MEDICATION SAFETY ISSUES
High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.
U.S. BRAND NAMES — Adenocard®; Adenoscan®
PHARMACOLOGIC CATEGORY
Antiarrhythmic Agent, Class IV
Diagnostic Agent
DOSING: ADULTS
Paroxysmal supraventricular tachycardia (Adenocard®): I.V. (rapid, over 1-2 seconds, via peripheral line): Initial: 6 mg; if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed (maximum single dose: 12 mg). Follow each dose with normal saline flush.
Recommended dosage adjustment for adenosine when administered via central line or with concurrent carbamazepine or dipyridamole (ACLS, 2005): Initial dose: 3 mg
Pharmacologic stress testing (Adenoscan®): I.V.: Continuous I.V. infusion via peripheral line: 140 mcg/kg/minute for 6 minutes using syringe or columetric infusion pump; total dose: 0.84 mg/kg. Thallium-201 is injected at midpoint (3 minutes) of infusion.
Acute vasodilator testing in pulmonary artery hypertension (unlabeled use) (Adenoscan®): I.V.: Initial: 50 mcg/kg/minute increased by 50 mcg/kg/minute every 2 minutes to a maximum dose of 500 mcg/kg/minute (Schrader, 1992) or to a maximum dose of 250 mcg/kg/minute (McLaughlin, 2009); acutely assess vasodilator response
DOSING: PEDIATRIC — Rapid I.V. push (over 1-2 seconds) via peripheral line:
(For additional information see "Adenosine: Pediatric drug information")
Paroxysmal supraventricular tachycardia (Adenocard®): Infants and Children:
Manufacturer's recommendation:
Children <50 kg: Initial: 0.05-0.1 mg/kg (maximum initial dose: 6 mg). If conversion of PSVT does not occur within 1-2 minutes, may increase dose by 0.05-0.1 mg/kg. May repeat until sinus rhythm is established or to a maximum single dose of 0.3 mg/kg or 12 mg. Follow each dose with normal saline flush.
Children ≥ 50 kg: Refer to adult dosing.
Pediatric advanced life support (PALS, 2005): Treatment of SVT: I.V., I.O.: Initial: 0.1 mg/kg (maximum initial dose: 6 mg); if not effective within 1-2 minutes, administer 0.2 mg/kg; may repeat 0.2 mg/kg if needed (maximum single dose: 12 mg). Follow each dose with normal saline flush.
DOSING: ELDERLY — Refer to adult dosing. Elderly may be more sensitive to effects of adenosine.
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL)
Adenocard®: 3 mg/mL (2 mL, 4 mL)
Adenoscan®: 3 mg/mL (20 mL, 30 mL)
DOSAGE FORMS: CONCISE
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL)
Adenocard®: 3 mg/mL (2 mL, 4 mL)
Adenoscan®: 3 mg/mL (20 mL, 30 mL)
GENERIC EQUIVALENT AVAILABLE — Yes
ADMINISTRATION — For rapid bolus I.V. use only; administer I.V. push over 1-2 seconds at a peripheral I.V. site as proximal as possible to trunk (not in lower arm, hand, lower leg, or foot); follow each bolus with a rapid normal saline flush (≥ 5 mL). Use of 2 syringes (one with adenosine dose and the other with NS flush) connected to a T-connector or stopcock is recommended (ACLS, 2005). Note: If administered via central line in adults, reduce initial dose to 3 mg (ACLS, 2005).
COMPATIBILITY — Stable in D5LR, D5W, LR, NS.
USE
Adenocard®: Treatment of paroxysmal supraventricular tachycardia (PSVT) including that associated with accessory bypass tracts (Wolff-Parkinson-White syndrome); when clinically advisable, appropriate vagal maneuvers should be attempted prior to adenosine administration; not effective for conversion of atrial fibrillation, atrial flutter, or ventricular tachycardia
Adenoscan®: Pharmacologic stress agent used in myocardial perfusion thallium-201 scintigraphy
USE - UNLABELED / INVESTIGATIONAL
ACLS/PALS Guidelines (2005):
Stable, narrow-complex AV nodal or sinus nodal reentry tachycardias (eg, reentry SVT);
Unstable reentry SVT while preparations are made for synchronized direct-current cardioversion;
Undefined, stable, narrow-complex SVT as a combination therapeutic and diagnostic maneuver;
Stable, wide-complex tachycardias in patients with a recurrence of a known reentry pathway that has been previously defined
Adenoscan®: Acute vasodilator testing in pulmonary artery hypertension
ADVERSE REACTIONS SIGNIFICANT — Note: Frequency varies based on use; higher frequency of infusion-related effects, such as flushing and lightheadedness, were reported with continuous infusion (Adenoscan®).
>10%:
Cardiovascular: Facial flushing (18% to 44%)
Central nervous system: Headache (2% to 18%), lightheadedness (2% to 12%)
Gastrointestinal: GI discomfort (13%)
Neuromuscular & skeletal: Discomfort of neck, throat, jaw (<1% to 15%)
Respiratory: Chest pressure/discomfort (7% to 40%), dyspnea (12% to 28%)
1% to 10%:
Cardiovascular: AV block (infusion 6%; third degree <1%), ST segment depression (3%), hypotension (<1% to 2%), palpitation, chest pain
Central nervous system: Nervousness (2%), apprehension, dizziness
Gastrointestinal: Nausea (3%)
Neuromuscular & skeletal: Upper extremity discomfort (up to 4%), numbness (up to 2%), paresthesia (up to 2%)
Respiratory: Hyperventilation
Miscellaneous: Diaphoresis
<1% (Limited to important or life-threatening): Asystole (prolonged), atrial fibrillation (upon termination of PSVT), back discomfort, bradycardia, bronchospasm, burning sensation, blurred vision, hypertension (transient), injection site reaction, intracranial pressure increased, lower extremity discomfort, metallic taste, pressure in groin, respiratory arrest, seizure, torsade de pointes, ventricular fibrillation, ventricular tachycardia
CONTRAINDICATIONS — Hypersensitivity to adenosine or any component of the formulation; second- or third-degree AV block or sick sinus syndrome (except in patients with a functioning artificial pacemaker); use in patients with atrial fibrillation/flutter with underlying Wolff-Parkinson-White (WPW) syndrome is considered to be contraindicated (Fuster, 2006)
In addition to the above, Adenoscan® should be avoided in patients with known or suspected bronchoconstrictive or bronchospastic lung disease.
WARNINGS / PRECAUTIONS
Concerns related to adverse effects: Atrial fibrillation/flutter: There have been reports of atrial fibrillation/flutter when administered to patients with paroxysmal supraventricular tachycardia (PSVT) and may be especially problematic in patients with PSVT and underlying Wolff-Parkinson-White syndrome. Conduction disturbances: Adenosine decreases conduction through the AV node and may produce first-, second-, or third-degree heart block. Patients with pre-existing S-A nodal dysfunction may experience prolonged sinus pauses after adenosine; use caution in patients with first-degree AV block or bundle branch block; avoid use of adenosine for pharmacologic stress testing in patients with high-grade AV block or sinus node dysfunction (unless a functional pacemaker is in place). Rare, prolonged episodes of asystole have been reported, with fatal outcomes in some cases. Hypotension: May produce profound vasodilation with subsequent hypotension. When used as a bolus dose (PSVT), effects are generally self-limiting (due to the short half-life of adenosine). However, when used as a continuous infusion (pharmacologic stress testing), effects may be more pronounced and persistent, corresponding to continued exposure. Use infusions with caution in patients with autonomic dysfunction, carotid stenosis (with cerebrovascular insufficiency), uncorrected hypovolemia, pericarditis, pleural effusion and/or stenotic valvular heart disease. Proarrhythmic effects: Monitor for proarrhythmic effects (eg, polymorphic ventricular tachycardia) during and shortly after administration/termination of arrhythmia. The benign transient occurrence of atrial and ventricular ectopy is common upon termination of arrhythmia.
Disease-related concerns: Electrolyte imbalance: Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy. Heart transplant recipients: Use with extreme caution in heart transplant recipients; adenosine may cause prolonged asystole; reduction of initial adenosine dose is recommended (ACLS, 2005); considered by some to be contraindicated in this setting (Delacretaz, 2006). Pulmonary artery hypertension: Acute vasodilator testing (not an approved use): Use with extreme caution in patients with concomitant heart failure (LV systolic dysfunction with significantly elevated left heart filling pressures) or pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis; significant decompensation has occurred with other highly selective pulmonary vasodilators resulting in acute pulmonary edema. Respiratory disease: Avoid use in patients with bronchoconstriction or bronchospasm (eg, asthma); mild-to-moderate exacerbations have been reported following use in a limited number of patients with asthma. Use caution in patients with obstructive lung disease not associated with bronchoconstriction (eg, emphysema, bronchitis); respiratory compromise has occurred during use. Wolff-Parkinson-White (WPW) syndrome: Use in patients with atrial fibrillation/flutter with underlying WPW syndrome is considered to be contraindicated since ventricular fibrillation may result (Fuster, 2006).
Concurrent drug therapy issues: Caffeine: Pharmacologic stress testing: Since caffeine antagonizes the activity of adenosine, withhold for 5 half-lives prior to adenosine use; avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing. Carbamazepine: Concomitant use potentiates the effects of adenosine; reduction of initial adenosine dose is recommended when used for SVT (ACLS, 2005). Dipyridamole: Concomitant use potentiates the effects of adenosine; reduction of initial adenosine dose is recommended when used for SVT (ACLS, 2005). Drugs which slow AV node conduction: Use with caution in patients receiving other drugs which slow AV node conduction (eg, digoxin, verapamil). Theophylline: Pharmacologic stress testing: Since theophylline antagonizes the activity of adenosine, withhold for 5 half-lives prior to adenosine use whenever possible.
Special populations: Elderly: Use with caution in the elderly; may be at increased risk of hemodynamic effects, bradycardia, and/or AV block.
Dosage form specific issues: Adenocard®: Transient AV block is expected. When used in PSVT, at the time of conversion to normal sinus rhythm, a variety of new rhythms may appear on the ECG. Administer as a rapid bolus, either directly into a vein or (if administered into an I.V. line), as close to the patient as possible (followed by saline flush).
Other warnings/precautions: Appropriate use: ECG monitoring is required during use. Equipment for resuscitation and trained personnel experienced in handling medical emergencies should always be immediately available. Adenosine does not convert atrial fibrillation/flutter to normal sinus rhythm; however, may be used diagnostically in these settings if the underlying rhythm is not apparent.
DRUG INTERACTIONS
CarBAMazepine: May enhance the adverse/toxic effect of Adenosine. Specifically, the risk of higher degree heart block may be increased. Management: Consider using a lower initial dose of adenosine in patients who are receiving carbamazepine. Risk D: Consider therapy modification
Dipyridamole: May enhance the therapeutic effect of Adenosine. Dose reduction of adenosine may be needed. Management: Reduction of the initial dose of adenosine may be warranted. Risk D: Consider therapy modification
Nicotine: May enhance the AV-blocking effect of Adenosine. Nicotine may enhance the tachycardic effect of Adenosine. Risk C: Monitor therapy
Theophylline Derivatives: May diminish the therapeutic effect of Adenosine. Risk D: Consider therapy modification
ETHANOL / NUTRITION / HERB INTERACTIONS — Food: Avoid food or drugs with caffeine. Adenosine's therapeutic effect may be decreased if used concurrently with caffeine. Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
PREGNANCY RISK FACTOR — C (show table)
PREGNANCY IMPLICATIONS — Reports of administration during pregnancy have indicated no adverse effects on fetus or newborn attributable to adenosine.
LACTATION — Excretion in breast milk unknown
DIETARY CONSIDERATIONS — Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
MONITORING PARAMETERS — ECG, heart rate, blood pressure
CANADIAN BRAND NAMES — Adenocard®; Adenoscan®; Adenosine Injection, USP
INTERNATIONAL BRAND NAMES — Adenocard (BR); Adenocor (AU, BE, BG, CZ, DK, EE, EG, ES, FI, GB, HN, HU, IE, IL, KP, LU, MY, NO, PE, PL, PT, SE, TH, TW, UY, VE, ZA); Adenocur (NL); Adenoject (IN); Adenoscan (ES, HK); Adenosin Ebewe (PL); Adenosina Biol (AR, PY); Adenozer (TW); Adrekar (AT, DE); Cardiovert (PH); Fosfobion (PL); Krenosin (FR, IT, LU, MX); Krenosine (CH); Soladen (PL); Tricor (CN)
MECHANISM OF ACTION — Slows conduction time through the AV node, interrupting the re-entry pathways through the AV node, restoring normal sinus rhythm
PHARMACODYNAMICS / KINETICS
Onset of action: Rapid
Duration: Very brief
Metabolism: Blood and tissue to inosine then to adenosine monophosphate (AMP) and hypoxanthine
Half-life elimination: <10 seconds
Showing posts with label Adenosine. Show all posts
Showing posts with label Adenosine. Show all posts
Monday, May 24, 2010
Adenosine
MEDICATION SAFETY ISSUES
High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.
U.S. BRAND NAMES — Adenocard®; Adenoscan®
PHARMACOLOGIC CATEGORY
Antiarrhythmic Agent, Class IV
Diagnostic Agent
DOSING: ADULTS
Paroxysmal supraventricular tachycardia (Adenocard®): I.V. (rapid, over 1-2 seconds, via peripheral line): Initial: 6 mg; if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed (maximum single dose: 12 mg). Follow each dose with normal saline flush.
