Drug class: Selective beta-1-Adrenergic Agonists

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

Introduction

Dopamine, an endogenous catecholamine that is the immediate precursor of norepinephrine, is a sympathomimetic agent with prominent dopaminergic and β₁-adrenergic effects at low to moderate doses and α-adrenergic effects at high doses.^{112 115}

Uses for DOPamine

Shock

Used as adjunctive therapy to correct hemodynamic imbalances (e.g., increase cardiac output and BP) in the treatment of shock.^{100 112 115}

Pressor therapy is not a substitute for replacement of blood, plasma, fluids, and/or electrolytes.^b Correct blood volume depletion as fully as possible before administration.^b

The Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock recommend norepinephrine as the vasopressor of choice in adults with septic shock; although dopamine was used widely in the past, more recent evidence indicates that the drug is associated with a greater risk of adverse effects (e.g., arrhythmias) and possibly also an increased risk of death compared with norepinephrine.^{153 154 155 158 163} In these guidelines, dopamine is considered an alternative to norepinephrine only in highly selected patients with septic shock (e.g., those with low risk of tachyarrhythmias and bradycardia).¹⁵³

Also used to provide vasopressor support in other types of shock (e.g., cardiogenic, hemorrhagic), generally as a temporary measure until underlying cause can be treated.^{152 157 158 159 160 161 162}

Some evidence suggests that dopamine may be associated with increased risk of mortality compared with norepinephrine in patients with cardiogenic shock.^{115 154 161 162} Early revascularization is standard of care in patients with cardiogenic shock; individualize use of vasopressors in this setting.^{161 162}

Some experts state dopamine may be considered for treatment of drug-induced hypovolemic shock when patient is unresponsive to fluid volume expansion and inotropic and/or vasopressor support is required.¹¹²

May increase cardiac output, BP, and urine flow in shock; however, exact effects are dose related and based on patient's clinical status at time of administration.¹¹⁵ In low or intermediate doses, usually does not produce sufficient peripheral vasoconstriction to increase BP.¹¹⁵ If hypotension persists, a more potent vasoconstrictor such as norepinephrine may be required.¹¹⁵

Appears to be most effective when therapy is begun shortly after the signs and symptoms of shock appear and before physiologic parameters such as BP and myocardial function undergo severe deterioration and before urine flow has decreased to <0.3 mL/minute.¹¹⁵

Advanced Cardiovascular Life Support

Used in ACLS^{† [off-label]} for treatment of symptomatic bradycardia in adults, particularly if associated with hypotension; although not a first-line drug, may be considered in patients who are unresponsive to atropine, or as a temporizing measure while awaiting a pacemaker.^{400 401}

Also used during resuscitation for management of patients in cardiac arrest.¹¹² Principal goal of pharmacologic therapy during cardiac arrest is to facilitate the return of spontaneous circulation (ROSC), and epinephrine is the drug of choice for this use.^{400 401} Vasoactive drugs such as dopamine may be used for hemodynamic support following resuscitation.^{403 404}

Acute Renal Failure

Low-dose (“renal dose,” e.g., <5 mcg/kg per minute) therapy does not appear to prevent or ameliorate acute (e.g., oliguric) renal failure in critically ill patients^{100 102 105 106 107 108 112} despite some evidence of increased renal and mesenteric perfusion from selective dopaminergic effects.^{107 109 110} Currently available data do not support any benefit from such therapy, and routine use of low-dose (“renal dose”) dopamine therapy for prevention or amelioration of acute renal failure in critically ill patients not recommended.^{102 105 106 107 108 112 153 156}

In addition, low-dose dopamine infusions are not without risk and may be associated with adverse effects (e.g., suppression of respiratory drive,^{101 102 104 106} increased cardiac output and myocardial oxygen consumption,^{101 102 104 106} arrhythmias,^{101 102 104 106} hypokalemia,^{101 102 104} hypophosphatemia,^{101 102 104} gut ischemia,^{101 102 104} disruption of metabolic and immunologic homeostasis).^{101 102 104 107}

Heart Failure

May be used for inotropic support in patients with refractory heart failure^{† [off-label]}.¹⁶⁵ Because parenteral inotropes 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

Low-dose dopamine infusion has been used in combination with loop diuretics to augment diuresis and improve renal blood flow in patients with acute decompensated heart failure^{† [off-label]}; however, current evidence does not support routine use of dopamine for this purpose.^{115 116 165 166 168 169 170 174}

DOPamine Dosage and Administration

Administration

Administer by IV infusion.^{115 116}

Also has been administered by intraosseous infusion^{† [off-label]} during ACLS.^{401 403}

IV Infusion

Infuse IV into a large vein, preferably the antecubital vein, using an infusion pump or other apparatus to control the rate of flow and avoid inadvertent administration of a bolus dose.^{115 116}

Use less suitable veins (e.g., hand or ankle vein) only when required, but switch to a preferred vein as soon as possible.¹¹⁵

Continuously monitor infusion site for free flow.¹¹⁵

Avoid extravasation.^{115 116} (See Boxed Warning and also see Extravasation under Cautions.)

