are a group of chemically

related compounds isolated primarily from


plant sources, such as the purple and white
foxglove plants (Digitalis purpureaand
Digitalis lanata).
Also known as digitalis glycosides, cardio
tonics
Glycosides consist of aglycone and
sugar groups .Aglycone responsible for
pharmacodynamic properties ;sugar
responsible for pharmacokinetic
properties
The following are the cardiac glycosides
available:
Kee, Joyce LeFever,
Hayes, Evelyn R., & McCuistion, Linda E.
Digoxin(Lanoxin)
(2006).Pharmacology: A Nursing Process Approach. St. Louis:
Digitoxin(crystodigin)
Saunders Elsevier.Pg. 601

Cardiac Glycosides
This group of drugs have three

effects on heart:
Positive inotropic(increases myocardial
contraction & stroke volume)
Negative chronotropic(decreases heart
rate)
Negative dromotropic(decreases
conduction of heart cells)

Kee, Joyce LeFever, Hayes, Evelyn R., & McCuistion, Linda E.


(2006).Pharmacology: A Nursing Process Approach. St. Louis:
Saunders Elsevier.Pg. 602

Cardiac Glycosides
Mechanism of action

This group of drugs act by:


Inhibiting the Na+/K+-ATPase pump--

increase in intracellular sodium


Causes increased influx of calcium, thus

increasing intracellular calcium which causes


cardiac muscle fibers to contract more efficiently.
It atrioventricular conduction
sensitivity of AV to vagal tone which
heart rate.
Cardiac glycosides and related preparations
were used to treat heart failure also called as
cardiac failure or congestive heart failure
Lippincott's Illustrated Reviews: Pharmacology, third Edition ,Pg-189

Cardiac Glycosides

Therapeutic uses:
Main indication:
Used in the treatment of Congestive heart failure
Treatment of Atrial dysrhythmias :like Atrial flutter,
Atrial fibrillation and paroxysmal atrial tachycardia,
supra ventricular tachycardia

contraindication:

Contraindicated in the presence of allergy to any


cardiac glycoside, as they may develop
hypersensitivity.
They are NOT given to patients with ventricular
dysrhythmias, heart block or sick sinus syndrome,
aortic stenosis, In persons with acute MI and
such
as
Kee,electrolyte
Joyce LeFever,imbalances
Hayes, Evelyn R.,
& McCuistion,
Linda E.
(2006).Pharmacology:
A Nursing Process Approach.
St. Louis: Saunders
Hypokalemia,hypomagnesemia,
hypercalcemia

Cardiac Glycosides
Drug drug interactions:
Many drugs interact with digoxin
Rifampin,

barbiturates,cholestyramine,antacids,kaolin,pectin,
sulfasalazine reduce therapeutic effects of digoxin
Calciumpreparations,quinidine,verapamail,cyclosporine,tert
racycline,erythromycin,spironolactone increase the risk of
digitalis toxicity
Amphotericin B, potassium wasting diuretics and steroids
taken with digoxin may cause hypokalemia and increase
the risk of digoxin toxicity. Potassium replacement must be
given.
B-blockers and calcium channel blockers cause slow heart
rate and arrhythmias

Lippincott Williams & Wilkins. Nursing Pharmacology Made Incredibly Easy!3rd Ed.Ch5. Pg.183

Cardiac Glycosides
Digitalization: the administration of a loading

dose to achieve therapeutic blood level of the


medication more rapidly.
Digitalis toxicity: an accumulation of digitalis in
the body that leads to nausea, vomiting and atrial
tachycardia.
It is one of the most commonly encountered drug
related reasons for hospitalization because digitalis
has a narrow therapeutic index and the endpoint of
effective therapy is often difficult to define and
measure.
The normal digoxin level is 0.8-2.0nanogram/ml.in
CHF patients it is taken as 1.5ng/ml
Individuals with hypokalemia can develop toxicity
even when their digoxin levels are not elevated .
Lippincott Williams & Wilkins. Nursing Pharmacology Made Incredibly Easy!3rd Ed.Ch5. Pg.184

Adverse Effects of
Digitalis Glycosides
Heart : Ventricular
Arrhythmias & Heart
block
CNS side-effects:
headache
weakness,seizures,dro
wsiness,
confusion, blurred
vision,
yellow vision
GI side-effects:
Anorexia,Nausea,Vomit
ing
DIGITALIS TOXICITY
Includes slow to rapid
ventricular rhythms,
nausea, vomitting,
blurred vision, anorexia,
abdominal pain, mental

Treatment of Digitalis Toxicity


Immediate withdrawal of
digitalis
I.V.

K+ supplementaion to
compensate for
intracellular K.
If that doesnt work

Lidocaine or phenytoin is effective against K+ digitalis-induced


dysrhythmias. Other treatment that may be used to treat life-threatening
arrhythmias until Fab is acquired aremagnesium,phenytoin, andlidocaine.
Magnesium suppresses digoxin-induced ventricular arrhythmias while
phenytoin and lidocaine suppresses digoxin-induced ventricular
automaticity and delay after depolarizations without depressing AV
conduction. In the case of an abnormally slow heart rate
(bradyarrhythmias),Atropine,catecholamines(isoprenalineorsalbutamol),
and/or temporarycardiac
pacingcan be used. Atropine is used incase of
If that doesnt work (severe case or resistance to drugs)
digitalis induced AV block

Antidote:

Use digoxins specific Fab fragments; Digoxin Immune Fab


(Digibind/ Digifab) The primary treatment of digoxin toxicity
isDigoxin immune fab (ovine), which is an antibody
made up of anti-digoxinimmunoglobulinfragments

Nursing implications
Administer the initial rapid digitalization and loading
dose as ordered I.V.
Take apical pulse for one whole minute before
administering the drug
If there is bradycardia
pulse less than 60 in adults
Less than 90 in infants
more than 110 in adults

Retake pulse after 1 hour

If bradycardia persists, withhold the drug

Notify the physician and document the event

Nursing implications
Check the spelling of the drug DIGOXIN is different
from DIGITOXIN
Check the dosage preparation and the level of Digitalis
in the blood
( therapeutic level is 0.5-2.0ng/ml)
Administer i.v drug VERY SLOW over 5 min to avoid
arrhythmias. DO NOT administer I.M as it can cause
severe pain.
Administer the drug without food if possible to avoid
delayed absorption
Weigh the patient daily to determine fluid retention .
Maintain emergency equipment and drugs like
potassium salts, lidocaine for arrhythmias, phenytoin for
seizures, atropine for bradycardia
Provide health teaching drug name ,action ,dosage
,side effects ,how to measure pulse and ask patient to

Nursing implications
On missed doses ,Dont play catch up. Take as
prescribed
On abnormal weight gain/loss to report:3 lbs/ day or
more
On driving: Avoid due to CNS s/e (Drowsiness)
On vision changes: These may normally exist within
the 1st 3 days of therapy
Monitor electrolytes, potassium ,sodium ,calcium
,magnesium, renal function tests including BUN
,CREATININE, blood tests including AST, ALT, Bilirubin.

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