Dosing & Uses
Dosage Forms & Strengths
injectable solution
-
Nitropress
- 25mg/mL (50mg/2mL vial) (Nitropress)
-
Nipride RTU
- 0.2mg/mL (20mg/100mL 0.9% NaCl)
- 0.5mg/mL (50mg/100mL 0.9% NaCl)
Hypertensive Crisis
Indicated for immediate reduction of blood pressure (BP) during hypertensive crisis
Initial infusion rate: 0.3 mcg/kg/min; evaluate BP for at least 5 minutes before titrating to a higher or lower dose to achieve desired BP
Not to exceed 10 mcg/kg/min
Dose may be titrated upward until
- Desired effect achieved, OR
- Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
- Maximum recommended infusion rate of 10 mcg/kg/min has been reached, whichever occurs first
Controlled Hypotension During Surgery
Indicated for induction and maintenance of controlled hypotension during surgery, to reduce bleeding
Initial infusion rate: 0.3 mcg/kg/min; evaluate BP for at least 5 minutes before titrating to higher or lower dose to achieve desired BP
Not to exceed 10 mcg/kg/min
Dose may be titrated upward until
- Desired effect achieved, OR
- Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
- Maximum recommended infusion rate of 10 mcg/kg/min has been reached, whichever occurs first
Acute Heart Failure
Indicated for treatment of acute heart failure to reduce left ventricular end-diastolic pressure, pulmonary capillary wedge pressure, peripheral vascular resistance, and mean arterial blood pressure
Initial infusion rate: 0.3 mcg/kg/min; evaluate BP for at least 5 minutes before titrating to higher or lower dose to achieve desired BP
Not to exceed 10 mcg/kg/min
Dose may be titrated upward until
- Desired effect achieved, OR
- Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
- Maximum recommended infusion rate of 10 mcg/kg/min has been reached, whichever occurs first
Dosing Considerations
Continuous blood pressure monitoring required during infusion
Cerebral Vasospasm (Orphan)
Treatment and prevention of cerebral vasospasm following subarachnoid hemorrhage
Orphan indication sponsor
- Jeffrey Evan Thomas, MD; Thomas Jefferson University and Wills Neurosensory, 834 Walnut Street, Suite 650; Philadelphia, PA 19107-5102
Other Indications & Uses
Off-label: MI (with dopamine); left ventricular failure (with O2, morphine, loop diuretic)
Dosage Forms & Strengths
injectable solution
-
Nitropress
- 25mg/mL (50mg/2mL vial) (Nitropress)
-
Nipride RTU
- 0.2mg/mL (20mg/100mL 0.9% NaCl)
- 0.5mg/mL (50mg/100mL 0.9% NaCl)
Hypertensive Crisis
Indicated for immediate reduction of blood pressure (BP) during hypertensive crisis
Initial infusion rate: 0.3 mcg/kg/min; evaluate BP for at least 5 minutes before titrating to higher or lower dose to achieve desired BP
Not to exceed 10 mcg/kg/min
Dose may be titrated upward until
- Desired effect achieved, OR
- Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
- Maximum recommended infusion rate of 10 mcg/kg/min has been reached, whichever occurs first
Controlled Hypotension During Surgery
Indicated for induction and maintenance of controlled hypotension during surgery, to reduce bleeding
Initial infusion rate: 0.3 mcg/kg/min; evaluate BP for at least 5 minutes before titrating to higher or lower dose to achieve desired BP
Not to exceed 10 mcg/kg/min
Dose may be titrated upward until
- Desired effect achieved, OR
- Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
- Maximum recommended infusion rate of 10 mcg/kg/min has been reached, whichever occurs first
Dosing Considerations
Continuous blood pressure monitoring required during infusion
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Contraindicated (0)
Serious - Use Alternative (2)
- avanafil
nitroprusside sodium, avanafil. Either increases effects of the other by Mechanism: pharmacodynamic synergism. Contraindicated. Additive hypotensive effects.
- lofexidine
lofexidine, nitroprusside sodium. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Avoid coadministration with other drugs that decrease pulse or blood pressure to mitigate risk of excessive bradycardia and hypotension.
Monitor Closely (22)
- amlodipine
amlodipine increases effects of nitroprusside sodium by pharmacodynamic synergism. Use Caution/Monitor.
- benazepril
nitroprusside sodium, benazepril. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Additive hypotensive effects.
- bretylium
nitroprusside sodium, bretylium. Either decreases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Each drug may cause hypotension.
- bupivacaine implant
nitroprusside sodium, bupivacaine implant. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: Local anesthetics may increase the risk of developing methemoglobinemia when concurrently exposed to drugs that also cause methemoglobinemia.
- clevidipine
clevidipine increases effects of nitroprusside sodium by pharmacodynamic synergism. Use Caution/Monitor.