Recommended dosage adjustment for adenosine when administered via central line or with concurrent carbamazepine or dipyridamole (ACLS, 2005): Initial dose: 3 mg
Pharmacologic stress testing (Adenoscan®): I.V.: Continuous I.V. infusion via peripheral line: 140 mcg/kg/minute for 6 minutes using syringe or columetric infusion pump; total dose: 0.84 mg/kg. Thallium-201 is injected at midpoint (3 minutes) of infusion.
Acute vasodilator testing in pulmonary artery hypertension (unlabeled use) (Adenoscan®): I.V.: Initial: 50 mcg/kg/minute increased by 50 mcg/kg/minute every 2 minutes to a maximum dose of 500 mcg/kg/minute (Schrader, 1992) or to a maximum dose of 250 mcg/kg/minute (McLaughlin, 2009); acutely assess vasodilator response
DOSING: PEDIATRIC — Rapid I.V. push (over 1-2 seconds) via peripheral line:
(For additional information see "Adenosine: Pediatric drug information")
Paroxysmal supraventricular tachycardia (Adenocard®): Infants and Children:
Manufacturer's recommendation:
Children <50 kg: Initial: 0.05-0.1 mg/kg (maximum initial dose: 6 mg). If conversion of PSVT does not occur within 1-2 minutes, may increase dose by 0.05-0.1 mg/kg. May repeat until sinus rhythm is established or to a maximum single dose of 0.3 mg/kg or 12 mg. Follow each dose with normal saline flush.
Children ≥ 50 kg: Refer to adult dosing.
Pediatric advanced life support (PALS, 2005): Treatment of SVT: I.V., I.O.: Initial: 0.1 mg/kg (maximum initial dose: 6 mg); if not effective within 1-2 minutes, administer 0.2 mg/kg; may repeat 0.2 mg/kg if needed (maximum single dose: 12 mg). Follow each dose with normal saline flush.
DOSING: ELDERLY — Refer to adult dosing. Elderly may be more sensitive to effects of adenosine.
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL)
Adenocard®: 3 mg/mL (2 mL, 4 mL)
Adenoscan®: 3 mg/mL (20 mL, 30 mL)
DOSAGE FORMS: CONCISE
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL)
Adenocard®: 3 mg/mL (2 mL, 4 mL)
Adenoscan®: 3 mg/mL (20 mL, 30 mL)
GENERIC EQUIVALENT AVAILABLE — Yes
ADMINISTRATION — For rapid bolus I.V. use only; administer I.V. push over 1-2 seconds at a peripheral I.V. site as proximal as possible to trunk (not in lower arm, hand, lower leg, or foot); follow each bolus with a rapid normal saline flush (≥ 5 mL). Use of 2 syringes (one with adenosine dose and the other with NS flush) connected to a T-connector or stopcock is recommended (ACLS, 2005). Note: If administered via central line in adults, reduce initial dose to 3 mg (ACLS, 2005).
COMPATIBILITY — Stable in D5LR, D5W, LR, NS.
USE
Adenocard®: Treatment of paroxysmal supraventricular tachycardia (PSVT) including that associated with accessory bypass tracts (Wolff-Parkinson-White syndrome); when clinically advisable, appropriate vagal maneuvers should be attempted prior to adenosine administration; not effective for conversion of atrial fibrillation, atrial flutter, or ventricular tachycardia
Adenoscan®: Pharmacologic stress agent used in myocardial perfusion thallium-201 scintigraphy
USE - UNLABELED / INVESTIGATIONAL
ACLS/PALS Guidelines (2005):
Stable, narrow-complex AV nodal or sinus nodal reentry tachycardias (eg, reentry SVT);
Unstable reentry SVT while preparations are made for synchronized direct-current cardioversion;
Undefined, stable, narrow-complex SVT as a combination therapeutic and diagnostic maneuver;
Stable, wide-complex tachycardias in patients with a recurrence of a known reentry pathway that has been previously defined
Adenoscan®: Acute vasodilator testing in pulmonary artery hypertension
ADVERSE REACTIONS SIGNIFICANT — Note: Frequency varies based on use; higher frequency of infusion-related effects, such as flushing and lightheadedness, were reported with continuous infusion (Adenoscan®).
>10%:
Cardiovascular: Facial flushing (18% to 44%)
Central nervous system: Headache (2% to 18%), lightheadedness (2% to 12%)
Gastrointestinal: GI discomfort (13%)
Neuromuscular & skeletal: Discomfort of neck, throat, jaw (<1% to 15%)
Respiratory: Chest pressure/discomfort (7% to 40%), dyspnea (12% to 28%)
1% to 10%:
Cardiovascular: AV block (infusion 6%; third degree <1%), ST segment depression (3%), hypotension (<1% to 2%), palpitation, chest pain
Central nervous system: Nervousness (2%), apprehension, dizziness
Gastrointestinal: Nausea (3%)
Neuromuscular & skeletal: Upper extremity discomfort (up to 4%), numbness (up to 2%), paresthesia (up to 2%)
Respiratory: Hyperventilation
Miscellaneous: Diaphoresis
<1% (Limited to important or life-threatening): Asystole (prolonged), atrial fibrillation (upon termination of PSVT), back discomfort, bradycardia, bronchospasm, burning sensation, blurred vision, hypertension (transient), injection site reaction, intracranial pressure increased, lower extremity discomfort, metallic taste, pressure in groin, respiratory arrest, seizure, torsade de pointes, ventricular fibrillation, ventricular tachycardia
CONTRAINDICATIONS — Hypersensitivity to adenosine or any component of the formulation; second- or third-degree AV block or sick sinus syndrome (except in patients with a functioning artificial pacemaker); use in patients with atrial fibrillation/flutter with underlying Wolff-Parkinson-White (WPW) syndrome is considered to be contraindicated (Fuster, 2006)
In addition to the above, Adenoscan® should be avoided in patients with known or suspected bronchoconstrictive or bronchospastic lung disease.
WARNINGS / PRECAUTIONS
Concerns related to adverse effects: Atrial fibrillation/flutter: There have been reports of atrial fibrillation/flutter when administered to patients with paroxysmal supraventricular tachycardia (PSVT) and may be especially problematic in patients with PSVT and underlying Wolff-Parkinson-White syndrome. Conduction disturbances: Adenosine decreases conduction through the AV node and may produce first-, second-, or third-degree heart block. Patients with pre-existing S-A nodal dysfunction may experience prolonged sinus pauses after adenosine; use caution in patients with first-degree AV block or bundle branch block; avoid use of adenosine for pharmacologic stress testing in patients with high-grade AV block or sinus node dysfunction (unless a functional pacemaker is in place). Rare, prolonged episodes of asystole have been reported, with fatal outcomes in some cases. Hypotension: May produce profound vasodilation with subsequent hypotension. When used as a bolus dose (PSVT), effects are generally self-limiting (due to the short half-life of adenosine). However, when used as a continuous infusion (pharmacologic stress testing), effects may be more pronounced and persistent, corresponding to continued exposure. Use infusions with caution in patients with autonomic dysfunction, carotid stenosis (with cerebrovascular insufficiency), uncorrected hypovolemia, pericarditis, pleural effusion and/or stenotic valvular heart disease. Proarrhythmic effects: Monitor for proarrhythmic effects (eg, polymorphic ventricular tachycardia) during and shortly after administration/termination of arrhythmia. The benign transient occurrence of atrial and ventricular ectopy is common upon termination of arrhythmia.
Disease-related concerns: Electrolyte imbalance: Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy. Heart transplant recipients: Use with extreme caution in heart transplant recipients; adenosine may cause prolonged asystole; reduction of initial adenosine dose is recommended (ACLS, 2005); considered by some to be contraindicated in this setting (Delacretaz, 2006). Pulmonary artery hypertension: Acute vasodilator testing (not an approved use): Use with extreme caution in patients with concomitant heart failure (LV systolic dysfunction with significantly elevated left heart filling pressures) or pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis; significant decompensation has occurred with other highly selective pulmonary vasodilators resulting in acute pulmonary edema. Respiratory disease: Avoid use in patients with bronchoconstriction or bronchospasm (eg, asthma); mild-to-moderate exacerbations have been reported following use in a limited number of patients with asthma. Use caution in patients with obstructive lung disease not associated with bronchoconstriction (eg, emphysema, bronchitis); respiratory compromise has occurred during use. Wolff-Parkinson-White (WPW) syndrome: Use in patients with atrial fibrillation/flutter with underlying WPW syndrome is considered to be contraindicated since ventricular fibrillation may result (Fuster, 2006).
Concurrent drug therapy issues: Caffeine: Pharmacologic stress testing: Since caffeine antagonizes the activity of adenosine, withhold for 5 half-lives prior to adenosine use; avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing. Carbamazepine: Concomitant use potentiates the effects of adenosine; reduction of initial adenosine dose is recommended when used for SVT (ACLS, 2005). Dipyridamole: Concomitant use potentiates the effects of adenosine; reduction of initial adenosine dose is recommended when used for SVT (ACLS, 2005). Drugs which slow AV node conduction: Use with caution in patients receiving other drugs which slow AV node conduction (eg, digoxin, verapamil). Theophylline: Pharmacologic stress testing: Since theophylline antagonizes the activity of adenosine, withhold for 5 half-lives prior to adenosine use whenever possible.
Special populations: Elderly: Use with caution in the elderly; may be at increased risk of hemodynamic effects, bradycardia, and/or AV block.
Dosage form specific issues: Adenocard®: Transient AV block is expected. When used in PSVT, at the time of conversion to normal sinus rhythm, a variety of new rhythms may appear on the ECG. Administer as a rapid bolus, either directly into a vein or (if administered into an I.V. line), as close to the patient as possible (followed by saline flush).
Other warnings/precautions: Appropriate use: ECG monitoring is required during use. Equipment for resuscitation and trained personnel experienced in handling medical emergencies should always be immediately available. Adenosine does not convert atrial fibrillation/flutter to normal sinus rhythm; however, may be used diagnostically in these settings if the underlying rhythm is not apparent.
DRUG INTERACTIONS
CarBAMazepine: May enhance the adverse/toxic effect of Adenosine. Specifically, the risk of higher degree heart block may be increased. Management: Consider using a lower initial dose of adenosine in patients who are receiving carbamazepine. Risk D: Consider therapy modification
Dipyridamole: May enhance the therapeutic effect of Adenosine. Dose reduction of adenosine may be needed. Management: Reduction of the initial dose of adenosine may be warranted. Risk D: Consider therapy modification
Nicotine: May enhance the AV-blocking effect of Adenosine. Nicotine may enhance the tachycardic effect of Adenosine. Risk C: Monitor therapy
Theophylline Derivatives: May diminish the therapeutic effect of Adenosine. Risk D: Consider therapy modification
ETHANOL / NUTRITION / HERB INTERACTIONS — Food: Avoid food or drugs with caffeine. Adenosine's therapeutic effect may be decreased if used concurrently with caffeine. Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
PREGNANCY RISK FACTOR — C (show table)
PREGNANCY IMPLICATIONS — Reports of administration during pregnancy have indicated no adverse effects on fetus or newborn attributable to adenosine.
LACTATION — Excretion in breast milk unknown
DIETARY CONSIDERATIONS — Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
MONITORING PARAMETERS — ECG, heart rate, blood pressure
CANADIAN BRAND NAMES — Adenocard®; Adenoscan®; Adenosine Injection, USP
INTERNATIONAL BRAND NAMES — Adenocard (BR); Adenocor (AU, BE, BG, CZ, DK, EE, EG, ES, FI, GB, HN, HU, IE, IL, KP, LU, MY, NO, PE, PL, PT, SE, TH, TW, UY, VE, ZA); Adenocur (NL); Adenoject (IN); Adenoscan (ES, HK); Adenosin Ebewe (PL); Adenosina Biol (AR, PY); Adenozer (TW); Adrekar (AT, DE); Cardiovert (PH); Fosfobion (PL); Krenosin (FR, IT, LU, MX); Krenosine (CH); Soladen (PL); Tricor (CN)
MECHANISM OF ACTION — Slows conduction time through the AV node, interrupting the re-entry pathways through the AV node, restoring normal sinus rhythm
PHARMACODYNAMICS / KINETICS
Onset of action: Rapid
Duration: Very brief
Metabolism: Blood and tissue to inosine then to adenosine monophosphate (AMP) and hypoxanthine
Half-life elimination: <10 seconds
High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.
U.S. BRAND NAMES — Adenocard®; Adenoscan®
PHARMACOLOGIC CATEGORY
Antiarrhythmic Agent, Class IV
Diagnostic Agent
DOSING: ADULTS
Paroxysmal supraventricular tachycardia (Adenocard®): I.V. (rapid, over 1-2 seconds, via peripheral line): Initial: 6 mg; if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed (maximum single dose: 12 mg). Follow each dose with normal saline flush.
Recommended dosage adjustment for adenosine when administered via central line or with concurrent carbamazepine or dipyridamole (ACLS, 2005): Initial dose: 3 mg
Pharmacologic stress testing (Adenoscan®): I.V.: Continuous I.V. infusion via peripheral line: 140 mcg/kg/minute for 6 minutes using syringe or columetric infusion pump; total dose: 0.84 mg/kg. Thallium-201 is injected at midpoint (3 minutes) of infusion.
