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Drug overview for SODIUM NITROPRUSSIDE (nitroprusside sodium):
Generic name: NITROPRUSSIDE SODIUM
Drug class: Nitroprusside Sodium
Therapeutic class: Cardiovascular Therapy Agents
Sodium nitroprusside is a vasodilating and hypotensive agent.
No enhanced Uses information available for this drug.
Generic name: NITROPRUSSIDE SODIUM
Drug class: Nitroprusside Sodium
Therapeutic class: Cardiovascular Therapy Agents
Sodium nitroprusside is a vasodilating and hypotensive agent.
No enhanced Uses information available for this drug.
DRUG IMAGES
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The following indications for SODIUM NITROPRUSSIDE (nitroprusside sodium) have been approved by the FDA:
Indications:
Acute decompensated heart failure
Controlled hypotension
Hypertensive crisis
Professional Synonyms:
Acute heart failure
Controlled decreased blood pressure
Overt cardiac failure
Overt CHF
Overt congestive heart failure
Overt heart failure
Uncontrolled cardiac failure
Indications:
Acute decompensated heart failure
Controlled hypotension
Hypertensive crisis
Professional Synonyms:
Acute heart failure
Controlled decreased blood pressure
Overt cardiac failure
Overt CHF
Overt congestive heart failure
Overt heart failure
Uncontrolled cardiac failure
The following dosing information is available for SODIUM NITROPRUSSIDE (nitroprusside sodium):
No enhanced Dosing information available for this drug.
Sodium nitroprusside is administered by IV infusion only using a controlled-infusion device (i.e., infusion pump); IV infusion devices regulated only by gravity or mechanical clamps should not be used. The rate of administration should be adjusted to maintain the desired hypotensive effect, as determined by continuous monitoring of blood pressure, using either a continually reinflated sphygmomanometer or, preferably, an intra-arterial pressure sensor. Because of the potential for toxicity, the drug should be administered for the shortest possible duration.
Prolonged infusions should not exceed a rate of 3 mcg/kg per minute to prevent thiocyanate (byproduct of sodium nitroprusside metabolism) concentrations from reaching neurotoxic levels; thiocyanate concentrations should be monitored daily if this rate is exceeded. Commercially available sodium nitroprusside injection concentrate (25 mg/mL) must be further diluted prior to IV infusion. The contents of one vial containing 50 mg of the drug should be diluted in 250-1000 mL of 5% dextrose injection.
Vials of the drug are for single use only. Nitroprusside solutions should be protected from light by promptly wrapping the containers in the supplied opaque sleeve, aluminum foil, or other opaque material; it is not necessary to cover the infusion drip chamber or IV tubing. If properly protected from light, diluted solutions of the drug are stable for 24 hours.
(See Chemistry and Stability: Stability.) Parenteral solutions of the drug should be inspected visually for particulate matter and discoloration prior to administration. The freshly prepared infusion solution has a very faint brownish tint; if it is highly colored (e.g., blue, green, red) or contains particulate matter, it should be discarded. No other drug should be added to the infusion fluid for simultaneous administration with sodium nitroprusside.
Prolonged infusions should not exceed a rate of 3 mcg/kg per minute to prevent thiocyanate (byproduct of sodium nitroprusside metabolism) concentrations from reaching neurotoxic levels; thiocyanate concentrations should be monitored daily if this rate is exceeded. Commercially available sodium nitroprusside injection concentrate (25 mg/mL) must be further diluted prior to IV infusion. The contents of one vial containing 50 mg of the drug should be diluted in 250-1000 mL of 5% dextrose injection.
Vials of the drug are for single use only. Nitroprusside solutions should be protected from light by promptly wrapping the containers in the supplied opaque sleeve, aluminum foil, or other opaque material; it is not necessary to cover the infusion drip chamber or IV tubing. If properly protected from light, diluted solutions of the drug are stable for 24 hours.
