Amyl nitrite: Drug information

For additional information see "Amyl nitrite: Patient drug information"

For abbreviations, symbols, and age group definitions show table

Pharmacologic Category

Vasodilator

Dosing: Adult

Provocation of latent left ventricular outflow tract gradient in hypertrophic cardiomyopathy

Provocation of latent left ventricular outflow tract gradient in hypertrophic cardiomyopathy (off-label use): Nasal inhalation: 3 to 4 deep inhalations from 1 crushed ampul over a 10 to 15 second period (Ref). Note: The use of more physiologic testing (eg, Valsalva maneuver, treadmill testing with Doppler echocardiography) may be preferred over amyl nitrite inhalation (Ref).

Dosing: Older Adult

Refer to adult dosing.

Adverse Reactions

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

Frequency not defined.

Cardiovascular: Facial flushing, hypotension, orthostatic hypotension, syncope, tachycardia

Dermatologic: Diaphoresis, pallor

Gastrointestinal: Fecal incontinence, nausea, vomiting

Genitourinary: Urinary incontinence

Nervous system: Asthenia, cerebral ischemia, dizziness, headache, restlessness

Contraindications

Glaucoma; recent head trauma or cerebral hemorrhage; pregnancy.

Warnings/Precautions

Concerns related to adverse effects:

• Hypotension: Amyl nitrite may cause severe hypotension; serious adverse effects may occur at doses less than the recommended therapeutic dose. Monitor for adequate perfusion and oxygenation; ensure patient is euvolemic. Use with caution in patients with preexisting diminished oxygen or cardiovascular reserve (eg, anemia, substantial blood loss, cardiac or respiratory compromise) and in patients who may be susceptible to injury from vasodilation.

• Methemoglobinemia: Amyl nitrite may cause methemoglobin formation resulting in diminished oxygen-carrying capacity; serious adverse effects may occur at doses less than the recommended therapeutic dose. Monitor for adequate perfusion and oxygenation. Use with caution in patients with preexisting diminished oxygen or cardiovascular reserve (eg, anemia, substantial blood loss, cardiac or respiratory compromise) and in patients at greater risk for developing methemoglobinemia (eg, congenital methemoglobin reductase deficiency). Use with caution with concomitant medications known to cause methemoglobinemia (eg, nitroglycerin, phenazopyridine).

Disease-related concerns:

• Aortic stenosis: Use with extreme caution or avoid in patients with severe aortic stenosis; may reduce coronary perfusion resulting in ischemia; considered by some to be a contraindication (Wesley Reagan 2005).

• Cardiovascular disease: Use with caution in patients with coronary artery disease and patients with hypotension. Transient episodes of dizziness, weakness, syncope, and cerebral ischemia secondary to postural hypotension may occur.

• Increased intracranial pressure: Use with caution in patients with increased intracranial pressure; use is contraindicated in patient with recent head trauma or cerebral hemorrhage.

Dosage Forms: US

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

Liquid, for inhalation: USP: 85% to 103% (0.3 mL)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Amyl Nitrite Inhalation)

0.3 mL (1): $0.63

Disclaimer: The pricing data provided represent a median AWP and/or AAWP price for the brand and/or generic product, respectively. The pricing data should be used for benchmarking purposes only, and as such should not be used to set or adjudicate any prices for charging or reimbursement functions. Pricing data is updated monthly.

Administration: Adult

Inhalation: Administer nasally via inhalation. The patient should be lying down during administration. Crush the ampul in a gauze pad and place in front of patient's mouth. One ampul lasts for ~3 minutes.

Use: Off-Label: Adult

Provocation of latent left ventricular outflow tract gradient in hypertrophic cardiomyopathy

Medication Safety Issues

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs (contraindicated in pregnancy) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Community/Ambulatory Care Settings).

Metabolism/Transport Effects

None known.

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 drug interactions program by clicking on the “Launch drug interactions program” link above.

Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When used at chemotherapy doses, hold blood pressure lowering medications for 24 hours before amifostine administration. If blood pressure lowering therapy cannot be held, do not administer amifostine. Use caution with radiotherapy doses of amifostine. Risk D: Consider therapy modification

Amisulpride (Oral): May enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor therapy

Arginine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Blood Pressure Lowering Agents: May enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Bromperidol: May diminish the hypotensive effect of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Risk X: Avoid combination

Dapsone (Topical): May enhance the adverse/toxic effect of Methemoglobinemia Associated Agents. Risk C: Monitor therapy

Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Risk C: Monitor therapy

Herbal Products with Blood Pressure Lowering Effects: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Iloperidone: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Levodopa-Foslevodopa: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Foslevodopa. Risk C: Monitor therapy

Local Anesthetics: Methemoglobinemia Associated Agents may enhance the adverse/toxic effect of Local Anesthetics. Specifically, the risk for methemoglobinemia may be increased. Risk C: Monitor therapy

Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nitric Oxide: May enhance the adverse/toxic effect of Methemoglobinemia Associated Agents. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Risk C: Monitor therapy

Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Risk C: Monitor therapy

Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Risk D: Consider therapy modification

Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Risk C: Monitor therapy

Phosphodiesterase 5 Inhibitors: May enhance the vasodilatory effect of Amyl Nitrite. Risk X: Avoid combination

Prilocaine: Methemoglobinemia Associated Agents may enhance the adverse/toxic effect of Prilocaine. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Management: Monitor for signs of methemoglobinemia when prilocaine is used in combination with other agents associated with development of methemoglobinemia. Avoid use of these agents with prilocaine/lidocaine cream in infants less than 12 months of age. Risk C: Monitor therapy

Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Riociguat: Amyl Nitrite may enhance the hypotensive effect of Riociguat. Risk X: Avoid combination

Silodosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Sodium Nitrite: Methemoglobinemia Associated Agents may enhance the adverse/toxic effect of Sodium Nitrite. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Risk C: Monitor therapy

Pregnancy Considerations

Amyl nitrite significantly decreases systemic BP and blood flow to the placenta. Amyl nitrite may also cause methemoglobin formation resulting in diminished oxygen-carrying capacity; fetal hemoglobin may be more susceptible to excessive nitrite-induced methemoglobinemia (Valenzuela 1986).

