Before the advent of digoxin immune fab (DIF), supportive interventions were the mainstay for treating cardiac glycoside toxicity. In 1976, Smith et al. reported the first use of these antibody fragments and were made commercially available by 1986. Due to its high effectiveness, they are now the mainstay for treating severe life-threatening digoxin toxicity or overdose. However, recommendations do not include non-life-threatening cardiac glycoside intoxications.
Current FDA Approved Indications :
Non-FDA Approved Indications:
Several studies have yielded a comfortable degree of cross-reactivity between digoxin and other plant-derived cardiac glycosides. This cross-reactivity forms the basis for administering digoxin immune fab in patients with poisoning from plants such as Acokanthera oblongifolia, Adonis microcarpa (pheasants eye), Asclepias physocarpa (balloon cotton bush), Bryophyllum tubiflorum (mother of millions), Calotropis procera (kings crown), Carissa laxiflora, Cerbera manghas (sea-mango), Cryptostegia grandiflora (rubber-vine), Nerium oleander, Thevetia peruviana (yellow oleander), Indian hemp and Cerbera odollam (pong-pong seeds). Furthermore, they bind and inhibit the ability of toad venom to block sodium-potassium ATPases. Therefore, in addition to supportive care and gastric decontamination, digoxin immune Fab can also be administered to reverse cardiotoxicity from toad venom.
As per recent analysis in the United States, digoxin toxicity presents in 10-18% of nursing home individuals. It also presents in 1.1% of outpatient and 0.4% of all hospitalized patients, respectively. The past decade has seen an overall reduction in the use of digoxin as a treatment modality. Research has shown a similar decline in the number of toxicity cases. Primarily, DIF is an antidote for severe life-threatening. Therefore, to grasp its reversal effect, it is essential to appreciate digoxin's pharmacological mechanism and its toxicity. Digoxin, a potent cardiac glycoside, is indicated for the treatment of heart failure and atrial fibrillation. It shows affinity to bind and block the potassium ion subunit of the sodium/potassium ATPase pump in cardiac myocytes. The pump functions to maintain a low concentration of sodium inside the myocyte normally. This blocking results in an increased concentration of sodium inside the myocyte cell. This increment of sodium hampers the ion exchange mechanism of other transporters located in the myocyte cell membrane. One such transporter, the sodium-calcium exchanger (NCX), helps maintain low intracellular calcium levels in exchange for pumping sodium inside. However, when administering digoxin, the elevated sodium concentration inside the myocyte decreases this exchange resulting in elevated calcium levels within the myocyte. The extra available calcium is actively reabsorbed and stored by the sarcoplasmic endoplasmic reticulum ATPase (SERCA). The resultant increase in overall calcium availability for cross-bridge formation between actin and myosin filaments ultimately leads to increased cardiac contractility (positive inotropic effect). Digoxin is also known to increase vagal tone in SA and AV nodes. The overall effect is to increase refractoriness and decrease conduction velocity in specialized conductive cardiac tissue. During toxicity, the Na/K ATPase is inhibited to a greater degree resulting in increased automaticity and inotropy. Furthermore, there is decreased dromotropy due to excessive inhibition of the AV node as a result of increased vagal tone.
Digoxin immune fab (DIF) are mixed anti-digoxin immunoglobulin fragments obtained from healthy sheep immunized with digoxin dicarboxymethoxylamine (DDMA). DDMA contains a cyclo-Penta-per-hydro-phenanthrene: lactone ring coupled to keyhole hemocyanin. This ring is an essential component of the final product. After isolation of immunoglobulins from the ovine serum, these isolates undergo digestion by papain and a process of affinity chromatography, yielding digoxin specific IgG Fab fragments.
DIF has an affinity for digoxin that ranges from 10^9 to 10^10 M-1. Its affinity is higher than the affinity of digoxin for the sodium pump receptor. This receptor is presumed responsible for its therapeutic and toxic effects. When administered to the intoxicated patient, DIF binds to digoxin molecules and reduces free digoxin levels. The reduction results in an equilibrium shift away from receptor binding and thereby decreases cardio-toxic effects. The kidney and the reticuloendothelial system eventually clear fab-digoxin complexes.
