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Drug overview for EPINEPHRINE CONVENIENCE KIT (epinephrine):
Generic name: EPINEPHRINE
Drug class: Beta-Adrenergic Agents
Therapeutic class: Cardiovascular Therapy Agents
Epinephrine is an endogenous catecholamine that is the active principle of the adrenal medulla; epinephrine acts directly on both alpha- and beta-adrenergic receptors.
No enhanced Uses information available for this drug.
Generic name: EPINEPHRINE
Drug class: Beta-Adrenergic Agents
Therapeutic class: Cardiovascular Therapy Agents
Epinephrine is an endogenous catecholamine that is the active principle of the adrenal medulla; epinephrine acts directly on both alpha- and beta-adrenergic receptors.
No enhanced Uses information available for this drug.
DRUG IMAGES
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The following indications for EPINEPHRINE CONVENIENCE KIT (epinephrine) have been approved by the FDA:
Indications:
Allergic reaction
Anaphylaxis
Mydriasis during ocular surgery
Professional Synonyms:
Anaphylactic reaction
Intraoperative mydriasis
Severe type I hypersensitivity reaction
Indications:
Allergic reaction
Anaphylaxis
Mydriasis during ocular surgery
Professional Synonyms:
Anaphylactic reaction
Intraoperative mydriasis
Severe type I hypersensitivity reaction
The following dosing information is available for EPINEPHRINE CONVENIENCE KIT (epinephrine):
Dosage of epinephrine salts is expressed in terms of epinephrine. Dosage of racepinephrine hydrochloride is expressed in terms of racepinephrine; racepinephrine is about one-half as active as epinephrine.
For the emergency treatment of allergic reactions, including anaphylaxis, the usual adult dose of epinephrine is 0.2-0.5 mg (0.2-0.5 mL of a 1-mg/mL solution) administered IM or subcutaneously; the dose may be repeated every 5-15 minutes as necessary.
A maximum single dose of 0.5 mg in adults is recommended. IM administration is preferred since absorption and subsequent achievement of peak plasma concentrations may be slower and substantially delayed following subcutaneous administration of the drug if shock is present.
For self-administration of epinephrine using a prefilled auto-injector (e.g., EpiPen(R)), an IM or subcutaneous dose of 0.3 mg is recommended. For severe persistent anaphylaxis, repeated doses may be needed; if more than 2 sequential doses are needed, subsequent doses should be administered under direct medical supervision.
In extreme circumstances (e.g., anaphylactic shock, cardiac arrest, or no response to initial IM injections), IV administration may be necessary since absorption of epinephrine may be impaired with subcutaneous or IM administration. The usual adult IV dose of epinephrine for the treatment of anaphylaxis ranges from 0.1 to 0.25
mg (1-2.5 mL of a 0.1-mg/mL solution); the dose may be repeated every 5-15 minutes as needed. Although there is no established dosage for continuous IV infusions of epinephrine, some studies have demonstrated efficacy at IV infusion rates of 2-15 mcg/minute, titrated based on severity of the reaction and clinical response.
Patients with anaphylaxis who respond to therapy require observation for possible recurrence even if there is an intervening asymptomatic period; length of observation time has not been established. Symptoms may recur within 1-36 hours after the initial reaction. The duration of direct observation and monitoring after an episode of anaphylaxis should be individualized based on the severity and duration of the anaphylactic event as well as other factors (e.g., response to treatment, pattern of previous anaphylactic reactions, comorbidities, patient reliability, access to medical care).
Some experts suggest that patients with moderate to severe anaphylaxis should be observed for a minimum of 4-8 hours after treatment.
When used for cardiac resuscitation in adults, epinephrine doses ranging from 0.1-1 mg have been used. In ACLS guidelines, a standard dosage of epinephrine (defined as 1 mg every 3-5 minutes by IV/IO injection) is recommended during adult cardiac arrest.
Current evidence indicates that higher doses (e.g., 0.1-0.2 mg/kg) do not provide any benefits in terms of survival or neurologic outcomes compared with the standard dose and may be harmful.
The optimum dose of epinephrine during cardiac resuscitation has been a subject of controversy. Many clinicians had questioned the commonly used doses of 0.5-1 mg because of concern that these doses were not based on body weight, and thus may be lower than necessary for optimum cardiovascular effects.
Interest in high doses of epinephrine was stimulated by animal studies indicating that such doses (e.g., 0.045-0.2 mg/kg) provided optimal improvement in hemodynamics, including ROSC, and timely achievement of successful cardiopulmonary resuscitation (CPR). Results of several clinical studies, including randomized controlled studies, found no substantial improvement in survival rates to hospital discharge nor trend for improved neurologic outcomes in patients with cardiac arrest receiving higher than usual doses of epinephrine, despite evidence of increased rates of ROSC and higher initial resuscitation rates with high-dose therapy. A retrospective study of functional neurologic outcomes (assessed by measurement of cerebral performance category) of patients with ventricular fibrillation who received high IV dosages of epinephrine during cardiac resuscitation found that such dosages were independently associated with unfavorable neurologic outcomes.
Patients with unfavorable neurologic outcomes after resuscitation had received substantially higher median cumulative doses (i.e., 4 mg (range: 2-8 mg)) of epinephrine than those with favorable neurologic outcomes who received a median cumulative dose of 1 mg (range: less than 1-3 mg). These findings persisted after neurologic outcomes were stratified by duration of CPR and other potentially confounding conditions were considered. Based on the currently available evidence, the American Heart Association (AHA) states that it is reasonable to administer standard-dose epinephrine (1 mg every 3-5 minutes) during cardiac arrest in adults; high-dose epinephrine should not be used routinely, but may be considered in certain situations (e.g., overdosage of beta-adrenergic or calcium-channel blocking agents).
The optimal timing of epinephrine administration, particularly in relation to defibrillation, is not known and may vary based on patient-specific factors and resuscitation conditions. In adults with asystole or pulseless electrical activity (PEA), epinephrine may be given as soon as feasible after the onset of cardiac arrest based on studies demonstrating improved survival to hospital discharge and increased ROSC when the drug was administered early during the course of treatment for a nonshockable rhythm.
If IV or IO access cannot be established during cardiac arrest, epinephrine may be administered via the endotracheal route. Although the optimal dose of epinephrine administered via an endotracheal tube remains to be established, some experts state that typical doses should be 2-2.5 times those administered IV.
If epinephrine is used for hemodynamic support following cardiac resuscitation, the usual IV dosage in adults is 0.1-0.5 mcg/kg per minute; the infusion rate should be titrated to patient response.
If epinephrine is used for the treatment of symptomatic bradycardia in adults, an initial infusion rate of 2-10 mcg/minute has been recommended and should be titrated to patient response. Intravascular volume and support should be assessed as needed.