Acute vasodilator testing in pulmonary artery hypertension (unlabeled use) (Adenoscan®): I.V.: Initial: 50 mcg/kg/minute increased by 50 mcg/kg/minute every 2 minutes to a maximum dose of 500 mcg/kg/minute (Schrader, 1992) or to a maximum dose of 250 mcg/kg/minute (McLaughlin, 2009); acutely assess vasodilator response
DOSING: PEDIATRIC — Rapid I.V. push (over 1-2 seconds) via peripheral line:
(For additional information see "Adenosine: Pediatric drug information")
Paroxysmal supraventricular tachycardia (Adenocard®): Infants and Children:
Manufacturer's recommendation:
Children <50 kg: Initial: 0.05-0.1 mg/kg (maximum initial dose: 6 mg). If conversion of PSVT does not occur within 1-2 minutes, may increase dose by 0.05-0.1 mg/kg. May repeat until sinus rhythm is established or to a maximum single dose of 0.3 mg/kg or 12 mg. Follow each dose with normal saline flush.
Children ≥ 50 kg: Refer to adult dosing.
Pediatric advanced life support (PALS, 2005): Treatment of SVT: I.V., I.O.: Initial: 0.1 mg/kg (maximum initial dose: 6 mg); if not effective within 1-2 minutes, administer 0.2 mg/kg; may repeat 0.2 mg/kg if needed (maximum single dose: 12 mg). Follow each dose with normal saline flush.
DOSING: ELDERLY — Refer to adult dosing. Elderly may be more sensitive to effects of adenosine.
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL)
Adenocard®: 3 mg/mL (2 mL, 4 mL)
Adenoscan®: 3 mg/mL (20 mL, 30 mL)
DOSAGE FORMS: CONCISE
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL)
Adenocard®: 3 mg/mL (2 mL, 4 mL)
Adenoscan®: 3 mg/mL (20 mL, 30 mL)
GENERIC EQUIVALENT AVAILABLE — Yes
ADMINISTRATION — For rapid bolus I.V. use only; administer I.V. push over 1-2 seconds at a peripheral I.V. site as proximal as possible to trunk (not in lower arm, hand, lower leg, or foot); follow each bolus with a rapid normal saline flush (≥ 5 mL). Use of 2 syringes (one with adenosine dose and the other with NS flush) connected to a T-connector or stopcock is recommended (ACLS, 2005). Note: If administered via central line in adults, reduce initial dose to 3 mg (ACLS, 2005).
COMPATIBILITY — Stable in D5LR, D5W, LR, NS.
USE
Adenocard®: Treatment of paroxysmal supraventricular tachycardia (PSVT) including that associated with accessory bypass tracts (Wolff-Parkinson-White syndrome); when clinically advisable, appropriate vagal maneuvers should be attempted prior to adenosine administration; not effective for conversion of atrial fibrillation, atrial flutter, or ventricular tachycardia
Adenoscan®: Pharmacologic stress agent used in myocardial perfusion thallium-201 scintigraphy
USE - UNLABELED / INVESTIGATIONAL
ACLS/PALS Guidelines (2005):
Stable, narrow-complex AV nodal or sinus nodal reentry tachycardias (eg, reentry SVT);
Unstable reentry SVT while preparations are made for synchronized direct-current cardioversion;
Undefined, stable, narrow-complex SVT as a combination therapeutic and diagnostic maneuver;
Stable, wide-complex tachycardias in patients with a recurrence of a known reentry pathway that has been previously defined
Adenoscan®: Acute vasodilator testing in pulmonary artery hypertension
ADVERSE REACTIONS SIGNIFICANT — Note: Frequency varies based on use; higher frequency of infusion-related effects, such as flushing and lightheadedness, were reported with continuous infusion (Adenoscan®).
>10%:
Cardiovascular: Facial flushing (18% to 44%)
Central nervous system: Headache (2% to 18%), lightheadedness (2% to 12%)
Gastrointestinal: GI discomfort (13%)
Neuromuscular & skeletal: Discomfort of neck, throat, jaw (<1% to 15%)
Respiratory: Chest pressure/discomfort (7% to 40%), dyspnea (12% to 28%)
1% to 10%:
Cardiovascular: AV block (infusion 6%; third degree <1%), ST segment depression (3%), hypotension (<1% to 2%), palpitation, chest pain
Central nervous system: Nervousness (2%), apprehension, dizziness
Gastrointestinal: Nausea (3%)
Neuromuscular & skeletal: Upper extremity discomfort (up to 4%), numbness (up to 2%), paresthesia (up to 2%)
Respiratory: Hyperventilation
Miscellaneous: Diaphoresis
<1% (Limited to important or life-threatening): Asystole (prolonged), atrial fibrillation (upon termination of PSVT), back discomfort, bradycardia, bronchospasm, burning sensation, blurred vision, hypertension (transient), injection site reaction, intracranial pressure increased, lower extremity discomfort, metallic taste, pressure in groin, respiratory arrest, seizure, torsade de pointes, ventricular fibrillation, ventricular tachycardia
CONTRAINDICATIONS — Hypersensitivity to adenosine or any component of the formulation; second- or third-degree AV block or sick sinus syndrome (except in patients with a functioning artificial pacemaker); use in patients with atrial fibrillation/flutter with underlying Wolff-Parkinson-White (WPW) syndrome is considered to be contraindicated (Fuster, 2006)
In addition to the above, Adenoscan® should be avoided in patients with known or suspected bronchoconstrictive or bronchospastic lung disease.
WARNINGS / PRECAUTIONS
Concerns related to adverse effects: Atrial fibrillation/flutter: There have been reports of atrial fibrillation/flutter when administered to patients with paroxysmal supraventricular tachycardia (PSVT) and may be especially problematic in patients with PSVT and underlying Wolff-Parkinson-White syndrome. Conduction disturbances: Adenosine decreases conduction through the AV node and may produce first-, second-, or third-degree heart block. Patients with pre-existing S-A nodal dysfunction may experience prolonged sinus pauses after adenosine; use caution in patients with first-degree AV block or bundle branch block; avoid use of adenosine for pharmacologic stress testing in patients with high-grade AV block or sinus node dysfunction (unless a functional pacemaker is in place). Rare, prolonged episodes of asystole have been reported, with fatal outcomes in some cases. Hypotension: May produce profound vasodilation with subsequent hypotension. When used as a bolus dose (PSVT), effects are generally self-limiting (due to the short half-life of adenosine). However, when used as a continuous infusion (pharmacologic stress testing), effects may be more pronounced and persistent, corresponding to continued exposure. Use infusions with caution in patients with autonomic dysfunction, carotid stenosis (with cerebrovascular insufficiency), uncorrected hypovolemia, pericarditis, pleural effusion and/or stenotic valvular heart disease. Proarrhythmic effects: Monitor for proarrhythmic effects (eg, polymorphic ventricular tachycardia) during and shortly after administration/termination of arrhythmia. The benign transient occurrence of atrial and ventricular ectopy is common upon termination of arrhythmia.
Disease-related concerns: Electrolyte imbalance: Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy. Heart transplant recipients: Use with extreme caution in heart transplant recipients; adenosine may cause prolonged asystole; reduction of initial adenosine dose is recommended (ACLS, 2005); considered by some to be contraindicated in this setting (Delacretaz, 2006). Pulmonary artery hypertension: Acute vasodilator testing (not an approved use): Use with extreme caution in patients with concomitant heart failure (LV systolic dysfunction with significantly elevated left heart filling pressures) or pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis; significant decompensation has occurred with other highly selective pulmonary vasodilators resulting in acute pulmonary edema. Respiratory disease: Avoid use in patients with bronchoconstriction or bronchospasm (eg, asthma); mild-to-moderate exacerbations have been reported following use in a limited number of patients with asthma. Use caution in patients with obstructive lung disease not associated with bronchoconstriction (eg, emphysema, bronchitis); respiratory compromise has occurred during use. Wolff-Parkinson-White (WPW) syndrome: Use in patients with atrial fibrillation/flutter with underlying WPW syndrome is considered to be contraindicated since ventricular fibrillation may result (Fuster, 2006).
Concurrent drug therapy issues: Caffeine: Pharmacologic stress testing: Since caffeine antagonizes the activity of adenosine, withhold for 5 half-lives prior to adenosine use; avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing. Carbamazepine: Concomitant use potentiates the effects of adenosine; reduction of initial adenosine dose is recommended when used for SVT (ACLS, 2005). Dipyridamole: Concomitant use potentiates the effects of adenosine; reduction of initial adenosine dose is recommended when used for SVT (ACLS, 2005). Drugs which slow AV node conduction: Use with caution in patients receiving other drugs which slow AV node conduction (eg, digoxin, verapamil). Theophylline: Pharmacologic stress testing: Since theophylline antagonizes the activity of adenosine, withhold for 5 half-lives prior to adenosine use whenever possible.
Special populations: Elderly: Use with caution in the elderly; may be at increased risk of hemodynamic effects, bradycardia, and/or AV block.
Dosage form specific issues: Adenocard®: Transient AV block is expected. When used in PSVT, at the time of conversion to normal sinus rhythm, a variety of new rhythms may appear on the ECG. Administer as a rapid bolus, either directly into a vein or (if administered into an I.V. line), as close to the patient as possible (followed by saline flush).
Other warnings/precautions: Appropriate use: ECG monitoring is required during use. Equipment for resuscitation and trained personnel experienced in handling medical emergencies should always be immediately available. Adenosine does not convert atrial fibrillation/flutter to normal sinus rhythm; however, may be used diagnostically in these settings if the underlying rhythm is not apparent.
DRUG INTERACTIONS
CarBAMazepine: May enhance the adverse/toxic effect of Adenosine. Specifically, the risk of higher degree heart block may be increased. Management: Consider using a lower initial dose of adenosine in patients who are receiving carbamazepine. Risk D: Consider therapy modification
Dipyridamole: May enhance the therapeutic effect of Adenosine. Dose reduction of adenosine may be needed. Management: Reduction of the initial dose of adenosine may be warranted. Risk D: Consider therapy modification
Nicotine: May enhance the AV-blocking effect of Adenosine. Nicotine may enhance the tachycardic effect of Adenosine. Risk C: Monitor therapy
Theophylline Derivatives: May diminish the therapeutic effect of Adenosine. Risk D: Consider therapy modification
ETHANOL / NUTRITION / HERB INTERACTIONS — Food: Avoid food or drugs with caffeine. Adenosine's therapeutic effect may be decreased if used concurrently with caffeine. Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
PREGNANCY RISK FACTOR — C (show table)
PREGNANCY IMPLICATIONS — Reports of administration during pregnancy have indicated no adverse effects on fetus or newborn attributable to adenosine.
LACTATION — Excretion in breast milk unknown
DIETARY CONSIDERATIONS — Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
MONITORING PARAMETERS — ECG, heart rate, blood pressure
CANADIAN BRAND NAMES — Adenocard®; Adenoscan®; Adenosine Injection, USP
INTERNATIONAL BRAND NAMES — Adenocard (BR); Adenocor (AU, BE, BG, CZ, DK, EE, EG, ES, FI, GB, HN, HU, IE, IL, KP, LU, MY, NO, PE, PL, PT, SE, TH, TW, UY, VE, ZA); Adenocur (NL); Adenoject (IN); Adenoscan (ES, HK); Adenosin Ebewe (PL); Adenosina Biol (AR, PY); Adenozer (TW); Adrekar (AT, DE); Cardiovert (PH); Fosfobion (PL); Krenosin (FR, IT, LU, MX); Krenosine (CH); Soladen (PL); Tricor (CN)
MECHANISM OF ACTION — Slows conduction time through the AV node, interrupting the re-entry pathways through the AV node, restoring normal sinus rhythm
PHARMACODYNAMICS / KINETICS
Onset of action: Rapid
Duration: Very brief
Metabolism: Blood and tissue to inosine then to adenosine monophosphate (AMP) and hypoxanthine
Half-life elimination: <10 seconds
Thursday, January 31, 2008
Adenosine
U.S. BRAND NAMES — Adenocard®; Adenoscan®
CANADIAN BRAND NAMES — Adenocard®; Adenoscan®; Adenosine Injection, USP
SYNONYMS — 9-Beta-D-ribofuranosyladenine
THERAPEUTIC CATEGORY Antiarrhythmic Agent, Miscellaneous
DOSING — Note: Adequate controlled studies in pediatric patients have not been conducted.
