naloxone (Rx)

Brand and Other Names:Narcan, Evzio
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injectable solution

  • 0.4mg/mL
  • 1mg/mL

IM/SC auto-injector

  • 0.4mg/0.4mL (2 auto-injectors/package)
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Opioid Overdose

Indicated for the complete or partial reversal of opioid depression (including respiratory depression) induced by natural and synthetic opioids

0.4-2 mg IV/IM/SC; repeat q2-3min PRN; not to exceed 10 mg (0.01 mg/kg) 

Consider other causes of respiratory depression if desired response not achieved after administering 10 mg cumulative total

Endotracheal (this is the least desirable route of administration and supported only by anecdotal evidence): 2-2.5 times (0.8-5 mg) initial IV dose

For chronic opioid abuse, use smallest doses (0.1-0.2 mg) to avoid acute withdrawal; titrate to reversal of respiratory depression

Following reversal, additional dose(s) may need to be administered at later interval (ie, 20 to 60 min) depending on type and duration of opioid

Continuous IV infusion (Off-label)

  • For use in patients exposed to long acting opioids (eg, methadone), sustained release products
  • Calculate dose/hr based on effective intermittent dose used and duration of adequate response seen
  • Alternatively, use two-thirds of initial effective naloxone bolus on an hourly basis (0.25-6.25 mg/hr); administer one-half of initial bolus dose 15 min after initiating continuous IV infusion to prevent drop in naloxone levels

Inhalation via Nebulization (Off-label)

  • 2 mg as inhalation via nebulization; may repeat
  • Switch to IV or IM administration when possible
  • Nebulization method is not included in the AHA recommendations for initial management of opioid-associated life-threatening emergency

Evzio Auto-Injector

  • Indicated for immediate administration as emergency treatment of known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression
  • 0.4 mg or 2 mg IM/SC into anterolateral aspect of the thigh (through clothing if necessary)
  • Seek emergency medical care immediately after use
  • Additional doses may be administered q2-3min until EMS arrives

Dosing considerations (Evzio)

  • Take-home, single-use auto-injector with visual and voice instruction for guidance
  • May be prescribed to a family member or caregiver
  • Compact size for portability with retractable needle system
  • Intended for immediate administration as emergency therapy in settings where opioids may be present
  • Not a substitute for emergency medical care
  • Also see Administration

Reversal of Respiratory Depression with Therapeutic Opioid Doses

0.04-0.4 mg IV/IM/SC initially; may repeat until desired response achieved; if desired response not observed after 0.8 mg total, consider other causes of respiratory depression

Postoperative Opioid Depression

0.1-0.2 mg IV q2-3min to desired degree of reversal (eg, adequate ventilation and alertness without significant pain)

May repeat within 1-2hr intervals depending on amount, type (eg, short or long acting) and timing of last dose administered; supplemental IM doses have produced longer lasting effects

Dosage Forms & Strengths

injectable solution

  • 0.4mg/mL
  • 1mg/mL

IM/SC auto-injector

  • 0.4mg/0.4mL (2 auto-injectors/package)
more...

Opioid Reversal

Postanesthesia (acute) opioid reversal

  • Neonates: 0.01 mg/kg IV into umbilical vein/IM/SC; give subsequent dose of 0.1 mg/kg if needed 
  • Children: 0.01 mg/kg IV once; may repeat with 0.1 mg/kg

Reversal of respiratory depression with therapeutic opioid dosing

  • Manufacturer dosing: 0.005-0.01 mg; repeat q2-3min PRN based on response
  • AAP dosing: 0.001-0.015 mg/kg/dose IV; titrate to effect 

Acute opioid overdose

  • ≤20 kg or <5 years: 0.1 mg/kg/dose IV/IM/SC/ET; if needed, repeat q2-3min PRN; not to exceed 2 mg/dose 
  • >20 kg or ≥5 years: 2 mg IV/IM/SC/ET; if needed, repeat q2-3min PRN
  • Consider endotracheal administration when IV/intraosseous route not available; optimal endotracheal dose unknown; 2-3 times the IV dose recommended

Opioid Overdose (Evzio Auto-Injector)

Indicated for immediate administration as emergency treatment of known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression

0.4 mg or 2 mg IM/SC into anterolateral aspect of the thigh (through clothing if necessary); if child is <1 yr, pinch the thigh muscle while administering the dose

Seek emergency medical care immediately after use

Additional doses may be administered q2-3min until EMS arrives

Dosing considerations (Evzio)

  • Take-home, single-use auto-injector with visual and voice instruction for guidance
  • May be prescribed to a family member or caregiver
  • Compact size for portability with retractable needle system
  • Intended for immediate administration as emergency therapy in settings where opioids may be present
  • Not a substitute for emergency medical care
  • Also see Administration
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Interactions

Interaction Checker

and naloxone

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    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            Frequency Not Defined

            Withdrawal reaction precipitated

            Abrupt reversal of narcotic depression may result in nausea, vomiting, sweating, tachycardia, increased blood pressure and tremulousness

            Cardiac arrest

            Ventricular fibrillation

            Dyspnea

            Pulmonary edema

            Abdominal cramps

            Diarrhea

            Cardiac arrest

            Hypertension

            Hypotension

            Ventricular tachycardia

            Paresthesia

            Restlessness

            Shivering

            Tonic-clonic seizures

            Yawning

            Diaphoresis

            Piloerection

            Hot flash

            Myalgia

            Tremor

            Weakness

            Rhinorrhea

            Sneezing

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            Warnings

            Contraindications

            Hypersensitivity

            Cautions

            Caution in patients with cardiovascular disease or patients receiving medications with potential adverse cardiovascular effects

            Caution in patients with history of seizures; avoid use in treatment of meperidine-induced seizures

            Recurrence of respiratory depression may occur if opioid involved is long-acting or a partial agonist (eg, methadone, buprenorphine); observe patients until there is no further risk of recurrent respiratory or CNS depression

            Avoid excessive dosages after use of opioids in surgery; abrupt postoperative reversal may unmask pain and may cause nausea, vomiting, sweating, seizures, hypertension, and tachycardia; other cardiovascular events, including pulmonary edema and arrhythmias may occur

            Auto-injector (Evzio)

            • Monitor injection site for residual needle parts and signs of infection when used to administered to infants <1year of age

            Opioid withdrawal

            • Use in patients who are opioid dependent may precipitate acute abstinence syndrome
            • Syndrome characterized by body aches, diarrhea, tachycardia, fever, runny nose, sneezing, piloerection, sweating, yawning, nausea or vomiting, nervousness, restlessness, or irritability, shivering or trembling, abdominal cramps, weakness, and hypertension
            • In neonates, opioid withdrawal may be life-threatening if not recognized and properly treated and may include convulsions, excessive crying, and hyperactive reflexes
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            Pregnancy & Lactation

            Pregnancy category: C

            Lactation: Not known if distributed in milk; use caution

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Competitive opioid antagonist; synthetic congener of oxymorphone

            Absorption

            Onset: 2 min (IV); 2-5 min (IM/SC)

            Duration: Depends on route of administration; generally 1-2 hr

            Elimination

            Half-life: 30-90 min (adults); 3-4 hr (neonates)

            Excretion: Urine

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            Administration

            IV Compatibilities

            Additive: Verapamil

            Syringe: Heparin, ondansetron, dimehydrinate

            Y-site: Fenoldopam, gatifloxacin, linezolid, propofol

            IV Incompatibilities

            Syringe: Pantoprazole

            Y-site: Amphotericin B cholSO4

            IV Preparation

            For infusion, dilute to 4 mcg/mL in D5W or NS

            Use within 24 hr

            IM/SC Preparation

            Before using, check to make sure the solution is not discolored

            Replace if the solution is discolored or contains a precipitate

            IM/SC Administration

            For IM or SC use only

            Seek emergency medical care immediately after use

            Since the duration of action of most opioids exceeds that of naloxone and the suspected opioid overdose may occur outside of supervised medical settings, seek immediate emergency medical assistance, keep the patient under continued surveillance until emergency personnel arrive, and administer repeated naloxone doses as necessary

            Evzio

            • Administer in anterolateral aspect of the thigh in adult and pediatric patients
            • Upon actuation, the autoinjector automatically inserts the needle IM or SC, and thereby delivers the naloxone injection, and then retracts the needle fully into its housing
            • In pediatric patients aged <1 yr, the caregiver should pinch the thigh muscle while administering the dose
            • Administer additional doses using a new auto-injector, if the patient does not respond or responds and then relapses into respiratory depression
            • Additional doses may be given q2-3min until emergency medical assistance arrive

            Storage

            Store at controlled room temperature 15-25°C (59-77°F) excursions permitted between 4-40°C (39-104°F)

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            Images

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

            To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

            Adding plans allows you to:

            • View the formulary and any restrictions for each plan.
            • Manage and view all your plans together – even plans in different states.
            • Compare formulary status to other drugs in the same class.
            • Access your plan list on any device – mobile or desktop.

            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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