When used for pediatric advanced life support (PALS), the usual IV or IO dose of epinephrine is 0.01 mg/kg (0.1 mL/kg of a 0.1-mg/mL solution), up to a maximum single dose of 1 mg, and the usual dose of epinephrine administered via an endotracheal tube is 0.1 mg/kg (0.1 mL/kg of a 1-mg/mL solution), up to a maximum single dose of 2.5
mg. The same IV, IO, or endotracheal dose should be repeated every 3-5 minutes if needed. Higher doses are not recommended because of the potential for harm, particularly in cases of asphyxia, and lack of survival benefit.
AHA states, however, that high-dose epinephrine may be considered in exceptional circumstances (e.g., beta-adrenergic blocking agent overdose).
In a prospective, randomized, double-blind study of 68 children who received either 0.01 mg/kg (standard dose) or 0.1 mg/kg (high dose) of epinephrine as rescue therapy for in-hospital cardiac arrest after failure of CPR and an initial dose of 0.01
mg/kg (standard dose) of epinephrine, high-dose rescue therapy was not associated with any benefits. High-dose epinephrine rescue therapy did not improve the survival rate at 24 hours compared with standard-dose therapy, and appeared to be harmful in children with asphyxia-precipitated cardiac arrest. In addition, a trend toward reduced rate of survival at 24 hours was observed among children who received high-dose therapy as compared with standard-dose therapy.
Also, the rates of ROSC or survival to hospital discharge were not significantly different between the 2 groups.
For postresuscitation stabilization in pediatric patients, epinephrine may be administered by IV or IO infusion at a rate of 0.1-1 mcg/kg per minute; the rate of infusion should be adjusted based on patient response. Although low-dose IV infusions (less than 0.3 mcg/kg per minute) generally produce predominantly beta-adrenergic effects, while higher-dose IV infusions (exceeding 0.3 mcg/kg per minute) generally result in alpha-adrenergic vasoconstriction, there is substantial interindividual variation in response, and infusion dosage should be titrated to the desired effect.
The usual neonatal IV dose of epinephrine is 0.01-0.03 mg/kg (0.1-0.3 mL/kg of a 0.1-mg/mL solution).
AHA states that higher IV doses are not recommended; in pediatric and animal studies, administration of IV doses in the range of 0.1 mg/kg have been associated with exaggerated hypertension, decreased myocardial function, and worsening neurologic function. In addition, the sequence of hypotension followed by hypertension is likely to increase the risk of intracranial hemorrhage, especially in neonates.
IV administration of epinephrine (0.01-0.03 mg/kg per dose) is the preferred route in neonates, since there are limited data available on endotracheal administration of epinephrine. If the endotracheal route is used, doses of 0.01 or 0.03
mg/kg will likely be ineffective. Although safety and efficacy have not been established, endotracheal administration of a higher dose (0.05-0.1 mg/kg) while IV access is being obtained may be considered.
In one retrospective study in children and neonates who received either mean doses of 0.01 mg/kg (standard dose) or 0.12 mg/kg (high dose) of epinephrine administered IV, via an endotracheal tube, or by IO infusion during CPR after cardiac arrest occurring during a hospital stay, high doses of the drug were not associated with improvements in rates of ROSC, short- or long-term survival rates, or overall outcome scores.
In this study, the time to ROSC was substantially shorter in patients receiving standard doses of epinephrine than in those receiving higher doses. In addition, high-dose epinephrine may be associated with adverse effects such as increased myocardial oxygen consumption during cardiac resuscitation, a postarrest hyperadrenergic state with tachycardia, hypertension and ventricular ectopy, myocardial necrosis, and worse postarrest myocardial dysfunction. Additional clinical studies are needed to evaluate fully the optimum dosage regimen of epinephrine in pediatric patients.
For the emergency treatment of infants and children with bradycardia and cardiorespiratory compromise (with a palpable pulse), epinephrine may be given at a dose of 0.01 mg/kg (0.1 mL/kg of a 0.1-mg/mL solution) by IV/IO injection, and repeated every 3-5 minutes as needed; alternatively, an endotracheal dose of 0.1 mg/kg (0.1 mL/kg of a 1-mg/mL solution) may be given if IV/IO access is not available.
For the treatment of severe asthma exacerbations when orally inhaled, selective short-acting beta2-adrenergic agonists are not available, an expert panel of the National Asthma Education and Prevention Program (NAEPP) states that epinephrine 0.3-0.5 mg may be given subcutaneously every 20 minutes for 3 doses in adults and adolescents older than 12 years of age.
Alternatively, some clinicians recommend a subcutaneous epinephrine dose of 0.01 mg/kg (using a 1-mg/mL solution), divided into 3 doses of approximately 0.3 mg each, administered at 20-minute intervals.
For the treatment of severe asthma exacerbations in children 12 years of age or younger, 0.01 mg/kg of epinephrine (0.01 mL/kg using a 1-mg/mL solution), but no more than 0.3-0.5
mg per dose, may be administered by subcutaneous injection at 20-minute intervals for 3 doses.
For the treatment of bronchospasm in adults, some manufacturers recommend an epinephrine dose of 0.1-0.25 mg (1-2.5 mL of a 0.1-mg/mL solution) by slow IV injection.
If IV administration of epinephrine is required for the management of asthma attacks in pediatric patients, some clinicians recommend a slow IV injection of 0.01 mg/kg in neonates and an initial IV dose of 0.05 mg (which may be repeated at 20- to 30-minute intervals) in infants.
For the temporary relief of mild symptoms of intermittent asthma, the usual dose of 2.25% racepinephrine inhalation solution (equivalent to 1% epinephrine) in adults and children 4 years of age or older is 1-3 inhalations; doses should not be repeated more often than every 3 hours. Patients should be advised to seek medical assistance immediately if symptoms are not relieved within 20 minutes or become worse.
For the emergency treatment of allergic reactions, including anaphylaxis, the usual adult dose of epinephrine is 0.2-0.5 mg (0.2-0.5 mL of a 1-mg/mL solution) administered IM or subcutaneously; the dose may be repeated every 5-15 minutes as necessary.
A maximum single dose of 0.5 mg in adults is recommended. IM administration is preferred since absorption and subsequent achievement of peak plasma concentrations may be slower and substantially delayed following subcutaneous administration of the drug if shock is present.
For self-administration of epinephrine using a prefilled auto-injector (e.g., EpiPen(R)), an IM or subcutaneous dose of 0.3 mg is recommended. For severe persistent anaphylaxis, repeated doses may be needed; if more than 2 sequential doses are needed, subsequent doses should be administered under direct medical supervision.
In extreme circumstances (e.g., anaphylactic shock, cardiac arrest, or no response to initial IM injections), IV administration may be necessary since absorption of epinephrine may be impaired with subcutaneous or IM administration. The usual adult IV dose of epinephrine for the treatment of anaphylaxis ranges from 0.1 to 0.25
mg (1-2.5 mL of a 0.1-mg/mL solution); the dose may be repeated every 5-15 minutes as needed. Although there is no established dosage for continuous IV infusions of epinephrine, some studies have demonstrated efficacy at IV infusion rates of 2-15 mcg/minute, titrated based on severity of the reaction and clinical response.
