Version October 2024
Hypotension, anesthesia-induced: Limited data available:
Note: For the parenteral product, two salts are available (sulfate and hydrochloride); ephedrine sulfate 10 mg is equivalent to ephedrine base 7.6 mg; ephedrine hydrochloride 9.4 mg is equivalent to ephedrine base 7.7 mg; clinical relevance of difference between salt forms is unknown. Parenteral products may be available in significantly different concentrations (eg, 50 mg/mL and 5 mg/mL); use caution.
Infants, Children, and Adolescents: Slow IV push: 0.1 to 0.3 mg/kg/dose; use the lowest effective dose; usual adult dose range: 5 to 10 mg/dose; repeat as needed to maintain blood pressure; maximum total dose: 50 mg (Ref).
Asthma, intermittent; acute symptom relief (OTC labeling): Note: Oral bronchodilator therapy, such as ephedrine, is not recommended for treatment of asthma due to slow onset of action and high rate of adverse effects (Ref).
Children ≥12 years and Adolescents: Oral: 12.5 to 25 mg every 4 hours as needed; maximum daily dose: 150 mg per 24 hours (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling; use with caution. Elimination of ephedrine may be delayed in patients with kidney impairment; the manufacturer recommends monitoring carefully for adverse events.
There are no dosage adjustments provided in the manufacturer's labeling.
(For additional information see "Ephedrine (systemic): Drug information")
Asthma, mild intermittent symptoms: Note: Clinical practice guidelines do not recommend nonselective beta agonists or oral beta-2 agonists, including oral ephedrine, for routine management and treatment of asthma due to their potential for excessive cardiac stimulation, especially in high doses (Ref).
Oral: OTC labeling:
Bronkaid Max: 25 mg every 4 hours as needed; maximum 150 mg per 24 hours.
Primatene: 12.5 to 25 mg every 4 hours as needed; maximum 150 mg per 24 hours.
Hypotension, anesthesia-induced: Note: Ephedrine sulfate 10 mg is equivalent to ephedrine base 7.6 mg; ephedrine hydrochloride 9.4 mg is equivalent to ephedrine base 7.7 mg.
Akovaz, Emerphed (ephedrine sulfate): IV: Initial: 5 to 10 mg; repeat as needed to maintain BP (maximum total cumulative dose: 50 mg).
Rezipres (ephedrine hydrochloride): IV: Initial: 4.7 to 9.4 mg; repeat as needed to maintain BP (maximum total cumulative dose: 47 mg).
Postoperative nausea and vomiting (prevention) (off-label use): IM: 0.5 mg/kg at the end of surgery (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling; use with caution.
There are no dosage adjustments provided in the manufacturer's labeling.
The following adverse drug reactions are derived from product labeling unless otherwise specified.
Postmarketing:
Cardiovascular: Bradycardia, hypertension (reactive), irregular pulse (RR interval variability), palpitations, tachycardia, ventricular ectopy
Gastrointestinal: Nausea, vomiting
Nervous system: Dizziness, restlessness
Miscellaneous: Tachyphylaxis
IV: There are no contraindications listed in the manufacturer’s labeling.
Oral: OTC labeling: When used for self-medication, do not use if history of allergic reaction to ephedrine or any component of the formulation, concurrently with or within 2 weeks of discontinuing a monoamine oxidase inhibitor, or if you do not have asthma.
Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Concerns related to adverse effects:
• Cardiovascular effects: May cause hypertension if used prophylactically for hypotension (only indicated for treatment of hypotension).
Disease-related concerns:
• Renal impairment: Use with caution in patients with renal impairment; increased elimination half-life may occur. Carefully monitor patients with renal impairment for adverse reactions.
Special populations:
• Older adult: Use with caution in the elderly.
Other warnings/precautions:
• Self-medication (OTC use): Prior to self-medication, patients should contact health care provider if they have diabetes, heart disease, hypertension, narrow angle glaucoma, psychiatric or emotional conditions, seizures, thyroid disease, trouble urinating due to an enlarged prostate, ever been hospitalized for asthma, are taking any medications for asthma, depression, obesity, psychiatric or emotional conditions, or are taking any medications that contain caffeine, ephedrine, phenylephrine, or pseudoephedrine (eg, allergy, cough/cold, or pain medications). Avoid foods or beverages that contain caffeine and dietary supplements that have a stimulant effect. Discontinue use and contact health care provider if asthma is not better in 60 minutes or gets worse, >2 asthma attacks in a week, need >150 mg in 24 hours or >100 mg in 24 hours for ≥3 days a week, or if insomnia, nervousness, a rapid heartbeat, seizures, or tremors occur.