- clonidine
nitroprusside sodium, clonidine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Additive hypotensive effects.
- dapsone topical
nitroprusside sodium increases toxicity of dapsone topical by altering metabolism. Modify Therapy/Monitor Closely. May induce methemoglobinemia.
- dichlorphenamide
dichlorphenamide, nitroprusside sodium. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Both drugs can cause metabolic acidosis.
- diltiazem
diltiazem increases effects of nitroprusside sodium by pharmacodynamic synergism. Use Caution/Monitor.
- felodipine
felodipine increases effects of nitroprusside sodium by pharmacodynamic synergism. Use Caution/Monitor.
- guanfacine
nitroprusside sodium, guanfacine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Additive hypotensive effects.
- isradipine
isradipine increases effects of nitroprusside sodium by pharmacodynamic synergism. Use Caution/Monitor.
- maraviroc
maraviroc, nitroprusside sodium. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of orthostatic hypotension.
- nicardipine
nicardipine increases effects of nitroprusside sodium by pharmacodynamic synergism. Use Caution/Monitor.
- nifedipine
nifedipine increases effects of nitroprusside sodium by pharmacodynamic synergism. Use Caution/Monitor.
- nisoldipine
nisoldipine increases effects of nitroprusside sodium by pharmacodynamic synergism. Use Caution/Monitor.
- nitroglycerin rectal
nitroglycerin rectal, nitroprusside sodium. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Observe for possible additive hypotensive effects during concomitant use. .
- sildenafil
nitroprusside sodium, sildenafil. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Additive hypotensive effects.
- tadalafil
nitroprusside sodium, tadalafil. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Additive hypotensive effects.
- tetracaine
tetracaine, nitroprusside sodium. Other (see comment). Use Caution/Monitor. Comment: Monitor for signs of methemoglobinemia when methemoglobin-inducing drugs are coadministered.
- vardenafil
nitroprusside sodium, vardenafil. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Additive hypotensive effects.
- verapamil
verapamil increases effects of nitroprusside sodium by pharmacodynamic synergism. Use Caution/Monitor.
Minor (0)
Adverse Effects
Frequency Not Defined
Common
- Bradyarrhythmia, hypotension, palpitations, tachyarrhythmia
- Apprehension, restlessness, confusion, dizziness, headache, somnolence
- Rash, sweating
- Thyroid suppression
- Injection site irritation
- Muscle twitch
- Oliguria, renal azotemia
Serious
- Cardiac dysrhythmia, hemorrhage, decreased platelet aggregation, excessive hypotensive response
- Raised intracranial pressure
- Metabolic acidosis
- Bowel obstruction
- Methemoglobinemia
- Cyanide poisoning
- Thiocyanate toxicity
Warnings
Black Box Warnings
Not suitable for direct injection; requires dilution prior to infusion
Hypotension may occur, leading to irreversible ischemic injury or death; requires appropriate monitoring equipment and experienced personnel
Cyanide toxicity may occur because of accumulation of cyanide ion
Contraindications
Hypersensitivity
Compensatory HTN (eg, arteriovenous shunt or aortic coarctation); (for controlled hypotension): inadequate cerebral circulation
Certain rare conditions, eg, congenital optic atrophy, tobacco amblyopia
Treatment of acute CHF associated with reduced peripheral vascular resistance such as high-output heart failure that may be seen in endotoxic sepsis
To produce hypotension during surgery in patients with known inadequate cerebral circulation, or in moribund patients (A.S.A. Class 5E) coming to emergency surgery
Cautions
Small transient excesses in the infusion rate of sodium nitroprusside can result in excessive hypotension, sometimes to levels so low as to compromise the perfusion of vital organs; nitroprusside-induced hypotension will be self-limited within 1-10 minutes after discontinuation of therapy; during these few minutes, it may be helpful to put the patient into a head-down (Trendelenburg) position to maximize venous return; if hypotension persists more than a few minutes after discontinuation of infusion therapy is not the cause, and the true cause must be sought
Therapy can cause increases in intracranial pressure; in patients whose intracranial pressure is already elevated, sodium nitroprusside should be used only with extreme caution
Use caution when administering nitroprusside to patients with hepatic insufficiency
When sodium nitroprusside (or any other vasodilator) is used for controlled hypotension during anesthesia, the patient’s capacity to compensate for anemia and hypovolemia may be diminished; if possible, pre-existing anemia and hypovolemia should be corrected prior to administration of therapy
Hypotensive anesthetic techniques may cause abnormalities of pulmonary ventilation/perfusion ratio; patients intolerant of these abnormalities may require a higher fraction of inspired oxygen