Patients with anaphylaxis who respond to therapy require observation for possible recurrence even if there is an intervening asymptomatic period; length of observation time has not been established. Symptoms may recur within 1-36 hours after the initial reaction. The duration of direct observation and monitoring after an episode of anaphylaxis should be individualized based on the severity and duration of the anaphylactic event as well as other factors (e.g., response to treatment, pattern of previous anaphylactic reactions, comorbidities, patient reliability, access to medical care).
Some experts suggest that patients with moderate to severe anaphylaxis should be observed for a minimum of 4-8 hours after treatment.
When used for cardiac resuscitation in adults, epinephrine doses ranging from 0.1-1 mg have been used. In ACLS guidelines, a standard dosage of epinephrine (defined as 1 mg every 3-5 minutes by IV/IO injection) is recommended during adult cardiac arrest.
Current evidence indicates that higher doses (e.g., 0.1-0.2 mg/kg) do not provide any benefits in terms of survival or neurologic outcomes compared with the standard dose and may be harmful.
The optimum dose of epinephrine during cardiac resuscitation has been a subject of controversy. Many clinicians had questioned the commonly used doses of 0.5-1 mg because of concern that these doses were not based on body weight, and thus may be lower than necessary for optimum cardiovascular effects.
Interest in high doses of epinephrine was stimulated by animal studies indicating that such doses (e.g., 0.045-0.2 mg/kg) provided optimal improvement in hemodynamics, including ROSC, and timely achievement of successful cardiopulmonary resuscitation (CPR). Results of several clinical studies, including randomized controlled studies, found no substantial improvement in survival rates to hospital discharge nor trend for improved neurologic outcomes in patients with cardiac arrest receiving higher than usual doses of epinephrine, despite evidence of increased rates of ROSC and higher initial resuscitation rates with high-dose therapy. A retrospective study of functional neurologic outcomes (assessed by measurement of cerebral performance category) of patients with ventricular fibrillation who received high IV dosages of epinephrine during cardiac resuscitation found that such dosages were independently associated with unfavorable neurologic outcomes.
Patients with unfavorable neurologic outcomes after resuscitation had received substantially higher median cumulative doses (i.e., 4 mg (range: 2-8 mg)) of epinephrine than those with favorable neurologic outcomes who received a median cumulative dose of 1 mg (range: less than 1-3 mg). These findings persisted after neurologic outcomes were stratified by duration of CPR and other potentially confounding conditions were considered. Based on the currently available evidence, the American Heart Association (AHA) states that it is reasonable to administer standard-dose epinephrine (1 mg every 3-5 minutes) during cardiac arrest in adults; high-dose epinephrine should not be used routinely, but may be considered in certain situations (e.g., overdosage of beta-adrenergic or calcium-channel blocking agents).
The optimal timing of epinephrine administration, particularly in relation to defibrillation, is not known and may vary based on patient-specific factors and resuscitation conditions. In adults with asystole or pulseless electrical activity (PEA), epinephrine may be given as soon as feasible after the onset of cardiac arrest based on studies demonstrating improved survival to hospital discharge and increased ROSC when the drug was administered early during the course of treatment for a nonshockable rhythm.
If IV or IO access cannot be established during cardiac arrest, epinephrine may be administered via the endotracheal route. Although the optimal dose of epinephrine administered via an endotracheal tube remains to be established, some experts state that typical doses should be 2-2.5 times those administered IV.
If epinephrine is used for hemodynamic support following cardiac resuscitation, the usual IV dosage in adults is 0.1-0.5 mcg/kg per minute; the infusion rate should be titrated to patient response.
If epinephrine is used for the treatment of symptomatic bradycardia in adults, an initial infusion rate of 2-10 mcg/minute has been recommended and should be titrated to patient response. Intravascular volume and support should be assessed as needed.
When used for pediatric advanced life support (PALS), the usual IV or IO dose of epinephrine is 0.01 mg/kg (0.1 mL/kg of a 0.1-mg/mL solution), up to a maximum single dose of 1 mg, and the usual dose of epinephrine administered via an endotracheal tube is 0.1 mg/kg (0.1 mL/kg of a 1-mg/mL solution), up to a maximum single dose of 2.5
mg. The same IV, IO, or endotracheal dose should be repeated every 3-5 minutes if needed. Higher doses are not recommended because of the potential for harm, particularly in cases of asphyxia, and lack of survival benefit.
AHA states, however, that high-dose epinephrine may be considered in exceptional circumstances (e.g., beta-adrenergic blocking agent overdose).
In a prospective, randomized, double-blind study of 68 children who received either 0.01 mg/kg (standard dose) or 0.1 mg/kg (high dose) of epinephrine as rescue therapy for in-hospital cardiac arrest after failure of CPR and an initial dose of 0.01
mg/kg (standard dose) of epinephrine, high-dose rescue therapy was not associated with any benefits. High-dose epinephrine rescue therapy did not improve the survival rate at 24 hours compared with standard-dose therapy, and appeared to be harmful in children with asphyxia-precipitated cardiac arrest. In addition, a trend toward reduced rate of survival at 24 hours was observed among children who received high-dose therapy as compared with standard-dose therapy.
Also, the rates of ROSC or survival to hospital discharge were not significantly different between the 2 groups.
For postresuscitation stabilization in pediatric patients, epinephrine may be administered by IV or IO infusion at a rate of 0.1-1 mcg/kg per minute; the rate of infusion should be adjusted based on patient response. Although low-dose IV infusions (less than 0.3 mcg/kg per minute) generally produce predominantly beta-adrenergic effects, while higher-dose IV infusions (exceeding 0.3 mcg/kg per minute) generally result in alpha-adrenergic vasoconstriction, there is substantial interindividual variation in response, and infusion dosage should be titrated to the desired effect.
The usual neonatal IV dose of epinephrine is 0.01-0.03 mg/kg (0.1-0.3 mL/kg of a 0.1-mg/mL solution).
AHA states that higher IV doses are not recommended; in pediatric and animal studies, administration of IV doses in the range of 0.1 mg/kg have been associated with exaggerated hypertension, decreased myocardial function, and worsening neurologic function. In addition, the sequence of hypotension followed by hypertension is likely to increase the risk of intracranial hemorrhage, especially in neonates.
IV administration of epinephrine (0.01-0.03 mg/kg per dose) is the preferred route in neonates, since there are limited data available on endotracheal administration of epinephrine. If the endotracheal route is used, doses of 0.01 or 0.03
mg/kg will likely be ineffective. Although safety and efficacy have not been established, endotracheal administration of a higher dose (0.05-0.1 mg/kg) while IV access is being obtained may be considered.
In one retrospective study in children and neonates who received either mean doses of 0.01 mg/kg (standard dose) or 0.12 mg/kg (high dose) of epinephrine administered IV, via an endotracheal tube, or by IO infusion during CPR after cardiac arrest occurring during a hospital stay, high doses of the drug were not associated with improvements in rates of ROSC, short- or long-term survival rates, or overall outcome scores.
