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Remifentanil: Drug information

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

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Special Alerts
FDA Requiring Updates to Opioid Prescribing Information April 2023

The FDA has issued a drug safety communication to announce safety-related updates to the prescribing information for immediate-release (IR) and extended-release (ER)/long-acting (LA) opioid analgesics, including updates to Boxed Warnings, Indications and Usage, Dosage and Administration, Warnings and Precautions, and the Medication Guide. These safety labeling changes are intended to provide clarity on appropriate patient populations for opioid treatment, appropriate dosage and administration, and updated information on the risks associated with opioid use. The required safety labeling changes include stating:

  • the risk of overdose increases as the dosage increases for all opioid pain medicines;

  • IR opioids should not be used for an extended period of time unless a patient's pain remains severe enough to require them and alternative treatment options continue to be inadequate;

  • many acute pain conditions treated in the outpatient setting require no more than a few days of an opioid pain medicine;

  • it is recommended to reserve ER/LA opioid pain medicines for severe and persistent pain that requires an extended treatment period with a daily opioid pain medicine and for which alternative treatment options are inadequate; and

  • a warning about opioid-induced hyperalgesia (OIH), including information on differentiating OIH symptoms from those of opioid tolerance and withdrawal.

Further information may be found at https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-prescribing-information-all-opioid-pain-medicines-provide-additional-guidance-safe-use.

ALERT: US Boxed Warning
Addiction, abuse, and misuse:

Because the use of remifentanil exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death, assess each patient’s risk prior to prescribing and reassess all patients regularly for the development of these behaviors and conditions.

Life-threatening respiratory depression:

Serious, life-threatening, or fatal respiratory depression may occur with use of remifentanil, especially during initiation or following a dosage increase. To reduce the risk of respiratory depression, proper dosing and titration of remifentanil are essential.

Risks from concomitant use with benzodiazepines or other CNS depressants:

Concomitant use of opioids with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of remifentanil and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate.

Brand Names: US
  • Ultiva
Pharmacologic Category
  • Analgesic, Opioid;
  • Anilidopiperidine Opioid
Dosing: Adult
General anesthesia

General anesthesia:

Induction: Continuous infusion: IV: 0.5 to 1 mcg/kg/minute; if endotracheal intubation is to occur in <8 minutes, an initial dose of 1 mcg/kg may be administered over 30 to 60 seconds.

Coronary bypass surgery: Continuous infusion: IV: 1 mcg/kg/minute.

Maintenance:

Intermittent: IV: 1 mcg/kg administered every 2 to 5 minutes.

Continuous infusion: IV: Consider increasing concomitant anesthetics with infusion rate >1 mcg/kg/minute. Infusion rate can be titrated upward in increments of 25% to 100% or downward in decrements of 25% to 50% every 2 to 5 minutes.

With nitrous oxide (66%): IV: 0.4 mcg/kg/minute (range: 0.1 to 2 mcg/kg/minute).

With isoflurane: IV: 0.25 mcg/kg/minute (range: 0.05 to 2 mcg/kg/minute).

With propofol: IV: 0.25 mcg/kg/minute (range: 0.05 to 2 mcg/kg/minute).

Coronary bypass surgery: Continuous infusion: IV: 1 mcg/kg/minute (range: 0.125 to 4 mcg/kg/minute); supplemental dose: 0.5 to 1 mcg/kg.

Postoperative recovery/Postanesthesia care unit

Postoperative recovery/Postanesthesia care unit (ie, immediate postoperative period):

Note: Bolus doses are not recommended.

Continuous infusion: IV: 0.1 mcg/kg/minute (range: 0.025 to 0.2 mcg/kg/minute). Infusion rate may be adjusted every 5 minutes in increments of 0.025 mcg/kg/minute. Infusion rates >0.2 mcg/kg/minute are associated with respiratory depression.

Coronary bypass surgery, continuation as an analgesic into the ICU: Continuous infusion: IV: 1 mcg/kg/minute (range: 0.05 to 1 mcg/kg/minute).

Analgesia during monitored anesthesia care

Analgesia during monitored anesthesia care:

Note: Supplemental oxygen is recommended.

Single IV dose administered 90 seconds prior to local anesthetic:

Remifentanil alone: IV: 1 mcg/kg over 30 to 60 seconds.

With midazolam: IV: 0.5 mcg/kg over 30 to 60 seconds.

Continuous infusion beginning 5 minutes prior to local anesthetic:

Remifentanil alone: IV: 0.1 mcg/kg minute.

With midazolam: IV: 0.05 mcg/kg/minute.

Continuous infusion administered after local anesthetic:

Remifentanil alone: IV: 0.05 mcg/kg/minute (range: 0.025 to 0.2 mcg/kg/minute).

With midazolam: IV: 0.025 mcg/kg/minute (range: 0.025 to 0.2 mcg/kg/minute).

Note: Following local or anesthetic block, infusion rate should be decreased to 0.05 mcg/kg/minute; rate adjustments of 0.025 mcg/kg/minute may be done at 5-minute intervals. Infusion rates >0.2 mcg/kg/minute are associated with respiratory depression.

Mechanically ventilated patients in the ICU, pain and sedation

Mechanically ventilated patients in the ICU, pain and sedation (off-label use):

Loading dose: IV: 1.5 mcg/kg once.

Maintenance dose: Continuous infusion: IV: 0.008 to 0.25 mcg/kg/minute (or 0.5 to 15 mcg/kg/hour) (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling; however, remifentanil pharmacokinetics are unchanged in patients with end stage renal disease.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling; however, remifentanil pharmacokinetics are unchanged in patients with severe hepatic impairment.

