Propine

Generic Name: Dipivefrin Hydrochloride
Class: Mydriatics
ATC Class: S01EA02
VA Class: OP103
Chemical Name: (±)-3,4-Dihydroxy-α-[(methylamino)methyl]benzyl alcohol 3,4-dipivalate
Molecular Formula: C19H29NO5
CAS Number: 64019-93-8

Introduction

Synthetic sympathomimetic amine.78

Uses for Propine

Ocular Hypertension and Glaucoma

Reduction of elevated IOP in patients with open-angle glaucoma.1 4 5 10 13 25 26 27 28 34 36 37 52 Used alone or in conjunction with other IOP-lowering drugs.1 4 5 7 10 13 25 26 27 28 31 34 36 37 38 51 52 53 56 57 59 60 62 87 88 May be used as initial therapy 1 7 10 13 25 26 27 28 34 52 or for control of IOP in those patients who have not responded adequately to other antiglaucoma agents.1 5 7 10 13 25 26 31 34 36 38 51 52 53 56 57 59 60 62 87 88

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May be preferred as an alternative to topical epinephrine in some patients (e.g., those with cardiovascular disease)31 because of increased intraocular penetration (lower doses are needed) and resultant decreased adverse systemic effects (e.g., cardiovascular effects) compared with epinephrine.7 11 26 28 31 34 57 69

Does not produce miosis, accommodative spasm, blurred vision, or night blindness.1 Less likely than epinephrine to cause adenochrome staining of contact lenses.1 4 7 12 58 61 70 71 72

Has been used to reduce IOP in the treatment of other ocular conditions, including ocular hypertension and pseudoexfoliative, low-tension, and secondary (e.g., post-angle closure, pigmentary, traumatic, herpes zoster) glaucomas.34 52

Propine Dosage and Administration

General

  • Adjust dosage according to individual requirements and response of patient as determined by tonometric readings before and during therapy.7

  • Because of diurnal variations in IOP, measure IOP at different times during the day to determine if an adequate hypotensive effect is maintained.7 Since IOP may not stabilize for a few weeks after initiating therapy, determine IOP after several weeks of therapy; thereafter, IOP should be determined as necessary.7 89 94

Administration

Ophthalmic Administration

Apply topically to the eye as an ophthalmic solution.1 4 Not for injection.1

Avoid contamination of the solution container.6

Dosage

Available as dipivefrin hydrochloride; dosage expressed in terms of the salt.1

Adults

Ocular Hypertension and Glaucoma
Initial Therapy
Ophthalmic

1 drop of a 0.1% solution in affected eye(s) every 12 hours.1 4 5 10

Adjunctive Therapy
Ophthalmic

In patients receiving several drugs for the treatment of glaucoma, adjustments to the regimen should involve one drug at a time and should usually occur at intervals of at least 1 week.89

Initially, 1 drop of a 0.1% solution every 12 hours while therapy with other drugs is continued.1 Beginning on the following day1 and continuing at intervals of at least 1 week until optimum response is achieved, reduce dosage of one of the other drugs or discontinue one of the other drugs.89 Adjust remaining regimen according to the IOP response of the patient.89

Conversion to Dipivefrin Therapy
Ophthalmic

Conversion from monotherapy with epinephrine: Discontinue epinephrine and initiate dipivefrin at 1 drop of a 0.1% solution into affected eye(s) every 12 hours1 5 at the time of the next scheduled dose of epinephrine.89 94

Conversion from monotherapy with antiglaucoma agents other than epinephrine: On day 1, continue other antiglaucoma agent and add 1 drop of a 0.1% dipivefrin solution every 12 hours.1 On day 2, discontinue the other drug and continue dipivefrin.1

Cautions for Propine

Contraindications

  • Angle-closure glaucoma, or patients predisposed to angle-closure.1 7

  • Known hypersensitivity to dipivefrin or any ingredient in the formulation.1 7

Warnings/Precautions

Sensitivity Reactions

Allergic Reactions

Blepharoconjunctivitis, requiring discontinuance of dipivefrin, reported after ≥5 months of therapy.4 36 37 54 55 59 63 Karyomegaly of conjunctival epithelial cells, 63 chemosis of the conjunctiva, 59 dry eczematoid dermatitis of the eyelids, 59 pruritus, 55 and blepharitis 25 53 55 reported.