In this study, the time to ROSC was substantially shorter in patients receiving standard doses of epinephrine than in those receiving higher doses. In addition, high-dose epinephrine may be associated with adverse effects such as increased myocardial oxygen consumption during cardiac resuscitation, a postarrest hyperadrenergic state with tachycardia, hypertension and ventricular ectopy, myocardial necrosis, and worse postarrest myocardial dysfunction. Additional clinical studies are needed to evaluate fully the optimum dosage regimen of epinephrine in pediatric patients.
For the emergency treatment of infants and children with bradycardia and cardiorespiratory compromise (with a palpable pulse), epinephrine may be given at a dose of 0.01 mg/kg (0.1 mL/kg of a 0.1-mg/mL solution) by IV/IO injection, and repeated every 3-5 minutes as needed; alternatively, an endotracheal dose of 0.1 mg/kg (0.1 mL/kg of a 1-mg/mL solution) may be given if IV/IO access is not available.
For the treatment of severe asthma exacerbations when orally inhaled, selective short-acting beta2-adrenergic agonists are not available, an expert panel of the National Asthma Education and Prevention Program (NAEPP) states that epinephrine 0.3-0.5 mg may be given subcutaneously every 20 minutes for 3 doses in adults and adolescents older than 12 years of age.
Alternatively, some clinicians recommend a subcutaneous epinephrine dose of 0.01 mg/kg (using a 1-mg/mL solution), divided into 3 doses of approximately 0.3 mg each, administered at 20-minute intervals.
For the treatment of severe asthma exacerbations in children 12 years of age or younger, 0.01 mg/kg of epinephrine (0.01 mL/kg using a 1-mg/mL solution), but no more than 0.3-0.5
mg per dose, may be administered by subcutaneous injection at 20-minute intervals for 3 doses.
For the treatment of bronchospasm in adults, some manufacturers recommend an epinephrine dose of 0.1-0.25 mg (1-2.5 mL of a 0.1-mg/mL solution) by slow IV injection.
If IV administration of epinephrine is required for the management of asthma attacks in pediatric patients, some clinicians recommend a slow IV injection of 0.01 mg/kg in neonates and an initial IV dose of 0.05 mg (which may be repeated at 20- to 30-minute intervals) in infants.
For the temporary relief of mild symptoms of intermittent asthma, the usual dose of 2.25% racepinephrine inhalation solution (equivalent to 1% epinephrine) in adults and children 4 years of age or older is 1-3 inhalations; doses should not be repeated more often than every 3 hours. Patients should be advised to seek medical assistance immediately if symptoms are not relieved within 20 minutes or become worse.
USP has changed its labeling standard for single-entity drug products to no longer allow the use of ratios to express drug concentrations. This labeling change was prompted by numerous reports of serious medication errors caused by confusion with different ratio expressions. Effective May 1, 2016, all single-entity preparations of epinephrine injection, USP should be labeled only in terms of strength per mL (i.e., mg/mL).
While concentrations of some epinephrine preparations were historically expressed in ratios (e.g., 1:1000 or 1:10,000), such designation is no longer acceptable because of the risk of dosing errors. Epinephrine usually is administered by IM, subcutaneous, or IV injection, or by continuous IV infusion. Epinephrine also has been administered by intraosseous (IO) injection+ in the setting of advanced cardiovascular life support (ACLS), generally when IV access is not readily available; onset of action and systemic concentrations are comparable to those achieved with venous administration.
If vascular access (IV or IO) cannot be established during cardiac arrest, epinephrine may be administered endotracheally; however, this method of administration results in lower plasma concentrations compared with the same dose given intravascularly. Epinephrine also has been administered by intracardiac injection (into the left ventricular chamber) during cardiac arrest; however, this route of administration is not recommended in current ACLS guidelines. The appropriate concentration and route of administration of epinephrine should be selected carefully; serious adverse effects (e.g., cerebral hemorrhage) have occurred after concentrated solutions of epinephrine intended for IM administration were administered IV.
Because of the risks associated with IV use, epinephrine generally should be administered by the IV route only in extreme situations (such as in the treatment of septic or anaphylactic shock, cardiac arrest, or when the patient is unresponsive to multiple IM injections). Dilute solutions of epinephrine (e.g., 0.1 mg/mL) should always be used when administering the drug IV. Commercially available epinephrine solutions for IM or subcutaneous injection are tenfold more concentrated (1 mg/mL) and should not be administered IV without dilution.
Solutions of epinephrine should be inspected visually for particulate matter and discoloration prior to administration. Epinephrine injection must not be used if it is discolored or cloudy or contains any particulate matter.
While concentrations of some epinephrine preparations were historically expressed in ratios (e.g., 1:1000 or 1:10,000), such designation is no longer acceptable because of the risk of dosing errors. Epinephrine usually is administered by IM, subcutaneous, or IV injection, or by continuous IV infusion. Epinephrine also has been administered by intraosseous (IO) injection+ in the setting of advanced cardiovascular life support (ACLS), generally when IV access is not readily available; onset of action and systemic concentrations are comparable to those achieved with venous administration.
If vascular access (IV or IO) cannot be established during cardiac arrest, epinephrine may be administered endotracheally; however, this method of administration results in lower plasma concentrations compared with the same dose given intravascularly. Epinephrine also has been administered by intracardiac injection (into the left ventricular chamber) during cardiac arrest; however, this route of administration is not recommended in current ACLS guidelines. The appropriate concentration and route of administration of epinephrine should be selected carefully; serious adverse effects (e.g., cerebral hemorrhage) have occurred after concentrated solutions of epinephrine intended for IM administration were administered IV.
Because of the risks associated with IV use, epinephrine generally should be administered by the IV route only in extreme situations (such as in the treatment of septic or anaphylactic shock, cardiac arrest, or when the patient is unresponsive to multiple IM injections). Dilute solutions of epinephrine (e.g., 0.1 mg/mL) should always be used when administering the drug IV. Commercially available epinephrine solutions for IM or subcutaneous injection are tenfold more concentrated (1 mg/mL) and should not be administered IV without dilution.
Solutions of epinephrine should be inspected visually for particulate matter and discoloration prior to administration. Epinephrine injection must not be used if it is discolored or cloudy or contains any particulate matter.
No dosing information available.
No generic dosing information available.
The following drug interaction information is available for EPINEPHRINE CONVENIENCE KIT (epinephrine):
There are 1 contraindications.
These drug combinations generally should not be dispensed or administered to the same patient. A manufacturer label warning that indicates the contraindication warrants inclusion of a drug combination in this category, regardless of clinical evidence or lack of clinical evidence to support the contraindication.
| Drug Interaction | Drug Names |
|---|---|
| Dihydroergotamine/Sympathomimetics SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: Concurrent use of dihydroergotamine and sympathomimetics may result in additive or synergistic effect on peripheral blood vessels.(1) CLINICAL EFFECTS: Concurrent use of dihydroergotamine and sympathomimetics may result in increased blood pressure due to peripheral vasoconstriction.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Dihydroergotamine is contraindicated with sympathomimetics because the combination may result in additive or synergistic elevation of blood pressure.(1) DISCUSSION: Significant elevation in blood pressure has been reported in patients treated with dihydroergotamine.(1) Sympathomimetics can be expected to have additional effects on blood pressure. |
DIHYDROERGOTAMINE MESYLATE, MIGRANAL, TRUDHESA |
There are 5 severe interactions.