Dosing: Obesity: Adult

The recommendations for dosing in patients with obesity are based upon the best available evidence and clinical expertise. Senior Editorial Team: Jeffrey F. Barletta, PharmD, FCCM; Manjunath P. Pai, PharmD, FCP; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC.

Class 1, 2, or 3 obesity (BMI ≥30 kg/m2):

Use adjusted body weight for initial weight-based dose calculations (based on indication), then titrate to clinical effect (Ref). Clinicians should not change dosing weight from one weight metric to another during therapy (ie, adjusted body weight to/from actual body weight) (Ref). Refer to "Dosing: Adult" for indication-specific doses.

Rationale for recommendations:

Studies evaluating other opioids in patients with obesity have shown large variations in opioid requirements with no relationship to actual body weight (Ref). Pharmacokinetic studies evaluating remifentanil, a highly lipophilic compound, have shown pharmacokinetic parameters are more closely related to lean body weight (LBW) or fat-free mass than to actual body weight. These studies suggest dosing based on ideal body weight or corrected LBW for target-controlled infusion systems (Ref).

Guidelines have suggested using LBW for initial weight-based dosing of opioids, titrated to effect (Ref); however, there are concerns with calculation errors when using the complex LBW formula, especially in critical situations (Ref). There are also concerns with underdosing in clinical situations where rapid sedation is needed (eg, induction of anesthesia, ICU sedation) (Ref). Use of an alternative size descriptor (ie, adjusted body weight) is recommended for dosing in patients with class 1, 2, or 3 obesity (BMI ≥30 kg/m2) (Ref).

Dosing: Older Adult

Decrease initial dose by 50% and cautiously titrate to effect. Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Remifentanil: Pediatric drug information")

Note: For use of continuous IV infusion in obese patients, dose should be based on ideal body weight (IBW) in obese patients (>30% over IBW).

Analgesia, postoperative; mechanically ventilated patient

Analgesia, postoperative; mechanically ventilated patient: Limited data available: Children and Adolescents 3-16 years: Continuous IV infusion: 0.1 mcg/kg/minute with or without adjunctive medication, titrate to effect; dosing based on a randomized, double-blind comparative trial of remifentanil versus fentanyl in 22 postoperative orthopedic spinal surgery patients requiring mechanical ventilation (remifentanil group, n=11; age: Mean:13 years, range: 3-16 years); similar efficacy and adverse effect profile were reported with both treatment groups (Ref).

Analgesia/sedation in mechanically ventilated patients

Analgesia/sedation in mechanically ventilated patients: Limited data available: Infants ≤2 months: Continuous IV infusion: Initial: 0.15 mcg/kg/minute, titrate to effect; dosing based on a randomized, double-blind, comparative study of neonates and young infants (n=23; GA: ≥36 weeks; PNA: <60 days) requiring mechanical ventilation who were given a combination of either midazolam/remifentanil (n=11) or midazolam/fentanyl (n=12); mean remifentanil effective dose: 0.23 mcg/kg/minute; maximum reported dose: 0.5 mcg/kg/minute; efficacy data and adverse effect profile were similar to fentanyl(Ref).

Anesthesia, maintenance of anesthesia

Anesthesia, maintenance of anesthesia: Continuous IV infusion:

Infants 1-2 months: Maintenance of anesthesia with nitrous oxide (70%): 0.4 mcg/kg/minute (range: 0.4-1 mcg/kg/minute); supplemental bolus dose of 1 mcg/kg may be administered, smaller bolus dose may be required with potent inhalation agents, potent neuraxial anesthesia, significant comorbidities, significant fluid shifts, or without atropine pretreatment

Infants ≥3 months, Children, and Adolescents: Limited data available: Maintenance of anesthesia with halothane, sevoflurane, or isoflurane: 0.25 mcg/kg/minute (range: 0.05-1.3 mcg/kg/minute); supplemental bolus dose of 1 mcg/kg may be administered every 2-5 minutes. Consider increasing concomitant anesthetics with infusion rate >1 mcg/kg/minute. Infusion rate can be titrated upward in increments up to 50% or titrated downward in decrements of 25% to 50%. May titrate every 2-5 minutes.

Anesthesia, total intravenous; with or without propofol induction

Anesthesia, total intravenous (TIVA); with or without propofol induction: Limited data available: Infants, Children, and Adolescents: IV: Loading dose (may omit if propofol induction used): 0.5 mcg/kg/minute for 3 minutes (total dose: 1.5 mcg/kg) or 1 mcg/kg over 1 minute; followed by an initial maintenance dose: 0.05-0.1 mcg/kg/minute; titrate in 0.05 mcg/kg/minute increments every 3 minutes to effect; usual effective range: 0.2-0.5 mcg/kg/minute; has been used in combination with propofol (bolus and/or infusion) (Ref).

Endotracheal intubation for elective procedures

Endotracheal intubation for elective procedures: Limited data available:

IV: Infants, Children, and Adolescents: Usual range: 1-3 mcg/kg/dose, doses as high as 4 mcg/kg have been used. Dosing based on multiple trials in patients undergoing elective procedures requiring intubation who were not receiving neuromuscular blockers and remifentanil administered in combination with other induction agents such as propofol, ketamine, or sevoflurane (Ref).

Intranasal (using parenteral 100 mcg/mL formulation): Children ≤7 years: 4 mcg/kg/dose; administer half of the total dose in each nostril; wait 2-3 minutes before attempting intubation. Dosing based on a double-blind, randomized, controlled trial (n=188), remifentanil was administered after sevoflurane induction and overall, was found more effective than saline placebo at both endpoints of 2 minutes and 3 minutes postdose. Results also showed that within the remifentanil treatment groups, good or excellent intubation conditions were reported more often at 3 minutes postdose than at 2 minutes (91.7% vs 68.2%) (Ref).