• Tolerance: Tachyphylaxis and tolerance may develop with repeated, prolonged, or excessive administration; temporary cessation of therapy restores its effectiveness.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Intravenous, as hydrochloride [preservative free]:
Rezipres: 23.5 mg/5 mL (5 mL [DSC])
Rezipres: 47 mg/10 mL (10 mL) [sulfite free]
Solution, Injection, as sulfate [preservative free]:
Generic: 50 mg/mL (1 mL [DSC])
Solution, Intravenous, as sulfate:
Akovaz: 50 mg/mL (1 mL)
Generic: 50 mg/mL (1 mL)
Solution, Intravenous, as sulfate [preservative free]:
Emerphed: 5 mg/mL (10 mL)
Generic: 5 mg/mL (10 mL); 50 mg/mL (1 mL)
Solution Prefilled Syringe, Intravenous [preservative free]:
Emerphed: 50 mg/10 mL (10 mL) [latex free]
Solution Prefilled Syringe, Intravenous, as sulfate [preservative free]:
Akovaz: 25 mg/5 mL (5 mL)
Emerphed: 25 mg/5 mL (5 mL) [latex free]
Tablet, Oral, as hydrochloride:
Primatene: 12.5 mg [contains fd&c yellow #6(sunset yellow)alumin lake, quinoline (d&c yellow #10) aluminum lake]
Tablet, Oral, as sulfate:
Bronkaid Max: 25 mg [dye free]
May be product dependent
Solution (Akovaz Intravenous)
50 mg/mL (per mL): $18.48
Solution (Emerphed Intravenous)
5 mg/mL (per mL): $3.48
Solution (ePHEDrine Sulfate (Pressors) Intravenous)
5 mg/mL (per mL): $3.48
50 mg/mL (per mL): $9.35 - $59.11
Solution (Rezipres Intravenous)
47 mg/10 mL (per mL): $4.80
Solution Prefilled Syringe (Akovaz Intravenous)
25 mg/5 mL (per mL): $2.96
Solution Prefilled Syringe (Emerphed Intravenous)
25 mg/5 mL (per mL): $9.00
50 mg/10 mL (per mL): $6.24
Tablets (Bronkaid Max Oral)
25 mg (per each): $0.19
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.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Injection, as sulfate:
Generic: 50 mg/mL (1 mL)
Parenteral: IV: Administer by slow IV push. Verify formulation prior to administration; available in vials requiring further dilution and also premixed syringes and vials (requiring no further dilution).
IV: Administer as an IV bolus. Verify formulation prior to administration; available in vials requiring further dilution and also premixed syringes and vials (requiring no further dilution).
IM: For postoperative nausea and vomiting (off-label use), administer IM (Ref).
IV:
Akovaz, Emerphed (ephedrine sulfate): Store at 25°C (77°F); excursions are permitted between 15°C and 30°C (59°F and 86°F). Single dose only; discard any unused portion. Store Emerphed in original container prior to use.
Rezipres (ephedrine hydrochloride): Store at 20°C to 25°C (68°F to 77°F); excursions are permitted between 15°C and 30°C (59°F and 86°F). Single dose only; discard any unused portion.
Oral: Store at 20°C to 25°C (68°F to 77°F).
Oral:
Temporary relief of mild symptoms (shortness of breath, chest tightness, wheezing) associated with intermittent asthma (Oral: OTC: FDA approved in ages ≥12 years and adults). Note: Although listed on OTC product labeling, ephedrine is not recommended for the treatment of asthma (GINA 2022; NAEPP 2007).
Parenteral:
Treatment of anesthesia-induced hypotension (Parenteral: FDA approved in adults). Note: Not recommended in the treatment guidelines for management of septic shock in pediatric patients (Weiss 2020).