These drug interactions can produce serious consequences in most patients. Actions required for severe interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration scheduling, and providing additional patient monitoring. Review the full interaction monograph for more information.
| Drug Interaction | Drug Names |
|---|---|
| Epinephrine/Non-Cardioselective Beta-Blockers SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Concurrent use of beta-blockers also block the beta effects of epinephrine, which results in predomination of alpha effects. The plasma clearance of epinephrine is decreased. CLINICAL EFFECTS: Concurrent use of epinephrine with beta-blockers may result in hypertension with reflex bradycardia. Epinephrine resistance in patients with anaphylaxis has been reported. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Avoid concomitant administration of epinephrine and beta-blockers if possible. If both drugs are administered, monitor blood pressure carefully. Hypertension and bradycardia are less likely to occur with cardioselective beta-blockers. Use caution when treating anaphylaxis with epinephrine since response may be poor. DISCUSSION: In a study of 6 subjects, an increase in mean arterial pressure (MAP) of 15.1% (p < 0.05) was observed after an infusion of epinephrine (10 ng/kg/min) followed by an intravenous injection of propranolol (40 mcg/kg). In addition, plasma clearance of epinephrine decreased to 54.7% of the control value after the dose of propranolol.(1) In another study of 6 subjects, patients were intravenously administered 15 mcg epinephrine, followed by propranolol 0.04 mg/kg, and then another dose of epinephrine. A mean decrease in heart rate of 37% (p < 0.001) was observed following the second dose of epinephrine.(2) In a study in 10 healthy subjects, an increase in MAP was observed after infusion of epinephrine (5 mcg/min) followed by infusion of propranolol (10 mg).(5) In a study in 1 healthy subject, marked bradycardia and atrioventricular block occurred after administration of propranolol (40 mg orally) with epinephrine (17 mcg/min intravenously).(6) In a study in 7 healthy subjects, and increase in MAP (8% increase in systolic blood pressure, 10% increase in diastolic blood pressure) was observed after injection of epinephrine (45 mcg in lidocaine) in to the maxilla after pretreatment with pindolol (5 mg).(7) A retrospective analysis of sinus surgery patients found that 9.1% had exaggerated intraoperative hypertensive events during the first surgical hour (defined as relative increase greater than 20% of systolic blood pressure or single systolic blood pressure value above 200 mmHg). Subjects with established beta blockade were found to be three times as likely to experience an exaggerated hypertensive event during the first intraoperative hour.(8) In a study, intraoral injection with 2% lidocaine containing epinephrine (45 mcg) after pretreatment with pindolol (5 mg) resulted reduced stroke volume, increase in afterload, decreased myocardial contractility, decreased heart rate, and an increase in blood pressure.(9) In a study in 8 subjects, a comparison of propranolol (80 mg three times daily) or metoprolol (100 mg three times daily) with epinephrine (8 mcg/min for 6 minutes) showed that propranolol significantly increases MAP while metoprolol, a beta1-selective beta-blocker, does not.(10) There are several case reports of significant hypertension with reflex bradycardia.(9-12) In some of these case reports patients had strokes.(12) |
BETAPACE, BETAPACE AF, CORGARD, HEMANGEOL, INDERAL LA, INDERAL XL, INNOPRAN XL, LABETALOL HCL, LABETALOL HCL-WATER, NADOLOL, PINDOLOL, PROPRANOLOL HCL, PROPRANOLOL HCL ER, PROPRANOLOL-HYDROCHLOROTHIAZID, SOTALOL, SOTALOL AF, SOTALOL HCL, SOTYLIZE, TIMOLOL MALEATE |
| Ergot Alkaloids/Sympathomimetics SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Concurrent use of ergot alkaloids and sympathomimetics may result in additive or synergistic effect on peripheral blood vessels. CLINICAL EFFECTS: Concurrent use of ergot alkaloids and sympathomimetics may result in increased blood pressure due to peripheral vasoconstriction. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: When possible, avoid the concurrent use of ergot alkaloids and sympathomimetics. If concurrent use is warranted, monitor blood pressure and for signs of vasoconstriction. Decreasing the dose of one or both drugs may be necessary. DISCUSSION: There have been reports of severe vasoconstriction resulting in gangrene in patients receiving intravenous ergonovine with dopamine or norepinephrine. |
ERGOLOID MESYLATES, ERGOMAR, ERGOTAMINE TARTRATE, ERGOTAMINE-CAFFEINE, METHYLERGONOVINE MALEATE, METHYSERGIDE MALEATE, MIGERGOT |
| Selected Inhalation Anesthetic Agents/Sympathomimetics SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: The exact mechanism is unknown. The anesthetics produce conduction changes that increase impulse re-entry into the myocardial tissue.(1) The anesthetics' ability to precipitate arrhythmias is enhanced by elevated arterial blood pressure, tachycardia, hypercapnia, and/or hypoxia, events that stimulate the release of endogenous catecholamines.(1) CLINICAL EFFECTS: Concurrent use of inhalation anesthetic agents and sympathomimetics may result in ventricular arrhythmias or sudden blood pressure and heart rate increase during surgery.(2) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Monitor blood pressure and avoid use of sympathomimetics in patients being treated with anesthetics on the day of surgery.(2) Intravenous use of epinephrine during surgery with halothane and related halogenated general anesthetics should be strongly discouraged. When intravenous epinephrine is necessary, nitrous oxide anesthesia supplemented with ether, muscle relaxants, or opioids should be used instead of halothane.(3,4) Epinephrine may safely be used subcutaneously with the following precautions: the patient is adequately ventilated to prevent hypoxia or respiratory acidosis; the total dose of epinephrine is limited to 100 mcg/10 minute period or 300 mcg/hour in adults, 3.5 mcg/Kg in infants, 2.5 mcg/Kg in children up to two years of age, and 1.45 mcg/Kg in children over two years of age; a minimum effective concentration of anesthetic is maintained; the drugs are not co-administered in patients with hypertension or other cardiovascular disorders; and the cardiac rhythm is continuously monitored during and after injection.(3-10) If arrhythmias occur after the administration of the epinephrine, the drugs of choice are lidocaine or propranolol, depending on the type of arrhythmia.(1) DISCUSSION: Administration of epinephrine during halothane anesthesia may may lead to serious ventricular arrhythmias.