A controlled-infusion device, preferably a volumetric pump, should be used; do not administer via an ordinary, gravity-controlled IV administration set.^{115 116}

Dopamine in 5% dextrose in flexible containers (e.g., LifeCare) should not be used in series connections.¹¹⁶

Consult manufacturer's labeling for proper methods of administration and other associated precautions.^{115 116}

Dilution

Must dilute the commercially available injection concentrate for IV infusion prior to administration;¹¹⁵ alternatively, may use commercially available prediluted solutions of dopamine hydrochloride in 5% dextrose.¹¹⁶

Individualize concentration according to patient dosage and fluid requirements.^b Consult manufacturer's prescribing information for suggested dilutions.¹¹⁵

Rate of Administration

Avoid bolus administration.¹¹⁵

Rate of IV infusion varies according to individual dose requirements.^{115 116} (See Dosage under Dosage and Administration.)

Standardize 4 Safety

Standardized concentrations for dopamine 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].

Consider limiting to 1 bag size for each recommended concentration (e.g., 250 vs 500 mL); this may reduce errors and also reduce inventory needs.

Dosage

Individualize and carefully adjust dosage to achieve the desired hemodynamic and renal response as indicated by heart rate, BP, urine flow, and, whenever possible, measurement of central venous or pulmonary wedge pressure and cardiac output.^{115 116} Once optimal hemodynamic effects have been achieved, use lowest possible dosage to maintain these effects.^b

When discontinuing therapy, it may be necessary to gradually decrease the dose while expanding blood volume with IV fluids to prevent a recurrence of hypotension.¹¹⁵ Sudden discontinuance can precipitate marked hypotension.^b (See Hypotension under Cautions.) In patients who have been receiving moderate to high doses, some clinicians recommend that the final dosage should not be less than 5 mcg/kg per minute in order to avoid hypotension.^b

Pediatric Patients

Shock

IV

Studies have not been conducted to specifically inform dosage recommendations in pediatric patients; however, clinical experience indicates that dosing in pediatric patients is generally similar to that in adults.^{115 116}

ACLS† [off-label]

IV or Intraosseous†

Usual infusion rate for postresuscitation stabilization is 2–20 mcg/kg per minute.⁴⁰³ Although dosages >5 mcg/kg per minute stimulate the cardiac β-adrenergic receptors, this effect may be reduced in infants.⁴⁰³ Infusion rates >20 mcg/kg per minute may result in excessive vasoconstriction.⁴⁰³

Adults

Shock

IV

Usually, initiate at a rate of 2–5 mcg/kg per minute;¹¹⁵ may increase by 1–4 mcg/kg per minute at 10- to 30-minute intervals until the optimal response is attained.^b In more severely ill patients, initiate at 5 mcg/kg per minute, and gradually increase in increments of 5–10 mcg/kg per minute up to 20–50 mcg/kg per minute as needed.¹¹⁵

In patients with occlusive vascular disease, some experts recommend initial rate of ≤1 mcg/kg per minute because of risk of local ischemia (e.g., gangrene).⁵⁹ Monitor closely for any signs or symptoms of compromised circulation; if this occurs, decrease rate or discontinue infusion.¹¹⁵

If MAO inhibitors were used within the previous 2–3 weeks, initiate dopamine at no greater than 10% of the usual dose.¹¹⁵ (See MAO Inhibitors under Cautions.)

Titrate dosage to achieve desired hemodynamic effects.¹¹⁵ Most patients can be maintained at <20 mcg/kg per minute; however, infusion rates >50 mcg/kg per minute have been used safely in advanced states of circulatory decompensation.¹¹⁵

ACLS†

IV

Usual initial dosage range for symptomatic bradycardia is 2–10 mcg/kg per minute; titrate according to patient response.⁴⁰¹ Infusion rates >10 mcg/kg per minute are associated with vasoconstrictive effects.⁴⁰¹

For postresuscitation stabilization, dosage of 5–10 mcg/kg per minute has been recommended.⁴⁰⁴

Heart Failure†

IV

Some clinicians recommend initial rate of 0.5–2 mcg/kg per minute in patients with severe, refractory heart failure.^b Usual dosage range is 5–10 mcg/kg per minute.¹⁶⁵

To minimize risk of adverse effects, use lowest possible dosage and evaluate patient regularly for the need for continued inotropic therapy.¹⁶⁵

