mannitol (Rx)

Brand and Other Names:Osmitrol
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injectable solution

  • 5%
  • 10%
  • 15%
  • 20%
  • 25%

Cerebral Edema

Reduction of intracranial pressure and treatment of cerebral edema

1.5-2 g/kg IV infused over 30-60 minutes  

Intraocular Pressure

1.5-2 g/kg IV infused over 30-60 minutes  

Anuria/Oliguria

Test dose: 200 mg/kg IV infused over 3-5 minutes

Load: 500-1000 mg/kg IV x1 dose

Maintenance: 250-500 mg/kg IV q4-6hr  

Bronchiectasis (Orphan)

Bronchitol: Facilitates clearance of mucus with bronchiectasis, and in patients with cystic fibrosis at risk for bronchiectasis

Orphan indication sponsor

  • Pharmaxis Ltd; 10 Rodborough Rd, NSW 2086, Australia

Other Information

Do NOT give simultaneously with blood

Use 15-25% solution

Other Indications & Uses

Brain mass

Dosage Forms & Strengths

injectable solution

  • 5%
  • 10%
  • 15%
  • 20%
  • 25%

Edema

0.25-1 g/kg IV initially; maintenance dose of 0.25-0.5 g/kg IV q4-6hr  

Anuria/Oliguria

Test dose: 0.2 g/kg IV over 3-5 minutes; not to exceed 12.5 g  

Discontinue if no diuresis within 2 hr

Other Information

Treatment of intoxications: Give therapeutic dose as 5 or 10% solution IV PRN

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Interactions

Interaction Checker

and mannitol

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            Adverse Effects

            Frequency Not Defined

            Angina-like chest pains

            CHF

            Hypotension

            Phlebitis

            Convulsions

            Chills

            Dizziness

            Headache

            Acidosis

            Fluid/electrolyte imbalances

            Thirst

            Nausea

            Vomiting

            Blurred vision

            Urinary retention

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            Warnings

            Contraindications

            Hypersensitivity, anuria, severe pulmonary edema or heart failure, severe dehydration, metabolic edema, progressive renal dz, active intracranial bleeding (except during craniotomy)

            Cautions

            Infusion of hypertonic solutions through a peripheral vein, at a concentration of 10% w/v or greater, may result in peripheral venous irritation, including phlebitis; other severe infusion site reactions, such as compartment syndrome and swelling associated with extravasation, can occur; administer, preferably, into a large central vein

            Do not mix with blood

            May cause hypovolemia, headache, polydipsia

            It might be more effective than pentobarbital, but less effective than hypertonic saline in pt w/acute traumatic brain injury

            Renal complications

            • Serious hypersensitivity reactions, including anaphylaxis, hypotension and dyspnea resulting in cardiac arrest and death reported; stop infusion immediately if signs or symptoms of suspected hypersensitivity reaction develop
            • Renal complications, including irreversible renal failure reported in patients receiving therapy; in patients with severe renal impairment, a test dose should be utilized; a second test dose may be tried if there is inadequate response, but attempt no more than two test doses
            • Reversible, oliguric acute kidney injury (AKI) has occurred in patients with normal pretreatment renal function who received large intravenous doses; patients with oliguric AKI who subsequently develop anuria while receiving mannitol are at risk of congestive heart failure, pulmonary edema, hypertensive crisis, coma and death
            • Although osmotic nephrosis associated with therapy is in principle reversible, osmotic nephrosis in general is known to potentially proceed chronic or even end-stage renal failure; monitor renal function closely during infusion; patients with pre-existing renal disease, patients with conditions that put them at high risk for renal failure, or those receiving potentially nephrotoxic drugs or other diuretics, are at increased risk of renal failure following administration of product; avoid concomitant administration of nephrotoxic drugs (e.g., aminoglycosides) or, other diuretics, if possible
            • During and following infusion for reduction in intracranial pressure, monitor patient clinically and laboratory tests for changes in fluid and electrolyte status; discontinue therapy if CNS toxicity develops
            • Administer with caution to patients with impaired renal function
            • If urine output declines during infusion, closely monitor patient’s clinical status for developing renal impairment, and infusion suspended, if necessary
            • Not for administration in patients with renal dysfunction until volume and electrolytes restored