(For additional information see "Adenosine: Drug information")
Manufacturer's recommendations: Rapid I.V.: Neonates, Infants, Children, and Adolescents weighing <50 kg: Initial dose: 0.05-0.1 mg/kg; if not effective within 1-2 minutes, increase dose by 0.05-0.1 mg/kg increments every 1-2 minutes to a maximum single dose of 0.3 mg/kg or until termination of PSVT Children and Adolescents weighing 50 kg and Adults: 6 mg, if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed
Alternative pediatric dosing: Neonates: Rapid I.V.: Initial dose: 0.05 mg/kg; if not effective within 2 minutes, increase dose by 0.05 mg/kg increments every 2 minutes to a maximum dose of 0.25 mg/kg or until termination of PSVT Infants and Children: PALS dose for treatment of SVT: Rapid I.V.; I.O.: Initial: 0.1 mg/kg (maximum: 6 mg); if not effective, give 0.2 mg/kg (maximum: 12 mg)
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
GENERIC AVAILABLE — Yes
ADMINISTRATION — Parenteral: For rapid bolus I.V. use, administer over 1-2 seconds at peripheral I.V. site closest to patient's heart (I.V. administration into lower extremities may result in therapeutic failure or requirement of higher doses); follow each bolus with NS flush (infants and children: 5-10 mL; adults: 20 mL); if given peripherally in adults, elevate the extremity for 10-20 seconds after the NS flush. To administer doses <600 mcg (0.2 mL of commercial product), a dilution with NS (final concentration: 300 mcg/mL) may be made. Note: Preliminary results in adults suggest adenosine may be administered via a central line at lower doses (eg, Adults: Initial dose: 3 mg); FDA approved labeling for pediatric patients weighing <50 kg states that doses listed may be administered either peripherally or centrally (further studies are needed)
USE — Treatment of paroxysmal supraventricular tachycardia (PSVT); used in adult ACLS algorithms for narrow-complex tachycardias, stable narrow-complex supraventricular tachycardias, and wide-complex tachycardias that are supraventricular in origin; used in PALS algorithms for probable supraventricular tachycardia; investigationally used as a continuous infusion for the treatment of primary pulmonary hypertension in adults and persistent pulmonary hypertension of the newborn (PPHN) (see Additional Information)
ADVERSE REACTIONS Cardiovascular: Flushing, arrhythmias, palpitations, chest pain, bradycardia, heart block, minimal hemodynamic disturbances, hypotension (<1%)
Central nervous system: Irritability, headaches, lightheadedness, dizziness
Gastrointestinal: Nausea, metallic taste
Respiratory: Dyspnea, hyperventilation, bronchoconstriction in asthmatics
CONTRAINDICATIONS — Hypersensitivity to adenosine or any component; second and third degree A-V block or sick sinus syndrome unless pacemaker placed
PRECAUTIONS — Bronchoconstriction may occur in asthmatics (avoid use in patients with bronchospasm or bronchoconstriction); use with caution in patients with underlying dysfunction of sinus or A-V node, obstructive lung disease, and those taking digoxin or verapamil; initial adenosine dose should be significantly decreased in patients receiving dipyridamole
WARNINGS — Heart block, including transient or prolonged asystole may occur as well as other arrhythmias; episodes of asystole or other arrhythmias may be fatal; if arrhythmia is not due to re-entry pathway through A-V node or sinus node (ie, atrial fibrillation, flutter, or tachycardia or ventricular tachycardia), adenosine will not terminate the arrhythmia but can produce transient ventriculoatrial or A-V block; possible mutagenic effects
DRUG INTERACTIONS — Dipyridamole potentiates effects of adenosine (dose of adenosine should be significantly reduced); methylxanthines (aminophylline, theophylline, caffeine) antagonize adenosine's effects so that larger doses of adenosine or an alternative agent may be required; carbamazepine may increase heart block; digoxin and verapamil may cause ventricular fibrillation (rare cases reported)
PREGNANCY RISK FACTOR — C (show table)
MONITORING PARAMETERS — Continuous EKG, heart rate, blood pressure, respirations
STABILITY — Do not refrigerate, precipitation may occur; contains no preservatives, discard unused portion
MECHANISM OF ACTION — Slows conduction time through the A-V node, interrupting the re-entry pathways through the A-V node, restoring normal sinus rhythm
PHARMACODYNAMICS Onset of action: Rapid
Duration: Very brief
PHARMACOKINETICS Metabolism: Removed from systemic circulation primarily by vascular endothelial cells and erythrocytes (by cellular uptake); rapidly metabolized intracellularly; phosphorylated by adenosine kinase to adenosine monophosphate (AMP) which is then incorporated into high-energy pool; intracellular adenosine is also deaminated by adenosine deaminase to inosine; inosine can be metabolized to hypoxanthine, then xanthine and finally to uric acid.
Half-life: <10 seconds
NURSING IMPLICATIONS — Be alert for dyspnea, shortness of breath, and possible exacerbation of asthma
ADDITIONAL INFORMATION — Not effective in atrial flutter, atrial fibrillation, or ventricular tachycardia; short duration of action is an advantage as adverse effects are usually rapidly self-limiting; effects may be prolonged in patients with denervated transplanted hearts. Individualize treatment of prolonged adverse effects: Give I.V. fluids for hypotension, aminophylline/theophylline may antagonize effects.
Limited information is available regarding the use of adenosine for the treatment of persistent pulmonary hypertension of the newborn (PPHN); efficacy, optimal dose, and duration of therapy is not established; a randomized, masked, placebo-controlled pilot study of 18 term infants with PPHN used initial doses of 25 mcg/kg/minute (n=9); after 30 minutes, doses were increased to 50 mcg/kg/minute if no improvement in PaO2 was observed; all patients received study drug via central line into the right atrium (inserted via the umbilical vein); significant improvement in oxygenation was observed in 4 of 9 newborns receiving 50 mcg/kg/minute; hypotension or tachycardia were not observed; further studies are needed (Kondur, 1996).
Adenosine is also available as Adenoscan®, which is used in adults as an adjunct to thallium-201 myocardial perfusion scintigraphy; see package insert for further information on this use.
CANADIAN BRAND NAMES — Adenocard®; Adenoscan®; Adenosine Injection, USP
SYNONYMS — 9-Beta-D-ribofuranosyladenine
THERAPEUTIC CATEGORY Antiarrhythmic Agent, Miscellaneous
DOSING — Note: Adequate controlled studies in pediatric patients have not been conducted.
(For additional information see "Adenosine: Drug information")
Manufacturer's recommendations: Rapid I.V.: Neonates, Infants, Children, and Adolescents weighing <50 kg: Initial dose: 0.05-0.1 mg/kg; if not effective within 1-2 minutes, increase dose by 0.05-0.1 mg/kg increments every 1-2 minutes to a maximum single dose of 0.3 mg/kg or until termination of PSVT Children and Adolescents weighing 50 kg and Adults: 6 mg, if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed
Alternative pediatric dosing: Neonates: Rapid I.V.: Initial dose: 0.05 mg/kg; if not effective within 2 minutes, increase dose by 0.05 mg/kg increments every 2 minutes to a maximum dose of 0.25 mg/kg or until termination of PSVT Infants and Children: PALS dose for treatment of SVT: Rapid I.V.; I.O.: Initial: 0.1 mg/kg (maximum: 6 mg); if not effective, give 0.2 mg/kg (maximum: 12 mg)
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
GENERIC AVAILABLE — Yes
ADMINISTRATION — Parenteral: For rapid bolus I.V. use, administer over 1-2 seconds at peripheral I.V. site closest to patient's heart (I.V. administration into lower extremities may result in therapeutic failure or requirement of higher doses); follow each bolus with NS flush (infants and children: 5-10 mL; adults: 20 mL); if given peripherally in adults, elevate the extremity for 10-20 seconds after the NS flush. To administer doses <600 mcg (0.2 mL of commercial product), a dilution with NS (final concentration: 300 mcg/mL) may be made. Note: Preliminary results in adults suggest adenosine may be administered via a central line at lower doses (eg, Adults: Initial dose: 3 mg); FDA approved labeling for pediatric patients weighing <50 kg states that doses listed may be administered either peripherally or centrally (further studies are needed)
USE — Treatment of paroxysmal supraventricular tachycardia (PSVT); used in adult ACLS algorithms for narrow-complex tachycardias, stable narrow-complex supraventricular tachycardias, and wide-complex tachycardias that are supraventricular in origin; used in PALS algorithms for probable supraventricular tachycardia; investigationally used as a continuous infusion for the treatment of primary pulmonary hypertension in adults and persistent pulmonary hypertension of the newborn (PPHN) (see Additional Information)
ADVERSE REACTIONS Cardiovascular: Flushing, arrhythmias, palpitations, chest pain, bradycardia, heart block, minimal hemodynamic disturbances, hypotension (<1%)
Central nervous system: Irritability, headaches, lightheadedness, dizziness
Gastrointestinal: Nausea, metallic taste
Respiratory: Dyspnea, hyperventilation, bronchoconstriction in asthmatics
CONTRAINDICATIONS — Hypersensitivity to adenosine or any component; second and third degree A-V block or sick sinus syndrome unless pacemaker placed
PRECAUTIONS — Bronchoconstriction may occur in asthmatics (avoid use in patients with bronchospasm or bronchoconstriction); use with caution in patients with underlying dysfunction of sinus or A-V node, obstructive lung disease, and those taking digoxin or verapamil; initial adenosine dose should be significantly decreased in patients receiving dipyridamole
WARNINGS — Heart block, including transient or prolonged asystole may occur as well as other arrhythmias; episodes of asystole or other arrhythmias may be fatal; if arrhythmia is not due to re-entry pathway through A-V node or sinus node (ie, atrial fibrillation, flutter, or tachycardia or ventricular tachycardia), adenosine will not terminate the arrhythmia but can produce transient ventriculoatrial or A-V block; possible mutagenic effects
DRUG INTERACTIONS — Dipyridamole potentiates effects of adenosine (dose of adenosine should be significantly reduced); methylxanthines (aminophylline, theophylline, caffeine) antagonize adenosine's effects so that larger doses of adenosine or an alternative agent may be required; carbamazepine may increase heart block; digoxin and verapamil may cause ventricular fibrillation (rare cases reported)
PREGNANCY RISK FACTOR — C (show table)
MONITORING PARAMETERS — Continuous EKG, heart rate, blood pressure, respirations
STABILITY — Do not refrigerate, precipitation may occur; contains no preservatives, discard unused portion
MECHANISM OF ACTION — Slows conduction time through the A-V node, interrupting the re-entry pathways through the A-V node, restoring normal sinus rhythm
PHARMACODYNAMICS Onset of action: Rapid
Duration: Very brief
PHARMACOKINETICS Metabolism: Removed from systemic circulation primarily by vascular endothelial cells and erythrocytes (by cellular uptake); rapidly metabolized intracellularly; phosphorylated by adenosine kinase to adenosine monophosphate (AMP) which is then incorporated into high-energy pool; intracellular adenosine is also deaminated by adenosine deaminase to inosine; inosine can be metabolized to hypoxanthine, then xanthine and finally to uric acid.
Half-life: <10 seconds
NURSING IMPLICATIONS — Be alert for dyspnea, shortness of breath, and possible exacerbation of asthma
ADDITIONAL INFORMATION — Not effective in atrial flutter, atrial fibrillation, or ventricular tachycardia; short duration of action is an advantage as adverse effects are usually rapidly self-limiting; effects may be prolonged in patients with denervated transplanted hearts. Individualize treatment of prolonged adverse effects: Give I.V. fluids for hypotension, aminophylline/theophylline may antagonize effects.
Limited information is available regarding the use of adenosine for the treatment of persistent pulmonary hypertension of the newborn (PPHN); efficacy, optimal dose, and duration of therapy is not established; a randomized, masked, placebo-controlled pilot study of 18 term infants with PPHN used initial doses of 25 mcg/kg/minute (n=9); after 30 minutes, doses were increased to 50 mcg/kg/minute if no improvement in PaO2 was observed; all patients received study drug via central line into the right atrium (inserted via the umbilical vein); significant improvement in oxygenation was observed in 4 of 9 newborns receiving 50 mcg/kg/minute; hypotension or tachycardia were not observed; further studies are needed (Kondur, 1996).
Adenosine is also available as Adenoscan®, which is used in adults as an adjunct to thallium-201 myocardial perfusion scintigraphy; see package insert for further information on this use.
Adenosine
U.S. BRAND NAMES — Adenocard®; Adenoscan®
CANADIAN BRAND NAMES — Adenocard®; Adenoscan®; Adenosine Injection, USP
SYNONYMS — 9-Beta-D-ribofuranosyladenine
THERAPEUTIC CATEGORY Antiarrhythmic Agent, Miscellaneous
DOSING — Note: Adequate controlled studies in pediatric patients have not been conducted.