Special Populations

Hepatic Impairment

No specific dosage recommendations.¹¹⁵

Renal Impairment

No specific dosage recommendations.¹¹⁵

Geriatric Patients

Initial dosage usually should be at the low end of the range.¹¹⁶

Cautions for DOPamine

Contraindications

• Pheochromocytoma.^{115 116}

• Uncorrected tachyarrhythmias or VF.^{115 116}

Warnings/Precautions

Warnings

MAO Inhibitors

Metabolized by MAO; therefore, inhibition of this enzyme prolongs duration of dopamine effects.¹¹⁵ Patients recently (within 2–3 weeks) treated with MAO inhibitors will require substantially reduced dopamine dosage.¹¹⁵ (See Dosage under Dosage and Administration.)

Alkalinizing Substances

Inactivated in alkaline solutions; do not administer with any alkaline diluent solution (e.g., sodium bicarbonate).¹¹⁵

Sensitivity Reactions

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.^{115 116}

General Precautions

Monitoring

Monitor BP and urine flow and, when possible, cardiac output and pulmonary wedge pressure.^{115 116} (See Hypovolemia and also Hypoxia, Hypercapnia, and Acidosis under Cautions.) Decrease rate or temporarily interrupt infusion if excessive vasoconstriction, decreased urine output, increased heart rate, or an arrhythmia occurs and observe the patient closely.^b

Extravasation

Extravasation may cause tissue necrosis and sloughing of surrounding tissues;¹¹⁵ avoid extravasation.¹¹⁵ Infuse IV into a large vein.¹¹⁵ (See Boxed Warning.)

Continuously monitor infusion site for free flow.¹¹⁵

Hypovolemia

Pressor therapy is not a substitute for replacement of blood, plasma, fluids, and/or electrolytes.^b Correct blood volume depletion as fully as possible before dopamine therapy is instituted.^b

May be used in an emergency as an adjunct to fluid replacement or as a temporary supportive measure to maintain coronary and cerebral artery perfusion until volume replacement can be completed, but dopamine must not be used as sole therapy in hypovolemic patients.^b

Monitor central venous pressure or left ventricular filling pressure; in addition, monitor central venous or pulmonary arterial diastolic pressure to avoid overloading the cardiovascular system, diluting serum electrolyte concentrations, and precipitating congestive heart failure or pulmonary edema.^b

Hypoxia, Hypercapnia, and Acidosis

Must be identified and corrected prior to, or concurrently with, dopamine administration.¹¹⁵ Can reduce the effectiveness and/or increase the toxicity of dopamine.¹¹⁵

Vasoconstriction

At high rates of infusion, vasoconstrictive effects of dopamine may cause compromised limb circulation and reversal of renal dilation and natriuresis.¹¹⁵

If a disproportionate increase in diastolic pressure occurs, decrease rate of infusion and observe the patient carefully for further evidence of predominant vasoconstrictor activity, unless such an effect is desired.¹¹⁵

Hypotension

If hypotension occurs, infusion rate should be increased rapidly in order to increase BP.¹¹⁵ If hypotension persists, discontinue dopamine and administer a drug with greater vasoconstricting properties (e.g., norepinephrine).¹¹⁵

Occlusive Vascular Disease

Carefully monitor patients with a history of occlusive vascular disease (e.g., atherosclerosis, arterial embolism, Raynaud’s disease, cold injury, diabetic endarteritis, or Buerger’s disease) for decreased circulation to the extremities indicated by changes in color or temperature of the skin or pain in the extremities.¹¹⁵

Correct by decreasing the rate of infusion or discontinuing dopamine;¹¹⁵ however, these changes occasionally have persisted and progressed after discontinuing the drug.^b

Some clinicians recommend IV administration of 5–10 mg of phentolamine mesylate if discoloration of the extremities occurs.^b

Weigh potential benefits of continuing dopamine against possible risk of necrosis.^b

Ventricular Arrhythmias

Ventricular arrhythmias may occur; monitor patient and reduce dosage if increased number of ectopic beats observed.¹¹⁵

Specific Populations

Pregnancy

Category C.¹¹⁶

No adequate and well-controlled studies in pregnant women; use during pregnancy only when potential benefits justify potential risks to fetus.¹¹⁵

When used in ACLS, may decrease blood flow to uterus; however, the woman must be resuscitated for survival of the fetus.¹¹²

If a vasopressor (e.g., dopamine) is used during labor in conjunction with oxytocic drugs, the vasopressor effect may be potentiated and result in severe hypertension.^b (See Specific Drugs and Laboratory Tests under Interactions.)

