nitroprusside sodium (Rx)

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

AdultPediatric

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

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Interactions

Interaction Checker

and nitroprusside sodium

No Results

     activity indicator 
    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

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             activity indicator 

            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)

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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 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
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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.

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                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)

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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 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

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                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.

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                Patient Handout

                Patient Education
                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) 2021 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.

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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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                Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.