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Drug Interactions between esmolol and pancuronium

This report displays the potential drug interactions for the following 2 drugs:

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Interactions between your drugs

Moderate

esmolol pancuronium

Applies to: esmolol and pancuronium

MONITOR: Neuromuscular blocking agents and beta-blockers may have additive cardiovascular depressant effects. In one study, 8 of 42 patients receiving beta-blockers developed bradycardia (less than 50 bpm) and hypotension (systolic BP less than 80 mmHg) when atracurium was administered. Most of these patients were under general anesthesia using diazepam, methohexital, droperidol, fentanyl, and nitrous oxide/oxygen. In isolated case reports, patients treated with timolol eye drops have developed bradycardia and hypotension when atracurium or alcuronium was administered. The interaction has also been reported with atenolol and atracurium.

MONITOR: Limited data suggest that beta-blockers may modestly potentiate the pharmacologic effects of neuromuscular blocking agents. The exact mechanism of interaction is unknown but may involve effects in the postsynaptic membrane, as beta-blockers alone have been reported to exacerbate or unmask myasthenia gravis. In one case report, two thyrotoxic patients treated with propranolol 120 mg/day for 14 days prior to surgery demonstrated prolonged neuromuscular blockade with tubocurarine. Likewise, eight study subjects receiving esmolol (300 to 500 mcg/kg/min) five minutes before induction of anesthesia experienced an approximately 3-minute delay in recovery from succinycholine-induced neuromuscular blockade relative to subjects receiving a placebo infusion. Other studies have not corroborated these findings. A study of 16 patients receiving chronic therapy (at least one month) with various beta-blockers found no significant difference in the onset and duration of action of rocuronium compared to 27 patients in the control group. Earlier studies even found a slight reduction in the effect of succinylcholine in patients treated with propranolol intravenously before surgery and a shorter duration of action of tubocurarine in patients administered propranolol or oxprenolol. Esmolol has been reported to delay the onset of action of rocuronium from 93 to 118 seconds.

MANAGEMENT: Clinicians should recognize the potential for altered effects of neuromuscular blocking agents in the presence of beta-blockers. Respiratory and cardiovascular status should be closely monitored.

References

  1. Glynne GL "Drug interaction?" Anaesthesia 39 (1984): 293
  2. Yate B, Mostafa SM "Drug interaction?" Anaesthesia 39 (1984): 728-9
  3. Herishanu Y, Rosenberg P "Beta-blockers and myasthenia gravis." Ann Intern Med 83 (1975): 834-5
  4. Murthy VS, Patel KD, Elangovan RG, Hwang TF, Solochek SM, Steck JD, Laddu AR "Cardiovascular and neuromuscular effects of esmolol during induction of anesthesia." J Clin Pharmacol 26 (1986): 351-7
  5. Harrah MD, Way WL, Katzung BG "The interaction of d-tubocurarine with antiarrhythmic drugs." Anesthesiology 33 (1970): 406-10
  6. Rozen MS, Whan FM "Prolonged curarization associated with propranolol." Med J Aust 1 (1972): 467-8
  7. Chapple DJ, Clark JS, Hughes R "Interaction between atracurium and drugs used in anaesthesia." Br J Anaesth 55 Suppl 1 (1983): s17-22
  8. Loan PB, Connolly FM, Mirakhur RK, Kumar N, Farling P "Neuromuscular effects of rocuronium in patients receiving beta-adrenoreceptor blocking, calcium entry blocking and anticonvulsant drugs." Br J Anaesth 78 (1997): 90-1
View all 8 references

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Drug and food interactions

Moderate

esmolol food

Applies to: esmolol

MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensives and other hypotensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.

MANAGEMENT: Caution and close monitoring for development of hypotension is advised during coadministration of these agents. Some authorities recommend avoiding alcohol in patients receiving vasodilating antihypertensive drugs. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.

References

  1. Sternbach H "Fluoxetine-associated potentiation of calcium-channel blockers." J Clin Psychopharmacol 11 (1991): 390-1
  2. Shook TL, Kirshenbaum JM, Hundley RF, Shorey JM, Lamas GA "Ethanol intoxication complicating intravenous nitroglycerin therapy." Ann Intern Med 101 (1984): 498-9
  3. Feder R "Bradycardia and syncope induced by fluoxetine." J Clin Psychiatry 52 (1991): 139
  4. Ellison JM, Milofsky JE, Ely E "Fluoxetine-induced bradycardia and syncope in two patients." J Clin Psychiatry 51 (1990): 385-6
  5. Rodriguez de la Torre B, Dreher J, Malevany I, et al. "Serum levels and cardiovascular effects of tricyclic antidepressants and selective serotonin reuptake inhibitors in depressed patients." Ther Drug Monit 23 (2001): 435-40
  6. Cerner Multum, Inc. "Australian Product Information." O 0
  7. Pacher P, Kecskemeti V "Cardiovascular side effects of new antidepressants and antipsychotics: new drugs, old concerns?" Curr Pharm Des 10 (2004): 2463-75
  8. Andrews C, Pinner G "Postural hypotension induced by paroxetine." BMJ 316 (1998): 595
View all 8 references

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Therapeutic duplication warnings

No warnings were found for your selected drugs.

Therapeutic duplication warnings are only returned when drugs within the same group exceed the recommended therapeutic duplication maximum.

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Drug Interaction Classification

These classifications are only a guideline. The relevance of a particular drug interaction to a specific individual is difficult to determine. Always consult your healthcare provider before starting or stopping any medication.
Major Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit.
Moderate Moderately clinically significant. Usually avoid combinations; use it only under special circumstances.
Minor Minimally clinically significant. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan.
Unknown No interaction information available.

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