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Isoproterenol: Pediatric drug information

Isoproterenol: Pediatric drug information
(For additional information see "Isoproterenol: Drug information" and see "Isoproterenol: Patient drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Brand Names: US
  • Isuprel [DSC]
Therapeutic Category
  • Adrenergic Agonist Agent;
  • Antiasthmatic;
  • Beta1 & Beta2-Adrenergic Agonist Agent;
  • Bronchodilator;
  • Sympathomimetic
Dosing: Neonatal

Note: Patients may exhibit dose-dependent vasodilation due to unopposed beta2-agonism elicited by isoproterenol.

Bradycardia; increase cardiac output

Bradycardia; increase cardiac output: Very limited data available: Continuous IV infusion: 0.05 to 1 mcg/kg/minute; titrate to effect (Ref)

Dosing: Pediatric

Note: Patients may exhibit dose-dependent vasodilation due to unopposed beta2-agonism elicited by isoproterenol.

Bradycardia, severe; AV nodal block

Bradycardia, severe; AV nodal block: Limited data available: Infants, Children, and Adolescents: Continuous IV infusion: 0.05 to 0.5 mcg/kg/minute; titrate to effect; doses as high as 2 mcg/kg/minute may be needed in some patients (Ref); usual adult range: 2 to 10 mcg/minute (Ref)

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Adult

(For additional information see "Isoproterenol: Drug information")

Note: May cause dose-dependent hypotension due to beta-2 agonist effects.

Bradycardia or atrioventricular block, symptomatic

Bradycardia or atrioventricular block, symptomatic (unresponsive to atropine): Continuous infusion: IV: Usual dosage range: 1 to 20 mcg/minute; titrate to clinical response (Ref).

Cardiogenic shock due to bradycardia

Cardiogenic shock due to bradycardia (off-label use): Continuous infusion: IV: 2 to 20 mcg/minute (Ref).

Provocation during tilt table testing, diagnostic agent for syncope

Provocation during tilt table testing, diagnostic agent for syncope (off-label use): Note: Timing of initiation and dose adjustment during test may be institution specific; refer to institutional protocols.

Continuous infusion: IV: Initial: 1 mcg/minute; increase as necessary based on clinical response up to 3 mcg/minute (Ref).

Torsade de pointes, to reduce recurrence

Torsade de pointes, to reduce recurrence (off-label use):

Note: For use only in patients who have a bradycardia-mediated cause of torsades de pointes. Avoid use in congenital long QT syndrome. Patient should be under the care of a clinician experienced with using isoproterenol for this condition (Ref).

Continuous infusion: IV: Usual dosage range: 2 to 10 mcg/minute; titrate to clinical response (Ref).

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling.

Adverse Reactions

The following adverse drug reactions are derived from product labeling unless otherwise specified.

Postmarketing:

Cardiovascular: Adams-Stokes syndrome, angina pectoris, atrioventricular block (Barold 2015), bradycardia (Duong 2020), chest pain (Duong 2020), coronary artery vasospasm (Duong 2020), flushing, hypertension, hypotension (Suwa 2004), increased ST segment on ECG (Okuya 2021), palpitations, tachyarrhythmia, tachycardia, ventricular arrhythmia (including non-sustained ventricular fibrillation) (Okuya 2021), ventricular premature contractions (Okuya 2021)

Dermatologic: Diaphoresis, pallor

Gastrointestinal: Nausea

Nervous system: Dizziness, headache, nervousness, tremor

Ophthalmic: Blurred vision (Duong 2020)

Respiratory: Dyspnea, pulmonary edema

Contraindications

Angina, preexisting ventricular arrhythmias, tachycardia or tachyarrhythmias; cardiac glycoside intoxication induced heart block or tachycardia.

Warnings/Precautions

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with cardiovascular disease (eg, coronary artery disease); may increase myocardial oxygen demand resulting in ischemia.

• Diabetes: Use with caution in patients with diabetes mellitus; may transiently increase blood glucose levels.