Lactation

Not known whether dopamine is distributed into human milk.¹¹⁵ Caution if used in nursing women.¹¹⁵

Pediatric Use

Manufacturer states safety and efficacy of IV dopamine not established in children;¹¹⁵ however, the drug has been used in pediatric patients of all age groups from neonate onward.¹¹⁶

Except for vasoconstrictive effects caused by inadvertent infusion of dopamine into the umbilical artery, adverse effects unique to the pediatric population have not been identified, nor have adverse effects identified in adults been found to be more common in pediatric patients.¹¹⁶

Has been administered at rates as high as 125 mcg/kg per minute in some neonates, but the usual dosage in children has been similar to that in adults on a mcg/kg per minute basis.¹¹⁶

In pediatric patients, dopamine is recommended as an appropriate drug for the treatment of shock that is unresponsive to fluids when systemic vascular resistance is low.⁴⁰³

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults.¹¹⁶

No differences in responses between geriatric and younger patients have been identified.¹¹⁶

Initial usual dosage should be at the low end of the dosage range, and caution should be exercised since renal, hepatic, and cardiovascular dysfunction and concomitant disease or other drug therapy are more common in this age group than in younger adults.¹¹⁶

Common Adverse Effects

Dopamine may cause cardiac conduction abnormalities (e.g., ventricular arrhythmia, atrial fibrillation, widened QRS complex, ectopic heartbeats), tachycardia, angina, palpitation, bradycardia, vasoconstriction, hypotension, hypertension, dyspnea, nausea, vomiting, headache, anxiety, azotemia, piloerection, and gangrene of the extremities.¹¹⁵

Drug Interactions

Specific Drugs and Laboratory Tests

DOPamine Pharmacokinetics

Absorption

Bioavailability

Rapidly metabolized in the GI tract after oral administration.^b

Onset

Within 5 minutes following IV administration.^b

Duration

<10 minutes.^b

Distribution

Extent

Widely distributed but does not cross the blood-brain barrier to a substantial extent.^b

Apparent volume of distribution in neonates ranges from 0.6–4 L/kg.^b

Not known whether dopamine crosses the placenta or is distributed into milk.^b

Elimination

Metabolism

Via the liver, kidneys, and plasma by MAO and catechol-O-methyltransferase (COMT) to the inactive compounds homovanillic acid (HVA) and 3,4-dihydroxyphenylacetic acid.^b

In patients receiving MAO inhibitors, the duration of action of dopamine may be as long as 1 hour.^b

About 25% of a dose of dopamine is metabolized to norepinephrine within the adrenergic nerve terminals.^b

Elimination Route

In urine principally as HVA and its sulfate and glucuronide conjugates and as 3,4-dihydroxyphenylacetic acid; a very small fraction of a dose is excreted unchanged.^b

Half-life

Plasma half-life: About 2 minutes.^b

Special Populations

Neonates: Elimination half-life of 5–11 minutes.^b

Critically ill infants and children: Clearance reportedly ranges from 48–168 mL/kg per minute, with the higher values reported in the younger patients.^b

Stability

Storage

Parenteral

Injection Concentrate for IV Infusion

20–25°C.¹¹⁵

Injection for IV Infusion

20–25°C.¹¹⁶ Do not freeze.¹¹⁶

Actions

• Stimulates adrenergic receptors of the sympathetic nervous system.^{b 112}

• Principally a direct stimulatory effect on β₁-adrenergic receptors.^b

• Acts on specific dopaminergic receptors in the renal, mesenteric, coronary, and intracerebral vascular beds to cause vasodilation.^b

• Little or no effect on β₂-adrenergic receptors.^b

• Main effects depend on the dose administered.^{115 b}

• In low doses (0.5–2 mcg/kg per minute), acts predominantly on dopaminergic receptors causing vasodilation in renal, mesenteric, coronary, and intracerebral vascular beds.^{112 115} Renal vasodilation results in increased renal blood flow, urine flow, and GFR.¹¹⁵

• At intermediate doses (2–10 mcg/kg per minute), stimulates β₁-adrenergic receptors, resulting in improved myocardial contractility; blood flow to peripheral vascular beds may decrease while mesenteric blood flow is increased because of increased cardiac output.¹¹⁵

• At doses of 10–20 mcg/kg per minute, α-adrenergic receptors are stimulated with consequent vasoconstrictor effects and an increase in BP.¹¹⁵

• At doses >20 mcg/kg per minute, α-adrenergic effects become more prominent compromising peripheral circulation and overriding the drug's dopaminergic effects; renal vasoconstriction may decrease previously augmented renal blood flow and urine output.^{115 b}

Advice to Patients

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.^{115 116}

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.^{115 116}

• Importance of informing patients of other important precautionary information.^{115 116} (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.

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