J Forensic Sci Toxicol | Volume 7, Issue 1 | Research Article | Open Access
Ketola RA* and Jylhä A
Forensic Chemistry Unit, Forensic Toxicology, Finnish Institute for Health and Welfare (THL), Finland
*Correspondance to: Raimo Ketola
Fulltext PDFDigoxin, a cardiotonic glycoside derived from Digitalis lanata, is widely prescribed for the treatment of congestive heart failure and atrial fibrillation. However, it has a narrow therapeutic index and a significant risk of toxicity. Digoxin toxicity manifests as gastrointestinal, neurological, and cardiac symptoms, with risk factors including renal impairment, drug-drug interactions, and electrolyte disturbances. Post mortem redistribution complicates the interpretation of digoxin concentrations, necessitating careful correlation with clinical history and case circumstances. This study evaluated analytical methods used for digoxin detection in post mortem (PM) blood samples in Finland during 2012 to 2025. Screening was initially performed using immunoassays, which were later supplemented and eventually replaced by liquid chromatography–tandem mass spectrometry (LC-MS/MS) to improve analytical specificity. In total, more than 34,000 analyses were conducted. Positive rates ranged from 1.8% with immunoassays to 25.5% with LC-MS/MS. Comparative analysis of 234 samples analyzed using both methods demonstrated high immunoassay specificity (99.1%), although concentrations were systematically underestimated compared with LC-MS/MS. The median digoxin concentration in positive cases was 1.5 μg/L. The 90th and 95th percentiles (3.8 μg/L and 5.1 μg/L, respectively) corresponded well with concentrations typically considered toxic and fatal. A total of 36 fatal digoxin intoxications were identified (0.11% of all cases), with a mean concentration of 14.1 μg/L, predominantly occurring in elderly individuals. These findings demonstrate the importance of LC-MS/MS for reliable post mortem quantification of digoxin, illustrate the prevalence of digoxin in forensic autopsy cases, and emphasize the relevance of concentration thresholds when distinguishing therapeutic use from toxic or fatal exposure.
Ketola RA, Jylhä A. Screening, Confirmation, Prevalence, and Fatality of Digoxin in Finland in 2012-2025. J Forensic Sci Toxicol. 2026; 7(1): 1023..