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Dantrolene

Pronunciation

Pronunciation

(DAN troe leen)

Index Terms

  • Dantrolene Sodium

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Capsule, Oral, as sodium:

Dantrium: 25 mg, 50 mg, 100 mg [DSC] [contains fd&c yellow #6 (sunset yellow)]

Generic: 25 mg, 50 mg, 100 mg

Solution Reconstituted, Intravenous, as sodium:

Dantrium: 20 mg (1 ea)

Revonto: 20 mg (1 ea)

Suspension Reconstituted, Intravenous, as sodium:

Ryanodex: 250 mg (1 ea) [contains polysorbate 80]

Brand Names: U.S.

  • Dantrium
  • Revonto
  • Ryanodex

Pharmacologic Category

  • Skeletal Muscle Relaxant

Pharmacology

Acts directly on skeletal muscle by interfering with release of calcium ion from the sarcoplasmic reticulum; prevents or reduces the increase in myoplasmic calcium ion concentration that activates the acute catabolic processes associated with malignant hyperthermia

Absorption

Oral: 70% (Allen 1988)

Distribution

Vd: 36.4 ± 11.7 L

Metabolism

Hepatic; major metabolites are 5-hydroxy dantrolene and an acetylamino metabolite of dantrolene.

Excretion

Feces (45% to 50%); urine (25% as unchanged drug and metabolites)

Half-Life Elimination

Neonates (at birth): ~20 hours (Shime 1988)

Children 2 to 7 years: 10 hours (range: 8.1 to 14.8 hours) (Lerman 1989)

Adults: 4 to 11 hours

Use: Labeled Indications

IV: Management of malignant hyperthermia (MH); prevention of MH in susceptible individuals (preoperative/postoperative administration)

Oral: Treatment of spasticity associated with upper motor neuron disorders (eg, spinal cord injury, stroke, cerebral palsy, or multiple sclerosis); management of MH; prevention of MH in susceptible individuals (preoperative/postoperative administration)

Note: Dantrolene prophylaxis is not recommended for most MH-susceptible patients, provided nontriggering anesthetics are used and an adequate supply of dantrolene is available.

Use: Unlabeled

Neuroleptic malignant syndrome (NMS)

Contraindications

IV: There are no contraindications listed within the manufacturer's labeling.

Oral: Active hepatic disease; should not be used when spasticity is used to maintain posture/balance during locomotion or to obtain/maintain increased function

Dosing: Adult

Spasticity: Oral:

Note: Dose should be titrated and individualized for maximum effect; use the lowest dose compatible with optimal response. Some patients may not respond until a higher daily dosage is achieved; each dose level should be maintained for 7 days to determine patient response. If no further benefit observed with the higher dose level, then decrease dosage to previous dose level. Because of the potential for hepatotoxicity, stop therapy if benefits are not evident within 45 days.

Initial: 25 mg once daily for 7 days; increase to 25 mg 3 times daily for 7 days, increase to 50 mg 3 times daily for 7 days, and then increase to 100 mg 3 times daily; some patients may require 100 mg 4 times daily; maximum dose: 400 mg daily

Malignant hyperthermia (MH):

Preoperative prophylaxis: Note: Dantrolene prophylaxis is not recommended for most MH-susceptible patients, provided nontriggering anesthetics are used and an adequate supply of dantrolene is available.

Oral: 4 to 8 mg/kg/day in 3 to 4 divided doses, begin 1 to 2 days prior to surgery with last dose 3 to 4 hours prior to surgery

IV: 2.5 mg/kg ~11/4 hours prior to anesthesia and infused over at least 1 minute (Ryanodex) or 1 hour (Dantrium, Revonto) with additional doses as needed and individualized

Crisis: IV: 2.5 mg/kg (MHAUS recommendation, available at www.mhaus.org); continuously repeat dose until symptoms subside or a cumulative dose of 10 mg/kg is reached (rarely, some patients may require up to 30 mg/kg for initial treatment). Note: Manufacturer's labeling suggests an initial minimum dose of 1 mg/kg.