Akovaz may be confused with Adrenalin
EPHEDrine may be confused with Epifrin, EPINEPHrine
Rezipres (ePHEDrine hydrochloride) may be confused with ePHEDrine sulfate products
The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes (adrenergic agonist, IV) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care Settings).
None known.
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 drug interactions program by clicking on the “Launch drug interactions program” link above.
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 drug interactions program
Alkalinizing Agents: May increase the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy
Alpha1-Blockers: May diminish the therapeutic effect of Alpha-/Beta-Agonists. Risk C: Monitor therapy
Atomoxetine: May enhance the hypertensive effect of Sympathomimetics. Atomoxetine may enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy
Atropine (Systemic): May enhance the therapeutic effect of EPHEDrine (Systemic). Risk C: Monitor therapy
Benzylpenicilloyl Polylysine: Alpha-/Beta-Agonists may diminish the diagnostic effect of Benzylpenicilloyl Polylysine. Management: Consider use of a histamine skin test as a positive control to assess a patient's ability to mount a wheal and flare response. Risk D: Consider therapy modification
Beta-Blockers: May diminish the therapeutic effect of EPHEDrine (Systemic). Risk C: Monitor therapy
Bretylium: May enhance the therapeutic effect of Alpha-/Beta-Agonists (Direct-Acting). Risk C: Monitor therapy
Bromocriptine: May enhance the hypertensive effect of Alpha-/Beta-Agonists. Management: Consider alternatives to this combination when possible. If combined, monitor for hypertension and tachycardia, and do not coadminister these agents for more than 10 days. Risk D: Consider therapy modification
Cannabinoid-Containing Products: May enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy
Carbonic Anhydrase Inhibitors: May increase the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy
Cardiac Glycosides: EPHEDrine (Systemic) may enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy
Chloroprocaine (Systemic): May enhance the hypertensive effect of Alpha-/Beta-Agonists. Risk C: Monitor therapy
CloNIDine: May enhance the therapeutic effect of EPHEDrine (Systemic). Risk C: Monitor therapy
CloZAPine: May diminish the therapeutic effect of Alpha-/Beta-Agonists. 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
DexAMETHasone (Systemic): EPHEDrine (Systemic) may decrease the serum concentration of DexAMETHasone (Systemic). Risk C: Monitor therapy
Doxofylline: Sympathomimetics may enhance the adverse/toxic effect of Doxofylline. Risk C: Monitor therapy
Droxidopa: EPHEDrine (Systemic) may enhance the hypertensive effect of Droxidopa. Risk C: Monitor therapy
Ergot Derivatives (Vasoconstrictive CYP3A4 Substrates): May enhance the vasoconstricting effect of Alpha-/Beta-Agonists. Risk X: Avoid combination
FentaNYL: Decongestants may decrease the serum concentration of FentaNYL. Risk C: Monitor therapy
Guanethidine: May enhance the arrhythmogenic effect of Sympathomimetics. Guanethidine may enhance the hypertensive effect of Sympathomimetics. Risk C: Monitor therapy
Hyaluronidase: May enhance the vasoconstricting effect of Alpha-/Beta-Agonists. Management: Do not use hyaluronidase to enhance the dispersion or absorption of alpha-/beta-agonists. Use of hyaluronidase for other purposes in patients receiving alpha-/beta-agonists may be considered as clinically indicated. Risk D: Consider therapy modification
Inhalational Anesthetics: EPHEDrine (Systemic) may enhance the arrhythmogenic effect of Inhalational Anesthetics. Risk X: Avoid combination
Iobenguane Radiopharmaceutical Products: Alpha-/Beta-Agonists (Indirect-Acting) may diminish the therapeutic effect of Iobenguane Radiopharmaceutical Products. Management: Discontinue all drugs that may inhibit or interfere with catecholamine transport or uptake for at least 5 biological half-lives before iobenguane administration. Do not administer these drugs until at least 7 days after each iobenguane dose. Risk X: Avoid combination
Kratom: May enhance the adverse/toxic effect of Sympathomimetics. Risk X: Avoid combination