• Distributive shock: Avoid use in patients with distributive shock; may reduce systemic vascular resistance (SVR) further resulting in hemodynamic compromise.

Special populations:

• Older patients: Use with caution in older patients.

Dosage form specific issues:

• Sulfites: Contains sulfites; may cause allergic reaction in susceptible individuals.

Other warnings/precautions:

• Appropriate use: Use with extreme caution; not currently a treatment of choice. Excessive or prolonged use may result in decreased effectiveness.

Warnings: Additional Pediatric Considerations

Isoproterenol is not recommended for treatment of bronchospasm. In children with refractory asthma, continuous isoproterenol infusion was associated with myocardial necrosis, congestive heart failure, further clinical deterioration, and death in some cases. The risk of cardiac toxicity was observed to be increased by concomitant corticosteroids or methylxanthines, acidosis, or hypoxemia; monitor patients closely (vital signs, ECG, cardiac enzymes) with therapy.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Injection, as hydrochloride:

Isuprel: 0.2 mg/mL (1 mL [DSC], 5 mL [DSC]) [contains disodium edta]

Generic: 0.2 mg/mL (1 mL, 5 mL)

Solution, Injection, as hydrochloride [preservative free]:

Generic: 0.2 mg/mL (1 mL, 5 mL)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Isoproterenol HCl Injection)

0.2 mg/mL (per mL): $16.80 - $264.00

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Injection, as hydrochloride:

Generic: 0.2 mg/mL (1 mL, 5 mL)

Administration: Pediatric

Parenteral: Administer by continuous IV infusion; requires the use of an infusion pump

Administration: Adult

IV: IV infusion administration requires the use of an infusion pump.

Usual Infusion Concentrations: Pediatric

IV infusion: 20 mcg/mL

Storage/Stability

Store intact vials/ampules at 20°C to 25°C (68°F to 77°F). Protect from light; keep in opaque container until used. Exposure to air, light, or increased temperature may cause a pink to brownish pink color to develop. Solutions should not be used if they are discolored or contain a precipitate. Stability of parenteral admixture in NS or D5W at room temperature (25°C [77°F]) or at refrigeration (4°C [39°F]) for ≥24 hours has been reported (Newton 1981; van Matre 2023); also refer to institution-specific policies and procedures.

Use

Mild or transient episodes of heart block that do not require electric shock or pacemaker therapy; serious episodes of heart block and Adams-Stokes attacks (except when caused by ventricular tachycardia or fibrillation); cardiac arrest until electric shock or pacemaker therapy is available; bronchospasm during anesthesia; adjunct to fluid and electrolyte replacement therapy and other drugs and procedures in the treatment of hypovolemic or septic shock and low cardiac output states (eg, decompensated heart failure, cardiogenic shock) (All indications: FDA approved in adults)

Note: The use of isoproterenol in advanced cardiac life support (ACLS) has largely been supplanted by the use of other adrenergic agents (eg, epinephrine and dopamine). The use of isoproterenol for bronchospasm during anesthesia and cardiogenic, hypovolemic, or septic shock is no longer recommended.

Medication Safety Issues
Sound-alike/look-alike issues:

Isuprel may be confused with Disophrol, Isordil

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.

Metabolism/Transport Effects

Substrate of COMT

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Atomoxetine: May enhance the hypertensive effect of Sympathomimetics. Atomoxetine may enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy

Beta-Blockers: May diminish the therapeutic effect of Isoproterenol. Risk C: Monitor therapy

Cannabinoid-Containing Products: May enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy

Chlorpheniramine: May enhance the therapeutic effect of Isoproterenol. Risk C: Monitor therapy

Cocaine (Topical): May enhance the hypertensive effect of Sympathomimetics. Management: Consider alternatives to use of this combination when possible. Monitor closely for substantially increased blood pressure or heart rate and for any evidence of myocardial ischemia with concurrent use. Risk D: Consider therapy modification

COMT Inhibitors: May increase the serum concentration of COMT Substrates. Risk C: Monitor therapy

DiphenhydrAMINE (Systemic): May enhance the therapeutic effect of Isoproterenol. Risk C: Monitor therapy