(For additional information see "Adenosine: Drug information")
Manufacturer's recommendations: Rapid I.V.: Neonates, Infants, Children, and Adolescents weighing <50 kg: Initial dose: 0.05-0.1 mg/kg; if not effective within 1-2 minutes, increase dose by 0.05-0.1 mg/kg increments every 1-2 minutes to a maximum single dose of 0.3 mg/kg or until termination of PSVT Children and Adolescents weighing 50 kg and Adults: 6 mg, if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed
Alternative pediatric dosing: Neonates: Rapid I.V.: Initial dose: 0.05 mg/kg; if not effective within 2 minutes, increase dose by 0.05 mg/kg increments every 2 minutes to a maximum dose of 0.25 mg/kg or until termination of PSVT Infants and Children: PALS dose for treatment of SVT: Rapid I.V.; I.O.: Initial: 0.1 mg/kg (maximum: 6 mg); if not effective, give 0.2 mg/kg (maximum: 12 mg)
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
GENERIC AVAILABLE — Yes
ADMINISTRATION — Parenteral: For rapid bolus I.V. use, administer over 1-2 seconds at peripheral I.V. site closest to patient's heart (I.V. administration into lower extremities may result in therapeutic failure or requirement of higher doses); follow each bolus with NS flush (infants and children: 5-10 mL; adults: 20 mL); if given peripherally in adults, elevate the extremity for 10-20 seconds after the NS flush. To administer doses <600 mcg (0.2 mL of commercial product), a dilution with NS (final concentration: 300 mcg/mL) may be made. Note: Preliminary results in adults suggest adenosine may be administered via a central line at lower doses (eg, Adults: Initial dose: 3 mg); FDA approved labeling for pediatric patients weighing <50 kg states that doses listed may be administered either peripherally or centrally (further studies are needed)
USE — Treatment of paroxysmal supraventricular tachycardia (PSVT); used in adult ACLS algorithms for narrow-complex tachycardias, stable narrow-complex supraventricular tachycardias, and wide-complex tachycardias that are supraventricular in origin; used in PALS algorithms for probable supraventricular tachycardia; investigationally used as a continuous infusion for the treatment of primary pulmonary hypertension in adults and persistent pulmonary hypertension of the newborn (PPHN) (see Additional Information)
ADVERSE REACTIONS Cardiovascular: Flushing, arrhythmias, palpitations, chest pain, bradycardia, heart block, minimal hemodynamic disturbances, hypotension (<1%)
Central nervous system: Irritability, headaches, lightheadedness, dizziness
Gastrointestinal: Nausea, metallic taste
Respiratory: Dyspnea, hyperventilation, bronchoconstriction in asthmatics
CONTRAINDICATIONS — Hypersensitivity to adenosine or any component; second and third degree A-V block or sick sinus syndrome unless pacemaker placed
PRECAUTIONS — Bronchoconstriction may occur in asthmatics (avoid use in patients with bronchospasm or bronchoconstriction); use with caution in patients with underlying dysfunction of sinus or A-V node, obstructive lung disease, and those taking digoxin or verapamil; initial adenosine dose should be significantly decreased in patients receiving dipyridamole
WARNINGS — Heart block, including transient or prolonged asystole may occur as well as other arrhythmias; episodes of asystole or other arrhythmias may be fatal; if arrhythmia is not due to re-entry pathway through A-V node or sinus node (ie, atrial fibrillation, flutter, or tachycardia or ventricular tachycardia), adenosine will not terminate the arrhythmia but can produce transient ventriculoatrial or A-V block; possible mutagenic effects
DRUG INTERACTIONS — Dipyridamole potentiates effects of adenosine (dose of adenosine should be significantly reduced); methylxanthines (aminophylline, theophylline, caffeine) antagonize adenosine's effects so that larger doses of adenosine or an alternative agent may be required; carbamazepine may increase heart block; digoxin and verapamil may cause ventricular fibrillation (rare cases reported)
PREGNANCY RISK FACTOR — C (show table)
MONITORING PARAMETERS — Continuous EKG, heart rate, blood pressure, respirations
STABILITY — Do not refrigerate, precipitation may occur; contains no preservatives, discard unused portion
MECHANISM OF ACTION — Slows conduction time through the A-V node, interrupting the re-entry pathways through the A-V node, restoring normal sinus rhythm
PHARMACODYNAMICS Onset of action: Rapid
Duration: Very brief
PHARMACOKINETICS Metabolism: Removed from systemic circulation primarily by vascular endothelial cells and erythrocytes (by cellular uptake); rapidly metabolized intracellularly; phosphorylated by adenosine kinase to adenosine monophosphate (AMP) which is then incorporated into high-energy pool; intracellular adenosine is also deaminated by adenosine deaminase to inosine; inosine can be metabolized to hypoxanthine, then xanthine and finally to uric acid.
Half-life: <10 seconds
NURSING IMPLICATIONS — Be alert for dyspnea, shortness of breath, and possible exacerbation of asthma
ADDITIONAL INFORMATION — Not effective in atrial flutter, atrial fibrillation, or ventricular tachycardia; short duration of action is an advantage as adverse effects are usually rapidly self-limiting; effects may be prolonged in patients with denervated transplanted hearts. Individualize treatment of prolonged adverse effects: Give I.V. fluids for hypotension, aminophylline/theophylline may antagonize effects.
Limited information is available regarding the use of adenosine for the treatment of persistent pulmonary hypertension of the newborn (PPHN); efficacy, optimal dose, and duration of therapy is not established; a randomized, masked, placebo-controlled pilot study of 18 term infants with PPHN used initial doses of 25 mcg/kg/minute (n=9); after 30 minutes, doses were increased to 50 mcg/kg/minute if no improvement in PaO2 was observed; all patients received study drug via central line into the right atrium (inserted via the umbilical vein); significant improvement in oxygenation was observed in 4 of 9 newborns receiving 50 mcg/kg/minute; hypotension or tachycardia were not observed; further studies are needed (Kondur, 1996).
Adenosine is also available as Adenoscan®, which is used in adults as an adjunct to thallium-201 myocardial perfusion scintigraphy; see package insert for further information on this use.
CANADIAN BRAND NAMES — Adenocard®; Adenoscan®; Adenosine Injection, USP
SYNONYMS — 9-Beta-D-ribofuranosyladenine
THERAPEUTIC CATEGORY Antiarrhythmic Agent, Miscellaneous
DOSING — Note: Adequate controlled studies in pediatric patients have not been conducted.
(For additional information see "Adenosine: Drug information")
Manufacturer's recommendations: Rapid I.V.: Neonates, Infants, Children, and Adolescents weighing <50 kg: Initial dose: 0.05-0.1 mg/kg; if not effective within 1-2 minutes, increase dose by 0.05-0.1 mg/kg increments every 1-2 minutes to a maximum single dose of 0.3 mg/kg or until termination of PSVT Children and Adolescents weighing 50 kg and Adults: 6 mg, if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed
Alternative pediatric dosing: Neonates: Rapid I.V.: Initial dose: 0.05 mg/kg; if not effective within 2 minutes, increase dose by 0.05 mg/kg increments every 2 minutes to a maximum dose of 0.25 mg/kg or until termination of PSVT Infants and Children: PALS dose for treatment of SVT: Rapid I.V.; I.O.: Initial: 0.1 mg/kg (maximum: 6 mg); if not effective, give 0.2 mg/kg (maximum: 12 mg)
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
GENERIC AVAILABLE — Yes
ADMINISTRATION — Parenteral: For rapid bolus I.V. use, administer over 1-2 seconds at peripheral I.V. site closest to patient's heart (I.V. administration into lower extremities may result in therapeutic failure or requirement of higher doses); follow each bolus with NS flush (infants and children: 5-10 mL; adults: 20 mL); if given peripherally in adults, elevate the extremity for 10-20 seconds after the NS flush. To administer doses <600 mcg (0.2 mL of commercial product), a dilution with NS (final concentration: 300 mcg/mL) may be made. Note: Preliminary results in adults suggest adenosine may be administered via a central line at lower doses (eg, Adults: Initial dose: 3 mg); FDA approved labeling for pediatric patients weighing <50 kg states that doses listed may be administered either peripherally or centrally (further studies are needed)
USE — Treatment of paroxysmal supraventricular tachycardia (PSVT); used in adult ACLS algorithms for narrow-complex tachycardias, stable narrow-complex supraventricular tachycardias, and wide-complex tachycardias that are supraventricular in origin; used in PALS algorithms for probable supraventricular tachycardia; investigationally used as a continuous infusion for the treatment of primary pulmonary hypertension in adults and persistent pulmonary hypertension of the newborn (PPHN) (see Additional Information)
ADVERSE REACTIONS Cardiovascular: Flushing, arrhythmias, palpitations, chest pain, bradycardia, heart block, minimal hemodynamic disturbances, hypotension (<1%)
Central nervous system: Irritability, headaches, lightheadedness, dizziness
Gastrointestinal: Nausea, metallic taste
Respiratory: Dyspnea, hyperventilation, bronchoconstriction in asthmatics
CONTRAINDICATIONS — Hypersensitivity to adenosine or any component; second and third degree A-V block or sick sinus syndrome unless pacemaker placed
PRECAUTIONS — Bronchoconstriction may occur in asthmatics (avoid use in patients with bronchospasm or bronchoconstriction); use with caution in patients with underlying dysfunction of sinus or A-V node, obstructive lung disease, and those taking digoxin or verapamil; initial adenosine dose should be significantly decreased in patients receiving dipyridamole
WARNINGS — Heart block, including transient or prolonged asystole may occur as well as other arrhythmias; episodes of asystole or other arrhythmias may be fatal; if arrhythmia is not due to re-entry pathway through A-V node or sinus node (ie, atrial fibrillation, flutter, or tachycardia or ventricular tachycardia), adenosine will not terminate the arrhythmia but can produce transient ventriculoatrial or A-V block; possible mutagenic effects
DRUG INTERACTIONS — Dipyridamole potentiates effects of adenosine (dose of adenosine should be significantly reduced); methylxanthines (aminophylline, theophylline, caffeine) antagonize adenosine's effects so that larger doses of adenosine or an alternative agent may be required; carbamazepine may increase heart block; digoxin and verapamil may cause ventricular fibrillation (rare cases reported)
PREGNANCY RISK FACTOR — C (show table)
MONITORING PARAMETERS — Continuous EKG, heart rate, blood pressure, respirations
STABILITY — Do not refrigerate, precipitation may occur; contains no preservatives, discard unused portion
MECHANISM OF ACTION — Slows conduction time through the A-V node, interrupting the re-entry pathways through the A-V node, restoring normal sinus rhythm
PHARMACODYNAMICS Onset of action: Rapid
Duration: Very brief
PHARMACOKINETICS Metabolism: Removed from systemic circulation primarily by vascular endothelial cells and erythrocytes (by cellular uptake); rapidly metabolized intracellularly; phosphorylated by adenosine kinase to adenosine monophosphate (AMP) which is then incorporated into high-energy pool; intracellular adenosine is also deaminated by adenosine deaminase to inosine; inosine can be metabolized to hypoxanthine, then xanthine and finally to uric acid.
Half-life: <10 seconds
NURSING IMPLICATIONS — Be alert for dyspnea, shortness of breath, and possible exacerbation of asthma
ADDITIONAL INFORMATION — Not effective in atrial flutter, atrial fibrillation, or ventricular tachycardia; short duration of action is an advantage as adverse effects are usually rapidly self-limiting; effects may be prolonged in patients with denervated transplanted hearts. Individualize treatment of prolonged adverse effects: Give I.V. fluids for hypotension, aminophylline/theophylline may antagonize effects.
Limited information is available regarding the use of adenosine for the treatment of persistent pulmonary hypertension of the newborn (PPHN); efficacy, optimal dose, and duration of therapy is not established; a randomized, masked, placebo-controlled pilot study of 18 term infants with PPHN used initial doses of 25 mcg/kg/minute (n=9); after 30 minutes, doses were increased to 50 mcg/kg/minute if no improvement in PaO2 was observed; all patients received study drug via central line into the right atrium (inserted via the umbilical vein); significant improvement in oxygenation was observed in 4 of 9 newborns receiving 50 mcg/kg/minute; hypotension or tachycardia were not observed; further studies are needed (Kondur, 1996).
Adenosine is also available as Adenoscan®, which is used in adults as an adjunct to thallium-201 myocardial perfusion scintigraphy; see package insert for further information on this use.
Wednesday, January 23, 2008
Adenosine
U.S. BRAND NAMES — Adenocard®; Adenoscan®
PHARMACOLOGIC CATEGORY Antiarrhythmic Agent, Class IVDiagnostic Agent
DOSING: ADULTS Paroxysmal supraventricular tachycardia (Adenocard®): I.V. (rapid - over 1-2 seconds, via peripheral line): 6 mg; if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed; maximum single dose: 12 mg. Follow each I.V. bolus of adenosine with normal saline flush. Note: Preliminary results in adults suggest adenosine may be administered via a central line at lower doses (ie, initial adult dose: 3 mg).
Pharmacologic stress agent (Adenoscan®): I.V.: Continuous I.V. infusion via peripheral line: 140 mcg/kg/minute for 6 minutes using syringe or columetric infusion pump; total dose: 0.84 mg/kg. Thallium-201 is injected at midpoint (3 minutes) of infusion.
Acute vasodilator testing (unlabeled use) (Adenoscan®): I.V.: Initial: 50 mcg/kg/minute increased by 50 mcg/kg/minute every 2 minutes to a maximum dose of 500 mcg/kg/minute; acutely assess vasodilator response
DOSING: PEDIATRIC
(For additional information see "Adenosine: Pediatric drug information")Paroxysmal supraventricular tachycardia (Adenocard®): Rapid I.V. push (over 1-2 seconds) via peripheral line: Infants and Children (manufacturer's recommendation): Children <50 kg: 0.05-0.1 mg/kg. If conversion of PSVT does not occur within 1-2 minutes, may increase dose by 0.05-0.1 mg/kg. May repeat until sinus rhythm is established or to a maximum single dose of 0.3 mg/kg or 12 mg. Follow each dose with normal saline flush. Children 50 kg: Refer to adult dosing.
Pediatric advanced life support (PALS): Treatment of SVT: I.V., I.O.: 0.1 mg/kg; if not effective, administer 0.2 mg/kg; maximum single dose: 12 mg. Follow each dose with normal saline flush.
DOSING: ELDERLY — Refer to adult dosing. Elderly may be more sensitive to effects of adenosine.
DOSING: RENAL IMPAIRMENT Hemodialysis: Significant drug removal is unlikely based on physiochemical characteristics.
Peritoneal dialysis: Significant drug removal is unlikely based on physiochemical characteristics.
Note: Higher doses may be needed for administration via peripheral versus central vein.
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
DOSAGE FORMS: CONCISE Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
GENERIC EQUIVALENT AVAILABLE — Yes
ADMINISTRATION — For rapid bolus I.V. use only; administer I.V. push over 1-2 seconds at a peripheral I.V. site as proximal as possible to trunk (not in lower arm, hand, lower leg, or foot); follow each bolus with normal saline flush. Note: Preliminary results in adults suggest adenosine may be administered via central line at lower doses (eg, adults initial dose: 3 mg)
COMPATIBILITY — Stable in D5LR, D5W, LR, NS.