Levothyroxine: May enhance the adverse/toxic effect of Sympathomimetics. Specifically, the risk of coronary insufficiency may be increased in patients with coronary artery disease. Levothyroxine may enhance the therapeutic effect of Sympathomimetics. Sympathomimetics may enhance the therapeutic effect of Levothyroxine. 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
Lisuride: May enhance the hypertensive effect of Alpha-/Beta-Agonists. Risk X: Avoid combination
Monoamine Oxidase Inhibitors: May enhance the hypertensive effect of Alpha-/Beta-Agonists (Indirect-Acting). While linezolid is expected to interact via this mechanism, management recommendations differ from other monoamine oxidase inhibitors. Refer to linezolid specific monographs for details. Risk X: Avoid combination
Oxytocin: May enhance the hypertensive effect of EPHEDrine (Systemic). Risk C: Monitor therapy
Ozanimod: May enhance the hypertensive effect of Sympathomimetics. Risk C: Monitor therapy
Pergolide: May enhance the hypertensive effect of Alpha-/Beta-Agonists. Risk C: Monitor therapy
Propofol: May enhance the therapeutic effect of EPHEDrine (Systemic). Risk C: Monitor therapy
QuiNIDine: May diminish the therapeutic effect of EPHEDrine (Systemic). EPHEDrine (Systemic) may diminish the therapeutic effect of QuiNIDine. Risk C: Monitor therapy
Reserpine: May diminish the therapeutic effect of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy
Rocuronium: EPHEDrine (Systemic) may enhance the therapeutic effect of Rocuronium. Risk C: Monitor therapy
Serotonin/Norepinephrine Reuptake Inhibitors: May enhance the tachycardic effect of Alpha-/Beta-Agonists. Serotonin/Norepinephrine Reuptake Inhibitors may enhance the vasopressor effect of Alpha-/Beta-Agonists. Management: If possible, avoid coadministration of direct-acting alpha-/beta-agonists and serotonin/norepinephrine reuptake inhibitors. If coadministered, monitor for increased sympathomimetic effects (eg, increased blood pressure, chest pain, headache). Risk D: Consider therapy modification
Solriamfetol: Sympathomimetics may enhance the hypertensive effect of Solriamfetol. Sympathomimetics may enhance the tachycardic effect of Solriamfetol. Risk C: Monitor therapy
Spironolactone: May diminish the vasoconstricting effect of Alpha-/Beta-Agonists. 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: May enhance the stimulatory effect of EPHEDrine (Systemic). Risk C: Monitor therapy
Tricyclic Antidepressants: May enhance the vasopressor effect of Alpha-/Beta-Agonists. Management: Avoid, if possible, the use of alpha-/beta-agonists in patients receiving tricyclic antidepressants. If combined, monitor for evidence of increased pressor effects and consider reductions in initial dosages of the alpha-/beta-agonist. Risk D: Consider therapy modification
Urinary Acidifying Agents: May decrease the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy
Vasopressin: Alpha-/Beta-Agonists (Direct-Acting) may enhance the hypertensive effect of Vasopressin. The effect of other hemodynamic parameters may also be enhanced. Risk C: Monitor therapy
Metabolic acidosis has been reported in neonates following maternal use of ephedrine; monitor.
Untreated maternal hypotension during cesarean delivery is associated with adverse events, including maternal nausea and vomiting, and bradycardia and acidosis in the fetus. Ephedrine injection is used at delivery for the prevention and/or treatment of maternal hypotension associated with spinal anesthesia in patients undergoing cesarean delivery (ACOG 2019). Serious postpartum hypertension and possibly stroke may occur if administered with oxytocic medications.
Blood pressure, pulse; monitor patients with renal impairment for adverse reactions.
Releases tissue stores of norepinephrine and thereby produces an alpha- and beta-adrenergic stimulation; longer-acting and less potent than epinephrine
Onset: IM: Within 10 to 20 minutes.
Metabolism: Minimally hepatic; metabolites include p-hydroxyephedrine, p-hydroxynorephedrine, norephedrine.
Half-life elimination: Dependent upon urinary pH; Urine pH 5: ~3 hours; Urine pH 6.3: ~6 hours.
Excretion: Urine (primarily unchanged; dependent upon urinary pH with greatest excretion in acid pH).
Altered kidney function: Elimination half-life may be increased.
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