Procedural sedation

Procedural sedation: Limited data available, dosage not established: Infants, Children, and Adolescents: IV: 0.5 mcg/kg with propofol has been used to induce analgesia and adjunct sedation prior to esophagogastroduodenoscopy (n=22; age range: 2-12 years) and short hemato-oncologic invasive procedures (n=30, age range: 2-18 years) (Ref). A higher dose of 3 mcg/kg was used in already sedated (sevoflurane) infants and young children who required apnea for CT or MRI imaging (n=12, age range: 6-16 months) (Ref). In a dose-finding trial, continuous IV infusion of remifentanil at 0.2 mcg/kg/minute has been shown more effective than a lower 0.1 mcg/kg/minute in 60 children 2-12 years undergoing diagnostic cardiac catheterization; pretreatment with oral midazolam and local groin anesthetic also utilized (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

Removed by hemodialysis (30%). There are no dosage adjustments provided in the manufacturer's labeling; however, remifentanil pharmacokinetics are unchanged in patients with end stage renal disease.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling; however, remifentanil pharmacokinetics are unchanged in patients with severe hepatic impairment.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Frequency of adverse events may vary based on surgical procedures and rate of infusion.

>10%:

Cardiovascular: Hypotension (2% to 19%)

Central nervous system: Headache (<2% to 18%)

Dermatologic: Pruritus (<2% to 18%)

Gastrointestinal: Nausea (<36% to 44%), vomiting (<16% to 22%)

Neuromuscular & skeletal: Muscle rigidity (≤11%; includes chest wall rigidity)

1% to 10%:

Cardiovascular: Bradycardia (1% to 7%; dose-dependent), shivering (<5%), hypertension (1% to 2%; dose-dependent), flushing (1%), flushing sensation (1%), tachycardia (≤1%; dose-dependent)

Central nervous system: Dizziness (<5%), chills (1%), agitation (≤1%)

Dermatologic: Diaphoresis (6%)

Local: Pain at injection site (1%)

Respiratory: Respiratory depression (<7%), apnea (<3%), hypoxia (≤1%)

Miscellaneous: Fever (<5%), postoperative pain (<2%)

<1%, postmarketing, and/or case reports: Abdominal distress, allodynia (opioid-induced hyperalgesia) (FDA Safety Communication 2023), amnesia, anaphylaxis, anxiety, awareness under anesthesia without pain, bronchitis, bronchospasm, cardiac arrhythmia, chest pain, confusion, constipation, cough, diarrhea, disorientation, disruption of body temperature regulation, dysphagia, dysphoria, dyspnea, dysuria, ECG changes, electrolyte disturbance, erythema, gastroesophageal reflux disease, hallucination, heart block, heartburn, hepatic insufficiency, hiccups, hyperglycemia, increased creatine phosphokinase, intestinal obstruction, involuntary body movements, laryngospasm, leukocytosis, lymphocytopenia, nasal congestion, nightmares, nystagmus, oliguria, paresthesia, pharyngitis, pleural effusion, prolonged emergence from anesthesia, pulmonary edema, rales, rapid awakening from anesthesia, rhinorrhea, rhonchi, seizure, skin rash, sleep disorder, stridor, syncope, thrombocytopenia, tremor, twitching, urinary incontinence, urinary retention, urticaria, xerostomia

Contraindications

Hypersensitivity (eg, anaphylaxis) to remifentanil or any component of the formulation; intrathecal or epidural administration.

Canadian labeling: Additional contraindications (not in US labeling): Known or suspected mechanical GI obstruction (eg, bowel obstruction or strictures) or any diseases/conditions that affect bowel transit (eg, ileus of any type); suspected surgical abdomen (eg, acute appendicitis or pancreatitis); mild pain that can be managed with other pain medications; acute or severe bronchial asthma, chronic obstructive airway, status asthmaticus; acute respiratory depression; hypercapnia; cor pulmonale; acute alcoholism, delirium tremens, and convulsive disorders; severe CNS depression, increased cerebrospinal or intracranial pressure and head injury; concurrent use or use within 14 days of an MAO inhibitor

Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Warnings/Precautions

Concerns related to adverse effects:

• Hyperalgesia: Opioid-induced hyperalgesia (OIH) has occurred with short-term and prolonged use of opioid analgesics. Symptoms may include increased levels of pain upon opioid dosage increase, decreased levels of pain upon opioid dosage decrease, or pain from ordinarily nonpainful stimuli; symptoms may be suggestive of OIH if there is no evidence of underlying disease progression, opioid tolerance, opioid withdrawal, or addictive behavior. Consider decreasing the current opioid dose or opioid rotation in patients who experience OIH.

• Hypotension: May cause hypotension; use with caution in patients with hypovolemia, cardiovascular disease (including acute MI), or drugs which may exaggerate hypotensive effects (including phenothiazines or general anesthetics). Monitor for symptoms of hypotension following initiation or dose titration.

• Intraoperative awareness: Intraoperative awareness has been reported when used with propofol infusion rates of ≤75 mcg/kg/minute in patients <55 years.

• Respiratory depression: Fatal respiratory depression may occur. Carbon dioxide retention from opioid-induced respiratory depression can exacerbate the sedating effects of opioids.

