Dosing & Uses
Dosage Forms & Strengths
injectable solution
- 25mg/mL (50mg/2mL vial) (Nitropress)
- 0.5mg/mL (50mg/100mL 0.9% NaCl) (Nipride RTU)
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
- 25mg/mL (50mg/2mL vial) (Nitropress)
- 0.5mg/mL (50mg/100mL 0.9% NaCl) (Nipride RTU)
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
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
Not for use in emergency surgery in very ill patients
Cautions
Head trauma, increases ICP, hyponatremia, hypothyroidism, severe hepatic or renal impairment, elderly
Cyanide toxicity can develop within 1 hr with infusions >10 mcg/kg/min
- Check thiocyanate levels, monitor pulse oximeter
Thiocyanate clearance decreased with renal failure
Protect from light, do not use if discolored
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
IV Administration
Infusion pump required
Undiluted vial not for direct injection
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Patient Handout
Formulary
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