Clinical studies have also indicated the clinical utility of digoxin immune fab in pre-eclampsia. Pre-eclampsia is an exaggerated inflammatory condition compounded by altered endothelial function. It constitutes widespread activation of platelets and WBC followed by elevated levels of IL-γ, IL-6, and tumor necrosis factor-α (TNF-α). Digoxin immune fab can also downregulate TNF-α induced endothelial surface adhesion molecules (ICAM, VCAM, and E-selectin). Furthermore, DIF also reduces TNF-α mediated downregulation of Na/K pumps. Maternal serum in pre-eclamptic females also contains elevated endogenous digoxin-like factors (EDLFs) such as cardenolide, ouabain, bufadienolide, and marinobufagenin. These factors have also demonstrated the capacity to inhibit the mesenteric artery and erythrocyte Na/K ATPase activity. Maternal hypertension in pre-eclampsia occurs when reduced Na/K pump activity contributes to the accumulation of intracellular calcium and thus systemic vasoconstriction. Therefore, digoxin immune fab can improve fetoplacental circulation and eclamptic/pre-eclamptic symptoms by restoring cellular Na/K ATPase activity. It may also provide protective effects against TNF-α mediated endothelial cell dysfunction to offset the exaggerated inflammatory state.
Digoxin immune fab comes as a lyophilized powder for solution. Each vial is for single use only and contains 40 mg of digoxin immune Fab protein. It must be mixed with 4mL of sterile water (reconstitution/dilution) to produce a solution containing 10 mg/mL of DIF protein. If the solution is not used immediately, it can be refrigerated (2 to 8 degrees Celcius) for no more than 4 hours after its dilution. The diluted digoxin immune fab is added to 0.9% NaCl for use as an intravenous injection. The administration of the infusion should be for at least over thirty minutes. If infusion rate-related reactions occur, then infusion should be stopped and readministered at a slower rate. Bolus injections should be a consideration for patients with imminent cardiac arrest. Patients with chronic toxicity, with no immediate life-threatening presentations, initially receive an infusion of half the original dose, which prevents the unmasking of underlying co-morbid that required digoxin administration.
Pharmacokinetics of Digoxin Immune Fab
Multiple types of formulations are readily available for therapy. Using randomized control studies, researchers compared the pharmacokinetic properties of various anti-digoxin antibodies. Consistent across all, an equal decrease in serum-free digoxin levels were noted. Measurement of total free digoxin levels before and after fab administration were also similar. These results indicate an equimolar binding affinity to digoxin. Furthermore, digoxin excreted in urine was also similar, with greater than 40% of the dose excreted by 24 hours. These findings indicate similar pharmacokinetic profiles. Therapeutically, data has also indicated similar response rates in patients. Digoxin immune fab has a larger volume of distribution (Vd) when compared to IgG. It spreads across the extracellular space with a volume of distribution (Vd) of 0.3 L/kg. In patients with normal renal function, it has a half-life of 12 to 20 hours. Upon fab administration, there is a 10- to 30-fold increase in the bound and free serum digoxin concentration within minutes. Digoxin-fab complexes are eliminated from the blood by renal excretion. This decreases free digoxin levels from 80% to from 0 to 5%. Urinary digoxin levels go undetectable within 5 to 7 days. Its renal clearance is estimated to be at 960 ng/mL (1.229 mmol/L). Hemodialysis and peritoneal dialysis do not help facilitate their excretion.
As a rule of thumb, each vial is known to bind 0.5 mg of digoxin. The dose of digoxin immune fab needs to be adjusted depending on the amount of digoxin that requires neutralization. It is important to note that there is not much of a correlation between digoxin concentration and symptoms. Once administered, levels of serum digoxin concentrations are unreliable, and only unbound digoxin levels are helpful in clinical estimation. The following guidelines m considered while calculating a required dosage:
Dosage Calculation Formulas :
The number of vials required must be rounded off to the nearest whole number.
Dosage and Treatment Based On Clinical Scenarios:
The frequency of many adverse events remains undefined. Adverse effects can be categorized depending on severity. The following adverse effects have been documented with the use of digoxin immune fab:
Severe Adverse Effects:
Moderate Adverse Effects:
Mild Adverse Effects:
(Note: Specific contraindications as yet remain undetermined)
Pregnancy and Lactation:
Fab products have been designated pregnancy category C by the FDA. This rating indicates that it should be used with caution and only if the benefit justifies the risks imposed on the fetus. It is not known if fab products can cause harm to the fetus or affect future reproductive ability. Due to a lack of human and animal studies, no clear data on their safety exists. Therefore, digoxin immune fab should only be administered in pregnancy only if needed.