(3-6,11-18) This has occurred when epinephrine was administered intravenously,(6) when it was administered with lidocaine as a dental block,(11,14) or when it was administered supraperiosteally.(5) Norepinephrine has been shown to interact with halothane in a manner similar to epinephrine.(1) In two case reports, patients were given terbutaline (0.25 to 0.35 mg) for wheezing following induction of anesthesia with halothane. One patient's heart rate increased from 68 to 100 beats/minute, and the ECG showed premature ventricular contractions and bigeminy, while the other patient developed multiple unifocal premature ventricular contractions and bigeminy. The arrhythmias resolved in both patients following lidocaine administration.(19) Although not documented, isoproterenol causes effects on the heart similar to terbutaline(20) and would probably interact with halothane in a similar manner. Other inhalation anesthetics that increase the incidence of arrhythmias with epinephrine include chloroform,(20) methoxyflurane,(20) and enflurane.(12) A similar interaction may be expected between the other inhalation anesthetics and sympathomimetics. |
DESFLURANE, FORANE, ISOFLURANE, SEVOFLURANE, SUPRANE, TERRELL, ULTANE |
| Selected Direct-Acting Sympathomimetics/Tricyclic Compounds SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Unknown. However, it is speculated that direct-acting sympathomimetic amines have an enhanced effect due to tricyclic blockage of norepinephrine reuptake. CLINICAL EFFECTS: Increased effect of direct acting sympathomimetics. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Consider avoiding the concurrent use of direct-acting sympathomimetics and tricyclic compounds. If concurrent use of direct-acting sympathomimetics and tricyclic compounds is warranted, the initial dose of the sympathomimetic should be lowered and the patient should be monitored for adverse cardiovascular effects. Use of tricyclic compounds and other sympathomimetics should be approached with caution. DISCUSSION: Epinephrine and other direct-acting sympathomimetic amines exert enhanced cardiovascular effects (e.g., arrhythmias, hypertension, and tachycardia) in individuals concurrently receiving or previously treated with tricyclic antidepressants. Other direct and mixed acting sympathomimetic amines have also been reported to interact with tricyclic antidepressants. These include norepinephrine, phenylephrine, dopamine, and methoxamine. Protriptyline, amitriptyline, and desipramine have also been reported to interact with direct-acting sympathomimetics. |
AMITRIPTYLINE HCL, AMOXAPINE, ANAFRANIL, CHLORDIAZEPOXIDE-AMITRIPTYLINE, CLOMIPRAMINE HCL, DESIPRAMINE HCL, DOXEPIN HCL, IMIPRAMINE HCL, IMIPRAMINE PAMOATE, NORPRAMIN, NORTRIPTYLINE HCL, PAMELOR, PERPHENAZINE-AMITRIPTYLINE, PROTRIPTYLINE HCL, SILENOR, TRIMIPRAMINE MALEATE |
| Iobenguane I 123/Agents that Affect Catecholamines SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Many compounds that reduce catecholamine uptake or that deplete catecholamine stores may interfere with iobenguane uptake into cells.(1) CLINICAL EFFECTS: Compounds that reduce catecholamine uptake or that deplete catecholamine stores may interfere with imaging completed with iobenguane.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Discuss the use of agents that affect catecholamines. Discontinue drugs that reduce catecholamine uptake or deplete catecholamine stores prior to imaging with iobenguane. Before imaging with iobenguane, discontinue agents that affect catecholamines for at least 5 biological half-lives, as clinically tolerated.(1) DISCUSSION: Many agents may reduce catecholamine uptake or deplete catecholamine stores.(1) Examples include: - CNS stimulants or amphetamines (e.g. cocaine, methylphenidate, dextroamphetamine) - norepinephrine and dopamine reuptake inhibitors (e.g. phentermine) - norepinephrine and serotonin reuptake inhibitors (e.g. tramadol) - monoamine oxidase inhibitors (e.g. phenelzine, linezolid) - central monoamine depleting drugs (e.g. reserpine) - non-select beta adrenergic blocking drugs (e.g. labetalol) - alpha agonists or alpha/beta agonists (e.g. pseudoephedrine, phenylephrine, ephedrine, phenylpropanolamine, naphazoline) - tricyclic antidepressants or norepinephrine reuptake inhibitors (e.g. amitriptyline, bupropion, duloxetine, mirtazapine, venlafaxine) - botanicals that may inhibit reuptake of norepinephrine, serotonin or dopamine (e.g. ephedra, ma huang, St. John's Wort, yohimbine) |
ADREVIEW |
There are 6 moderate interactions.
The clinician should assess the patient’s characteristics and take action as needed. Actions required for moderate interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration.
| Drug Interaction | Drug Names |
|---|---|
| Antidiabetics/Epinephrine SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Gluconeogenesis, glycogenolysis, and lipolysis are increased by epinephrine. Also, insulin secretion and glucose uptake by peripheral tissues are decreased by epinephrine. CLINICAL EFFECTS: Increased blood glucose resulting in decreased effectiveness of the antidiabetic agent. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Caution when starting or stopping epinephrine in diabetic patients. Adjust the antidiabetic dose as needed based on blood glucose levels. DISCUSSION: This interaction is likely to occur based upon well documented properties of the interacting drugs. However, there is individual variability in its occurrence. |
ACARBOSE, ADMELOG, ADMELOG SOLOSTAR, AFREZZA, APIDRA, APIDRA SOLOSTAR, BASAGLAR KWIKPEN U-100, BASAGLAR TEMPO PEN U-100, DUETACT, FIASP, FIASP FLEXTOUCH, FIASP PENFILL, FIASP PUMPCART, GLIMEPIRIDE, GLIPIZIDE, GLIPIZIDE ER, GLIPIZIDE XL, GLIPIZIDE-METFORMIN, GLUCOTROL XL, GLYBURIDE, GLYBURIDE MICRONIZED, GLYBURIDE-METFORMIN HCL, HUMALOG, HUMALOG JUNIOR KWIKPEN, HUMALOG KWIKPEN U-100, HUMALOG KWIKPEN U-200, HUMALOG MIX 50-50 KWIKPEN, HUMALOG MIX 75-25, HUMALOG MIX 75-25 KWIKPEN, HUMALOG TEMPO PEN U-100, HUMULIN R U-500, HUMULIN R U-500 KWIKPEN, INSULIN ASPART, INSULIN ASPART FLEXPEN, INSULIN ASPART PENFILL, INSULIN ASPART PROT MIX 70-30, INSULIN DEGLUDEC, INSULIN DEGLUDEC PEN (U-100), INSULIN DEGLUDEC PEN (U-200), INSULIN GLARGINE MAX SOLOSTAR, INSULIN GLARGINE SOLOSTAR, INSULIN GLARGINE-YFGN, INSULIN LISPRO, INSULIN LISPRO JUNIOR KWIKPEN, INSULIN LISPRO KWIKPEN U-100, INSULIN LISPRO PROTAMINE MIX, LANTUS, LANTUS SOLOSTAR, LYUMJEV, LYUMJEV KWIKPEN U-100, LYUMJEV KWIKPEN U-200, LYUMJEV TEMPO PEN U-100, MIGLITOL, MYXREDLIN, NATEGLINIDE, NOVOLOG, NOVOLOG FLEXPEN, NOVOLOG MIX 70-30, NOVOLOG MIX 70-30 FLEXPEN, NOVOLOG PENFILL, PIOGLITAZONE-GLIMEPIRIDE, PRECOSE, REZVOGLAR KWIKPEN, SEMGLEE (YFGN), SEMGLEE (YFGN) PEN, SOLIQUA 100-33, TOUJEO MAX SOLOSTAR, TOUJEO SOLOSTAR, TRESIBA, TRESIBA FLEXTOUCH U-100, TRESIBA FLEXTOUCH U-200, XULTOPHY 100-3.6 |
