Category: Federal Forum Posters
Purpose: Digoxin is not recommended as a first line therapy for rate control in the treatment of atrial fibrillation absent of heart failure despite its common use. Per the 2014 American College of Cardiology and American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society Guidelines, a beta blocker or non-dihydropyridine calcium channel blocker is preferred. In recent studies, digoxin has been associated with an increased risk of all cause mortality. Monotherapy treatment of atrial fibrillation with digoxin will be evaluated and recommendations will be given to increase use of first line therapies while minimizing use of digoxin.
Methods: The Corporate Data Warehouse was used to identify patients who are currently prescribed digoxin as monotherapy through a veterans affairs healthcare system (absent of a beta-blocker or non-dihydropyridine calcium channel blocker in the previous 2 years) and a documented diagnosis of atrial fibrillation International Classifications of Disease codes without a documented diagnosis of heart failure. An individual chart review was conducted using the Computerized Record Keeping System for collection of patient demographics, prescriber information, digoxin levels, serum creatinine, previous trial of or past adverse drug reaction to a first-line therapy option, improperly documented diagnosis of heart failure. Information gathered was then used to determine which patients would be eligible for re-evaluation for conversion to a first-line agent and a templated Computerized Record Keeping System note was entered for provider consideration.
Results: The Corporate Data Warehouse identified 28 patients on monotherapy with digoxin with a diagnosis of atrial fibrillation absent of a diagnosis of heart failure. Dual care was present in 89 percent of these patients and 78.6 percent (22 out of 28) were eligible for re-evaluation for atrial fibrillation regimen after chart review. Pharmacist recommendation was accepted in 9 percent, resulting in digoxin discontinuation for a first line agent in 2 patients, 54.5 percent resulted in no action after acknowledgement by provider, 22.7 percent are still pending, 29 percent needed updated chart information (diagnosis of heart failure need added to the problem list in 25 percent, adverse drug reaction updated in 3.6 percent, prior trial of a first-line agent in 7.1 percent).
Conclusion: After chart review and additional documentation, many of the patients within the veterans affairs healthcare system have trialed or are on a first line agent (non-Veterans Affairs) resulting in treatment with digoxin. Majority of these patients have dual care; documentation and monitoring of these patients needs improvement. Future strategies overcoming communication barriers with non- Veterans Affairs providers needs to be established.
Gina Lee– PGY1 Pharmacy Resident, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA