ropivacaine (Rx)

Brand and Other Names:Naropin
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injectable solution

  • 2mg/mL
  • 5mg/mL
  • 7.5mg/mL
  • 10mg/mL

Epidural/Caudal Anesthesia

75-200 mg (15-30 mL of 0.5%-1% solution)

Major Nerve Block

175-250 mg (35-50 mL) of 0.5% solution

75-300 mg (10-40 mL) of 0.75% solution

Field Block

5-200 mg (1-40 mL) of 0.5% solution

Labor Pain

20-40 mg (10-20 mL) initial of 0.2% solution, THEN

12-28 mg/hr (6-14 mL/hr) of 0.2% solution OR

20-30 mg/hr (10-15 mL/hr) continuous infusion of 0.2% solution

Post-Op Pain

Peripheral Nerve Block

  • 5-10 mL/hr continuous infusion of 0.2% solution

Lumbar or Thoracic Epidural

  • 6-14 mL/hr continuous infusion of 0.2% solution

Infiltration/ Minor Nerve Block

  • 1-100 mL dose of 0.2% solution
  • 1-40 mL dose of 0.5% solution

Administration

Doses should not be repeated more frequently than q3hr, no more than 400 mg (770 mg for post-op pain) in 24 hr

Dosage Forms & Strengths

injectable solution

  • 2mg/mL
  • 5mg/mL
  • 7.5mg/mL
  • 10mg/mL

Caudal Epidural Block (Off-Label)

1.25-6.5 mg/kg or 1 mL/kg of 0.2% strength  

Epidural Continuous Infusion (Off-Label)

< 4 Months

  • Safety and efficacy not established

4 Months to 7 years

  • 1 mg/kg loading dose; follow with 0.2-0.4 mg/kg/hr for 48 hr  

7-12 years

  • 3.6 mg loading dose; follow with 3.2 mg/hr infusion; may titrate up to 27.2 mg/hr PRN  

>12 years

  • 75-200 mg (15-30 mL of 0.5%-1% solution)
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Interactions

Interaction Checker

and ropivacaine

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        Significant - Monitor Closely

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            Contraindicated (1)

            • bupivacaine liposome

              ropivacaine increases toxicity of bupivacaine liposome by Other (see comment). Contraindicated. Comment: Do not admix with other local nonbupivacaine-based local anesthetics; admixing results in a rapid increase in free (unencapsulated) bupivacaine.

            Serious - Use Alternative (10)

            • abametapir

              abametapir will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. For 2 weeks after abametapir application, avoid taking drugs that are CYP3A4 substrates. If not feasible, avoid use of abametapir.

              abametapir will increase the level or effect of ropivacaine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. For 2 weeks after abametapir application, avoid taking drugs that are CYP1A2 substrates. If not feasible, avoid use of abametapir.

            • apalutamide

              apalutamide will decrease the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of apalutamide, a strong CYP3A4 inducer, with drugs that are CYP3A4 substrates can result in lower exposure to these medications. Avoid or substitute another drug for these medications when possible. Evaluate for loss of therapeutic effect if medication must be coadministered. Adjust dose according to prescribing information if needed.

            • bupivacaine implant

              ropivacaine, bupivacaine implant. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Avoid additional local anesthetic administration within 96 hr following bupivacaine implantation. If use of additional local anesthetics is unavoidable based on clinical need, monitor for neurologic and cardiovascular effects related to local anesthetic systemic toxicity.

              ropivacaine, bupivacaine implant. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Local anesthetics may increase the risk of developing methemoglobinemia when concurrently exposed to drugs that also cause methemoglobinemia.

            • givosiran

              givosiran will increase the level or effect of ropivacaine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP1A2 substrates with givosiran. If unavoidable, decrease the CYP1A2 substrate dosage in accordance with approved product labeling.

            • idelalisib

              idelalisib will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Idelalisib is a strong CYP3A inhibitor; avoid coadministration with sensitive CYP3A substrates

            • ivosidenib

              ivosidenib will decrease the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP3A4 substrates with ivosidenib or replace with alternative therapies. If coadministration is unavoidable, monitor patients for loss of therapeutic effect of these drugs.

            • ketoconazole

              ketoconazole will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • lonafarnib

              lonafarnib will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration with sensitive CYP3A substrates. If coadministration unavoidable, monitor for adverse reactions and reduce CYP3A substrate dose in accordance with product labeling.

            • tucatinib

              tucatinib will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid concomitant use of tucatinib with CYP3A substrates, where minimal concentration changes may lead to serious or life-threatening toxicities. If unavoidable, reduce CYP3A substrate dose according to product labeling.

            • voxelotor

              voxelotor will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Voxelotor increases systemic exposure of sensitive CYP3A4 substrates. Avoid coadministration with sensitive CYP3A4 substrates with a narrow therapeutic index. Consider dose reduction of the sensitive CYP3A4 substrate(s) if unable to avoid.

            Monitor Closely (25)

            • atazanavir

              atazanavir will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • benazepril

              ropivacaine, benazepril. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Increases risk of hypotension.

            • cannabidiol

              cannabidiol, ropivacaine. affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. Owing to the potential for both CYP1A2 induction and inhibition with the coadministration of CYP1A2 substrates and cannabidiol, consider reducing dosage adjustment of CYP1A2 substrates as clinically appropriate.

            • captopril

              ropivacaine increases effects of captopril by Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Both drugs lower blood pressure. Monitor blood pressure.

            • cenobamate

              cenobamate will decrease the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Increase dose of CYP3A4 substrate, as needed, when coadministered with cenobamate.

            • ciprofloxacin

              ciprofloxacin will increase the level or effect of ropivacaine by Mechanism: decreasing metabolism. Use Caution/Monitor. Monitor for increased ropivacaine toxicity.

            • cobicistat

              cobicistat will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • conivaptan

              conivaptan will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • darunavir

              darunavir will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • elagolix

              elagolix decreases levels of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Elagolix is a weak-to-moderate CYP3A4 inducer. Monitor CYP3A substrates if coadministered. Consider increasing CYP3A substrate dose if needed.

            • elvitegravir/cobicistat/emtricitabine/tenofovir DF

              elvitegravir/cobicistat/emtricitabine/tenofovir DF increases levels of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Cobicistat is a CYP3A4 inhibitor; contraindicated with CYP3A4 substrates for which elevated plasma concentrations are associated with serious and/or life-threatening events.

            • encorafenib

              encorafenib, ropivacaine. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Encorafenib both inhibits and induces CYP3A4 at clinically relevant plasma concentrations. Coadministration of encorafenib with sensitive CYP3A4 substrates may result in increased toxicity or decreased efficacy of these agents.

            • fedratinib

              fedratinib will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Adjust dose of drugs that are CYP3A4 substrates as necessary.

            • fexinidazole

              fexinidazole will increase the level or effect of ropivacaine by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor.

            • istradefylline

              istradefylline will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Istradefylline 40 mg/day increased peak levels and AUC of CYP3A4 substrates in clinical trials. This effect was not observed with istradefylline 20 mg/day. Consider dose reduction of sensitive CYP3A4 substrates.

            • mitotane

              mitotane decreases levels of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Mitotane is a strong inducer of cytochrome P-4503A4; monitor when coadministered with CYP3A4 substrates for possible dosage adjustments.

            • nadolol

              nadolol, ropivacaine. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Use extreme caution during concomitant use of bupivacaine and antihypertensive agents.

            • pindolol

              pindolol, ropivacaine. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Use extreme caution during concomitant use of bupivacaine and antihypertensive agents.

            • propranolol

              propranolol, ropivacaine. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Use extreme caution during concomitant use of bupivacaine and antihypertensive agents.

            • rucaparib

              rucaparib will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Adjust dosage of CYP3A4 substrates, if clinically indicated.

              rucaparib will increase the level or effect of ropivacaine by affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. Adjust dosage of CYP1A2 substrates, if clinically indicated.

            • stiripentol

              stiripentol, ropivacaine. affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. Stiripentol is a CYP1A2 inhibitor and inducer. Monitor CYP1A2 substrates coadministered with stiripentol for increased or decreased effects. CYP1A2 substrates may require dosage adjustment.

              stiripentol, ropivacaine. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Stiripentol is a CYP3A4 inhibitor and inducer. Monitor CYP3A4 substrates coadministered with stiripentol for increased or decreased effects. CYP3A4 substrates may require dosage adjustment.

            • tazemetostat

              tazemetostat will decrease the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • tecovirimat

              tecovirimat will decrease the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Tecovirimat is a weak CYP3A4 inducer. Monitor sensitive CYP3A4 substrates for effectiveness if coadministered.

            • teriflunomide

              teriflunomide decreases levels of ropivacaine by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor.

            • timolol

              timolol, ropivacaine. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Use extreme caution during concomitant use of bupivacaine and antihypertensive agents.

            Minor (2)

            • hyaluronidase

              hyaluronidase, ropivacaine. Other (see comment). Minor/Significance Unknown. Comment: Hyaluronidase hastens the onset of local analgesia and reduces swelling, but increases systemic absorption of anesthetic. This decreases the duration of action and increases incidence of systemic reaction.

            • ribociclib

              ribociclib will increase the level or effect of ropivacaine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

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            Adverse Effects

            Frequency Not Defined

            Bradycardia, myocardial depression, , cardiac arrhythmias, edema, hypotension, cardiovascular collapse, cardiac arrest, palpitation, tachycardia, anginal pain, hypertension (epinephrine-containing solutions)

            Anxiety, apprehension, chills, headache, restlessness, nervousness, disorientation, confusion, dizziness, tremors, twitching, shivering, seizures; CNS depression manifested restlessness, tremors, drowsiness, unconsciousness, tinnitus

            Nausea, vomiting

            Blurred vision, miosis

            Respiratory arrest, status asthmaticus

            Anaphylactoid reactions (sometimes fatal)

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            Warnings

            Contraindications

            Hypersensitivity to ropivacaine or amide-type local anesthetics, sensitivity to parabens

            Obstetrical paracervical block anesthesia

            Cautions

            History of malignant hyperthermia

            DO NOT use solutions with epinephrine in distal areas of body (eg, digit, nose, ear)

            Use preservative-free preparations for spinal or epidural anesthesia

            Monitor patient's state of consciousness following the injection; anxiety, dizziness, restlessness, tremors, depression, or blurred vision may be signs of CNS toxicity

            Addition of vasoconstrictor, epinephrine, will promote local hemostasis, decrease systemic absorption, and increase duration of action

            Respiratory arrest reported with use

            Seizures reported with systemic toxicity

            Chondrolysis associated with intra-articular infusions following arthroscopic and other surgical procedures (off-label use)

            Methemoglobinemia

            • Use of local anesthetics may cause methemoglobinemia, a serious condition that must be treated promptly; patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, infants under 6 months of age, and concurrent exposure to oxidizing agents or their metabolites are more susceptible to developing clinical manifestations of the condition
            • Advise patients or caregivers to seek immediate medical attention if patient experiences the following signs or symptoms: pale, gray, or blue colored skin (cyanosis); headache; rapid heart rate; shortness of breath; lightheadedness; or fatigue; discontinue Bicillin C-R and any other oxidizing agents; depending on severity of signs and symptoms, patients may respond to supportive care, including oxygen therapy and hydration; a more severe clinical presentation may require treatment with methylene blue, exchange transfusion, or hyperbaric oxygen
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            Pregnancy & Lactation

            Pregnancy Category: C

            Lactation: not known if excreted in breast milk

            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

            Local anesthetics prevent generation/conduction of nerve impulses by reducing sodium permeability & increasing action potential threshold

            Pharmacokinetics

            Duration: 3-15 hr; dose and route dependent; the greater the degree of vasodilation produced by the local anesthetic, the faster the rate of absorption & shorter the duration of action

            Onset of action: 3-15 min (route dependent)

            Protein bound: 94%

            Metabolism: Liver

            Half-life: 5-7 hr (IV)

            Metabolites: ester- & amide-type local anesthetics

            Excretion: Urine (86%)

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            Formulary

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            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.