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Dose response characterization of the association of serum digoxin concentration with mortality outcomes in the Digitalis Investigation Group trial.

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posted on 09.08.2017 by Adams KF Jr, Butler J, Patterson JH, Gattis Stough W, Bauman JL, van Veldhuisen DJ, Schwartz TA, Sabbah H, Mackowiak JI, Ventura HO, Ghali JK
AIMS:Many patients with heart failure and reduced EF remain at high risk for hospitalization despite evidence-based therapy. Digoxin may decrease hospitalization; however, uncertainty persists concerning its proper administration and effect on mortality. This study investigated whether using dose response concepts to re-evaluate the relationship between serum digoxin concentration and key mortality outcomes in patients with reduced EF in the Digitalis Investigation Group trial would help clarify efficacy and safety. METHODS AND RESULTS: Multivariable Cox proportional hazards modelling and propensity score adjustment assessed the relationship between serum digoxin concentration (≥0.5 ng/mL) as a continuous variable and mortality outcomes. In patients treated with digoxin, a significant linear association was found between serum concentration and all-cause mortality [adjusted hazard ratio (HR) 1.25, 95% confidence interval (CI) 1.14-1.38, P < 0.001 per 0.5 ng/mL increase in serum concentration]. Based on this relationship, a bidirectional association was found between digoxin therapy and all-cause mortality when compared with placebo. The lowest serum concentrations (0.5-0.7 ng/mL) were associated with the lowest risk of all-cause mortality (adjusted HR 0.77, 95% CI 0.67-0.89, P < 0.001) while high serum concentrations (1.6-2.0 ng/mL) were associated with increased mortality (adjusted HR 1.33, 95% CI 1.12-1.58, P = 0.001). Consistent with this finding, lower serum concentrations (0.5-0.7 ng/mL) were associated with reduced death from worsening heart failure and a neutral effect on cardiovascular death not due to worsening heart failure. CONCLUSION: These findings favour targeting serum concentrations from 0.5 to 0.7 ng/mL when dosing digoxin in patients with heart failure and reduced EF.

Funding

Covis Pharmaceuticals, Inc. provided an unrestricted research grant that was used to support this statistical analysis of the DIG data set.

History

Publisher Statement

This is the pre-peer reviewed version of the following article: Adams, K. F., Butler, J., Patterson, J. H., Stough, W. G., Bauman, J. L., van Veldhuisen, D. J., Schwartz, T. A., Sabbah, H., Mackowiak, J. I., Ventura, H. O. and Ghali, J. K. Dose response characterization of the association of serum digoxin concentration with mortality outcomes in the Digitalis Investigation Group trial. European Journal of Heart Failure. 2016. 18(8): 1072-1081. doi: 10.1002/ejhf.584, which has been published in final form at Adams, K. F., Butler, J., Patterson, J. H., Stough, W. G., Bauman, J. L., van Veldhuisen, D. J., Schwartz, T. A., Sabbah, H., Mackowiak, J. I., Ventura, H. O. and Ghali, J. K. Dose response characterization of the association of serum digoxin concentration with mortality outcomes in the Digitalis Investigation Group trial. European Journal of Heart Failure. 2016. 18(8): 1072-1081. 10.1002/ejhf.584.

Publisher

Wiley

Language

en_US

issn

1388-9842

Issue date

01/08/2016

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