USE Adenocard®: Treatment of paroxysmal supraventricular tachycardia (PSVT) including that associated with accessory bypass tracts (Wolff-Parkinson-White syndrome); when clinically advisable, appropriate vagal maneuvers should be attempted prior to adenosine administration; not effective in atrial flutter, atrial fibrillation, or ventricular tachycardia
Adenoscan®: Pharmacologic stress agent used in myocardial perfusion thallium-201 scintigraphy
USE - UNLABELED / INVESTIGATIONAL — Adenoscan®: Acute vasodilator testing in pulmonary artery hypertension
ADVERSE REACTIONS SIGNIFICANT — Note: Frequency varies based on use; higher frequency of infusion-related effects, such as flushing and lightheadedness, were reported with continuous infusion (Adenoscan®).
>10%: Cardiovascular: Facial flushing (18% to 44%) Central nervous system: Headache (2% to 18%), lightheadedness (2% to 12%) Neuromuscular & skeletal: Discomfort of neck, throat, jaw (<1% to 15%) Respiratory: Dyspnea (12% to 28%), chest pressure/discomfort (7% to 40%)
1% to 10%: Cardiovascular: Hypotension (<1% to 2%), AV block (infusion 6%; third degree <1%), ST segment depression (3%), palpitation, chest pain Central nervous system: Dizziness, nervousness (2%), apprehension Gastrointestinal: Nausea (3%) Neuromuscular & skeletal: Upper extremity discomfort (up to 4%), numbness (up to 2%), paresthesia (up to 2%) Respiratory: Hyperventilation Miscellaneous: Diaphoresis
<1% (Limited to important or life-threatening): Asystole (prolonged), atrial fibrillation, back discomfort, bradycardia, bronchospasm, blurred vision, burning sensation, hypertension (transient), injection site reaction, intracranial pressure increased, metallic taste, pressure in groin, respiratory arrest, seizure, torsade de pointes, ventricular fibrillation, ventricular tachycardia
CONTRAINDICATIONS — Hypersensitivity to adenosine or any component of the formulation; second- or third-degree AV block or sick sinus syndrome (except in patients with a functioning artificial pacemaker), atrial flutter, atrial fibrillation, and ventricular tachycardia (this drug is not effective in converting these arrhythmias to sinus rhythm). The manufacturer states that Adenoscan® should be avoided in patients with known or suspected bronchoconstrictive or bronchospastic lung disease.
WARNINGS / PRECAUTIONS Concerns related to adverse effects: Atrial fibrillation/flutter: There have been reports of atrial fibrillation/flutter in patients with paroxysmal supraventricular tachycardia (PSVT) associated with accessory conduction pathways after adenosine. Does not convert afib/flutter to normal sinus rhythm; risk of serious arrhythmias/hypotension. Not for use in patients with afib/flutter associated with Wolff-Parkinson-White Syndrome. Conduction disturbances: Adenosine decreases conduction through the AV node and may produce first-, second-, or third-degree heart block. Patients with pre-existing S-A nodal dysfunction may experience prolonged sinus pauses after adenosine; use caution in patients with first-degree AV block or bundle branch block; avoid use of adenosine for pharmacologic stress testing in patients with high-grade AV block or sinus node dysfunction (unless a functional pacemaker is in place). Rare, prolonged episodes of asystole have been reported, with fatal outcomes in some cases. Hypotension: May produce profound vasodilation with subsequent hypotension. When used as a bolus dose (PSVT), effects are generally self-limiting (due to the short half-life of adenosine). However, when used as a continuous infusion (pharmacologic stress testing), effects may be more pronounced and persistent, corresponding to continued exposure. Use infusions with caution in patients with autonomic dysfunction, carotid stenosis (with cerebrovascular insufficiency), uncorrected hypovolemia, pericarditis, pleural effusion and/or stenotic valvular heart disease. Proarrhythmic effects: Watch for proarrhythmic effects; monitor and adjust dose to prevent QTc prolongation.
Disease-related concerns: Asthma: A limited number of patients with asthma have received adenosine and have not experienced exacerbation of their asthma. Adenosine may cause bronchoconstriction in patients with asthma; should be used cautiously in patients with obstructive lung disease not associated with bronchoconstriction (eg, emphysema, bronchitis). Electrolyte imbalance: Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy.
Concurrent drug therapy issues: Caffeine: Pharmacologic stress testing: Withhold for five half-lives prior to adenosine use; avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing. Drugs which slow AV conduction: Use with caution in patients receiving other drugs which slow AV conduction (eg, digoxin, verapamil). Theophylline: Withhold for five half-lives prior to adenosine use whenever possible (eg, pharmacological stress testing).
Special populations: Elderly: Use with caution in the elderly; may be at increased risk of hemodynamic effects, bradycardia, and/or AV block.
Dosage form specific issues: Adenocard®: Transient AV block is expected. When used in PSVT, at the time of conversion to normal sinus rhythm, a variety of new rhythms may appear on the ECG. Administer as a rapid bolus, either directly into a vein or (if administered into an I.V. line), as close to the patient as possible (followed by saline flush).
Other warnings/precautions: CAST trial: In the Cardiac Arrhythmia Suppression Trial (CAST), recent (>6 days but <2 years ago) myocardial infarction patients with asymptomatic, nonlife-threatening ventricular arrhythmias did not benefit and may have been harmed by attempts to suppress the arrhythmia with flecainide or encainide. An increased mortality or nonfatal cardiac arrest rate (7.7%) was seen in the active treatment group compared with patients in the placebo group (3%). The applicability of the CAST results to other populations is unknown. Antiarrhythmic agents should be reserved for patients with life-threatening ventricular arrhythmias.
DRUG INTERACTIONS Carbamazepine may increase heart block.
Dipyridamole potentiates effects of adenosine; reduce dose of adenosine.
Theophylline and caffeine (methylxanthines) antagonize adenosine's effects; may require increased dose of adenosine.
ETHANOL / NUTRITION / HERB INTERACTIONS — Food: Avoid food or drugs with caffeine. Adenosine's therapeutic effect may be decreased if used concurrently with caffeine. Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
PREGNANCY RISK FACTOR — C (show table)
PREGNANCY IMPLICATIONS — Reports of administration during pregnancy have indicated no adverse effects on fetus or newborn attributable to adenosine.
LACTATION — Excretion in breast milk unknown
DIETARY CONSIDERATIONS — Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
MONITORING PARAMETERS — ECG monitoring, heart rate, blood pressure
TOXICOLOGY / OVERDOSE COMPREHENSIVE — Since the half-life of adenosine is <10 seconds, any adverse effects are rapidly self-limiting. Intoxication is usually short-lived since the half-life of the drug is very short. Treatment of prolonged effects requires individualization. Theophylline and other methylxanthines are competitive inhibitors of adenosine and may have a role in reversing its toxic effects. To reverse the effects of Adenoscan®, administer theophylline 50-125 mg slow I.V. push.
CANADIAN BRAND NAMES — Adenocard®; Adenoscan®; Adenosine Injection, USP
INTERNATIONAL BRAND NAMES — Adenocard (BR, CA); Adenocor (AU, BE, BG, CN, CZ, DK, EC, EE, EG, ES, FI, GB, HU, IE, IL, KR, MY, NO, NZ, PE, PL, TH, TW, UY, VE, ZA); Adenocur (NL); Adenoject (IN); Adenoscan (CA, HK); Adenosin Ebewe (PL); Adenosina Biol (AR, PY); Adenosine Injection, USP (CA); Adrekar (AT, DE); Cardiovert (PH); Fosfobion (PL); Krenosin (FR, IT, MX); Krenosine (CH); Soladen (PL)
MECHANISM OF ACTION — Slows conduction time through the AV node, interrupting the re-entry pathways through the AV node, restoring normal sinus rhythm
PHARMACODYNAMICS / KINETICS Onset of action: Rapid
Duration: Very brief
Metabolism: Blood and tissue to inosine then to adenosine monophosphate (AMP) and hypoxanthine
Half-life elimination: <10 seconds
PHARMACOLOGIC CATEGORY Antiarrhythmic Agent, Class IVDiagnostic Agent
DOSING: ADULTS Paroxysmal supraventricular tachycardia (Adenocard®): I.V. (rapid - over 1-2 seconds, via peripheral line): 6 mg; if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed; maximum single dose: 12 mg. Follow each I.V. bolus of adenosine with normal saline flush. Note: Preliminary results in adults suggest adenosine may be administered via a central line at lower doses (ie, initial adult dose: 3 mg).
Pharmacologic stress agent (Adenoscan®): I.V.: Continuous I.V. infusion via peripheral line: 140 mcg/kg/minute for 6 minutes using syringe or columetric infusion pump; total dose: 0.84 mg/kg. Thallium-201 is injected at midpoint (3 minutes) of infusion.
Acute vasodilator testing (unlabeled use) (Adenoscan®): I.V.: Initial: 50 mcg/kg/minute increased by 50 mcg/kg/minute every 2 minutes to a maximum dose of 500 mcg/kg/minute; acutely assess vasodilator response
DOSING: PEDIATRIC
(For additional information see "Adenosine: Pediatric drug information")Paroxysmal supraventricular tachycardia (Adenocard®): Rapid I.V. push (over 1-2 seconds) via peripheral line: Infants and Children (manufacturer's recommendation): Children <50 kg: 0.05-0.1 mg/kg. If conversion of PSVT does not occur within 1-2 minutes, may increase dose by 0.05-0.1 mg/kg. May repeat until sinus rhythm is established or to a maximum single dose of 0.3 mg/kg or 12 mg. Follow each dose with normal saline flush. Children 50 kg: Refer to adult dosing.
Pediatric advanced life support (PALS): Treatment of SVT: I.V., I.O.: 0.1 mg/kg; if not effective, administer 0.2 mg/kg; maximum single dose: 12 mg. Follow each dose with normal saline flush.
DOSING: ELDERLY — Refer to adult dosing. Elderly may be more sensitive to effects of adenosine.
DOSING: RENAL IMPAIRMENT Hemodialysis: Significant drug removal is unlikely based on physiochemical characteristics.
Peritoneal dialysis: Significant drug removal is unlikely based on physiochemical characteristics.
Note: Higher doses may be needed for administration via peripheral versus central vein.
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
DOSAGE FORMS: CONCISE Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
GENERIC EQUIVALENT AVAILABLE — Yes
ADMINISTRATION — For rapid bolus I.V. use only; administer I.V. push over 1-2 seconds at a peripheral I.V. site as proximal as possible to trunk (not in lower arm, hand, lower leg, or foot); follow each bolus with normal saline flush. Note: Preliminary results in adults suggest adenosine may be administered via central line at lower doses (eg, adults initial dose: 3 mg)
COMPATIBILITY — Stable in D5LR, D5W, LR, NS.
USE Adenocard®: Treatment of paroxysmal supraventricular tachycardia (PSVT) including that associated with accessory bypass tracts (Wolff-Parkinson-White syndrome); when clinically advisable, appropriate vagal maneuvers should be attempted prior to adenosine administration; not effective in atrial flutter, atrial fibrillation, or ventricular tachycardia
Adenoscan®: Pharmacologic stress agent used in myocardial perfusion thallium-201 scintigraphy
USE - UNLABELED / INVESTIGATIONAL — Adenoscan®: Acute vasodilator testing in pulmonary artery hypertension
ADVERSE REACTIONS SIGNIFICANT — Note: Frequency varies based on use; higher frequency of infusion-related effects, such as flushing and lightheadedness, were reported with continuous infusion (Adenoscan®).
>10%: Cardiovascular: Facial flushing (18% to 44%) Central nervous system: Headache (2% to 18%), lightheadedness (2% to 12%) Neuromuscular & skeletal: Discomfort of neck, throat, jaw (<1% to 15%) Respiratory: Dyspnea (12% to 28%), chest pressure/discomfort (7% to 40%)
1% to 10%: Cardiovascular: Hypotension (<1% to 2%), AV block (infusion 6%; third degree <1%), ST segment depression (3%), palpitation, chest pain Central nervous system: Dizziness, nervousness (2%), apprehension Gastrointestinal: Nausea (3%) Neuromuscular & skeletal: Upper extremity discomfort (up to 4%), numbness (up to 2%), paresthesia (up to 2%) Respiratory: Hyperventilation Miscellaneous: Diaphoresis
<1% (Limited to important or life-threatening): Asystole (prolonged), atrial fibrillation, back discomfort, bradycardia, bronchospasm, blurred vision, burning sensation, hypertension (transient), injection site reaction, intracranial pressure increased, metallic taste, pressure in groin, respiratory arrest, seizure, torsade de pointes, ventricular fibrillation, ventricular tachycardia
CONTRAINDICATIONS — Hypersensitivity to adenosine or any component of the formulation; second- or third-degree AV block or sick sinus syndrome (except in patients with a functioning artificial pacemaker), atrial flutter, atrial fibrillation, and ventricular tachycardia (this drug is not effective in converting these arrhythmias to sinus rhythm). The manufacturer states that Adenoscan® should be avoided in patients with known or suspected bronchoconstrictive or bronchospastic lung disease.