Allergic reactions may be caused by excipients in the preparation.66

Cross-Sensitivity

Cross-sensitivity reported in patients who have previously exhibited a sensitivity reaction to epinephrine.1 13 51 54 55 63

General Precautions

Aphakia

Reversible macular edema reported in aphakic patients with glaucoma treated with epinephrine; caution is advised.1 5 52 55 64 65 89

Systemic Effects

Ophthalmic use of epinephrine occasionally causes systemic sympathomimetic effects, such as tachycardia,1 7 arrhythmias,1 28 31 and hypertension;1 28 31 however, systemic sympathomimetic effects occur rarely with topical administration of dipivefrin.5

Use with caution in patients with vascular hypertension or cardiac disorders, including arrhythmias and cardiovascular disease; consider cardiovascular status before initiating therapy.15 89 94

Specific Populations

Pregnancy

Category B.1

Lactation

Not known whether dipivefrin distributed into milk.1 Caution advised if topical dipivefrin is used.1

Pediatric Use

Safety and efficacy not established.1

Geriatric Use

No substantial differences in safety and efficacy relative to younger adults.1

Common Adverse Effects

Ocular congestion or hyperemia,1 25 34 36 37 52 59 63 burning,1 4 5 10 15 25 26 stinging.1 5 10 15 25 51

Interactions for Propine

Specific Drugs

Drug

Interaction

Comments

Ocular hypotensive agents

Additive IOP-lowering effects1 26 38 51 54 56 57 59 60

Used to therapeutic advantage1 7 26 38 54 56 57 59 60

Propine Pharmacokinetics

Absorption

Bioavailability

Following topical application to the eye, about 7% of administered dose absorbed across the cornea into the aqueous humor mainly as epinephrine.8 Lipid solubility enhances ocular absorption of dipivefrin over that of epinephrine.7 8 13 16 38

Rarely, absorption following topical application to the eye may be sufficient to cause systemic sympathomimetic effects to occur.31

Onset

Reduction in IOP usually evident within 30 minutes after topical application and peaks within 1 hour.1 4 5 7

Duration

Reduction in IOP persists for ≥12 hours.89 94

Distribution

Extent

Rapidly distributed throughout ocular tissues and fluids in rabbits.7 16 30 39 44 In humans, dipivefrin and its metabolites detected in the cornea,8 aqueous humor,8 and to a lesser extent, the tissues and fluids of the contralateral untreated eye;16 32 however, distribution in human ocular tissues and fluids not fully characterized.94

Systemic distribution following administration of topical dipivefrin not determined.94

Not known whether dipivefrin crosses the placenta or distributes into milk; 1 94 however, systemically absorbed epinephrine crosses the placenta and distributes into milk.4 42

Elimination

Metabolism

Following topical application and ocular absorption, rapidly and extensively hydrolyzed to epinephrine via esterases (e.g., acetylcholinesterase, pseudocholinesterase, carbonic anhydrase) in the cornea, conjunctiva, and aqueous humor.1 4 5 8 11 14 16 30 33 39 40 46 47 50 74

Epinephrine released from the prodrug is metabolized by catechol-O-methyltransferase (COMT) and MAO in the eye, liver, and other tissues.11 16 39 45 46 48 49

Half-life

Averages 1.8, 0.9, and 3.1 hours in the cornea, aqueous humor, and iris/ciliary body, respectively.44

Stability

Storage

Ophthalmic

Solution

Tight, light-resistant containers at 15–30°C.1 98

Actions

  • Prodrug with little or no pharmacologic activity until hydrolyzed into epinephrine.1 7 9 12 14 22 35 89

  • Lowers IOP1 4 5 10 13 25 26 27 28 34 36 37 52 in patients with glaucoma;1 4 5 10 13 25 26 27 28 34 36 37 52 lowers IOP to a lesser extent in the normal eye; causes mydriasis.27 77 Appears to lower IOP by stimulating α -and/or β2-adrenergic receptors, 7 11 23 24 67 90 93 95 96 resulting in an increase in pressure-independent (uveoscleral) and, to a lesser extent in pressure-dependent (trabecular) aqueous humor outflow.1 4

Advice to Patients

  • Importance of learning and adhering to proper administration techniques to avoid contamination of the product.1

  • Advise patients to consult a clinician immediately regarding continued use of ophthalmic preparations if an intercurrent ocular condition (e.g., trauma, infection, sensitivity, irritation) occurs.1 89 94

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs and dietary or herbal supplements, as well as concomitant illnesses.1

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1

  • Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Dipivefrin Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Ophthalmic

Solution

0.1%*

Dipivefrin Hydrochloride Ophthalmic Solution

Bausch & Lomb, Falcon

Propine (with benzalkonium chloride)

Allergan

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions May 1, 2007. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

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