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Adenosine

Class: Class IV Antiarrhythmics
VA Class: CV300
Chemical Name: 6-Amino-9-β-dribofuranosyl-9H-purine
Molecular Formula: C10H13N5O4
CAS Number: 58-61-7
Brands: Adenocard, Adenoscan

Medically reviewed by Drugs.com on Nov 5, 2021. Written by ASHP.

Introduction

Antiarrhythmic and pharmacologic stress test agent; endogenous nucleoside.

Uses for Adenosine

Treatment of Supraventricular Tachyarrhythmias

Termination of paroxysmal supraventricular tachycardia (PSVT), including that associated with accessory bypass tracts (e.g., Wolff-Parkinson-White syndrome).

Drug of choice for terminating stable, regular narrow-complex tachycardias, including PSVT due to AV nodal reentrant tachycardia (AVNRT) and AV reentrant tachycardia (AVRT).

Attempt appropriate vagal maneuvers (e.g., Valsalva maneuver, carotid sinus massage) when clinically indicated prior to adenosine use.

May consider adenosine in selected patients with unstable, narrow-complex tachycardia while preparing for cardioversion. (See Cardiovascular and Cerebrovascular Effects under Cautions.)

May be useful for diagnosis and treatment of stable, regular monomorphic wide-complex tachycardias if the etiology of the rhythm cannot be determined.

Not effective in terminating arrhythmias not due to reentry involving the AV or sinus node (e.g., atrial flutter, atrial fibrillation, ventricular tachycardia). Risk of serious arrhythmias and/or hypotension in patients with preexcited arrhythmias. (See Cardiovascular and Cerebrovascular Effects under Cautions.)

Some clinicians state that adenosine is contraindicated in patients with atrial fibrillation or flutter associated with Wolff-Parkinson-White syndrome; risk of dramatically accelerating ventricular rate.

Considered drug of choice for conversion of supraventricular tachycardia (SVT) in pediatric patients when pharmacologic therapy indicated. Also may be useful in pediatric patients for diagnosis and treatment of wide-complex tachycardias of supraventricular origin if rhythm is regular and monomorphic.

Thallium Stress Test

Adjunct to thallous (thallium) chloride TI 201 myocardial perfusion scintigraphy (thallium stress test) in patients unable to undergo adequate stress testing with exercise.

Diagnosis of Supraventricular Tachycardias

Used to aid diagnosis of stable, regular narrow-complex SVTs. Transient AV block may occur following administration of the drug, which can unmask atrial activity in certain arrhythmias (e.g., atrial tachycardia, atrial flutter).

Also has been used diagnostically in patients with stable, regular wide-complex tachycardias; if tachycardia is a result of SVT with aberrancy, adenosine will likely be effective in slowing or converting the arrhythmia to normal sinus rhythm.

Some experts discourage overuse for diagnostic purposes; use only in suspected arrhythmias of supraventricular origin. (See Cardiovascular and Cerebrovascular Effects under Cautions.)

Adenosine Dosage and Administration

Administration

Administer by peripheral IV injection or IV infusion depending on use.

Also has been administered via a central vein or by intraosseous (IO) injection in pediatric patients without reliable/immediate IV access.

Safety and efficacy of intracoronary administration (as adjunct to thallium stress test) not established.

For solution compatibility information, see Compatibility under Stability.

IV Injection

Supraventricular tachyarrhythmias (e.g., PSVT): Administer by rapid IV (“bolus”) injection into a peripheral vein.

To ensure the drug reaches the systemic circulation, inject directly into a vein. If given through an IV line, inject as closely as possible to the patient’s venous access, then follow each dose with a rapid flush of 0.9% sodium chloride injection (e.g., flush with ≥5 mL for pediatric patients and 20 mL for adults).

Rate of Administration

Supraventricular tachyarrhythmias (e.g., PSVT): Administer over 1–2 seconds.

IV Infusion

Thallium Stress Test: Administer by continuous infusion into a peripheral vein.

Rate of Administration

Administer over 6 minutes.