24-hour MH Hotline (for emergencies only):

United States: 1-800-644-9737

Outside the U.S.: 00-1-209-417-3722

Postcrisis follow-up:

MHAUS protocol suggestion: 1 mg/kg every 4 to 6 hours (route not specified) or a continuous IV infusion of 0.25 mg/kg/hour for at least 24 hours; further doses may be indicated

Manufacturer's labeling: Oral: 4 to 8 mg/kg/day in 4 divided doses for 1 to 3 days; IV dantrolene may be used to prevent or attenuate recurrence of MH signs when oral therapy is not practical; individualize dosage beginning with 1 mg/kg or more as the clinical situation dictates

Neuroleptic malignant syndrome (off-label use): IV: 1 to 2.5 mg/kg, may repeat dose up to maximum cumulative dose of 10 mg/kg/day, then switch to oral dosage (Strawn, 2007; Susman, 2001)

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Spasticity: Oral:

Note: Dose should be titrated and individualized for maximum effect; use the lowest dose compatible with optimal response. Some patients may not respond until a higher daily dosage is achieved; each dose level should be maintained for 7 days to determine patient response. If no further benefit observed with the higher dose level, then decrease dosage to previous dose level. Because of the potential for hepatotoxicity, stop therapy if benefits are not evident within 45 days.

Initial: 0.5 mg/kg/dose once daily for 7 days; increase to 0.5 mg/kg/dose 3 times daily for 7 days, increase to 1 mg/kg/dose 3 times daily for 7 days, and then increase to 2 mg/kg/dose 3 times daily; some patients may require 2 mg/kg/dose 4 times daily; maximum dose: 400 mg daily

Malignant hyperthermia (MH): Refer to adult dosing.

Dosing: Renal Impairment

There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Hepatic Impairment

There are no dosage adjustments provided in the manufacturer’s labeling; use of oral dantrolene in patients with active liver disease (eg, hepatitis and cirrhosis) is contraindicated.

Reconstitution

Injection, powder for reconstitution:

Dantrium, Revonto: Reconstitute vial by adding 60 mL of sterile water for injection only (not bacteriostatic water for injection); avoid glass bottles for IV infusion due to potential for precipitate formation.

Ryanodex: Reconstitute vial by adding 5 mL of sterile water for injection only (not bacteriostatic water for injection); shake well (suspension is an orange color). Do not dilute or transfer the suspension to another container to infuse the product.

Extemporaneously Prepared

A 5 mg/mL oral suspension may be made with dantrolene capsules, a citric acid solution, and either simple syrup or syrup BP (containing 0.15% w/v methylhydroxybenzoate). Add the contents of five 100 mg dantrolene capsules to a citric acid solution (150 mg citric acid powder in 10 mL water); mix while adding the chosen vehicle in incremental proportions to almost 100 mL. Transfer to a calibrated bottle and add quantity of vehicle sufficient to make 100 mL. Label "shake well" and "refrigerate". Simple syrup suspension is stable for 2 days refrigerated; syrup BP suspension is stable for 30 days refrigerated.

Nahata MC, Pai VB, and Hipple TF, Pediatric Drug Formulations, 5th ed, Cincinnati, OH: Harvey Whitney Books Co, 2004.

Administration

IV: Therapeutic or emergency dose can be administered with rapid continuous IV push. Follow-up doses should be administered over at least 1 minute (Ryanodex) or 1 hour (Dantrium, Revonto).

Vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation.

Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.

Compatibility

Incompatible with D5W, NS, and other acidic solutions

Storage

Capsules: Store at 20°C to 25°C (68°F to 77°F).

Injection, powder for reconstitution: Protect from light. Use reconstituted solution within 6 hours of preparation.

Dantrium: Store unreconstituted vials and reconstituted solutions at 15°C to 30°C (59°F to 86°F).

Revonto: Store unreconstituted vials and reconstituted solutions at 20°C to 25°C (68°F to 77°F).

Ryanodex: Store unreconstituted vials at 20°C to 25°C (68°F to 77°F); excursions are permitted between 15°C and 30°C (59°F and 86°F). Store reconstituted solutions at 20°C to 25°C (68°F to 77°F).

Drug Interactions

Alcohol (Ethyl): CNS Depressants may enhance the CNS depressant effect of Alcohol (Ethyl). Monitor therapy

Analgesics (Opioid): CNS Depressants may enhance the CNS depressant effect of Analgesics (Opioid). Management: Avoid concomitant use of opioid analgesics and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Consider therapy modification

Azelastine (Nasal): CNS Depressants may enhance the CNS depressant effect of Azelastine (Nasal). Avoid combination

Blonanserin: CNS Depressants may enhance the CNS depressant effect of Blonanserin. Consider therapy modification

Bosentan: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

Brimonidine (Topical): May enhance the CNS depressant effect of CNS Depressants. Monitor therapy

Buprenorphine: CNS Depressants may enhance the CNS depressant effect of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine patches (Butrans brand) at 5 mcg/hr in adults when used with other CNS depressants. Consider therapy modification