• Serotonin syndrome: Potentially life-threatening serotonin syndrome (SS) has occurred with concomitant use of remifentanil and serotonergic agents (eg, SSRIs, SNRIs, triptans, TCAs, 5-HT3 receptor antagonists, mirtazapine, trazodone, tramadol) and agents that impair metabolism of serotonin (eg, MAO inhibitors). Monitor patients closely for signs of SS such as mental status changes (eg, agitation, hallucinations, delirium, coma); autonomic instability (eg, tachycardia, labile blood pressure, diaphoresis); neuromuscular changes (eg, tremor, rigidity, myoclonus); GI symptoms (eg, nausea, vomiting, diarrhea); and/or seizures. Discontinue remifentanil if serotonin syndrome is suspected.

Disease-related concerns:

• Abdominal conditions: May obscure diagnosis or clinical course of patients with acute abdominal conditions.

• Biliary tract impairment: Use with caution in patients with biliary tract dysfunction, including acute pancreatitis; opioids may cause constriction of sphincter of Oddi.

• Bradycardia: Use with caution when administering to patients with bradycardia.

• Delirium tremens: Use with caution in patients with delirium tremens.

• Head trauma: Use with extreme caution in patients with head injury, intracranial lesions, or elevated intracranial pressure (ICP); exaggerated elevation of ICP may occur.

• Obesity: Use with caution in patients who are morbidly obese.

• Prostatic hyperplasia/urinary stricture: Use with caution in patients with prostatic hyperplasia and/or urinary stricture.

• Psychosis: Use with caution in patients with toxic psychosis.

• Respiratory disease: Use with caution and monitor for respiratory depression in patients with significant chronic obstructive pulmonary disease or cor pulmonale, and those with a substantially decreased respiratory reserve, hypoxia, hypercapnia, or preexisting respiratory depression, particularly when initiating and titrating therapy; critical respiratory depression may occur, even at therapeutic dosages.

• Seizures: Use with caution in patients with a history of seizure disorders; may increase risk or exacerbate preexisting seizure disorders.

• Thyroid dysfunction: Use with caution in patients with thyroid dysfunction.

Special populations:

• Cachectic or debilitated patients: Use with caution in cachectic or debilitated patients; there is a greater potential for critical respiratory depression, even at therapeutic dosages.

• Older adult: Use with caution in the elderly; may be more sensitive to adverse effects. Decrease initial dose.

Other warnings/precautions:

• Abuse/misuse/diversion: Use with caution in patients with a history of substance use disorder; potential for drug dependency exists. Other factors associated with increased risk for misuse include concomitant depression or other mental health conditions, higher opioid dosages, or taking other CNS depressants.

• Appropriate use: Inadequate clearing of IV tubing following administration has been associated with muscle rigidity, respiratory depression, and apnea when another fluid is administered through the same line. Do not administer into the same IV tubing with blood due to potential inactivation by nonspecific esterases in blood products.

• Discontinuation of therapy: Interruption of an infusion will result in offset of effect within 5 to 10 minutes; the discontinuation of an infusion should be preceded by the establishment of adequate postoperative analgesia.

• General anesthesia use: Not recommended as the sole agent for induction of anesthesia, because the loss of consciousness cannot be assured.

• Rapid infusion: Rapid IV infusion (single dose >1 mcg/kg over 30 to 60 seconds and infusion rates >0.1 mcg/kg/minute) should only be used during maintenance of general anesthesia; rapid infusion may result in skeletal muscle and chest wall rigidity. Chest wall rigidity may resolve by decreasing the infusion rate, discontinuing the infusion, or by administering a neuromuscular blocking agent.

• Trained individuals: Remifentanil should only be administered by health care providers specifically trained in the use of anesthetic agents. Should not be used in diagnostic or therapeutic procedures outside the monitored anesthesia setting; resuscitative and intubation equipment should be readily available.

Dosage Forms: US

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

Solution Reconstituted, Intravenous:

Ultiva: 1 mg (1 ea)

Generic: 2 mg (1 ea)

Solution Reconstituted, Intravenous [preservative free]:

Ultiva: 1 mg (1 ea); 2 mg (1 ea); 5 mg (1 ea)

Generic: 1 mg (1 ea); 2 mg (1 ea); 5 mg (1 ea)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (reconstituted) (Remifentanil HCl Intravenous)

1 mg (per each): $77.17

2 mg (per each): $147.00 - $154.34

5 mg (per each): $312.00 - $328.31

Solution (reconstituted) (Ultiva Intravenous)

1 mg (per each): $73.55

2 mg (per each): $147.10

5 mg (per each): $312.98

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 Reconstituted, Intravenous:

Generic: 1 mg (1 ea); 2 mg (1 ea)

Controlled Substance

C-II

Administration: Adult

IV: For IV use only. An infusion device should be used to administer continuous infusions. During the maintenance of general anesthesia, IV boluses may be administered over 30 to 60 seconds. Injections should be given into IV tubing close to the venous cannula; tubing should be cleared after treatment to prevent residual effects when other fluids are administered through the same IV line.

Administration: Pediatric

IV: An infusion pump should be used to administer continuous infusions. During the maintenance of general anesthesia, IV boluses ≤1 mcg/kg may be administered over 30 to 60 seconds; for doses >1 mcg/kg, administer over >60 seconds (to reduce the potential to develop skeletal muscle and chest wall rigidity). Injections should be given into IV tubing close to the venous cannula; tubing should be cleared after treatment to prevent residual effects when other fluids are administered through the same IV line.

Use: Labeled Indications

General anesthesia: Analgesic for use during the induction and maintenance of general anesthesia; continued analgesia into the immediate postoperative period in adults under the direct supervision of an anesthesia practitioner in a postoperative anesthesia care unit or intensive care setting; analgesic component of monitored anesthesia in adults.