Dosage

Pediatric Patients

Supraventricular Tachyarrhythmias
PSVT
IV

Children <50 kg: Initially, 0.05–0.1 mg/kg. If conversion of PSVT does not occur within 1–2 minutes, increase subsequent doses by 0.05–0.1 mg/kg until sinus rhythm is established or a maximum single dose of 0.3 mg/kg (not exceeding 12 mg) has been given.

Children ≥50 kg: Initially, 6 mg. If conversion does not occur within 1–2 minutes, a 12-mg dose may be administered and repeated once, if necessary. Maximum single dose is 12 mg.

A lower initial dose (50% of the usual recommended initial dose for children) may be effective if given via a central vein, because the rhythm effects of adenosine are concentration dependent.

Adults

Supraventricular Tachyarrhythmias
PSVT
IV

Initially, 6 mg. If conversion does not occur within 1–2 minutes, administer a 12-mg dose; may repeat 12-mg dose once, if necessary.

If recurs after conversion, additional doses of adenosine or a longer-acting AV nodal blocking agent (e.g., diltiazem, β-adrenergic blocking agent) may be used. If adenosine fails to convert PSVT, rate control may be attempted with a nondihydropyridine calcium-channel blocking agent (e.g., diltiazem, verapamil) or a β-adrenergic blocking agent.

A lower initial dose of adenosine (3 mg for adults) may be effective if given via a central vein because the rhythm effects of adenosine are concentration dependent.

Thallium Stress Test
IV

0.14 mg/kg per minute for 6 minutes (total dose of 0.84 mg/kg).

Administer required dose of thallous (thallium) chloride TI 201 at the midpoint (i.e., after the first 3 minutes) of the adenosine infusion and as close as possible to the venous access site to prevent an inadvertent increase in the dose of adenosine (the contents of the IV tubing) being administered.

Prescribing Limits

Pediatric Patients

Supraventricular Tachyarrhythmias
PSVT
IV

Children <50 kg: Manufacturer recommends maximum single dose of 0.3 mg/kg (do not exceed 12 mg).

Children ≥50 kg: Manufacturer recommends maximum single dose of 12 mg.

Some experts recommend maximum single dose of 6 mg for initial injection.

Adults

Supraventricular Tachyarrhythmias
PSVT
IV

Maximum recommended single dose is 12 mg.

Special Populations

Cardiac Transplant Patients

Administer with caution because of risk of cardiac denervation-related hypersensitivity. (See Cardiovascular and Cerebrovascular Effects under Cautions.)

Cautions for Adenosine

Contraindications

  • Known hypersensitivity to adenosine.

  • Second- or third-degree AV block (except in patients with a functioning artificial pacemaker).

  • Sinus node disease (e.g., sick sinus syndrome, symptomatic bradycardia [except in those with a functioning artificial pacemaker]).

  • Known or suspected bronchoconstrictive or bronchospastic lung disease (e.g., asthma).

Warnings/Precautions

Cardiovascular and Cerebrovascular Effects

Serious cardiovascular and cerebrovascular events, including myocardial ischemic events, rhythm and conduction abnormalities, hypotension, hypertension, and stroke, reported rarely. Ensure availability of cardiac resuscitation equipment and trained staff prior to administration.

Myocardial Ischemic Events

Risk of rare but serious adverse cardiovascular events, including MI and death, in patients receiving adenosine as a cardiac stress testing agent during myocardial perfusion imaging; similar risk also observed with regadenoson, another pharmacologic stress test agent.

Avoid use in patients with signs or symptoms of acute myocardial ischemia (e.g., unstable angina, cardiovascular instability).

Rhythm and Conduction Abnormalities

Risk of first-, second-, or third-degree heart block, sinus bradycardia, and, rarely, sinus pause due to the drug's direct depressant effects on SA and AV nodes. Avoid use in patients with sinus node dysfunction or high-grade AV block unless patient has a functioning artificial pacemaker (see Contraindications under Cautions); use caution in patients with preexisting first-degree AV block or bundle branch block. Discontinue therapy in patients who develop persistent or symptomatic high-level AV block.

