[2010, amended 2018] 1.4.27 Routine monitoring of serum digoxin concentrations is not recommended. A digoxin concentration measured within 8 to 12 hours of the last dose may be useful to confirm a clinical impression of toxicity or 1.4.28 The serum digoxin concentration should be interpreted in the clinical context as toxicity may occur even when the concentration is within the 'therapeutic range'. [2003] 17 of 1.5 Treating heart failure with reduced ejection fraction in people with chronic kidney disease 1.5.1 For people who have heart failure with reduced ejection fraction and chronic kidney disease with an eGFR of 30 ml/min/1.73 m2 or above: offer the treatment outlined in the section on treating heart failure with reduced ejection fraction and if the person's eGFR is 45 ml/min/1.73 m2 or below, consider lower doses and/ or slower titration of dose of ACE inhibitors or ARBs, MRAs and digoxin. [2018] 1.5.2 For people who have heart failure with reduced ejection fraction and chronic kidney disease with an eGFR below 30 ml/min/1.73 m2 , the specialist heart failure MDT should consider liaising with a renal 1.5.3 Monitor the response to titration of medicines closely in people who have heart failure with reduced ejection fraction and chronic kidney disease, taking into account the increased risk of hyperkalaemia. [2018] 1.6 Managing all types of heart failure When managing pharmacological treatment, follow the recommendations in the NICE guidelines on medicines adherence and medicines optimisation. 