Use: Off-Label: Adult

Mechanically ventilated patients in the ICU, pain and sedation

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

Remifentanil may be confused with ALfentanil

High alert medication:

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

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 Lexicomp 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

Alizapride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Alvimopan: Opioid Agonists may enhance the adverse/toxic effect of Alvimopan. This is most notable for patients receiving long-term (i.e., more than 7 days) opiates prior to alvimopan initiation. Management: Alvimopan is contraindicated in patients receiving therapeutic doses of opioids for more than 7 consecutive days immediately prior to alvimopan initiation. Risk D: Consider therapy modification

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

Amphetamines: May enhance the analgesic effect of Opioid Agonists. Risk C: Monitor therapy

Anticholinergic Agents: May enhance the adverse/toxic effect of Opioid Agonists. Specifically, the risk for constipation and urinary retention may be increased with this combination. Risk C: Monitor therapy

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

Azelastine (Nasal): May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Blonanserin: CNS Depressants may enhance the CNS depressant effect of Blonanserin. Management: Use caution if coadministering blonanserin and CNS depressants; dose reduction of the other CNS depressant may be required. Strong CNS depressants should not be coadministered with blonanserin. Risk D: Consider therapy modification

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

Bradycardia-Causing Agents: May enhance the bradycardic effect of other Bradycardia-Causing Agents. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

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

Bromopride: May enhance the CNS depressant effect of CNS Depressants. 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

Bromperidol: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Cannabinoid-Containing Products: CNS Depressants may enhance the CNS depressant effect of Cannabinoid-Containing Products. Risk C: Monitor therapy

Ceritinib: Bradycardia-Causing Agents may enhance the bradycardic effect of Ceritinib. Management: If this combination cannot be avoided, monitor patients for evidence of symptomatic bradycardia, and closely monitor blood pressure and heart rate during therapy. Risk D: Consider therapy modification

Chlormethiazole: May enhance the CNS depressant effect of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used. Risk D: Consider therapy modification

Chlorphenesin Carbamate: May enhance the adverse/toxic effect of CNS Depressants. Risk C: Monitor therapy

CNS Depressants: May enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification

Daridorexant: May enhance the CNS depressant effect of CNS Depressants. Management: Dose reduction of daridorexant and/or any other CNS depressant may be necessary. Use of daridorexant with alcohol is not recommended, and the use of daridorexant with any other drug to treat insomnia is not recommended. Risk D: Consider therapy modification

Desmopressin: Opioid Agonists may enhance the hyponatremic effect of Desmopressin. Risk C: Monitor therapy

DexmedeTOMIDine: CNS Depressants may enhance the CNS depressant effect of DexmedeTOMIDine. Management: Monitor for increased CNS depression during coadministration of dexmedetomidine and CNS depressants, and consider dose reductions of either agent to avoid excessive CNS depression. Risk D: Consider therapy modification

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

Difelikefalin: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Dimethindene (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Diuretics: Opioid Agonists may enhance the adverse/toxic effect of Diuretics. Opioid Agonists may diminish the therapeutic effect of Diuretics. Risk C: Monitor therapy

DroPERidol: May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (eg, opioids, barbiturates) with concomitant use. Risk D: Consider therapy modification

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

Eluxadoline: Opioid Agonists may enhance the constipating effect of Eluxadoline. Risk X: Avoid combination

Etrasimod: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Fexinidazole: Bradycardia-Causing Agents may enhance the arrhythmogenic effect of Fexinidazole. Risk X: Avoid combination

Fingolimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Fingolimod. Management: Consult with the prescriber of any bradycardia-causing agent to see if the agent could be switched to an agent that does not cause bradycardia prior to initiating fingolimod. If combined, perform continuous ECG monitoring after the first fingolimod dose. Risk D: Consider therapy modification

Flunarizine: CNS Depressants may enhance the CNS depressant effect of Flunarizine. Risk X: Avoid combination

Flunitrazepam: CNS Depressants may enhance the CNS depressant effect of Flunitrazepam. Management: Reduce the dose of CNS depressants when combined with flunitrazepam and monitor patients for evidence of CNS depression (eg, sedation, respiratory depression). Use non-CNS depressant alternatives when available. Risk D: Consider therapy modification

Gastrointestinal Agents (Prokinetic): Opioid Agonists may diminish the therapeutic effect of Gastrointestinal Agents (Prokinetic). 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

HydrOXYzine: May enhance the CNS depressant effect of CNS Depressants. Management: Consider a decrease in the CNS depressant dose, as appropriate, when used together with hydroxyzine. Increase monitoring of signs/symptoms of CNS depression in any patient receiving hydroxyzine together with another CNS depressant. Risk D: Consider therapy modification

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

Ivabradine: Bradycardia-Causing Agents may enhance the bradycardic effect of Ivabradine. Risk C: Monitor therapy

Ixabepilone: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Kava Kava: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Kratom: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Lemborexant: May enhance the CNS depressant effect of CNS Depressants. Management: Dosage adjustments of lemborexant and of concomitant CNS depressants may be necessary when administered together because of potentially additive CNS depressant effects. Close monitoring for CNS depressant effects is necessary. Risk D: Consider therapy modification

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

Lisuride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Lofexidine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Magnesium Sulfate: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Methotrimeprazine: CNS Depressants may enhance the CNS depressant effect of Methotrimeprazine. Methotrimeprazine may enhance the CNS depressant effect of CNS Depressants. Management: Reduce the usual dose of CNS depressants by 50% if starting methotrimeprazine until the dose of methotrimeprazine is stable. Monitor patient closely for evidence of CNS depression. Risk D: Consider therapy modification

Metoclopramide: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

MetyroSINE: CNS Depressants may enhance the sedative effect of MetyroSINE. Risk C: Monitor therapy