| Sympathomimetics (Direct, Mixed-Acting)/Guanethidine SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Direct or mixed-acting sympathomimetics may inhibit uptake of guanethidine at the adrenergic neuron. CLINICAL EFFECTS: Decreased antihypertensive effectiveness. Effects may be seen for several days after discontinuation of the direct or mixed-acting sympathomimetic. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Avoid concomitant administration of these drugs. If both drugs are administered, adjust the guanethidine dose as needed based on blood pressure. DISCUSSION: Documentation supports routine monitoring of this interaction. It should be noted that this interaction can occur quickly. |
GUANETHIDINE HEMISULFATE |
| Sympathomimetics/Rauwolfia Alkaloids SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Reserpine depletes catecholamine stores within the peripheral vascular adrenergic nerve endings, thus indirect acting sympathomimetics are unable to trigger the release of catecholamines. The reserpine-induced catecholamine release increases sensitivity to the effects of direct acting sympathomimetics. CLINICAL EFFECTS: Increased effects of direct acting sympathomimetics. Decreased effects of indirect acting sympathomimetics. Mixed acting sympathomimetics will show effects based on the predominance of either direct or indirect activity. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: If these agents are administered concurrently, monitor blood pressure. The dose of the sympathomimetic may need to be adjusted. DISCUSSION: This interaction has been well documented in animal studies and human case reports have confirmed the interaction. Reserpine has been shown to decrease the response to epinephrine administered for hypotension. Reserpine has also been shown to decrease the effectiveness of ophthalmic epinephrine, a direct acting sympathomimetic. Ophthalmic phenylephrine has been shown to decrease the hypotensive effects of reserpine. |
RESERPINE |
| Sympathomimetics (Direct, Mixed-Acting)/Methyldopa SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Unknown. CLINICAL EFFECTS: The pressor response to sympathomimetics may be increased. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Start with low doses of sympathomimetics and monitor blood pressure of patients during concurrent administration of sympathomimetics and methyldopa. DISCUSSION: The pressor response to sympathomimetics has been reported to be increased during methyldopa administration. In addition to increased duration of pressor response, severe hypertension has been reported. |
METHYLDOPA, METHYLDOPA-HYDROCHLOROTHIAZIDE, METHYLDOPATE HCL |
| Entacapone; Opicapone/COMT-Metabolized Agents SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Entacapone and opicapone are selective and reversible inhibitors of catechol-O-methyltransferase (COMT) and drugs that are metabolized by COMT can not be fully metabolized when given with entacapone or opicapone.(1) CLINICAL EFFECTS: COMT-metabolized agents can interact with entacapone or opicapone and may result in an increased heart rates, arrhythmias, or an excessive change in blood pressure.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The manufacturers of entacapone and opicapone recommend using caution when administering entacapone or opicapone and a COMT-metabolized agent regardless of the route of administration (including inhalation).(1-3) DISCUSSION: In an interaction study, ventricular tachycardia was observed after epinephrine and entacapone administration.(1) Another study on the effect of entacapone given with isoproterenol and epinephrine concluded that entacapone may potentiate the chronotropic and arrhythmogenic effects of isoproterenol and epinephrine.(4) |
CARBIDOPA-LEVODOPA-ENTACAPONE, ENTACAPONE, ONGENTYS |
| Epinephrine/Cardioselective Beta-Blockers SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Concurrent use of beta-blockers also block the beta effects of epinephrine, which results in predomination of alpha effects. The plasma clearance of epinephrine is decreased. CLINICAL EFFECTS: Concurrent use of epinephrine with beta-blockers may result in hypertension with reflex bradycardia. Epinephrine resistance in patients with anaphylaxis has been reported. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Hypertension and bradycardia are less likely to occur with cardioselective beta-blockers. If both drugs are administered, monitor blood pressure carefully. Use caution when treating anaphylaxis with epinephrine since response may be poor. DISCUSSION: A 29-year-old male undergoing elective nasal septoplasty developed severe hypertension with a blood pressure of 207/123 mmHg after topical epinephrine (1:1000) was applied to the nasal mucosa. Intravenous metoprolol was administered but the patient went into cardiogenic shock thought to be a result of unopposed alpha stimulation by the combination of epinephrine and metoprolol.(1) A study observed the differences in cardiovascular responses to subcutaneous epinephrine (given to provide hemostasis during scalp incision for craniotomy) between patients who received propranolol vs. metoprolol vs. no pretreatment. While metoprolol prevented the cardiovascular effects of epinephrine infiltration, propranolol pretreatment was associated with a highly significant increase (P less than 0.01) in mean arterial pressure and a significant decrease (P less than 0.05) in heart rate.(2) A double-blind cross-over trial studied the effects of epinephrine infusion during treatment with propranolol vs. metoprolol in 8 hypertensive patients. Patients on propranolol experienced significant increases in blood pressure and systemic vascular resistance (SVR), whereas patients on metoprolol had less increase in systolic blood pressure while the diastolic pressure remained unchanged and SVR decreased.(3) In spontaneously hypertensive rats, epinephrine in combination with pindolol induced remarkable hemodynamic changes (in particular, increase in diastolic blood pressure), which were prevented by phentolamine pretreatment, whereas epinephrine with acebutolol pretreatment induced no significant hemodynamic changes.(4) |
ACEBUTOLOL HCL, ATENOLOL, ATENOLOL-CHLORTHALIDONE, BETAXOLOL HCL, BISOPROLOL FUMARATE, BISOPROLOL-HYDROCHLOROTHIAZIDE, BREVIBLOC, BYSTOLIC, CARVEDILOL, CARVEDILOL ER, COREG, COREG CR, ESMOLOL HCL, ESMOLOL HCL-SODIUM CHLORIDE, ESMOLOL HCL-WATER, KAPSPARGO SPRINKLE, LOPRESSOR, METOPROLOL SUCCINATE, METOPROLOL TARTRATE, METOPROLOL-HYDROCHLOROTHIAZIDE, NEBIVOLOL HCL, RAPIBLYK, TENORETIC 100, TENORETIC 50, TENORMIN, TOPROL XL |
The following contraindication information is available for EPINEPHRINE CONVENIENCE KIT (epinephrine):
Drug contraindication overview.
No enhanced Contraindications information available for this drug.
No enhanced Contraindications information available for this drug.