When used for termination of PSVT, new arrhythmias (VPCs, atrial premature complexes, atrial fibrillation, sinus bradycardia, sinus tachycardia, skipped beats, and varying degrees of AV nodal block) may occur at the time of conversion to normal sinus rhythm. Such arrhythmias generally transient and self-limiting, although episodes of asystole, sometimes fatal, have been reported. Ventricular fibrillation (both resuscitated and fatal events) also reported. In most cases, these adverse effects occurred in patients receiving concomitant therapy with digoxin or digoxin and verapamil; a causal relationship, however, not established. (See Specific Drugs under Interactions.)

Hemodynamic and Associated Effects

Marked hypotension possible due to potent peripheral vasodilating effects of the drug; risk may be increased in patients with autonomic dysfunction, stenotic valvular heart disease, pericarditis or pericardial effusion, stenotic carotid artery disease with cerebrovascular insufficiency, or hypovolemia. Discontinue in patients who develop persistent or symptomatic hypotension.

Clinically important increases in BP also may occur; generally transient, but may persist for several hours.

Cerebrovascular events, including hemorrhagic and ischemic stroke, possibly related to hemodynamic effects of the drug, also reported.

Respiratory Effects

Risk of dyspnea, bronchoconstriction, bronchospasm, and respiratory compromise.

May exacerbate symptoms (e.g., bronchoconstriction) in patients with asthma. (See Contraindications under Cautions.)

Use with caution in patients with obstructive lung disease not associated with bronchoconstriction (e.g., emphysema, bronchitis). Ensure availability of appropriate resuscitative measures. Discontinue drug in patients who develop severe respiratory difficulty.

Seizures

Risk of new-onset or recurrent seizures. Seizure activity, including tonic-clonic (grand mal) seizures, reported; in some cases, prolonged and required emergency management.

Concomitant use of aminophylline may increase risk of seizures. (See Specific Drugs under Interactions.)

Sensitivity Reactions

Hypersensitivity

Risk of hypersensitivity reactions, possibly requiring resuscitative measures; manifestations have included dyspnea, throat tightness, flushing, erythema, and chest discomfort. (See Contraindications under Cautions.)

Ensure availability of appropriate personnel and resuscitative equipment.

Specific Populations

Pregnancy

Category C.

Because of its rapid onset and brief duration of action, adenosine may have advantages over other antiarrhythmic agents (e.g., verapamil, digoxin) in the acute treatment of PSVT in pregnant women in whom vagal maneuvers have failed. Use with caution because hypotension may compromise placental (fetal) blood flow.

Lactation

Not known whether adenosine is distributed into milk. Discontinue nursing or the drug. Some clinicians suggest that breast-feeding may be possible because of the drug’s short half-life.

Pediatric Use

Safety and efficacy (as adjunct to thallium stress test) not established in children ≤18 years of age.

Safety and efficacy (as antiarrhythmic for PSVT) not established in pediatric patients; however, IV adenosine has been used for the treatment of PSVT in neonates, infants, children, and adolescents and some clinicians consider it a drug of choice for SVT in pediatric patients.

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults. Use with caution since increased sensitivity cannot be ruled out; some geriatric patients may have diminished cardiac or nodal dysfunction, concomitant disease, or drug therapy that may alter hemodynamic function and result in severe bradycardia or AV block.

Hepatic Impairment

Hepatic function not required for therapeutic effect or inactivation; hepatic dysfunction not expected to alter efficacy or tolerability.

Renal Impairment

Renal function not required for therapeutic effect or inactivation; renal dysfunction not expected to alter efficacy or tolerability.

Common Adverse Effects

For termination of PSVT: Facial flushing, shortness of breath/dyspnea, chest pressure, nausea, headache, lightheadedness, dizziness, numbness, tingling in the arms.

As an adjunct to thallium stress test: Facial flushing, chest discomfort, dyspnea or urge to breathe deeply, headache, throat/neck/jaw discomfort, GI discomfort, lightheadedness/dizziness, upper extremity discomfort, ST-segment depression, first- or second-degree AV block, paresthesia, hypotension, nervousness, arrhythmias.