Midodrine: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Minocycline (Systemic): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

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

Monoamine Oxidase Inhibitors: May enhance the adverse/toxic effect of Remifentanil. Specifically, the risk for opioid toxicity (eg, respiratory depression) may be increased. Remifentanil may enhance the serotonergic effect of Monoamine Oxidase Inhibitors. This could result in serotonin syndrome. Management: The use of remifentanil is not recommended for patients taking monoamine oxidase inhibitors (MAOIs) or within 14 days of MAOI discontinuation. If coadministration is required, use test doses and titrate small doses of remifentanil frequently. Risk D: Consider therapy modification

Nabilone: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

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

Nalfurafine: Opioid Agonists may enhance the adverse/toxic effect of Nalfurafine. Opioid Agonists may diminish the therapeutic effect of Nalfurafine. Risk C: Monitor therapy

Nalmefene: May diminish the therapeutic effect of Opioid Agonists. Management: Avoid the concomitant use of oral nalmefene and opioid agonists. Discontinue oral nalmefene 1 week prior to any anticipated use of opioid agonists. If combined, larger doses of opioid agonists will likely be required. Risk D: Consider therapy modification

Naltrexone: May diminish the therapeutic effect of Opioid Agonists. Management: Seek therapeutic alternatives to opioids. See full drug interaction monograph for detailed recommendations. Risk X: Avoid combination

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

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

Olopatadine (Nasal): May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Opioid Agonists: CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification

Opioids (Mixed Agonist / Antagonist): May diminish the analgesic effect of Opioid Agonists. Management: Seek alternatives to mixed agonist/antagonist opioids in patients receiving pure opioid agonists, and monitor for symptoms of therapeutic failure/high dose requirements (or withdrawal in opioid-dependent patients) if patients receive these combinations. Risk X: Avoid combination

Orphenadrine: CNS Depressants may enhance the CNS depressant effect of Orphenadrine. Risk X: Avoid combination

Oxomemazine: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Oxybate Salt Products: CNS Depressants may enhance the CNS depressant effect of Oxybate Salt Products. Management: Consider alternatives to this combination when possible. If combined, dose reduction or discontinuation of one or more CNS depressants (including the oxybate salt product) should be considered. Interrupt oxybate salt treatment during short-term opioid use Risk D: Consider therapy modification

OxyCODONE: CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification

Ozanimod: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Paraldehyde: CNS Depressants may enhance the CNS depressant effect of Paraldehyde. Risk X: Avoid combination

Pegvisomant: Opioid Agonists may diminish the therapeutic effect of Pegvisomant. Risk C: Monitor therapy

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

Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Piribedil: CNS Depressants may enhance the CNS depressant effect of Piribedil. Risk C: Monitor therapy

Ponesimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Ponesimod. Management: Avoid coadministration of ponesimod with drugs that may cause bradycardia when possible. If combined, monitor heart rate closely and consider obtaining a cardiology consult. Do not initiate ponesimod in patients on beta-blockers if HR is less than 55 bpm. Risk D: Consider therapy modification

Pramipexole: CNS Depressants may enhance the sedative effect of Pramipexole. Risk C: Monitor therapy

Procarbazine: May enhance the CNS depressant effect of CNS Depressants. 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

Ramosetron: Opioid Agonists may enhance the constipating effect of Ramosetron. Risk C: Monitor therapy

Ropeginterferon Alfa-2b: CNS Depressants may enhance the adverse/toxic effect of Ropeginterferon Alfa-2b. Specifically, the risk of neuropsychiatric adverse effects may be increased. Management: Avoid coadministration of ropeginterferon alfa-2b and other CNS depressants. If this combination cannot be avoided, monitor patients for neuropsychiatric adverse effects (eg, depression, suicidal ideation, aggression, mania). Risk D: Consider therapy modification

ROPINIRole: CNS Depressants may enhance the sedative effect of ROPINIRole. Risk C: Monitor therapy

Rotigotine: CNS Depressants may enhance the sedative effect of Rotigotine. Risk C: Monitor therapy

Rufinamide: May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced. Risk C: Monitor therapy

Samidorphan: May diminish the therapeutic effect of Opioid Agonists. Risk X: Avoid combination

Serotonergic Agents (High Risk): Opioid Agonists may enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

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

Sincalide: Drugs that Affect Gallbladder Function may diminish the therapeutic effect of Sincalide. Management: Consider discontinuing drugs that may affect gallbladder motility prior to the use of sincalide to stimulate gallbladder contraction. Risk D: Consider therapy modification

Siponimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Siponimod. Management: Avoid coadministration of siponimod with drugs that may cause bradycardia. If combined, consider obtaining a cardiology consult regarding patient monitoring. Risk D: Consider therapy modification

Somatostatin Analogs: Opioid Agonists may diminish the analgesic effect of Somatostatin Analogs. Opioid Agonists may enhance the analgesic effect of Somatostatin Analogs. Risk C: Monitor therapy

Succinylcholine: May enhance the bradycardic effect of Opioid Agonists. Risk C: Monitor therapy

Suvorexant: CNS Depressants may enhance the CNS depressant effect of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended. Risk D: Consider therapy modification

Thalidomide: CNS Depressants may enhance the CNS depressant effect of Thalidomide. Risk X: Avoid combination

Tofacitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Valerian: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Zolpidem: CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. Risk D: Consider therapy modification

Zuranolone: May enhance the CNS depressant effect of CNS Depressants. Management: Consider alternatives to the use of zuranolone with other CNS depressants or alcohol. If combined, consider a zuranolone dose reduction and monitor patients closely for increased CNS depressant effects. Risk D: Consider therapy modification

Pregnancy Considerations

Remifentanil crosses the placenta; fetal and maternal concentrations may be similar.