            Central nervous system toxicity

            • CNS toxicity manifested by, confusion, lethargy, or coma reported in patients, some resulting in death, in particular in presence of impaired renal function, CNS toxicity may result from high serum mannitol concentrations, serum hyperosmolarity resulting in intracellular dehydration within CNS, hyponatremia or other disturbances of electrolyte and acid/base balance secondary to mannitol administration
            • At high concentrations, mannitol may cross blood brain barrier and interfere with ability of brain to maintain pH of cerebrospinal fluid especially in presence of acidosis
            • In patients with preexisting compromise of blood brain barrier, risk of increasing cerebral edema (general and focal) associated with repeated or continued use of product must be individually weighed against expected benefits
            • A rebound increase of intracranial pressure may occur several hours after infusion; patients with a compromised blood brain barrier are at increased risk
            • Concomitant administration of neurotoxic drugs (e.g., aminoglycosides) may potentiate neurotoxicity; avoid concomitant use of neurotoxic drugs, if possible

            Fluid electrolyte imbalance

            • Depending on dosage and duration, administration may result in hypervolemia leading to or exacerbating existing congestive heart failure
            • Accumulation of mannitol due to insufficient renal excretion increases risk of hypervolemia; mannitol-induced osmotic diuresis may cause or worsen dehydration/hypovolemia and hemoconcentration; therapy may also cause hyperosmolarity
            • Depending on dosage and duration of administration, electrolyte and acid/base imbalances may also result from transcellular shifts in water and electrolytes, osmotic diuresis and/or other mechanisms; such imbalances may be severe and potentially fatal
            • Metabolic acidosis/alkalosis
            • Pediatric patients <2 years, particularly preterm and term neonates, may be at higher risk for fluid and electrolyte abnormalities following administration due to decreased glomerular filtration rate and limited ability to concentrate urine
            • During and following infusion for reduction in intracranial pressure, monitor fluid and electrolyte status and discontinue therapy if imbalances occur
            • Imbalances resulting from therapy
              • Hypernatremia, dehydration and hemoconcentration
              • Hyponatremia, which can lead to headache, nausea, seizures, lethargy, coma, cerebral edema, and death; acute symptomatic hyponatremic encephalopathy is considered a medical emergency
              • Hypo/hyperkalemia; the development of electrolyte imbalances (eg, hyperkalemia, hypokalemia) associated with mannitol administration may result in cardiac adverse reactions in patients receiving drugs sensitive to such imbalances (e.g., digoxin, agents that may cause QT prolongation, neuromuscular blocking agents)
            • During and following infusion for reduction in intracranial pressure, monitor:
              • Serum osmolarity, serum electrolytes (including sodium, potassium, calcium and phosphate) and acid base balance
              • The osmol gap
              • Signs of hypo- or hypervolemia, including urine output
              • Renal, cardiac and pulmonary function
              • Intracranial pressure
              • Discontinue therapy if renal, cardiac, or pulmonary status worsens or CNS toxicity develops
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            Pregnancy & Lactation

            Pregnancy

            Animal reproduction studies not conducted with mannitol; also not known whether mannitol can cause fetal harm when administered to pregnant woman or can affect reproduction capacity; product should be given to pregnant woman only if clearly needed

            Labor and delivery

            • Studies have not been conducted to evaluate effects on labor and delivery; exercise caution when administering product during labor and delivery

            Lactation

            Not known whether product is excreted in human milk; because many drugs are excreted in human milk, exercise caution when product administered to nursing woman

            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

            Half life: 100 min

            Onset

            Diuresis: 1-3 hr after IV administration of mannitol. Lowering of

            IOP reduction: 30-60 min

            ICP reduction: 15 min

            Duration

            IOP reduction: 4-6 hr

            ICP reduction: 3-8 hr

            Other Information

            Metabolism: liver (very slight)

            Metabolites: glycogen

            Excretion: urine (80%)

            Mechanism of Action

            Osmotic diuretic

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            Administration

            IV Incompatibilities:

            Additive: etoposide w/ cisplatin & KCl(?), imipenem-cilastatin (may be used for shorter periods), meropenem (may be used for shorter periods)

            Y-site: cefepime, doxorubicin liposomal, filgrastim

            IV Compatibilities

            Additive (partial list): cefoxitin, cimetidine, furosemide. metoclopramide, ondansetron

            Y-site: allopurinol, cisatracurium, etoposide phosphate, linezolid, ondansetron, propofol, vinorelbine

            IV Preparation

            Infusion only

            Use administration set with filter for infusion of injections containing 20% or more, since crystals may be present

            For transurethral prostatic resection, mannitol irrigation solns are instilled into bladder via indwelling urethral catheter

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            Images

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            Formulary

            FormularyPatient Discounts

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