(See Chemistry and Stability: Stability.) Parenteral solutions of the drug should be inspected visually for particulate matter and discoloration prior to administration. The freshly prepared infusion solution has a very faint brownish tint; if it is highly colored (e.g., blue, green, red) or contains particulate matter, it should be discarded. No other drug should be added to the infusion fluid for simultaneous administration with sodium nitroprusside.
| DRUG LABEL | DOSING TYPE | DOSING INSTRUCTIONS |
|---|---|---|
| SODIUM NITROPRUSSIDE 50 MG/2ML | Maintenance | Adults infuse 0.25 mcg/kg/minute by continuous infusion route titrate upward every few min until adequate blood pressure or rate of 10mcg/kg/min |
| DRUG LABEL | DOSING TYPE | DOSING INSTRUCTIONS |
|---|---|---|
| SODIUM NITROPRUSSIDE 50 MG/2ML | Maintenance | Adults infuse 0.25 mcg/kg/minute by continuous infusion route titrate upwardevery few min until adequate blood pressure or rate of 10mcg/kg/min |
The following drug interaction information is available for SODIUM NITROPRUSSIDE (nitroprusside sodium):
There are 2 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 |
|---|---|
| CGMP Specific PDE Type-5 Inhibitors/Nitrates 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: Nitrates activate guanyl cyclase, an enzyme that increases levels of cyclic guanosine monophosphate (cGMP). cGMP produces smooth muscle relaxation. Avanafil,(1) sildenafil,(2) tadalafil,(3,4) and vardenafil (5-7) inhibit phosphodiesterase type 5 (PDE5), which is responsible for the breakdown of cGMP. Concurrent use of nitrates with avanafil,(1) sildenafil,(2) tadalafil,(3,4) or vardenafil(5-7) results in potentiation of the effect of nitrates. CLINICAL EFFECTS: The concurrent use of CGMP specific PDE type-5 inhibitors and nitrates potentiates the hypotensive effects of nitrates(1-7) which may result in dizziness, syncope, heart attack, or stroke.(4) The concurrent use of sildenafil and sodium nitroprusside may potentiate the antiaggregatory effect of sodium nitroprusside in addition to increased hypotensive effects.(2) PREDISPOSING FACTORS: Plasma levels of the PDE type-5 inhibitor may be higher in the following patients: those older than 65, with hepatic impairment, with severe renal impairment, or using concomitant CYP3A4 inhibitors. This may increase the severity of the interaction. PATIENT MANAGEMENT: The administration of avanafil to patients receiving organic nitrates, either regularly and/or intermittently, is contraindicated. In a patient who has taken avanafil, at least 12 hours should elapse after the last dose of avanafil before nitrate administration is considered and it should only be administered under close medical supervision with appropriate hemodynamic monitoring.(1) The administration of sildenafil to patients receiving organic nitrates, either regularly and/or intermittently, in any form is contraindicated.(2) The administration of tadalafil to patients receiving any form of organic nitrate, either regularly and/or intermittently, is contraindicated.(3,4) Patients should be instructed to seek immediate medical attention if they experience anginal chest pain following tadalafil. In such cases where nitrate administration is considered medically necessary, at least 48 hours should elapse after tadalafil administration before nitrate administration is considered. In such cases, nitrates should only be administered under close medical supervision with appropriate hemodynamic monitoring.(4) The administration of vardenafil to patients receiving nitrates or nitric oxide donors is contraindicated.(5-7) In patients prescribed vardenafil in whom nitrate administration is deemed medically necessary in a life-threatening situation, the Canadian manufacturer of vardenafil states that at least 24 hours should have elapsed after the last dose of vardenafil before the nitrate administration is considered. Nitrates should only be administered under close medical supervision with appropriate hemodynamic monitoring.(7) The concomitant use of nicorandil(8) or subinguinal nitroglycerin(9) and PDE type-5 inhibitors is contraindicated. Treat hypotension resulting from concurrent use as a nitrate overdose, with elevation of the extremities and central volume expansion.(10) DISCUSSION: Nitrates activate guanylate cyclase, an enzyme that increases levels of cGMP. cGMP produces smooth muscle relaxation. Avanafil,(1) sildenafil,(2) tadalafil,(3,4) and vardenafil (5-7) inhibit PDE5, which is responsible for the breakdown of cGMP. Concurrent use of nitrates with avanafil,(1) sildenafil,(2) tadalafil,(3,4) or vardenafil(5-7) results in potentiation of the effect of nitrates. It is unknown when nitrates, if necessary, can be safely administered to patients who have taken CGMP specific PDE type-5 inhibitors. Following a single 100 mg oral dose of sildenafil, peak plasma levels are approximately 440 ng/mL and levels 24 hours post dose are approximately 2 ng/ml. Sildenafil plasma levels at 24 hours post dose are three to eight times higher in the following patients: those age greater than 65, those with hepatic impairment, those with severe renal impairment (creatinine clearance less than 30 ml/min), and those with concomitant use of potent CYP P-450-3A4 inhibitors (erythromycin). Although plasma levels of sildenafil are lower at 24 hours post dose, the manufacturer of sildenafil states that it is still unknown whether nitrates can safely be coadministered at that time.