Prolonged use of opioids during pregnancy can cause neonatal withdrawal syndrome, which may be life-threatening if not recognized and treated according to protocols developed by neonatology experts. Opioids used as part of obstetric analgesia/anesthesia during labor and delivery may temporarily affect the fetal heart rate (ACOG 209 2019). Opioids may cause respiratory depression and psychophysiologic effects in the neonate; newborns of mothers receiving remifentanil during labor should be closely monitored (Devroe 2015; Noskova 2015).

Pharmacokinetic properties of remifentanil are not significantly altered by pregnancy; dosing adjustment is not required for maternal indications (Smith 2017). Remifentanil is used to treat maternal pain during labor and immediately postpartum (ACOG 209 2019; Devroe 2015; Weibel 2017).

The ACOG recommends that pregnant women should not be denied medically necessary surgery, regardless of trimester. If the procedure is elective, it should be delayed until after delivery (ACOG 775 2019).

Breastfeeding Considerations

It is not known if remifentanil is present in breast milk.

According to the manufacturer, the decision to continue or discontinue breastfeeding during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother; monitor infants for excess sedation and respiratory depression. Remifentanil has a limited duration of action; use may be appropriate for breastfeeding women undergoing short procedures (ABM [Reece-Stremtan 2017]).

The Academy of Breast Feeding Medicine recommends postponing elective surgery until milk supply and breastfeeding are established. Milk should be expressed ahead of surgery when possible. In general, when the child is healthy and full term, breastfeeding may resume, or milk may be expressed once the mother is awake and in recovery. For children who are at risk for apnea, hypotension, or hypotonia, milk may be saved for later use when the child is at lower risk (ABM [Reece-Stremtan 2017]).

Monitoring Parameters

Respiratory and cardiovascular status, blood pressure, heart rate

Critically ill: The Numeric Rating Scale should be used in patients who are able to self-report pain. In patients who are unable to self-report pain, the Behavioral Pain Scale and the Critical-Care Pain Observational Tool can be used in intubated or nonintubated patients (SCCM [Devlin 2018]).

Mechanism of Action

Binds with stereospecific mu-opioid receptors at many sites within the CNS, increases pain threshold, alters pain reception, inhibits ascending pain pathways

Pharmacokinetics (Adult Data Unless Noted)

Note: In pediatric patients (neonates through adolescents), pharmacokinetic data showed variable age-related changes with distribution (ie, highest Vd associated with lowest age) and clearance (ie, fastest clearance in the youngest patients); however, no age-related changes with half-life (Ross 2001).

Onset of action: IV: 1 to 3 minutes; Peak effect: 3 to 5 minutes

Duration: 3 to 10 minutes (Scott 2005)

Distribution:

Pediatric patients (Ross 2001): Vdss:

Neonates ≤2 months: 453 ± 145 mL/kg

Infants and Children >2 months to <2 years: 308 ± 89 mL/kg

Children 2 to 6 years: 240 mL/kg ± 131 mL/kg

Children 7 to 12 years: 249 mL/kg ± 91 mL/kg

Adolescents 13 to <16 years: 223 ± 31 mL/kg

Adolescents 16 to 18 years: 243 ± 109 mL/kg

Adults: Vd: Initial: 100 mL/kg; Vdss: 350 mL/kg

Protein binding: ~70% (primarily alpha-1 acid glycoprotein)

Metabolism: Rapid via blood and tissue esterases; not metabolized by plasma cholinesterase (pseudocholinesterase) and is not appreciably metabolized by the liver

Half-life elimination (dose dependent):

Pediatric patients (Ross 2001): Effective:

Neonates ≤2 months: 5.4 minutes (range: 3 to 8 minutes)

Infants and Children >2 months to <2 years: 3.4 minutes (range: 2 to 6 minutes)

Children 2 to 6 years: 3.6 minutes (range: 1 to 6 minutes)

Children 7 to 12 years: 5.3 minutes (range: 3 to 7 minutes)

Adolescents: 13 to <16 years: 3.7 minutes (range: 2 to 5 minutes)

Adolescents 16 to 18 years: 5.7 minutes (range: 5 to 6 minutes)

Adults: Terminal: 10 to 20 minutes; Effective: 3 to 10 minutes

Time to peak, serum: Intranasal: Children ≤7 years: ~3.5 minutes (Verghese 2008)

Excretion: Urine

Clearance:

Pediatric patients (Ross 2001):

Neonates ≤2 months of age: 90.5 ± 36.8 mL/minute/kg

Infants and Children >2 months to <2 years: 92.1 ± 25.8 mL/minute/kg

Children 2 to 6 years: 76.0 ± 22.4 mL/minute/kg

Children 7 to 12 years: 59.7 ± 22.5 mL/minute/kg

Adolescents 13 to <16 years: 57.2 ± 21.2 mL/minute/kg

Adolescents 16 to 18 years: 46.5 ± 2.1 mL/minute/kg

Adults: ~40 mL/minute/kg

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Older adult: Clearance is reduced ~25%.

