nitroprusside sodium (Rx)

Brand and Other Names:Nipride RTU, Nitropress, more...Sodium Nitroprusside
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Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

injectable solution

  • 25mg/mL (50mg/2mL vial) (Nitropress)
  • 0.5mg/mL (50mg/100mL 0.9% NaCl) (Nipride RTU)
more...

Hypertensive Crisis

Indicated for immediate reduction of blood pressure (BP) during hypertensive crisis in adult and pediatric patients

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 the desired BP

Not to exceed 10 mcg/kg/min

The dose may be titrated upward until

  • Desired effect is achieved, OR
  • Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
  • The 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 in adults and children during surgery, to reduce bleeding

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 the desired BP

Not to exceed 10 mcg/kg/min

The dose may be titrated upward until

  • Desired effect is achieved, OR
  • Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
  • The maximum recommended infusion rate of 10 mcg/kg/min has been reached, whichever occurs first

Treatment of 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 a higher or lower dose to achieve the desired BP

Not to exceed 10 mcg/kg/min

The dose may be titrated upward until

  • Desired effect is achieved, OR
  • Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
  • The 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)
more...

Hypertensive Crisis

Indicated for immediate reduction of blood pressure (BP) during hypertensive crisis in adult and pediatric patients

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 the desired BP

Not to exceed 10 mcg/kg/min

The dose may be titrated upward until

  • Desired effect is achieved, OR
  • Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
  • The 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 in adults and children during surgery, to reduce bleeding

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 the desired BP

Not to exceed 10 mcg/kg/min

The dose may be titrated upward until

  • Desired effect is achieved, OR
  • Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
  • The maximum recommended infusion rate of 10 mcg/kg/min has been reached, whichever occurs first

Dosing Considerations

Continuous blood pressure monitoring required during infusion

Hypertensive Crisis

Indicated for immediate reduction of blood pressure (BP) during hypertensive crisis in adult and pediatric patients

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 the desired BP

Not to exceed 10 mcg/kg/min

The dose may be titrated upward until

  • Desired effect is achieved, OR
  • Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
  • The 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 in adults and children during surgery, to reduce bleeding

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 the desired BP

Not to exceed 10 mcg/kg/min

The dose may be titrated upward until

  • Desired effect is achieved, OR
  • Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
  • The maximum recommended infusion rate of 10 mcg/kg/min has been reached, whichever occurs first

Treatment of 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 a higher or lower dose to achieve the desired BP

Not to exceed 10 mcg/kg/min

The dose may be titrated upward until

  • Desired effect is achieved, OR
  • Systemic BP cannot be further reduced without compromising the perfusion of vital organs, OR
  • The maximum recommended infusion rate of 10 mcg/kg/min has been reached, whichever occurs first

Dosing Considerations

Continuous blood pressure monitoring required during infusion

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Interactions

Interaction Checker

and nitroprusside sodium

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    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

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            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
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            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

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            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.

            more...
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            Pharmacology

            Mechanism of Action

            Relaxes vascular smooth muscle to reduce afterload & preload by producing NO

            Also 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)

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            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 soln (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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            Formulary

            FormularyPatient Discounts

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

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            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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