Drug class: Selective beta-1-Adrenergic Agonists

Medically reviewed by Drugs.com on Jun 10, 2024. Written by ASHP.

Introduction

Synthetic sympathomimetic that is structurally related to dopamine; generally considered a relatively selective β₁-adrenergic agonist.

Uses for DOBUTamine

Cardiac Decompensation

Used for inotropic support in the short-term management of cardiac decompensation caused by depressed contractility from organic heart disease or cardiac surgery.^{113 114 116 165}

Safety and efficacy in the long-term (e.g., >48 hours) treatment of congestive heart failure not established.¹¹⁴

Because positive inotropes have not demonstrated improved outcomes and can be potentially harmful (e.g., increased risk of arrhythmias) in patients with heart failure, some experts recommend that such use be reserved for patients with severe systolic dysfunction who have low cardiac index and evidence of systemic hypoperfusion and/or congestion, or for palliative therapy in those with end-stage heart failure.¹⁶⁵ To minimize risk of adverse effects, use lowest possible dosage and evaluate regularly for need for continued inotropic therapy.¹⁶⁵

Used in the treatment of septic or cardiogenic shock to improve myocardial contractility and maintain systemic perfusion.^{153 159 161 165} Current expert guidelines recommend a trial of dobutamine (alone or in addition to a vasopressor) in patients with septic shock if myocardial dysfunction is present, or if there is ongoing hypoperfusion despite adequate intravascular volume and mean arterial pressure.¹⁵³ Early revascularization is standard of care in patients with cardiogenic shock; individualize use of inotropes in this setting.^{161 162}

Advanced Cardiovascular Life Support (ACLS)

Has been used for postresuscitation stabilization^{† [off-label]} in patients who require additional cardiac output and blood pressure support following cardiac arrest.^{403 404}

Cardiac Diagnostic Testing

Has been used as a pharmacologic stress test agent^{† [off-label]} during echocardiography in patients unable to exercise.^{120 122 124 125 126 127}

Also has been used as an alternative to exercise stress testing in patients undergoing myocardial perfusion imaging^{† [off-label]}.^{119 121 123 128 129 130} However, coronary vasodilating agents (e.g., adenosine, dipyridamole, regadenoson) are drugs of choice for this use; dobutamine generally recommended only as an alternative in patients who have contraindications (e.g., bronchospastic airway disease).^{119 121 123}

DOBUTamine Dosage and Administration

Administration

Administer by IV infusion.^{113 114}

Also has been administered by intraosseous (IO) infusion^{† [off-label]} in the setting of ACLS.^{401 403}

IV Infusion

Administer using an infusion pump or other apparatus to control flow rate and avoid inadvertent rapid IV (“bolus”) administration.^{113 114}

Dobutamine hydrochloride injection concentrate must be further diluted prior to IV infusion;¹¹³ alternatively, commercially available prediluted solutions of dobutamine hydrochloride in 5% dextrose injection may be used.¹¹⁴

Dobutamine hydrochloride in 5% dextrose injection is commercially available in flexible plastic containers.¹¹⁴ Do not use in series connections.¹¹⁴

Consult manufacturer's labeling for proper methods of administration and other associated precautions.^{113 114 115}

Dilution

Must dilute dobutamine hydrochloride concentrate for injection with a compatible IV solution prior to administration (dilute 20 mL of concentrate in at least 50 mL of diluent and 40 mL of concentrate in at least 100 mL of diluent).¹¹³

Individualize concentration according to patient dosage and fluid requirements; concentrations up to 5000 mcg/mL have been used.^{113 114}

Rate of Administration

Avoid rapid IV (“bolus”) administration.¹¹⁴

Individualize IV infusion rate to achieve the desired clinical response.^{113 114}

Initiate at a slow rate (e.g., 0.5–1 mcg/kg per minute) and carefully adjust at intervals of a few minutes according to response; usually 2–20 mcg/kg per minute is needed to increase cardiac output.^{113 114}