Head trauma, increases ICP, hyponatremia, hypothyroidism, severe hepatic or renal impairment, elderly
Cyanide toxicity
- Infusions at rates above 2 mcg/kg/min generate cyanide ion (CN¯) faster than the body can normally dispose of it
- Methemoglobin normally present in the body can buffer a certain amount of CN¯, but the capacity is exhausted by the CN¯ produced from about 500 mcg/kg of sodium nitroprusside; this amount of sodium nitroprusside is administered in less than an hour when the drug is administered at 10 mcg/kg/min (the maximum recommended rate); thereafter, the toxic effects of CN¯ may be rapid, serious, and even lethal
- Cyanide toxicity may manifest itself as venous hyperoxemia with bright red venous blood, as cells become unable to extract oxygen delivered to them; metabolic (lactic) acidosis; air hunger; confusion; and death
- Cyanide toxicity due to causes other than nitroprusside has been associated with angina pectoris and myocardial infarction; ataxia, seizures, and stroke; and other diffuse ischemic damage
- Hypertensive patients, and patients concomitantly receiving other antihypertensive medications, may be more sensitive to the effects of sodium nitroprusside than normal subjects
- Check thiocyanate levels, monitor pulse oximeter
- Thiocyanate clearance may decrease with renal failure
Drug interaction overview
- The hypotensive effect of sodium nitroprusside is augmented by that of most other hypotensive drugs, including ganglionic blocking agents, negative inotropic agents, and inhaled anesthetics
Pregnancy & Lactation
Pregnancy Category: C
Lactation: not known if distributed into 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.Pharmacology
Mechanism of Action
Relaxes vascular smooth muscle to reduce afterload and preload by producing NO
Dilates coronary arteries
Pharmacokinetics
Half-Life: Parent drug: 2 min, metabolite (thiocyanate): 3 days, longer in patients with impaired renal function or hyponatremia
Onset of action: <2 min
Duration: 1-10 min
Metabolism: in blood (100%); ferrous ion in nitroprusside molecule reacts rapidly with sulfhydryl compounds in RBCs which results in cyanide release, which is then metabolized in liver and kidney by rhodanese to thiocyanate
Metabolites: Thiocyanate (inactive)
Excretion: Mainly in urine, excreted entirely as metabolites, principally thiocyanate
Dialyzable: Yes (HD)
Administration
IV Incompatibilities
Additive: atracurium
Y-site: amiodarone(?), cisatracurium (at 2+ mg/mL cisatra, may be compatible at 0.1 mg/mL cisatra), haloperidol (at 5 mg/mL halo, may be compatible at 0.5 mg/mL halo), levofloxacin, propafenone(?)
IV Compatibilities
Solution: D5W, LR, NS (when not exposed to bright light)
Additive: cimetidine, enalaprilat, ranitidine, verapamil
Syringe: caffeine, heparin
Y-site: alprostadil, atracurium, bivalirudin, CaCl2, dexmedetomidine, diltiazem, dobutamine, dopamine, enalaprilat, esmolol, famotidine, furosemide, heparin, hetastarch, inamrinone, insulin, isoproterenol, labetalol, lidocaine, MgSO4, midazolam, morphine sulfate, nicardipine, nitroglycerin, pancuronium, KCl, potassium phosphates, procainamide, propofol, tacrolimus, theophylline, vecuronium
IV Preparation
Reconstitute 50 mg vial in 2-3 mL D5W or SWI (NOT BWI, increases decomposition rate)
Dilute reconstituted solution (or 25 mg/mL vial, contains 2 mL) with 250-1000 mL D5W (final conc 50-200 mcg/mL)
Wrap container in aluminum foil
Solution should be reddish-brown; discard if blue
Do not freeze
Use within 24 hr
Protect from light, do not use if discolored
IV Administration
Infusion pump required
Undiluted vial not for direct injection
Images
| BRAND | FORM. | UNIT PRICE | PILL IMAGE |
|---|---|---|---|
| Nitropress intravenous - | 25 mg/mL vial |  | |
| Nitropress intravenous - | 25 mg/mL vial |  | |
| sodium nitroprusside intravenous - | 25 mg/mL vial |  | |
| sodium nitroprusside intravenous - | 25 mg/mL vial |  | |
| sodium nitroprusside intravenous - | 25 mg/mL vial |  |
Copyright © 2010 First DataBank, Inc.
Patient Handout
sodium nitroprusside intravenous
NO MONOGRAPH AVAILABLE AT THIS TIME
USES: Consult your pharmacist.
HOW TO USE: Consult your pharmacist.
SIDE EFFECTS: Consult your pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
PRECAUTIONS: Consult your pharmacist.
DRUG INTERACTIONS: Consult your pharmacist.Keep a list of all your medications with you, and share the list with your doctor and pharmacist.
OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.
NOTES: No monograph available at this time.
MISSED DOSE: Consult your pharmacist.
STORAGE: Consult your pharmacist.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.
Information last revised July 2016. Copyright(c) 2023 First Databank, Inc.
IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.
Formulary
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