Calcium Channel Blockers (Nondihydropyridine): Dantrolene may enhance the hyperkalemic effect of Calcium Channel Blockers (Nondihydropyridine). Dantrolene may enhance the negative inotropic effect of Calcium Channel Blockers (Nondihydropyridine). Management: This interaction has only been described with intravenous dantrolene administration. Avoid combination

Cannabis: May enhance the CNS depressant effect of CNS Depressants. Monitor therapy

Chlorphenesin Carbamate: May enhance the adverse/toxic effect of CNS Depressants. Monitor therapy

CNS Depressants: May enhance the adverse/toxic effect of other CNS Depressants. Monitor therapy

CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

CYP3A4 Inducers (Strong): May increase the metabolism of CYP3A4 Substrates. Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification

Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates. Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Consider therapy modification

Deferasirox: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

Dexketoprofen: May enhance the adverse/toxic effect of Dantrolene. Monitor therapy

Dimethindene (Systemic): May enhance the CNS depressant effect of CNS Depressants. Monitor therapy

Doxylamine: May enhance the CNS depressant effect of CNS Depressants. Management: The manufacturer of Diclegis (doxylamine/pyridoxine), intended for use in pregnancy, specifically states that use with other CNS depressants is not recommended. Monitor therapy

Dronabinol: May enhance the CNS depressant effect of CNS Depressants. Monitor therapy

Droperidol: May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (e.g., opioids, barbiturates) with concomitant use. Consider therapy modification

Enzalutamide: May decrease the serum concentration of CYP3A4 Substrates. Management: Concurrent use of enzalutamide with CYP3A4 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP3A4 substrate should be performed with caution and close monitoring. Consider therapy modification

Estrogen Derivatives: May enhance the hepatotoxic effect of Dantrolene. Monitor therapy

Flunitrazepam: CNS Depressants may enhance the CNS depressant effect of Flunitrazepam. Consider therapy modification

HYDROcodone: CNS Depressants may enhance the CNS depressant effect of HYDROcodone. Management: Avoid concomitant use of hydrocodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Consider therapy modification

HydrOXYzine: May enhance the CNS depressant effect of CNS Depressants. Monitor therapy

Kava Kava: May enhance the adverse/toxic effect of CNS Depressants. Monitor therapy

Lacidipine: May enhance the adverse/toxic effect of Dantrolene. Monitor therapy

Lofexidine: May enhance the CNS depressant effect of CNS Depressants. Monitor therapy

Magnesium Sulfate: May enhance the CNS depressant effect of CNS Depressants. Monitor therapy

Methotrimeprazine: May enhance the CNS depressant effect of CNS Depressants. CNS Depressants may enhance the CNS depressant effect of Methotrimeprazine. Management: Reduce adult dose of CNS depressant agents by 50% with initiation of concomitant methotrimeprazine therapy. Further CNS depressant dosage adjustments should be initiated only after clinically effective methotrimeprazine dose is established. Consider therapy modification

MetyroSINE: CNS Depressants may enhance the sedative effect of MetyroSINE. Monitor therapy

Minocycline: May enhance the CNS depressant effect of CNS Depressants. Monitor therapy

Mirtazapine: CNS Depressants may enhance the CNS depressant effect of Mirtazapine. Monitor therapy

Mitotane: May decrease the serum concentration of CYP3A4 Substrates. Management: Doses of CYP3A4 substrates may need to be adjusted substantially when used in patients being treated with mitotane. Consider therapy modification

Nabilone: May enhance the CNS depressant effect of CNS Depressants. Monitor therapy

Orphenadrine: CNS Depressants may enhance the CNS depressant effect of Orphenadrine. Avoid combination

OxyCODONE: CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Consider therapy modification

Paraldehyde: CNS Depressants may enhance the CNS depressant effect of Paraldehyde. Avoid combination

Perampanel: May enhance the CNS depressant effect of CNS Depressants. Management: Patients taking perampanel with any other drug that has CNS depressant activities should avoid complex and high-risk activities, particularly those such as driving that require alertness and coordination, until they have experience using the combination. Consider therapy modification

Piribedil [INT]: CNS Depressants may enhance the CNS depressant effect of Piribedil [INT]. Monitor therapy

Pramipexole: CNS Depressants may enhance the sedative effect of Pramipexole. Monitor therapy

ROPINIRole: CNS Depressants may enhance the sedative effect of ROPINIRole. Monitor therapy

Rotigotine: CNS Depressants may enhance the sedative effect of Rotigotine. Monitor therapy