Standardize 4 Safety

Standardized concentrations for dobutamine have been established through Standardize 4 Safety (S4S), a national patient safety initiative to reduce medication errors, especially during transitions of care.^{249 250} Because recommendations from the S4S panels may differ from the manufacturer’s prescribing information, caution is advised when using concentrations that differ from labeling, particularly when using rate information from the label.^{249 250} For additional information on S4S (including updates that may be available), see[Web].^{249 250}

Dosage

Available as dobutamine hydrochloride; dosage expressed in terms of dobutamine.^{113 114}

Individual response to dobutamine is variable; titrate dosage to achieve the desired clinical response.^{113 114}

Carefully adjust rate and duration of infusion according to heart rate, BP, urine flow, presence of ectopic heartbeats, and, whenever possible, central venous or pulmonary wedge pressure and cardiac output.^{113 114}

Pediatric Patients

Cardiac Decompensation

IV

Initiate at a slow rate (e.g., 0.5–1 mcg/kg per minute) and titrate to desired response.¹¹⁴

Usually, 2–20 mcg/kg per minute is needed to increase cardiac output.¹¹⁴

ACLS

IV/IO

For postresuscitation stabilization^{† [off-label]}, usual dosage range is 2–20 mcg/kg per minute.⁴⁰³

Adults

Cardiac Decompensation

IV

Initiate at a slow rate (e.g., 0.5–1 mcg/kg per minute) and titrate to desired response.^{113 114}

Usually, 2–20 mcg/kg per minute is needed to increase cardiac output.^{113 114}

In rare cases, infusion rates up to 40 mcg/kg per minute have been required.^{113 114}

Duration of therapy is based on patient response; clinical experience mostly short-term (e.g., not more than several hours).^{113 114}

ACLS

IV

For postresuscitation stabilization^†, usual dosage range is 5–10 mcg/kg per minute.⁴⁰⁴

Special Populations

Hepatic Impairment

No specific hepatic dosage recommendations.^{113 114}

Renal Impairment

No specific renal dosage recommendations.^{113 114}

Geriatric Patients

Initiate therapy at lower end of usual range because of age-related decreases in hepatic, renal, and/or cardiac function and concomitant disease and drug therapy.¹¹⁴

Cautions for DOBUTamine

Contraindications

• Idiopathic hypertrophic subaortic stenosis.^{113 114}

• Known hypersensitivity to dobutamine hydrochloride or any ingredient in the formulation.^{113 114}

Warnings/Precautions

Warnings

Cardiovascular Effects

Marked increases in heart rate and BP (especially systolic pressure) can occur.^{113 114} Heart rate increase of ≥30 beats per minute or an increase in systolic BP of ≥50 mm Hg reported.^{113 114}

Cardiovascular effects are usually dose related, and dosage should be reduced or the infusion temporarily discontinued if such effects occur.^{113 114 b}

Patients with preexisting hypertension are at increased risk of an exaggerated pressor response.^{113 114}

Patients with atrial fibrillation should be digitalized because of the risk of developing a rapid ventricular response.^{113 114}

Ectopic Activity

Can precipitate or exacerbate ventricular ectopic activity; rarely, causes ventricular tachycardia.^{113 114}

Sensitivity Reactions

Hypersensitivity Reactions

Hypersensitivity, including skin rash, fever, eosinophilia, and bronchospasm, have been reported occasionally.^{113 114}

Sulfites

Some formulations contain sulfites, which may cause allergic-type reactions (including anaphylaxis and life-threatening or less severe asthmatic episodes) in certain susceptible individuals.^{113 114}

General Precautions

Hypovolemia

Hypovolemia should be corrected with an appropriate plasma volume expander before initiating dobutamine.^{113 114}

MI

Clinical experience insufficient to rule out possibility of intensified or extended myocardial ischemia.^{113 114}

Cardiac Mechanical Obstruction

No benefit may be apparent in the presence of marked mechanical obstruction (e.g., severe valvular aortic stenosis).^{113 114}

Monitoring Parameters

Monitor ECG, BP and, when possible, cardiac output and pulmonary wedge pressure.^{113 114}

