ModerateCardiac glycosides (digitalis)×Angiotensin II receptor blocker (ARB)
Updated · Methodology
Mechanism
Telmisartan moderately inhibits intestinal P-glycoprotein. Digoxin AUC rises by 20–50%, which may trigger toxicity, especially in older patients and in chronic kidney disease.
Symptoms
Nausea, vomiting, loss of appetite, confusion, yellow-green halos around lights, arrhythmia (bigeminy, AV block). Symptoms appear earlier in older patients and chronic kidney disease.
Management
On telmisartan start, check digoxin levels at 1–2 weeks. In significant chronic kidney disease (clearance below 50 mL/min), reduce digoxin by 25%. In older patients, target 0.5–0.8 ng/mL. Alternatives: losartan or valsartan, with less effect on P-glycoprotein.
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Sources
- FDA: Telmisartan tablet (Alembic Pharmaceuticals Limited) – Prescribing Information section 7 (2014)– ; DailyMed setid 4be6575f-ea8d-4cd8-a49d-3d1c93f2621a
- EMA: Ficha técnica: Telmisartán (EU/1/98/090), sección 4.5 (2026)– EMA SmPC vía AEMPS CIMA, nº 98090002 (EU/1/98/090), sección 4.5, consultado 10/2026