The serum digoxin level has no correlation with clinical toxicity following Fab administration because most laboratories use assays that measure both bound and unbound digoxin, although there are some laboratories that measure only free digoxin levels. Minutes after Fab fragment administration, the free digoxin level falls to zero, but the total serum digoxin level (bound to Fab fragments) increases 10- to 20-fold. 12 The Fab-digoxin complex is eliminated by renal excretion.1B In the case of renal failure, the complex may persist in the circulation for prolonged periods. Recurrent toxicity can occur up to 10 days after Fab fragment administration in patients with renal failure. Hemodialysis does not enhance the elimination of the digoxin-Fab complex. 1B
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