May produce slight reductions in serum potassium concentrations and hypokalemia may occur rarely; monitor serum potassium concentrations.^{113 114}

Specific Populations

Pregnancy

Category B.^{113 114}

Lactation

Not known whether dobutamine is distributed into human milk.¹¹³ Caution if used in nursing women.¹¹³

Pediatric Use

Some manufacturers state that safety and efficacy have not been evaluated in pediatric patients.¹¹³ Others state that dobutamine increases cardiac output and systemic pressure in pediatric patients of all age groups.¹¹⁴

In premature neonates, dobutamine may be less effective than dopamine in increasing systemic BP without causing undue tachycardia and has not been shown to provide any additional benefit when administered to such infants who are already receiving optimal dopamine therapy.¹¹⁴

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults; some clinical experience suggest that geriatric patients may have higher incidence of substantial hypotension.¹¹⁴

Use with caution since renal, hepatic, and cardiovascular dysfunction and concomitant disease or other drug therapy are more common in this age group.¹¹⁴

Common Adverse Effects

Ectopic heartbeats, increased heart rate, elevations in BP, hypotension, phlebitis, local inflammatory changes.^{113 114}

Drug Interactions

No evidence of interactions in clinical studies when used with atropine, cardiac glycosides (digoxin), furosemide, heparin, lidocaine, morphine, nitroglycerin, isosorbide dinitrate, potassium chloride, folic acid, protamine, acetaminophen, or spironolactone.^{113 114}

Specific Drugs

DOBUTamine Pharmacokinetics

Absorption

Onset

Onset occurs within 2 minutes after initiation of IV infusion; peaks within 10 minutes.^b

Duration

Effects cease shortly after infusion discontinuance.^b

Distribution

Extent

Not known if dobutamine crosses the placenta^b or is distributed into milk.¹¹³

Elimination

Metabolism

Metabolized in the liver and other tissues by catechol-O-methyltransferase (COMT) to an inactive compound, 3-O-methyldobutamine, and by conjugation with glucuronic acid.^b

Elimination Route

Conjugates of dobutamine and 3-O-methyldobutamine excreted mainly in urine and to a minor extent in feces.^b

Half-life

About 2 minutes.^b

Stability

Storage

Parenteral

Pink discoloration indicates slight oxidation of the drug; however, there is no important loss of potency if administered within the recommended time period.¹¹⁴

Concentrate for Injection for IV Infusion

20–25°C.¹¹³ Do not freeze.¹¹³

Following dilution, use within 24 hours.¹¹³

Injection in 5% Dextrose for IV Infusion

20–25°C; may be exposed briefly to temperatures up to 40°C.^{114 115} Do not freeze or expose to excessive heat.^{114 115}

Actions

• The main effect of therapeutic doses is cardiac stimulation.^b

• Principally a selective, direct stimulatory effect on β₁-adrenergic receptors, but the mechanisms of action are complex.^{100 101}

• In therapeutic doses, also mild β₂- and α₁-adrenergic receptor agonist effects.¹⁰⁰

• β₁-Adrenergic effects exert a potent positive inotropic effect, resulting in increased myocardial contractility and cardiac output.^b

  Increased left ventricular filling pressure decreases in patients with congestive heart failure.^b

• Therapeutic doses cause decreased peripheral resistance; however, systolic BP and pulse pressure may remain unchanged or be increased because of augmented cardiac output.^b

• Usual doses do not substantially change heart rate.^b

• Coronary blood flow and myocardial oxygen consumption are usually increased because of increased myocardial contractility.^b

• May facilitate AV conduction and shorten or cause no important change in intraventricular conduction.^b

• Pulmonary vascular resistance may decrease if it is elevated initially and mean pulmonary artery pressure may decrease or remain unchanged.^b

• Unlike dopamine, dobutamine does not seem to affect dopaminergic receptors and causes no renal or mesenteric vasodilation; however, urine flow may increase because of increased cardiac output.^b

Advice to Patients

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.^{113 114}

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.^{113 114}

• Importance of informing patients of other important precautionary information.^{113 114} (See Cautions.)

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer’s labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

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

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

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