Abstract 4135497: Model-informed dosing recommendations for digoxin in interstage single ventricle heart disease

Digoxin is commonly used in infants with single ventricle heart disease (SVD) and may decrease mortality in the interstage period. While labeled for the treatment of heart failure in infants, dosing recommendations do not account for alterations in drug disposition in SVD. We aimed to characterize digoxin pharmacokinetics (PK) in interstage infants with SVD. Infants <3 months with SVD who received enteral digoxin per standard of care after stage 1 and prior to stage 2 palliation were included in this prospective, multicenter, open-label PK study. Preterm infants and those with creatinine >2mg/dL or on extracorporeal support at enrollment were excluded. PK samples were prospectively collected and digoxin plasma concentrations quantitated by HPLC/MS/MS assay validated per FDA guidance. Population PK analysis was performed in NONMEM. Effects of covariates on PK parameters were evaluated. Dosing simulations were conducted in a virtual cohort of infants with SVD that optimized dosing to achieve trough concentrations of 0.5-2 ng/mL, the label-endorsed reference range for heart failure. Across 10 sites, 50 infants contributed 207 PK samples. Table 1 shows cohort characteristics. A 2-compartment model with transit compartment absorption and linear elimination best described the data. Renal function and weight were significant covariates. Infants with SVD had lower apparent clearance than previously reported in infants without SVD. Current labeled dosing resulted in simulated exposures above the reference range ( Figure 1 ). A new dosing regimen for infants with SVD is proposed. Digoxin PK is altered in infants with SVD. Dosing should account for renal function, age, and weight.