(2) In vitro studies with human platelets have shown that sildenafil potentiates the antiaggregatory effect of sodium nitroprusside.(2) In a study of 150 subjects who received tadalafil (20 mg) daily for 7 days, sublingual nitroglycerin was administered at 2, 4, 8, 24, 48, 72, and 96 hours after tadalafil. A significant interaction between tadalafil and nitroglycerin was observed up to and including 24 hours post-tadalafil. At 48 hours, the interaction was not observed by most hemodynamic measures. After 48 hours, the interaction was not detectable.(4) In a population-based cohort study of 61,487 men who received nitrates, 5,710 (9%) concurrently received PDE Type-5 inhibitors (PDE5i). Crude hazard ratios found a significant and inverse association between combination use of nitrates and PDE5i and all cause, cardiovascular, and non-cardiovascular mortality. All-cause mortality incidence rates were 2.69 cases per 100 person-years for the nitrate and PDE5i group vs 3.83 cases per 100 person-years in the nitrate-only group. Concurrent use of nitrates and PDE5i found a multivariate adjusted HR for all-cause mortality of 1.39 (95% CI: 1.28-1.51). Concurrent use of nitrates and PDE5i found an adjusted HR for cardiovascular death, non-cardiovascular death, myocardial infarction, heart failure, revascularization, and major adverse cardiovascular event (MACE) in patients treated with both nitrates and PDE5i was 1.34 (95% CI: 1.11-1.62), 1.40 (95% CI: 1.27-1.54), 1.72 (95% CI: 1.55-1.90), 1.67 (95% CI: 1.48-1.90), 1.95 (95% CI: 1.78-2.13), and 1.70 (95% CI: 1.58-1.83), respectively, compared with patients with nitrates only.(11) |
ADCIRCA, ALYQ, AVANAFIL, CIALIS, ENTADFI, OPSYNVI, REVATIO, SILDENAFIL CITRATE, STENDRA, TADALAFIL, TADLIQ, VARDENAFIL HCL, VIAGRA |
| Riociguat/Nitrates & Nitric Oxide Donors 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: Nitrates activate guanyl cyclase, an enzyme that increases levels of cyclic guanosine monophosphate (cGMP), which produces smooth muscle relaxation. Riociguat stimulates the nitric oxide-soluble guanylate cyclase-cGMP pathway and also increases cGMP. Concurrent use of nitrates with riociguat results in potentiation of the effect of both agents.(1) CLINICAL EFFECTS: The concurrent use riociguat and nitrates potentiates the hypotensive effects of both agents, which may result in dizziness, syncope, heart attack, or stroke.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The administration of riociguat to patients receiving nitrates, or nitric oxide donors, in any form is contraindicated.(1) DISCUSSION: Riociguat (2.5 mg) potentiated the blood pressure lowering effect of sublingual nitroglycerin (0.4 mg) when taken 4 hour and 8 hours after riociguat. Syncope was reported in some patients.(1) |
ADEMPAS |
There are 0 severe interactions.
There are 2 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 |
|---|---|
| Tizanidine/Selected Antihypertensives SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Tizanidine is an alpha-2 agonist. Concurrent use with antihypertensive agents may result in additive effects on blood pressure.(1) CLINICAL EFFECTS: Concurrent use of antihypertensives and tizanidine may result in hypotension.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Patients receiving concurrent therapy should be monitored for hypotension. The risk of hypotension may be decreased by careful titration of tizanidine dosages and monitoring for hypotension prior to dose advancement. Counsel patients about the risk of orthostatic hypotension.(1) DISCUSSION: Severe hypotension has been reported following the addition of tizanidine to existing lisinopril therapy.(2-4) |
TIZANIDINE HCL, ZANAFLEX |
| Apomorphine/Selected Antihypertensives and Vasodilators SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Apomorphine causes dose-dependent decreases in blood pressure. Concurrent use with antihypertensive agents may result in additive effects on blood pressure.(1) CLINICAL EFFECTS: Concurrent use of antihypertensives and apomorphine may result in orthostatic hypotension with or without dizziness, nausea, or syncope.(1) PREDISPOSING FACTORS: The risk of orthostatic hypotension may be increased during dose escalation of apomorphine and in patients with renal or hepatic impairment.(1) PATIENT MANAGEMENT: Patients receiving concurrent therapy should be monitored for hypotension. Counsel patients about the risk of orthostatic hypotension.(1) DISCUSSION: Healthy volunteers who took sublingual nitroglycerin (0.4 mg) concomitantly with apomorphine experienced a mean largest decrease in supine systolic blood pressure (SBP) of 9.7 mm Hg and in supine diastolic blood pressure (DBP) of 9.3 mm Hg, and a mean largest decrease in standing SBP and DBP of 14.3 mm Hg and 13.5 mm Hg, respectively. The maximum decrease in SBP and DBP was 65 mm Hg and 43 mm Hg, respectively. When apomorphine was taken alone, the mean largest decrease in supine SBP and DBP was 6.1 mm Hg and 7.3 mm Hg, respectively, and in standing SBP and DBP was 6.7 mm Hg and 8.4 mm Hg, respectively.(1) |
APOKYN, APOMORPHINE HCL, ONAPGO |
The following contraindication information is available for SODIUM NITROPRUSSIDE (nitroprusside sodium):
Drug contraindication overview.