WARNINGS / PRECAUTIONS Concerns related to adverse effects: Atrial fibrillation/flutter: There have been reports of atrial fibrillation/flutter in patients with paroxysmal supraventricular tachycardia (PSVT) associated with accessory conduction pathways after adenosine. Does not convert afib/flutter to normal sinus rhythm; risk of serious arrhythmias/hypotension. Not for use in patients with afib/flutter associated with Wolff-Parkinson-White Syndrome. Conduction disturbances: Adenosine decreases conduction through the AV node and may produce first-, second-, or third-degree heart block. Patients with pre-existing S-A nodal dysfunction may experience prolonged sinus pauses after adenosine; use caution in patients with first-degree AV block or bundle branch block; avoid use of adenosine for pharmacologic stress testing in patients with high-grade AV block or sinus node dysfunction (unless a functional pacemaker is in place). Rare, prolonged episodes of asystole have been reported, with fatal outcomes in some cases. Hypotension: May produce profound vasodilation with subsequent hypotension. When used as a bolus dose (PSVT), effects are generally self-limiting (due to the short half-life of adenosine). However, when used as a continuous infusion (pharmacologic stress testing), effects may be more pronounced and persistent, corresponding to continued exposure. Use infusions with caution in patients with autonomic dysfunction, carotid stenosis (with cerebrovascular insufficiency), uncorrected hypovolemia, pericarditis, pleural effusion and/or stenotic valvular heart disease. Proarrhythmic effects: Watch for proarrhythmic effects; monitor and adjust dose to prevent QTc prolongation.
Disease-related concerns: Asthma: A limited number of patients with asthma have received adenosine and have not experienced exacerbation of their asthma. Adenosine may cause bronchoconstriction in patients with asthma; should be used cautiously in patients with obstructive lung disease not associated with bronchoconstriction (eg, emphysema, bronchitis). Electrolyte imbalance: Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy.
Concurrent drug therapy issues: Caffeine: Pharmacologic stress testing: Withhold for five half-lives prior to adenosine use; avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing. Drugs which slow AV conduction: Use with caution in patients receiving other drugs which slow AV conduction (eg, digoxin, verapamil). Theophylline: Withhold for five half-lives prior to adenosine use whenever possible (eg, pharmacological stress testing).
Special populations: Elderly: Use with caution in the elderly; may be at increased risk of hemodynamic effects, bradycardia, and/or AV block.
Dosage form specific issues: Adenocard®: Transient AV block is expected. When used in PSVT, at the time of conversion to normal sinus rhythm, a variety of new rhythms may appear on the ECG. Administer as a rapid bolus, either directly into a vein or (if administered into an I.V. line), as close to the patient as possible (followed by saline flush).
Other warnings/precautions: CAST trial: In the Cardiac Arrhythmia Suppression Trial (CAST), recent (>6 days but <2 years ago) myocardial infarction patients with asymptomatic, nonlife-threatening ventricular arrhythmias did not benefit and may have been harmed by attempts to suppress the arrhythmia with flecainide or encainide. An increased mortality or nonfatal cardiac arrest rate (7.7%) was seen in the active treatment group compared with patients in the placebo group (3%). The applicability of the CAST results to other populations is unknown. Antiarrhythmic agents should be reserved for patients with life-threatening ventricular arrhythmias.
DRUG INTERACTIONS Carbamazepine may increase heart block.
Dipyridamole potentiates effects of adenosine; reduce dose of adenosine.
Theophylline and caffeine (methylxanthines) antagonize adenosine's effects; may require increased dose of adenosine.
ETHANOL / NUTRITION / HERB INTERACTIONS — Food: Avoid food or drugs with caffeine. Adenosine's therapeutic effect may be decreased if used concurrently with caffeine. Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
PREGNANCY RISK FACTOR — C (show table)
PREGNANCY IMPLICATIONS — Reports of administration during pregnancy have indicated no adverse effects on fetus or newborn attributable to adenosine.
LACTATION — Excretion in breast milk unknown
DIETARY CONSIDERATIONS — Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
MONITORING PARAMETERS — ECG monitoring, heart rate, blood pressure
TOXICOLOGY / OVERDOSE COMPREHENSIVE — Since the half-life of adenosine is <10 seconds, any adverse effects are rapidly self-limiting. Intoxication is usually short-lived since the half-life of the drug is very short. Treatment of prolonged effects requires individualization. Theophylline and other methylxanthines are competitive inhibitors of adenosine and may have a role in reversing its toxic effects. To reverse the effects of Adenoscan®, administer theophylline 50-125 mg slow I.V. push.
CANADIAN BRAND NAMES — Adenocard®; Adenoscan®; Adenosine Injection, USP
INTERNATIONAL BRAND NAMES — Adenocard (BR, CA); Adenocor (AU, BE, BG, CN, CZ, DK, EC, EE, EG, ES, FI, GB, HU, IE, IL, KR, MY, NO, NZ, PE, PL, TH, TW, UY, VE, ZA); Adenocur (NL); Adenoject (IN); Adenoscan (CA, HK); Adenosin Ebewe (PL); Adenosina Biol (AR, PY); Adenosine Injection, USP (CA); Adrekar (AT, DE); Cardiovert (PH); Fosfobion (PL); Krenosin (FR, IT, MX); Krenosine (CH); Soladen (PL)
MECHANISM OF ACTION — Slows conduction time through the AV node, interrupting the re-entry pathways through the AV node, restoring normal sinus rhythm
PHARMACODYNAMICS / KINETICS Onset of action: Rapid
Duration: Very brief
Metabolism: Blood and tissue to inosine then to adenosine monophosphate (AMP) and hypoxanthine
Half-life elimination: <10 seconds
Adenosine
U.S. BRAND NAMES — Adenocard®; Adenoscan®
PHARMACOLOGIC CATEGORY Antiarrhythmic Agent, Class IVDiagnostic Agent
DOSING: ADULTS Paroxysmal supraventricular tachycardia (Adenocard®): I.V. (rapid - over 1-2 seconds, via peripheral line): 6 mg; if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed; maximum single dose: 12 mg. Follow each I.V. bolus of adenosine with normal saline flush. Note: Preliminary results in adults suggest adenosine may be administered via a central line at lower doses (ie, initial adult dose: 3 mg).
Pharmacologic stress agent (Adenoscan®): I.V.: Continuous I.V. infusion via peripheral line: 140 mcg/kg/minute for 6 minutes using syringe or columetric infusion pump; total dose: 0.84 mg/kg. Thallium-201 is injected at midpoint (3 minutes) of infusion.
Acute vasodilator testing (unlabeled use) (Adenoscan®): I.V.: Initial: 50 mcg/kg/minute increased by 50 mcg/kg/minute every 2 minutes to a maximum dose of 500 mcg/kg/minute; acutely assess vasodilator response
DOSING: PEDIATRIC
(For additional information see "Adenosine: Pediatric drug information")Paroxysmal supraventricular tachycardia (Adenocard®): Rapid I.V. push (over 1-2 seconds) via peripheral line: Infants and Children (manufacturer's recommendation): Children <50 kg: 0.05-0.1 mg/kg. If conversion of PSVT does not occur within 1-2 minutes, may increase dose by 0.05-0.1 mg/kg. May repeat until sinus rhythm is established or to a maximum single dose of 0.3 mg/kg or 12 mg. Follow each dose with normal saline flush. Children 50 kg: Refer to adult dosing.
Pediatric advanced life support (PALS): Treatment of SVT: I.V., I.O.: 0.1 mg/kg; if not effective, administer 0.2 mg/kg; maximum single dose: 12 mg. Follow each dose with normal saline flush.
DOSING: ELDERLY — Refer to adult dosing. Elderly may be more sensitive to effects of adenosine.
DOSING: RENAL IMPAIRMENT Hemodialysis: Significant drug removal is unlikely based on physiochemical characteristics.
Peritoneal dialysis: Significant drug removal is unlikely based on physiochemical characteristics.
Note: Higher doses may be needed for administration via peripheral versus central vein.
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
DOSAGE FORMS: CONCISE Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
GENERIC EQUIVALENT AVAILABLE — Yes
ADMINISTRATION — For rapid bolus I.V. use only; administer I.V. push over 1-2 seconds at a peripheral I.V. site as proximal as possible to trunk (not in lower arm, hand, lower leg, or foot); follow each bolus with normal saline flush. Note: Preliminary results in adults suggest adenosine may be administered via central line at lower doses (eg, adults initial dose: 3 mg)
COMPATIBILITY — Stable in D5LR, D5W, LR, NS.
USE Adenocard®: Treatment of paroxysmal supraventricular tachycardia (PSVT) including that associated with accessory bypass tracts (Wolff-Parkinson-White syndrome); when clinically advisable, appropriate vagal maneuvers should be attempted prior to adenosine administration; not effective in atrial flutter, atrial fibrillation, or ventricular tachycardia
Adenoscan®: Pharmacologic stress agent used in myocardial perfusion thallium-201 scintigraphy
USE - UNLABELED / INVESTIGATIONAL — Adenoscan®: Acute vasodilator testing in pulmonary artery hypertension
ADVERSE REACTIONS SIGNIFICANT — Note: Frequency varies based on use; higher frequency of infusion-related effects, such as flushing and lightheadedness, were reported with continuous infusion (Adenoscan®).
>10%: Cardiovascular: Facial flushing (18% to 44%) Central nervous system: Headache (2% to 18%), lightheadedness (2% to 12%) Neuromuscular & skeletal: Discomfort of neck, throat, jaw (<1% to 15%) Respiratory: Dyspnea (12% to 28%), chest pressure/discomfort (7% to 40%)
1% to 10%: Cardiovascular: Hypotension (<1% to 2%), AV block (infusion 6%; third degree <1%), ST segment depression (3%), palpitation, chest pain Central nervous system: Dizziness, nervousness (2%), apprehension Gastrointestinal: Nausea (3%) Neuromuscular & skeletal: Upper extremity discomfort (up to 4%), numbness (up to 2%), paresthesia (up to 2%) Respiratory: Hyperventilation Miscellaneous: Diaphoresis
<1% (Limited to important or life-threatening): Asystole (prolonged), atrial fibrillation, back discomfort, bradycardia, bronchospasm, blurred vision, burning sensation, hypertension (transient), injection site reaction, intracranial pressure increased, metallic taste, pressure in groin, respiratory arrest, seizure, torsade de pointes, ventricular fibrillation, ventricular tachycardia
CONTRAINDICATIONS — Hypersensitivity to adenosine or any component of the formulation; second- or third-degree AV block or sick sinus syndrome (except in patients with a functioning artificial pacemaker), atrial flutter, atrial fibrillation, and ventricular tachycardia (this drug is not effective in converting these arrhythmias to sinus rhythm). The manufacturer states that Adenoscan® should be avoided in patients with known or suspected bronchoconstrictive or bronchospastic lung disease.
WARNINGS / PRECAUTIONS Concerns related to adverse effects: Atrial fibrillation/flutter: There have been reports of atrial fibrillation/flutter in patients with paroxysmal supraventricular tachycardia (PSVT) associated with accessory conduction pathways after adenosine. Does not convert afib/flutter to normal sinus rhythm; risk of serious arrhythmias/hypotension. Not for use in patients with afib/flutter associated with Wolff-Parkinson-White Syndrome. Conduction disturbances: Adenosine decreases conduction through the AV node and may produce first-, second-, or third-degree heart block. Patients with pre-existing S-A nodal dysfunction may experience prolonged sinus pauses after adenosine; use caution in patients with first-degree AV block or bundle branch block; avoid use of adenosine for pharmacologic stress testing in patients with high-grade AV block or sinus node dysfunction (unless a functional pacemaker is in place). Rare, prolonged episodes of asystole have been reported, with fatal outcomes in some cases. Hypotension: May produce profound vasodilation with subsequent hypotension. When used as a bolus dose (PSVT), effects are generally self-limiting (due to the short half-life of adenosine). However, when used as a continuous infusion (pharmacologic stress testing), effects may be more pronounced and persistent, corresponding to continued exposure. Use infusions with caution in patients with autonomic dysfunction, carotid stenosis (with cerebrovascular insufficiency), uncorrected hypovolemia, pericarditis, pleural effusion and/or stenotic valvular heart disease. Proarrhythmic effects: Watch for proarrhythmic effects; monitor and adjust dose to prevent QTc prolongation.
Disease-related concerns: Asthma: A limited number of patients with asthma have received adenosine and have not experienced exacerbation of their asthma. Adenosine may cause bronchoconstriction in patients with asthma; should be used cautiously in patients with obstructive lung disease not associated with bronchoconstriction (eg, emphysema, bronchitis). Electrolyte imbalance: Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy.
Concurrent drug therapy issues: Caffeine: Pharmacologic stress testing: Withhold for five half-lives prior to adenosine use; avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing. Drugs which slow AV conduction: Use with caution in patients receiving other drugs which slow AV conduction (eg, digoxin, verapamil). Theophylline: Withhold for five half-lives prior to adenosine use whenever possible (eg, pharmacological stress testing).
Special populations: Elderly: Use with caution in the elderly; may be at increased risk of hemodynamic effects, bradycardia, and/or AV block.
Dosage form specific issues: Adenocard®: Transient AV block is expected. When used in PSVT, at the time of conversion to normal sinus rhythm, a variety of new rhythms may appear on the ECG. Administer as a rapid bolus, either directly into a vein or (if administered into an I.V. line), as close to the patient as possible (followed by saline flush).
Other warnings/precautions: CAST trial: In the Cardiac Arrhythmia Suppression Trial (CAST), recent (>6 days but <2 years ago) myocardial infarction patients with asymptomatic, nonlife-threatening ventricular arrhythmias did not benefit and may have been harmed by attempts to suppress the arrhythmia with flecainide or encainide. An increased mortality or nonfatal cardiac arrest rate (7.7%) was seen in the active treatment group compared with patients in the placebo group (3%). The applicability of the CAST results to other populations is unknown. Antiarrhythmic agents should be reserved for patients with life-threatening ventricular arrhythmias.