Although not a contraindication, its excretion into milk is unknown. Many studies have revealed that drugs are actively secretable into milk. Caution is necessary when administering a nursing mother digoxin immune fab. However, the risk appears to be small because the immune fab fragments in ingested milk would undergo digestion in the infant's stomach. However, risk in infants cannot be ruled out.
Ovine Protein Hypersensitivity:
Digoxin immune fab is a sheep derived protein. The immunoglobulin fractions are isolated from the serum of immunized sheep. In certain individuals, animal antibodies facilitate the formation of immune complexes. The adverse events include anaphylaxis, delayed allergic reactions, and a possible febrile response. Prior exposure/therapy with ovine fab is another potential risk factor for the development of acute allergic reactions related to Fab product administration. The Fab product is devoid of the antigenic determining Fc portion. This feature makes it less immunogenic and, therefore, less capable of mounting a fatal immune response. Due to its monovalence, it is also unlikely to form extended antigen-antibody immune complexes.
Hypersensitivity to Papaya Extracts and Bromelain:
Clinicians should not administer digoxin immune fab to patients with allergies to papain, chymopapain, and bromelain. Papain targets the isolated immunoglobulin fractions and cleaves them into Fab and Fc fragments. Trace amounts of activated or inactivated papain may still be present in the final product. Other allergens such as dust mite and latex have a certain homology to antigenic structures in papain. Such cases may also carry a risk of being allergic to papain. Administring the drug should only be considered if the benefits outweigh the risks, and treatment modalities of anaphylactic reactions are within an arm's reach.
Monitoring includes measurement of the following:
Parameters that require measurement before and after infusion include temperature, blood pressure, ECG, and serum potassium.
Serum Digoxin Concentration
It is important to measure serum digoxin before administration because post-administration levels do not correlate to clinical toxicity. Lab values take into consideration both unbound and bound serum digoxin levels. Furthermore, digoxin immune fab can also interfere with digitalis immunoassay measurements. The assay does not possess the ability to distinguish between free or bound digoxin. Therefore, this increases the risk of attaining false-positive results. It is considered clinically safe to re-consider serum digoxin levels only when fab fragments have been completely excreted from the body. Complete elimination varies from days to weeks. As a general rule of thumb, three weeks after administration qualifies as safe to reuse serum digoxin levels for clinical decision making. Equilibration of digoxin in the body requires at least 6 to 8 hours. Therefore, measurements may also be inaccurate if levels are drawn too close to dose administration. The rise of serum-free digoxin after Fab administration should not be considered alarming. Most of these digoxin molecules are bound to fab and will not bind to cardiac Na/K ATPases.
Serum Potassium Concentration
Digoxin results in a shift of potassium to the outside of the cell. Administration of Fab results in the redistribution of potassium back into cells resulting in hypokalemia. Serum potassium returns to baseline within 2 to 6 hours. Therefore, potassium levels must be monitored hourly for 4 to 6 hours after administration. The improvement in potassium level is a sign of clinical efficacy. If necessary, potassium supplementation is also an option.
Monitoring Precautions :
Digoxin immune fab is administered in a medically supervised and intensive care setting. The maximum amount of digoxin immune fab that can be safely administered has not yet been determined. However, 1280 mg in children and 1600 mg in adults have resulted in minimal to no symptoms. Toxicity events seldom occur and are projected to be a result of worsening side effects associated with digoxin therapy.
Digoxin immune fab is an anti-digoxin immunoglobulin fragment only used in the hospital setting. It is indicated in the treatment of digoxin toxicity. In acute toxicity, the drug is usually administered by an emergency physician. However, a board-certified cardiology pharmacist must play a role in dosing, scheduling, and administration. Cardiac nurses must be made aware of the possible complications that can arise during infusion. They must also receive instruction to report such adverse reactions immediately to the cardiologist.
Educating the patient is essential and requires a sequential approach. Discuss the potential use of this drug concerning their health condition. Educate the patient about the various signs and symptoms of delayed allergic reactions. Provide or describe possible adverse effects and instruct the patient to report back immediately. A careful history is necessary to rule out a possible allergy to papaya extracts, ovine proteins, and prior fab therapy. Extra care is a requirement when administering in patients with renal failure and previous heart disease. An interprofessional team approach is vital to optimizing outcomes in patients receiving digoxin immune fab for digoxin poisoning.
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