Doxofylline: Sympathomimetics may enhance the adverse/toxic effect of Doxofylline. Risk C: Monitor therapy

EPINEPHrine (Systemic): Isoproterenol may enhance the therapeutic effect of EPINEPHrine (Systemic). Risk X: Avoid combination

Guanethidine: May enhance the arrhythmogenic effect of Sympathomimetics. Guanethidine may enhance the hypertensive effect of Sympathomimetics. Risk C: Monitor therapy

Inhalational Anesthetics: May enhance the arrhythmogenic effect of Isoproterenol. Risk X: Avoid combination

Kratom: May enhance the adverse/toxic effect of Sympathomimetics. Risk X: Avoid combination

Levothyroxine: May enhance the therapeutic effect of Isoproterenol. Risk C: Monitor therapy

Linezolid: May enhance the hypertensive effect of Sympathomimetics. Management: Consider initial dose reductions of sympathomimetic agents, and closely monitor for enhanced blood pressure elevations, in patients receiving linezolid. Risk D: Consider therapy modification

Monoamine Oxidase Inhibitors: May enhance the therapeutic effect of Isoproterenol. Risk C: Monitor therapy

Ozanimod: May enhance the hypertensive effect of Sympathomimetics. Risk C: Monitor therapy

Solriamfetol: Sympathomimetics may enhance the hypertensive effect of Solriamfetol. Sympathomimetics may enhance the tachycardic effect of Solriamfetol. Risk C: Monitor therapy

Sympathomimetics: May enhance the adverse/toxic effect of other Sympathomimetics. Risk C: Monitor therapy

Tedizolid: May enhance the hypertensive effect of Sympathomimetics. Tedizolid may enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy

Theophylline Derivatives: Isoproterenol may decrease the serum concentration of Theophylline Derivatives. Risk C: Monitor therapy

Pregnancy Considerations

Animal reproduction studies have not been conducted by the manufacturer. Use of isoproterenol may interfere with uterine contractions at term (Mahon 1967).

Monitoring Parameters

Heart rate, blood pressure, respiratory rate, arterial blood gases, central venous pressure, ECG, urine output; in pediatric patients, daily cardiac enzymes

Mechanism of Action

Stimulates beta1- and beta2-receptors resulting in relaxation of bronchial, GI, and uterine smooth muscle, increased heart rate and contractility, vasodilation of peripheral vasculature

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: IV: Immediate

Duration: IV: 10-15 minutes

Metabolism: Via conjugation in many tissues including hepatic and pulmonary

Half-life elimination: 2.5-5 minutes

Excretion: Urine (primarily as sulfate conjugates)

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AR) Argentina: Isoproterenol phoroneus;
  • (AT) Austria: Isoprenalin macure | Isuprel;
  • (AU) Australia: Cipla isoprenaline | Isoprenaline macure;
  • (BE) Belgium: Isoprenaline hcl macure | Isuprel;
  • (DK) Denmark: Isoprenalin sad;
  • (FI) Finland: Isoprenaline macure;
  • (FR) France: Isoprenaline hydrochloride tillomed | Isuprel;
  • (GB) United Kingdom: Ims isoprenaline | Suscardia;
  • (GR) Greece: Isoprenalina;
  • (IE) Ireland: Isoprenaline;
  • (IT) Italy: Isoprenalina cloridrato galenica senese | Isoprenalina cloridrato salf;
  • (KW) Kuwait: Isuprel;
  • (LT) Lithuania: Aleudrina;
  • (LU) Luxembourg: Isuprel;
  • (NL) Netherlands: Isoprenaline hcl macure | Isoprenalinesulfaat;
  • (NO) Norway: Isoprenaline macure;
  • (PR) Puerto Rico: Isoproterenol HCL;
  • (PT) Portugal: Isoprenalina macure;
  • (QA) Qatar: Isuprel;
  • (SE) Sweden: Isoprenaline macure;
  • (SI) Slovenia: Izoprenalin macure;
  • (TW) Taiwan: Isoproterenol | Proternol L
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