COMMENTARY

The Demonization of Digitalis: Plain Stupid

Melissa Walton-Shirley

Disclosures

May 19, 2015

I walked around the stack of useless insurance forms for an afternoon. Buried within it were five requests to change the medication regimen of patients served well for a decade. When I read the latest request to stop my patient's digitalis and start lisinopril. I blurted loudly, "That's the stupidest thing I've ever heard," a line stolen from my favorite TV commercial. Cue the little towheaded boy who deadpans directly to the camera, after hearing that many vacation days in America are never used. The suggestion to stop digitalis in this patient is even more stupid and detrimental. My patient, who had refractory tachycardia in atrial fibrillation prior to being prescribed digitalis, would have no doubt been in the ER within days of implementing that stellar insurance-company suggestion. When I first treated her, it took me days to abolish the patient's palpitations and shortness of air. She's been stable for nearly a decade. In 1 week I could reverse all of that if I'd followed the recommendation. In addition, the insurance company accountant wouldn't need a calculator to show that it's far less costly to continue a drug that works than to visit an ER. Add to that the implementation of a diltiazem drip and the titration of PO meds with an overnight stay or two.

Why the uptick of digitalis worries?

It's been 15 years since I saw a case of true digitalis toxicity. I check trough levels twice per year. Any concerning bradycardia is addressed with a level and then a Holter. I discontinue digitalis in patients with an accelerated left ventricular outflow tract (LVOT) velocity. I reduce it as serum creatinines mature. I don't use it for the treatment of primary congestive heart failure (CHF), especially in women, unless the CHF is afib-tachycardia mediated. I've seen two patients with weight loss, one rash, and two cases of diarrhea in my 23 years of practice that were likely associated with digitalis use. I use it confidently and successfully. In the hands of an experienced physician, it works well.

Conversely, I can prescribe amiodarone without any hassle from any insurance company. It's useful in the proper patient setting, but amiodarone has way more side effects than digitalis, including permanent and fatal pulmonary fibrosis and liver dysfunction. It can cause profound bradycardia in some patients. It has wicked drug interactions with digitalis, some antibiotics, and beta-blockers. At the higher doses that were used more than 2 decades ago, some patients became Smurf-like, with the bluest skin color I've ever seen. Don't get me started on the neuropathy risk. The point is that I can prescribe amiodarone without getting an insurance company request for a prior authorization.

William Withering by all accounts was a genius and among the first to use digitalis to treat "dropsy."[1] He was a flautist, harpsichord enthusiast, and an expert in Latin who pushed his foxglove dosing to the point of nausea and vomiting. Assured the patient was fully loaded, he would back down on the dose and let them enjoy improvement in what was probably afib with rapid-ventricular-rate-(RVR)–related CHF. He was perhaps the earliest physician to focus his attention on patient care rather than profit, so today he would have no doubt been annoyed by a prior-auth request for "his" compound. Later, Charles Darwin, a research rival (not the Charles Darwin, but his uncle) also published on the benefits of digitalis.[2] If he had been sent prior auth requests, I’m sure he would have used them as high-quality toilet paper.

Here is my fantasy letter to the insurance companies:

If Hippocrates didn't have to sign a prior auth for his patients to chew a foxglove leaf, I shouldn't have to sign one to administer digitalis in a pill package whose pharmacokinetics, risks, and benefits are well understood. I can and do check levels. I'm an experienced cardiologist and scientist who's studied and used this compound successfully for over 2 decades. Don't ever ask me to stop any medicine that's working for a patient. If you need to borrow money to cover digitalis for my patient, borrow it from your CEO's annual bonus. Stop faxing me your dosing suggestions. You don't know my patient. Telling me how to practice medicine and to stop digitalis in someone in whom it is working and who has excellent trough levels and an improved quality of life is indeed the stupidest thing I ever heard. Wait, directing me to substitute lisinopril in this scenario is even "stupider."
PLAIN STUPID. So stop it.

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