Use in pregnancy is contraindicated for indications in the FDA-approved product labeling.

Breastfeeding Considerations

It is not known if amyl nitrite is present in breast milk.

The manufacturer recommends that caution be exercised when administering amyl nitrite to breastfeeding women.

Monitoring Parameters

Monitor BP and heart rate during therapy.

Mechanism of Action

Relaxes vascular smooth muscle; decreases venous ratios and arterial BP; reduces left ventricular work; decreases myocardial O₂ consumption.

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: Within 30 seconds.

Duration: 3 to 15 minutes; Pharmacologic provocation of latent left ventricular outflow tract gradient in hypertrophic cardiomyopathy: ~30 seconds (Wesley Reagan 2005).

Absorption: Inhalation: Readily absorbed through respiratory tract.

Metabolism: In the liver to form inorganic nitrates (less potent).

Half-life elimination: Amyl nitrite: <1 hour; Methemoglobin: 1 hour.

Excretion: Urine (~33%).

Brand Names: International

International Brand Names by Country

For country code abbreviations (show table)

(CZ) Czech Republic: Nitramyl;
(DE) Germany: Nitramyl;
(EE) Estonia: Amylnitrit;
(ES) Spain: Nitrito amilo;
(GB) United Kingdom: Amyl nitri;
(JP) Japan: Amyl nitrite afp | Amyl nitrite sankyo;
(LT) Lithuania: Nitramyl;
(PL) Poland: Nitramyl

Agency for Toxic Substances and Disease Registry (ATSDR). Medical Management Guidelines for Hydrogen Cyanide (HCN). http://www.atsdr.cdc.gov/MHMI/mmg8.pdf.
Amyl nitrite [prescribing information]. Blairstown, NJ: The James Alexander Corporation; December 2004.
Bailey B. Are there teratogenic risks associated with antidotes used in the acute management of poisoned pregnant women? Birth Defects Res A Clin Mol Teratol. 2003;67(2):133-140. doi:10.1002/bdra.10007 [PubMed 12769509]
Berlin CM. The treatment of cyanide poisoning in children. Pediatrics. 1970;46(5):793-796. [PubMed 4320419]
Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused Update Incorporated into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008;118(15):e523-e661. [PubMed 18820172]
De Capitani EM, Borrasca-Fernandes CF, Branco Pimenta M, et al. Suicide attempt with acetonitrile ingestion in a nursing mother. Clin Toxicol (Phila). 2017;55(8):929-933. doi:10.1080/15563650.2017.1324977 [PubMed 28494173]
Geller RJ, Barthold C, Saiers JA, et al. Pediatric cyanide poisoning: causes, manifestations, management, and unmet needs. Pediatrics. 2006;118(5):2146-2158. [PubMed 17079589]
Holstege CP, Kirk MA. Cyanide and hydrogen sulfide. In: Nelson LS, Howland M, Lewin NA, et al, eds. Goldfrank's Toxicologic Emergencies. 11th ed. McGraw-Hill Education; 2019: 1684-1693.
Holstege CP, Kirk MA. Cyanide and hydrogen sulfide. Goldfrank's Toxicologic Emergencies. 10th ed. Hoffman RS, Howland MA, Lewin NA, Nelson LS, et al, eds. McGraw-Hill Companies Inc; 2015:1602-1611.
Maron BJ, McKenna WJ, Danielson GK, et al. American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy. A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines. J Am Coll Cardiol. 2003;42(9):1687-1713. [PubMed 14607462]
Nagueh SF, Bierig SM, Budoff MJ, et al. American Society of Echocardiography Clinical Recommendations for Multimodality Cardiovascular Imaging of Patients With hypertrophic Cardiomyopathy: Endorsed by the American Society of Nuclear Cardiology, Society for Cardiovascular Magnetic Resonance, and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr. 2011;24(5):473-498. [PubMed 21514501]
Nichol LM, Mills NL, Starkey IR. Amyl nitrite induced cerebral and coronary vasospasm. QJM. 2011;104(1):83-84. [PubMed 20843773]
Ommen SR, Mital S, Burke MA, et al. 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2020;76(25):e159-e240. doi:10.1016/j.jacc.2020.08.045 [PubMed 33229116]
Valenzuela A, Guerra R, Lazcano L, et al. Differential prooxidative effect of adult and fetal hemoglobin. FEBS Lett. 1986;196(2):353-356. [PubMed 2419158]
Wesley Reagan B, Helmcke F, Kenneth Kerut E. Commonly used respiratory and pharmacologic interventions in the echocardiography laboratory. Echocardiography. 2005;22(5):455-460. [PubMed 15901303]

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Amyl nitrite: Drug information