DRUG INTERACTIONS Carbamazepine may increase heart block.
Dipyridamole potentiates effects of adenosine; reduce dose of adenosine.
Theophylline and caffeine (methylxanthines) antagonize adenosine's effects; may require increased dose of adenosine.
ETHANOL / NUTRITION / HERB INTERACTIONS — Food: Avoid food or drugs with caffeine. Adenosine's therapeutic effect may be decreased if used concurrently with caffeine. Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
PREGNANCY RISK FACTOR — C (show table)
PREGNANCY IMPLICATIONS — Reports of administration during pregnancy have indicated no adverse effects on fetus or newborn attributable to adenosine.
LACTATION — Excretion in breast milk unknown
DIETARY CONSIDERATIONS — Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
MONITORING PARAMETERS — ECG monitoring, heart rate, blood pressure
TOXICOLOGY / OVERDOSE COMPREHENSIVE — Since the half-life of adenosine is <10 seconds, any adverse effects are rapidly self-limiting. Intoxication is usually short-lived since the half-life of the drug is very short. Treatment of prolonged effects requires individualization. Theophylline and other methylxanthines are competitive inhibitors of adenosine and may have a role in reversing its toxic effects. To reverse the effects of Adenoscan®, administer theophylline 50-125 mg slow I.V. push.
CANADIAN BRAND NAMES — Adenocard®; Adenoscan®; Adenosine Injection, USP
INTERNATIONAL BRAND NAMES — Adenocard (BR, CA); Adenocor (AU, BE, BG, CN, CZ, DK, EC, EE, EG, ES, FI, GB, HU, IE, IL, KR, MY, NO, NZ, PE, PL, TH, TW, UY, VE, ZA); Adenocur (NL); Adenoject (IN); Adenoscan (CA, HK); Adenosin Ebewe (PL); Adenosina Biol (AR, PY); Adenosine Injection, USP (CA); Adrekar (AT, DE); Cardiovert (PH); Fosfobion (PL); Krenosin (FR, IT, MX); Krenosine (CH); Soladen (PL)
MECHANISM OF ACTION — Slows conduction time through the AV node, interrupting the re-entry pathways through the AV node, restoring normal sinus rhythm
PHARMACODYNAMICS / KINETICS Onset of action: Rapid
Duration: Very brief
Metabolism: Blood and tissue to inosine then to adenosine monophosphate (AMP) and hypoxanthine
Half-life elimination: <10 seconds
PHARMACOLOGIC CATEGORY Antiarrhythmic Agent, Class IVDiagnostic Agent
DOSING: ADULTS Paroxysmal supraventricular tachycardia (Adenocard®): I.V. (rapid - over 1-2 seconds, via peripheral line): 6 mg; if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed; maximum single dose: 12 mg. Follow each I.V. bolus of adenosine with normal saline flush. Note: Preliminary results in adults suggest adenosine may be administered via a central line at lower doses (ie, initial adult dose: 3 mg).
Pharmacologic stress agent (Adenoscan®): I.V.: Continuous I.V. infusion via peripheral line: 140 mcg/kg/minute for 6 minutes using syringe or columetric infusion pump; total dose: 0.84 mg/kg. Thallium-201 is injected at midpoint (3 minutes) of infusion.
Acute vasodilator testing (unlabeled use) (Adenoscan®): I.V.: Initial: 50 mcg/kg/minute increased by 50 mcg/kg/minute every 2 minutes to a maximum dose of 500 mcg/kg/minute; acutely assess vasodilator response
DOSING: PEDIATRIC
(For additional information see "Adenosine: Pediatric drug information")Paroxysmal supraventricular tachycardia (Adenocard®): Rapid I.V. push (over 1-2 seconds) via peripheral line: Infants and Children (manufacturer's recommendation): Children <50 kg: 0.05-0.1 mg/kg. If conversion of PSVT does not occur within 1-2 minutes, may increase dose by 0.05-0.1 mg/kg. May repeat until sinus rhythm is established or to a maximum single dose of 0.3 mg/kg or 12 mg. Follow each dose with normal saline flush. Children 50 kg: Refer to adult dosing.
Pediatric advanced life support (PALS): Treatment of SVT: I.V., I.O.: 0.1 mg/kg; if not effective, administer 0.2 mg/kg; maximum single dose: 12 mg. Follow each dose with normal saline flush.
DOSING: ELDERLY — Refer to adult dosing. Elderly may be more sensitive to effects of adenosine.
DOSING: RENAL IMPAIRMENT Hemodialysis: Significant drug removal is unlikely based on physiochemical characteristics.
Peritoneal dialysis: Significant drug removal is unlikely based on physiochemical characteristics.
Note: Higher doses may be needed for administration via peripheral versus central vein.
DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
DOSAGE FORMS: CONCISE Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL) Adenocard®: 3 mg/mL (2 mL, 4 mL) Adenoscan®: 3 mg/mL (20 mL, 30 mL)
GENERIC EQUIVALENT AVAILABLE — Yes
ADMINISTRATION — For rapid bolus I.V. use only; administer I.V. push over 1-2 seconds at a peripheral I.V. site as proximal as possible to trunk (not in lower arm, hand, lower leg, or foot); follow each bolus with normal saline flush. Note: Preliminary results in adults suggest adenosine may be administered via central line at lower doses (eg, adults initial dose: 3 mg)
COMPATIBILITY — Stable in D5LR, D5W, LR, NS.
USE Adenocard®: Treatment of paroxysmal supraventricular tachycardia (PSVT) including that associated with accessory bypass tracts (Wolff-Parkinson-White syndrome); when clinically advisable, appropriate vagal maneuvers should be attempted prior to adenosine administration; not effective in atrial flutter, atrial fibrillation, or ventricular tachycardia
Adenoscan®: Pharmacologic stress agent used in myocardial perfusion thallium-201 scintigraphy
USE - UNLABELED / INVESTIGATIONAL — Adenoscan®: Acute vasodilator testing in pulmonary artery hypertension
ADVERSE REACTIONS SIGNIFICANT — Note: Frequency varies based on use; higher frequency of infusion-related effects, such as flushing and lightheadedness, were reported with continuous infusion (Adenoscan®).
>10%: Cardiovascular: Facial flushing (18% to 44%) Central nervous system: Headache (2% to 18%), lightheadedness (2% to 12%) Neuromuscular & skeletal: Discomfort of neck, throat, jaw (<1% to 15%) Respiratory: Dyspnea (12% to 28%), chest pressure/discomfort (7% to 40%)
1% to 10%: Cardiovascular: Hypotension (<1% to 2%), AV block (infusion 6%; third degree <1%), ST segment depression (3%), palpitation, chest pain Central nervous system: Dizziness, nervousness (2%), apprehension Gastrointestinal: Nausea (3%) Neuromuscular & skeletal: Upper extremity discomfort (up to 4%), numbness (up to 2%), paresthesia (up to 2%) Respiratory: Hyperventilation Miscellaneous: Diaphoresis
<1% (Limited to important or life-threatening): Asystole (prolonged), atrial fibrillation, back discomfort, bradycardia, bronchospasm, blurred vision, burning sensation, hypertension (transient), injection site reaction, intracranial pressure increased, metallic taste, pressure in groin, respiratory arrest, seizure, torsade de pointes, ventricular fibrillation, ventricular tachycardia
CONTRAINDICATIONS — Hypersensitivity to adenosine or any component of the formulation; second- or third-degree AV block or sick sinus syndrome (except in patients with a functioning artificial pacemaker), atrial flutter, atrial fibrillation, and ventricular tachycardia (this drug is not effective in converting these arrhythmias to sinus rhythm). The manufacturer states that Adenoscan® should be avoided in patients with known or suspected bronchoconstrictive or bronchospastic lung disease.
WARNINGS / PRECAUTIONS Concerns related to adverse effects: Atrial fibrillation/flutter: There have been reports of atrial fibrillation/flutter in patients with paroxysmal supraventricular tachycardia (PSVT) associated with accessory conduction pathways after adenosine. Does not convert afib/flutter to normal sinus rhythm; risk of serious arrhythmias/hypotension. Not for use in patients with afib/flutter associated with Wolff-Parkinson-White Syndrome. Conduction disturbances: Adenosine decreases conduction through the AV node and may produce first-, second-, or third-degree heart block. Patients with pre-existing S-A nodal dysfunction may experience prolonged sinus pauses after adenosine; use caution in patients with first-degree AV block or bundle branch block; avoid use of adenosine for pharmacologic stress testing in patients with high-grade AV block or sinus node dysfunction (unless a functional pacemaker is in place). Rare, prolonged episodes of asystole have been reported, with fatal outcomes in some cases. Hypotension: May produce profound vasodilation with subsequent hypotension. When used as a bolus dose (PSVT), effects are generally self-limiting (due to the short half-life of adenosine). However, when used as a continuous infusion (pharmacologic stress testing), effects may be more pronounced and persistent, corresponding to continued exposure. Use infusions with caution in patients with autonomic dysfunction, carotid stenosis (with cerebrovascular insufficiency), uncorrected hypovolemia, pericarditis, pleural effusion and/or stenotic valvular heart disease. Proarrhythmic effects: Watch for proarrhythmic effects; monitor and adjust dose to prevent QTc prolongation.
Disease-related concerns: Asthma: A limited number of patients with asthma have received adenosine and have not experienced exacerbation of their asthma. Adenosine may cause bronchoconstriction in patients with asthma; should be used cautiously in patients with obstructive lung disease not associated with bronchoconstriction (eg, emphysema, bronchitis). Electrolyte imbalance: Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy.
Concurrent drug therapy issues: Caffeine: Pharmacologic stress testing: Withhold for five half-lives prior to adenosine use; avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing. Drugs which slow AV conduction: Use with caution in patients receiving other drugs which slow AV conduction (eg, digoxin, verapamil). Theophylline: Withhold for five half-lives prior to adenosine use whenever possible (eg, pharmacological stress testing).
Special populations: Elderly: Use with caution in the elderly; may be at increased risk of hemodynamic effects, bradycardia, and/or AV block.
Dosage form specific issues: Adenocard®: Transient AV block is expected. When used in PSVT, at the time of conversion to normal sinus rhythm, a variety of new rhythms may appear on the ECG. Administer as a rapid bolus, either directly into a vein or (if administered into an I.V. line), as close to the patient as possible (followed by saline flush).
Other warnings/precautions: CAST trial: In the Cardiac Arrhythmia Suppression Trial (CAST), recent (>6 days but <2 years ago) myocardial infarction patients with asymptomatic, nonlife-threatening ventricular arrhythmias did not benefit and may have been harmed by attempts to suppress the arrhythmia with flecainide or encainide. An increased mortality or nonfatal cardiac arrest rate (7.7%) was seen in the active treatment group compared with patients in the placebo group (3%). The applicability of the CAST results to other populations is unknown. Antiarrhythmic agents should be reserved for patients with life-threatening ventricular arrhythmias.
DRUG INTERACTIONS Carbamazepine may increase heart block.
Dipyridamole potentiates effects of adenosine; reduce dose of adenosine.
Theophylline and caffeine (methylxanthines) antagonize adenosine's effects; may require increased dose of adenosine.
ETHANOL / NUTRITION / HERB INTERACTIONS — Food: Avoid food or drugs with caffeine. Adenosine's therapeutic effect may be decreased if used concurrently with caffeine. Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
PREGNANCY RISK FACTOR — C (show table)
PREGNANCY IMPLICATIONS — Reports of administration during pregnancy have indicated no adverse effects on fetus or newborn attributable to adenosine.
LACTATION — Excretion in breast milk unknown
DIETARY CONSIDERATIONS — Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
MONITORING PARAMETERS — ECG monitoring, heart rate, blood pressure
TOXICOLOGY / OVERDOSE COMPREHENSIVE — Since the half-life of adenosine is <10 seconds, any adverse effects are rapidly self-limiting. Intoxication is usually short-lived since the half-life of the drug is very short. Treatment of prolonged effects requires individualization. Theophylline and other methylxanthines are competitive inhibitors of adenosine and may have a role in reversing its toxic effects. To reverse the effects of Adenoscan®, administer theophylline 50-125 mg slow I.V. push.
CANADIAN BRAND NAMES — Adenocard®; Adenoscan®; Adenosine Injection, USP
INTERNATIONAL BRAND NAMES — Adenocard (BR, CA); Adenocor (AU, BE, BG, CN, CZ, DK, EC, EE, EG, ES, FI, GB, HU, IE, IL, KR, MY, NO, NZ, PE, PL, TH, TW, UY, VE, ZA); Adenocur (NL); Adenoject (IN); Adenoscan (CA, HK); Adenosin Ebewe (PL); Adenosina Biol (AR, PY); Adenosine Injection, USP (CA); Adrekar (AT, DE); Cardiovert (PH); Fosfobion (PL); Krenosin (FR, IT, MX); Krenosine (CH); Soladen (PL)
MECHANISM OF ACTION — Slows conduction time through the AV node, interrupting the re-entry pathways through the AV node, restoring normal sinus rhythm
PHARMACODYNAMICS / KINETICS Onset of action: Rapid
Duration: Very brief
Metabolism: Blood and tissue to inosine then to adenosine monophosphate (AMP) and hypoxanthine
Half-life elimination: <10 seconds
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