Large-scale digitoxin intoxication.

Area of Science:

• Pharmacology
• Clinical Toxicology
• Cardiology

Background:

• Manufacturing errors in digoxin tablets led to incorrect dosages being administered.
• Patients received tablets containing digitoxin and digoxin instead of the prescribed digoxin dosage.

Purpose of the Study:

• To describe the symptoms and clinical manifestations of digitalis intoxication in patients who received incorrectly manufactured digoxin tablets.
• To analyze the cardiac, neurological, and ophthalmological effects of the medication error.

Main Methods:

• Retrospective analysis of 179 patients who ingested incorrectly composed digoxin tablets.
• Clinical observation and electrocardiogram (ECG) analysis to document symptoms and cardiac disturbances.
• Ophthalmological examinations to investigate visual complaints.

Main Results:

• 179 patients experienced digitalis intoxication due to incorrect digoxin tablets.
• 48 patients showed 105 distinct cardiac rhythm or atrioventricular conduction disturbances on ECG.
• 95% of patients reported extreme fatigue and serious eye conditions, likely due to transient retrobulbar neuritis.

Conclusions:

• Incorrectly manufactured digoxin tablets can lead to significant digitalis intoxication with diverse clinical symptoms.
• Cardiac, visual, and neurological adverse effects are prominent in patients with this medication error.
• Prompt identification and management are crucial for patients experiencing digitalis toxicity from pharmaceutical errors.