Esmolol Digoxin

Transfer to alternative agent (e.g., propranolol, digoxin, verapamil) Vi hr after first dose of alternative agent, reduce esmolol INF rate by 50% following second dose of alternative agent, monitor patient s response and, if satisfactory control is maintained for the first hr, discontinue esmolol INF... 

Clinically important, potentially hazardous interactions with acebutolol, amiodarone, aspirin, atenolol, atorvastatin, betaxolol, carbamazepine, carteolol, celiprolol, donidine, dabigatran, dantrolene, digoxin, dofetilide, epirubicin, eplerenone, erythromycin, esmolol, eucalyptus, everolimus, lovastatin, metoprolol, mistletoe, nadolol, oxprenolol, penbutolol, pindolol, propranolol, quinidine, ranolazine, sibutramine, simvastatin, timolol, trabectedin... 

Patients may present with a slow ventricular response (in the absence of AV nodal-blocking drugs) and thus do not require therapy with digoxin, verapamil, or esmolol. This type of presentation should alert the clinician to the possibility of preexisting SA or AV nodal conduction disease such as sick sinus syndrome. DCC should not be attempted in these patients without a temporary pacemaker in place (see below). 

Answer D. An increase in AV conduction is characteristic of quinidine, which exerts quite marked blocking actions on muscarinic receptors in the heart. Thus, an atrial rate, formerly transmitted to the ventricles in a 2 1 ratio, may be transmitted in a 1 1 ratio after quinidine. This effect of quinidine can be offset by the prior administration of an antiar-rhythmic drug that decreases AV nodal conduction, such as digoxin or verapamil. All of the drugs listed (except quinidine) slow AV nodal conduction, but adenosine and esmolol (a beta blocker) are very short-acting agents used IV only. 

A. Esmolol may transiently increase the semm digoxin level by 10-20%, but the clinical significance of this is unknown. 

Mscellaneous. A single dose of intravenous esmolol did not affect the pharmacokinetics of multiple-dose digoxin, except that a small increase was seen in the AUC of digoxin. The pharmacokinetics of multiple-dose digoxin have been shown to be unaffected by acebutolol, bevan-tolol 200 mg daily, bisoprolol 10 mg daily, nebivolol 10 mg daily, or sotalol 80 to 320 mg daily. 

In healthy subjects, the pharmacodynamics of digoxin were unaffected by bevantolol, and esmolol, with no significant changes in heart rate or blood pressure occurring. 

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