Interactions for Adenosine

Specific Drugs

Drug

Interaction

Comments

ACE inhibitors

Potential for additive/synergistic depressant effects on SA and AV nodes

Use with caution

β-Adrenergic blocking agents

Potential for additive/synergistic depressant effects on SA and AV nodes

Use with caution

Calcium channel-blocking agents

Potential for additive/synergistic depressant effects on SA and AV nodes

Use with caution

Carbamazepine

Possible increased degree of heart block

Digoxin or digoxin/verapamil

Potential for additive/synergistic depressant effects on SA and AV nodes; serious and/or life-threatening effects (asystole, ventricular fibrillation) reported rarely

Use with caution and with appropriate resuscitative measures available

Dipyridamole

Potentiation of adenosine vasoactive effects

Safety and efficacy of adenosine in presence of dipyridamole not established; in general, withhold administration of drugs that inhibit or augment pharmacologic effects of adenosine for at least 5 half-lives prior to adenosine administration

Methylxanthines (aminophylline, caffeine, theophylline)

Inhibition of adenosine vasoactive effects

Aminophylline: Concomitant use may increase risk of seizures

Increased doses of adenosine may be required

Safety and efficacy of adenosine in presence of methylxanthines not established; in general, withhold administration of drugs that inhibit or augment pharmacologic effects of adenosine for at least 5 half-lives prior to adenosine administration

Do not use methylxanthines in patients who experience adenosine-induced seizures

Quinidine

Potential for additive/synergistic depressant effects on SA and AV nodes

Use with caution

Adenosine Pharmacokinetics

Elimination

Metabolism

Rapidly metabolized intracellularly to inactive metabolites.

Elimination Route

Cleared by cellular uptake, primarily by erythrocytes and vascular endothelial cells.

Half-life

<10 seconds.

Stability

Storage

Parenteral

Injection

15–30°C. Do not refrigerate.

If crystallization occurs, warm to room temperature.

Contains no preservative; discard unused solution.

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution CompatibilityHID

Compatible

Dextrose 5% in Ringer’s injection, lactated

Dextrose 5% in water

Ringer’s injection, lactated

Sodium chloride 0.9%

Y-Site Injection Compatibility

Compatible

Abciximab

Actions

  • Slows conduction time through the AV node; can interrupt reentrant pathways through the AV node and restore normal sinus rhythm in patients with PSVT, including that associated with Wolff-Parkinson-White syndrome.

  • Increases blood flow in normal coronary arteries with little or no increase in stenotic arteries, resulting in a greater difference in thallous (thallium) chloride TI 201 uptake in myocardium supplied by normal versus stenotic coronary arteries.

  • Potent vasodilator in most vascular beds; however, vasoconstriction is produced in renal afferent arterioles and hepatic veins.

  • Produces a net mild to moderate reduction in systolic, diastolic, and mean arterial blood pressure and a reflex increase in heart rate.

  • May exert pharmacologic effects by activation of purine (cell-surface A1 and A2 adenosine) receptors; relaxation of vascular smooth muscle may be mediated by reduction in calcium uptake through inhibition of slow inward calcium current and activation of adenylate cyclase in smooth muscle cells.

  • May reduce vascular tone by modulation of sympathetic neurotransmission.

  • Respiratory stimulant, probably because of activation of carotid body chemoreceptors; IV administration produces an increase in minute ventilation and a reduction in arterial PCO2 resulting in respiratory alkalosis.

Advice to Patients

  • Importance of informing patients about serious adverse effects associated with adenosine, such as MI, arrhythmias, cardiac arrest, heart block, substantial changes in BP, bronchoconstriction, hypersensitivity reactions, seizures, and stroke.

  • Importance of patients informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs (e.g., aminophylline, theophylline), caffeine-containing foods or beverages, as well as any concomitant illnesses (e.g., asthma, COPD).

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

  • 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.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

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

Adenosine

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection, for rapid IV injection only

3 mg/mL*

Adenocard

Astellas

Adenosine Injection

Injection, for IV infusion only

3 mg/mL

Adenoscan

Astellas

AHFS DI Essentials™. © Copyright 2022, Selected Revisions November 15, 2016. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

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

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