No enhanced Contraindications information available for this drug.
No enhanced Contraindications information available for this drug.
There are 1 contraindications.
Absolute contraindication.
| Contraindication List |
|---|
| Coarctation of aorta |
There are 7 severe contraindications.
Adequate patient monitoring is recommended for safer drug use.
| Severe List |
|---|
| Chronic obstructive pulmonary disease |
| Intracerebral hemorrhage |
| Intracranial hypertension |
| Leber's hereditary optic atrophy |
| Severe renal impairment |
| Tobacco amblyopia |
| Vitamin b12 deficiency |
There are 5 moderate contraindications.
Clinically significant contraindication, where the condition can be managed or treated before the drug may be given safely.
| Moderate List |
|---|
| Anemia |
| Disease of liver |
| Hyponatremia |
| Hypothyroidism |
| Hypovolemia |
The following adverse reaction information is available for SODIUM NITROPRUSSIDE (nitroprusside sodium):
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 10 severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
| None. |
Cyanide toxicity Methemoglobinemia Severe hypotension |
| Rare/Very Rare |
|---|
|
Abnormal ECG Bradycardia Hypothyroidism Ileus Intracranial hypertension Platelet aggregation inhibition Tachycardia |
There are 10 less severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
| None. | None. |
| Rare/Very Rare |
|---|
|
Acute abdominal pain Dizziness Flushing Headache disorder Hyperhidrosis Injection site sequelae Muscle fasciculation Nausea Palpitations Skin rash |
The following precautions are available for SODIUM NITROPRUSSIDE (nitroprusside sodium):
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 |
Animal reproduction studies have not been performed with sodium nitroprusside. It is also not known whether the drug can cause fetal harm when administered to pregnant women. The manufacturer states that sodium nitroprusside should be used during pregnancy only when clearly needed; some experts state that the drug is contraindicated in women with preeclampsia or eclampsia. The effects of sodium thiosulfate administration during pregnancy, either alone or in conjunction with sodium nitroprusside, are unknown.
It is not known if sodium nitroprusside and its metabolites are distributed into human milk. Because many drugs are distributed into milk and because of the potential for serious adverse effects in nursing infants, a decision should be made whether to discontinue nursing or the drug, taking into account the importance of the drug to the woman.
No enhanced Geriatric Use information available for this drug.
The following prioritized warning is available for SODIUM NITROPRUSSIDE (nitroprusside sodium):
No warning message for this drug.
No warning message for this drug.
The following icd codes are available for SODIUM NITROPRUSSIDE (nitroprusside sodium)'s list of indications:
| Acute decompensated heart failure | |
| I50.21 | Acute systolic (congestive) heart failure |
| I50.23 | Acute on chronic systolic (congestive) heart failure |
| I50.31 | Acute diastolic (congestive) heart failure |
| I50.33 | Acute on chronic diastolic (congestive) heart failure |
| I50.41 | Acute combined systolic (congestive) and diastolic (congestive) heart failure |
| I50.43 | Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure |
| I50.811 | Acute right heart failure |
| I50.813 | Acute on chronic right heart failure |
| Controlled hypotension | |
| I95.89 | Other hypotension |
| Hypertensive crisis | |
| I16 | Hypertensive crisis |
| I16.0 | Hypertensive urgency |
| I16.1 | Hypertensive emergency |
| I16.9 | Hypertensive crisis, unspecified |
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