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 increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Amifostine: Blood Pressure Lowering Agents may increase hypotensive effects 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 increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may increase hypotensive effects of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor

Arginine: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Barbiturates: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Benperidol: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Blood Pressure Lowering Agents: May increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor

Brimonidine (Topical): May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Bromperidol: May decrease hypotensive effects of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may increase hypotensive effects of Bromperidol. Risk X: Avoid

Dapsone (Topical): May increase adverse/toxic effects of Methemoglobinemia Associated Agents. Risk C: Monitor

Diazoxide: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

DULoxetine: Blood Pressure Lowering Agents may increase hypotensive effects of DULoxetine. Risk C: Monitor

Herbal Products with Blood Pressure Lowering Effects: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Hypotension-Associated Agents: Blood Pressure Lowering Agents may increase hypotensive effects of Hypotension-Associated Agents. Risk C: Monitor

Iloperidone: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Levodopa-Foslevodopa: Blood Pressure Lowering Agents may increase hypotensive effects of Levodopa-Foslevodopa. Risk C: Monitor

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

Lormetazepam: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Metergoline: May decrease antihypertensive effects of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may increase orthostatic hypotensive effects of Metergoline. Risk C: Monitor

Molsidomine: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Naftopidil: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Nicergoline: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Nicorandil: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

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

Nitroprusside: Blood Pressure Lowering Agents may increase hypotensive effects of Nitroprusside. Risk C: Monitor

Obinutuzumab: May increase hypotensive effects 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 increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Pholcodine: Blood Pressure Lowering Agents may increase hypotensive effects of Pholcodine. Risk C: Monitor

Phosphodiesterase 5 Inhibitors: May increase vasodilatory effects of Amyl Nitrite. Risk X: Avoid

Prilocaine: Methemoglobinemia Associated Agents may increase adverse/toxic effects 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

Primaquine: Methemoglobinemia Associated Agents may increase adverse/toxic effects of Primaquine. Specifically, the risk for methemoglobinemia may be increased. Management: Avoid concomitant use of primaquine and other drugs that are associated with methemoglobinemia when possible. If combined, monitor methemoglobin levels closely. Risk D: Consider Therapy Modification

Prostacyclin Analogues: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Quinagolide: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

Riociguat: Amyl Nitrite may increase hypotensive effects of Riociguat. Risk X: Avoid

Silodosin: May increase hypotensive effects of Blood Pressure Lowering Agents. Risk C: Monitor

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

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

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Amyl nitrite: Drug information