There are 0 contraindications.
There are 12 severe contraindications.
Adequate patient monitoring is recommended for safer drug use.
| Severe List |
|---|
| Angina |
| Angle-closure glaucoma |
| Cardiac arrhythmia |
| Cardiogenic shock |
| Cerebral arteriosclerosis |
| Congenital long QT syndrome |
| Coronary artery disease |
| Dilated cardiomyopathy |
| Hemorrhagic shock |
| Hypertension |
| Hyperthyroidism |
| Sinus tachycardia |
There are 1 moderate contraindications.
Clinically significant contraindication, where the condition can be managed or treated before the drug may be given safely.
| Moderate List |
|---|
| Diabetes mellitus |
The following adverse reaction information is available for EPINEPHRINE CONVENIENCE KIT (epinephrine):
Adverse reaction overview.
No enhanced Common Adverse Effects information available for this drug.
No enhanced Common Adverse Effects information available for this drug.
There are 22 severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
| None. |
Hypertension |
| Rare/Very Rare |
|---|
|
Acute myocardial infarction Angina Cardiac arrhythmia Cardiomyopathy Cerebrovascular accident Chest pain Extravasation injury Gangrene Hyperglycemia Hypokalemia Intracranial bleeding Kidney disease with reduction in glomerular filtration rate (GFr) Lactic acidosis Myocardial ischemia Necrotizing fasciitis Paradoxical bronchospasm Pulmonary edema Supraventricular tachycardia Ventricular arrhythmias Ventricular fibrillation Ventricular premature beats |
There are 25 less severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
|
Dizziness General weakness Headache disorder Nausea Nervousness Pallor Palpitations Symptoms of anxiety Tachycardia Tremor Vomiting |
None. |
| Rare/Very Rare |
|---|
|
Acute cognitive impairment Agitation Apprehension Blanching of skin Drowsy Hyperhidrosis Hypoesthesia Injection site infection Injection site sequelae Memory impairment Oliguria Panic disorder Paresthesia Xerostomia |
The following precautions are available for EPINEPHRINE CONVENIENCE KIT (epinephrine):
No enhanced Pediatric Use information available for this drug.
Contraindicated
Severe Precaution
Management or Monitoring Precaution
Contraindicated
| None |
Severe Precaution
| None |
Management or Monitoring Precaution
| None |
Epinephrine usually inhibits spontaneous or oxytocin-induced contractions of the pregnant human uterus and may delay the second stage of labor. In dosages sufficient to reduce uterine contractions, the drug may cause a prolonged period of uterine atony with hemorrhage. If used during pregnancy, epinephrine may cause anoxia to the fetus and/or spontaneous abortion.
When administered in advanced cardiovascular life support (ACLS) during cardiac resuscitation, epinephrine may decrease blood flow to the uterus; however, the woman must be resuscitated for survival of the fetus. Some manufacturers state that epinephrine should be avoided during the second stage of labor; parenteral administration of the drug to maintain blood pressure during spinal anesthesia for delivery can cause acceleration of fetal heart rate and should not be used in obstetric patients when maternal systolic/diastolic blood pressure exceeds 130/80 mm Hg. Epinephrine should be administered cautiously by oral inhalation to pregnant patients.
Epinephrine should be used during pregnancy only if the potential benefits justify the possible risks to the fetus. There is some evidence to support that epidural administration of some local anesthetics (e.g., lidocaine) with epinephrine during labor is safe.
When administered in advanced cardiovascular life support (ACLS) during cardiac resuscitation, epinephrine may decrease blood flow to the uterus; however, the woman must be resuscitated for survival of the fetus. Some manufacturers state that epinephrine should be avoided during the second stage of labor; parenteral administration of the drug to maintain blood pressure during spinal anesthesia for delivery can cause acceleration of fetal heart rate and should not be used in obstetric patients when maternal systolic/diastolic blood pressure exceeds 130/80 mm Hg. Epinephrine should be administered cautiously by oral inhalation to pregnant patients.
Epinephrine should be used during pregnancy only if the potential benefits justify the possible risks to the fetus. There is some evidence to support that epidural administration of some local anesthetics (e.g., lidocaine) with epinephrine during labor is safe.
No enhanced Lactation information available for this drug.
No enhanced Geriatric Use information available for this drug.
The following prioritized warning is available for EPINEPHRINE CONVENIENCE KIT (epinephrine):
No warning message for this drug.
No warning message for this drug.
The following icd codes are available for EPINEPHRINE CONVENIENCE KIT (epinephrine)'s list of indications:
| Allergic reaction | |
| T78.40 | Allergy, unspecified |
| T78.40xA | Allergy, unspecified, initial encounter |
| Anaphylaxis | |
| T78.0 | Anaphylactic reaction due to food |
| T78.00 | Anaphylactic reaction due to unspecified food |
| T78.00xA | Anaphylactic reaction due to unspecified food, initial encounter |
| T78.01 | Anaphylactic reaction due to peanuts |
| T78.01xA | Anaphylactic reaction due to peanuts, initial encounter |
| T78.02 | Anaphylactic reaction due to shellfish (crustaceans) |
| T78.02xA | Anaphylactic reaction due to shellfish (crustaceans), initial encounter |
| T78.03 | Anaphylactic reaction due to other fish |
| T78.03xA | Anaphylactic reaction due to other fish, initial encounter |
| T78.04 | Anaphylactic reaction due to fruits and vegetables |
| T78.04xA | Anaphylactic reaction due to fruits and vegetables, initial encounter |
| T78.05 | Anaphylactic reaction due to tree nuts and seeds |
| T78.05xA | Anaphylactic reaction due to tree nuts and seeds, initial encounter |
| T78.06 | Anaphylactic reaction due to food additives |
| T78.06xA | Anaphylactic reaction due to food additives, initial encounter |
| T78.07 | Anaphylactic reaction due to milk and dairy products |
| T78.07xA | Anaphylactic reaction due to milk and dairy products, initial encounter |
| T78.08 | Anaphylactic reaction due to eggs |
| T78.08xA | Anaphylactic reaction due to eggs, initial encounter |
| T78.09 | Anaphylactic reaction due to other food products |
| T78.09xA | Anaphylactic reaction due to other food products, initial encounter |
| T78.2 | Anaphylactic shock, unspecified |
| T78.2xxA | Anaphylactic shock, unspecified, initial encounter |
| T80.5 | Anaphylactic reaction due to serum |
| T80.51 | Anaphylactic reaction due to administration of blood and blood products |
| T80.51xA | Anaphylactic reaction due to administration of blood and blood products, initial encounter |
| T80.52 | Anaphylactic reaction due to vaccination |
| T80.52xA | Anaphylactic reaction due to vaccination, initial encounter |
| T80.59 | Anaphylactic reaction due to other serum |
| T80.59xA | Anaphylactic reaction due to other serum, initial encounter |
| T88.6 | Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered |
| T88.6xxA | Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, initial encounter |
Formulary Reference Tool