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

  • (AE) United Arab Emirates: Ultiva;
  • (AR) Argentina: Fada remifentanilo | Redormin | Remicit | Remifas | Remifentanilo gray | Remifentanilo kabi | Remifentanilo kilab | Remifentanilo northia | Remifentanilo richet | Remiflo | Restinil | Sagal | Ultiva;
  • (AT) Austria: Remifentanil | Remifentanil chiesi | Remifentanil kabi | Remifentanil sandoz | Remifentanil Teva | Ultiva;
  • (AU) Australia: Apo remifentanil | Dbl remifentanil | Remifentanil aft | Remifentanil alphapharm | Remifentanil sandoz | Ultiva;
  • (BE) Belgium: Remifentanil | Remifentanil actavis | Remifentanil Fresenius kabi | Remifentanil hospira | Remifentanil mylan | Remifentanil sandoz | Remifentanil Teva | Ultiva;
  • (BG) Bulgaria: Remifentanil Tchaikapharma;
  • (BR) Brazil: Cloridrato de remifentanila | Remifas | Remistesi | Ultiva;
  • (CH) Switzerland: Remifentanil fresenius | Remifentanil sandoz | Remifentanil Teva;
  • (CN) China: Rui jie;
  • (CO) Colombia: Rafentilo | Remifentafilo | Remifentanilo | Remifentanilo b. braun | Serilone | Suremifen | Tenotalis | Ultiva;
  • (CZ) Czech Republic: Remifentanil braun | Ultiva;
  • (DE) Germany: Remifentanil | Remifentanil actavis | Remifentanil B.Bra | Remifentanil hameln | Remifentanil hexal | Remifentanil kabi | Remifentanil Teva | Remimed | Ultiva;
  • (DO) Dominican Republic: Remifas;
  • (EC) Ecuador: Remifentanilo | Restinil | Ultiva;
  • (EE) Estonia: Remifentanil kabi | Ultiva;
  • (ES) Spain: Remifentanilo combino pharm | Remifentanilo kabi | Remifentanilo kern pharma | Remifentanilo Normon | Remifentanilo sala | Ultiva;
  • (FI) Finland: Remifentanil actavis | Remifentanil b. braun | Remifentanil hospira | Remifentanil orion | Ultiva;
  • (FR) France: Remifentanil actavis | Remifentanil b braun | Remifentanil hospira | Remifentanil mylan | Remifentanil Teva | Ultiva;
  • (GB) United Kingdom: Remifentanil | Ultiva;
  • (GR) Greece: Dormiden | Remifentanil/teva | Ultiva | Ultizen;
  • (HK) Hong Kong: Ultiva;
  • (HU) Hungary: Ultiva;
  • (IE) Ireland: Remifentanil | Remifentanil actavis | Ultiva;
  • (IT) Italy: Remifentanil accord | Remifentanil actavis | Remifentanil b. braun | Remifentanil hospira | Remifentanil kabi | Remifentanil mylan | Remifentanil orion | Remifentanil Teva | Ultiva;
  • (JO) Jordan: Rimfanile | Ultiva;
  • (JP) Japan: Remifentanil | Ultiva;
  • (KE) Kenya: Ultiva;
  • (KR) Korea, Republic of: Domiden | Kabi remifentanil | Remiva | Tivare | Ultian | Ultifen | Ultiva;
  • (KW) Kuwait: Remifentanil b. braun;
  • (LB) Lebanon: Ultiva;
  • (LT) Lithuania: Remifentanil kabi | Ultiva;
  • (LU) Luxembourg: Ultiva;
  • (LV) Latvia: Remifentanil kabi | Ultiva;
  • (MX) Mexico: Proximicil | Selatron | Ultiva;
  • (MY) Malaysia: Ultiva;
  • (NL) Netherlands: Remifentanil actavis | Remifentanil Fresenius kabi | Remifentanil hospira | Remifentanil mylan | Remifentanil Teva | Ultiva;
  • (NO) Norway: Remifentanil | Remifentanil actavis | Remifentanil braun | Remifentanil orion | Ultiva;
  • (NZ) New Zealand: Aft Remifentanil | Ultiva;
  • (PE) Peru: Remifentanilo | Ultiva | Utivex;
  • (PL) Poland: Remifentanil actavis | Remifentanil b.braun | Remifentanil chiesi | Remifentanil kabi | Ultiva;
  • (PR) Puerto Rico: Ultiva;
  • (PT) Portugal: Remifentanil | Remifentanilo | Remifentanilo actavis | Remifentanilo b. braun | Remifentanilo hospira | Remifentanilo kabi | Remifentanilo Sandoz | Remifentanilo teva | Ultiva;
  • (PY) Paraguay: Remifentanilo kabi | Remifentanilo quimfa | Restinil | Sagal;
  • (QA) Qatar: Dormiden | Lentanil | Rentanil | Ultiva;
  • (RO) Romania: Remifentanil kabi | Ultiva;
  • (SA) Saudi Arabia: Remifentanil medis;
  • (SE) Sweden: Remifentanil actavis | Remifentanil b.braun | Remifentanil Fresenius kabi | Remifentanil orion | Remifentanil reig jofre | Remifentanil sandoz | Remifentanil Teva | Ultiva;
  • (SG) Singapore: Ultiva;
  • (SI) Slovenia: Remifentanil chiesi | Remifentanil hameln | Remifentanil orion | Remifentanil sandoz | Remifentanil Teva | Remifentanilo kern pharma | Ultiva;
  • (SK) Slovakia: Remifentanil braun | Remifentil Chiesi | Ultiva;
  • (TN) Tunisia: Remifentanil medis | Remifentanil mylan | Ultiva;
  • (TR) Turkey: Opiva | Rentanil | Ultiva;
  • (TW) Taiwan: Remifentanil alvogen;
  • (UG) Uganda: Ultiva;
  • (UY) Uruguay: Fada remifentanilo | Restinil | Ultiva;
  • (VE) Venezuela, Bolivarian Republic of: Remifentanilo | Ultiva;
  • (ZA) South Africa: Mylan remifentanil | Remifentanil fresenius | Ultiva
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