Drug Profile

Digoxin is approved by the Food and Drug Administration (FDA) for the treatment of mild-to-moderate heart failure. It often is used in combination with a thiazide diuretic (water pill) or a loop diuretic such as furosemide (LASIX) in more severe cases, as well as an angiotensin-converting enzyme (ACE) inhibitor and a beta blocker. The symptoms of heart failure include fatigue, difficulty breathing, swelling (especially in the legs and ankles) and rapid or “galloping” heartbeats.

Digoxin also is approved to control the rate of beating of the large chambers of the heart (ventricles) in people with atrial fibrillation, the most common disorder of the heart's rhythm, or arrhythmia.[1] Atrial fibrillation can cause palpitations (feelings that the heart is skipping a beat, fluttering, or beating too hard or fast), shortness of breath, chest pain, dizziness and fatigue. However, in many patients, the condition causes no symptoms.

Before prescribing digoxin for heart failure, doctors usually first try administering a thiazide diuretic (or a loop diuretic in more severe cases), as well as an ACE inhibitor and a beta blocker. Patients should be prescribed digoxin only if these other medications do not control symptoms well enough. In general, a patient over 60 years of age should take a smaller daily dose than the usual 0.25 milligrams,[2] especially if the patient has impaired kidney function.

A substantial body of research has demonstrated that treatment with digoxin in atrial fibrillation patients is associated with an increased risk of death.[3],[4],[5],[6],[7],[8] Based on these findings and the other known adverse effects of digoxin, other drugs, such as beta blockers, should be tried first to control the heart rate in atrial fibrillation patients.

Adverse effects

Anyone taking digoxin is at risk of toxic effects (digitalis toxicity). While a patient is taking digoxin, their doctor should regularly check the levels of the drug in the blood. Both the patient and the doctor also should watch for the subtle symptoms of toxicity: fatigue, loss of appetite, nausea and vomiting, problems with vision, bad dreams, nervousness, drowsiness and hallucinations.[9] Other signs of toxicity are changes in heart rhythm, slow pulse and lethargy. Because there is a narrow range between a helpful and a harmful amount of digoxin in the body, patients should take the drug daily in the exact amount prescribed. If too much digoxin enters the body, the patient may experience the effects listed above. If there is too little digoxin, a patient may develop symptoms of heart failure or a rapid heart rate.

The abrupt onset of dementia has been associated with digoxin use. The dementia is reversible when digoxin use is stopped.[10]

Studies show ...

An article published in the Journal of Clinical Oncology in 2011 presented information from a Denmark study on the incidence of breast cancer in women using digoxin and in women using angina drugs. The study found that women using digoxin had an increased risk of breast cancer, and that risk normalized when digoxin was discontinued. However, the authors of the study stated the following in their conclusion:

Although the digoxin effect we observed was similar to that of postmenopausal estrogens, it was nevertheless small, and the importance of digoxin to the clinical management of heart disease may outweigh our inferences regarding increased risks of breast cancer.[11]

A study published in Pharmacoepidemiology and Drug Safety in 2014 showed that treatment with digoxin was associated with a higher risk of colorectal cancer.[12]

In 2021, PLOS One published results of an observational study showing that digoxin use was associated with an increased risk of death from all causes in patients with advanced chronic kidney disease.[13]

A retrospective observational study published in 2021 in Cancer Causes and Control found that digoxin use was associated with a modestly increased risk of pancreatic cancer.[14]

Misprescribing and conditions for ceasing digoxin treatment

Digoxin is often overprescribed for older adults.[15] One study of people using digoxin outside the hospital found that four out of 10 received no benefit from the drug.[16] Because of digoxin’s toxic effects, taking the drug without any benefit is both wasteful and dangerous. As many as one in five digoxin users develop signs of toxic effects,[17] and much of this could be prevented if the people who did not need digoxin were taken off the drug. Evidence shows that up to eight out of 10 long-term digoxin users can successfully stop using the drug, under close supervision by a doctor, with no harmful results.[18] This is partly due to digoxin being wrongly prescribed in the first place.

If you have used digoxin regularly for some time, ask your doctor if you might be able to try withdrawing from the drug. You are more likely to be able to stop taking digoxin if you meet the following conditions:

1. You have used digoxin for a long time without your initial symptoms of heart failure coming back.
2. You have a normal heart rhythm.
3. You are not using digoxin to control an irregular heart rhythm.

There is no precise way to know in advance who can stop taking digoxin. People taking digoxin to correct an irregular heart rhythm should not attempt to stop taking the drug, but most other people will benefit from a trial of withdrawal under close supervision by a doctor.

Drug Interactions

Digoxin can interact with several dozen other drugs (see our November 2018 Worst Pills, Best Pills News article, “Potentially Dangerous Digoxin Drug Interactions,” for details). These interactions can result in either digoxin toxicity or decreased digoxin effectiveness, depending on the other drug being used concomitantly.

In 2023, European Journal of Clinical Pharmacology published an article showing that digoxin was associated with an increased risk of death in patients with atrial fibrillation.[19]