Rufinamide: May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced. Monitor therapy

Selective Serotonin Reuptake Inhibitors: CNS Depressants may enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced. Monitor therapy

Siltuximab: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

Sodium Oxybate: May enhance the CNS depressant effect of CNS Depressants. Management: Consider alternatives to combined use. When combined use is needed, consider minimizing doses of one or more drugs. Use of sodium oxybate with alcohol or sedative hypnotics is contraindicated. Consider therapy modification

St John's Wort: May decrease the serum concentration of CYP3A4 Substrates. Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification

Suvorexant: CNS Depressants may enhance the CNS depressant effect of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended. Consider therapy modification

Tapentadol: May enhance the CNS depressant effect of CNS Depressants. Management: Avoid concomitant use of tapentadol and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Consider therapy modification

Tetrahydrocannabinol: May enhance the CNS depressant effect of CNS Depressants. Monitor therapy

Thalidomide: CNS Depressants may enhance the CNS depressant effect of Thalidomide. Avoid combination

Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

Trimeprazine: May enhance the CNS depressant effect of CNS Depressants. Monitor therapy

Vecuronium: Dantrolene may enhance the neuromuscular-blocking effect of Vecuronium. Monitor therapy

Zolpidem: CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. Consider therapy modification

Adverse Reactions

Frequency not always defined.

Cardiovascular: Flushing (intravenous: 27%), atrioventricular block (intravenous: 3%), tachycardia (3%), cardiac failure, phlebitis, variable blood pressure

Central nervous system: Drowsiness (17%; drowsiness may persist for 48 hours post dose), voice disorder (intravenous: 13%), feeling abnormal (intravenous: 10%), dizziness (3%), headache (3%), myasthenia (3%), chills, choking sensation, confusion, depression, fatigue, insomnia, malaise, nervousness, seizure, speech disturbance

Dermatologic: Acneiform eruption (capsules), diaphoresis, eczematous rash, erythema (intravenous), hair disease (abnormal growth), pruritus, urticaria

Gastrointestinal: Dysphagia (10%; use caution at meal time on day of administration as swallowing may be difficult), nausea (10%), vomiting (3%), abdominal cramps, anorexia, constipation, diarrhea, dysgeusia, gastric irritation, gastrointestinal hemorrhage, sialorrhea

Genitourinary: Crystalluria, difficulty in micturition, erectile dysfunction, hematuria, nocturia, urinary frequency, urinary incontinence, urinary retention

Hematologic & oncologic: Anemia, aplastic anemia, leukopenia, lymphocytic lymphoma, thrombocytopenia

Hepatic: Hepatitis

Hypersensitivity: Anaphylaxis

Local: Injection site reaction (intravenous: 3%; pain, erythema, swelling), local tissue necrosis (with extravasation due to high product pH)

Neuromuscular & skeletal: Limb pain (intravenous: 3%), back pain, myalgia

Ophthalmic: Blurred vision (intravenous: 3%), diplopia, epiphora, visual disturbance

Respiratory: Dyspnea (intravenous), pleural effusion (with pericarditis), pulmonary edema (rare), respiratory depression

Miscellaneous: Fever

<1% (Limited to important or life-threatening): Decrease in forced vital capacity (intravenous), dyspnea (intravenous), hepatic disease, hepatotoxicity (oral), increased liver enzymes (oral), respiratory muscle failure (intravenous)

ALERT: U.S. Boxed Warning

Hepatotoxicity (capsule):

Dantrolene has a potential for hepatotoxicity; do not use in conditions other than those recommended. Symptomatic hepatitis (fatal and nonfatal) has been reported at various dose levels of the drug. The incidence reported in patients taking dosages of up to 400 mg/day is much lower than in those taking dosages of 800 mg or more per day. Even sporadic short courses of these higher dose levels within a treatment regimen markedly increased the risk of serious hepatic injury. Liver dysfunction as evidenced by blood chemical abnormalities alone (liver enzyme elevations) has been observed in patients exposed to dantrolene for varying periods of time. Overt hepatitis has occurred at varying intervals after initiation of therapy, but has been most frequently observed between the third and twelfth month of therapy. The risk of hepatic injury appears to be greater in women, patients older than 35 years, and patients taking other medication(s). Use dantrolene only in conjunction with appropriate monitoring of hepatic function, including frequent determination of AST or ALT. If no observable benefit is derived from dantrolene after a total of 45 days, discontinue therapy. Prescribe the lowest possible effective dose for the individual patient.

Warnings/Precautions

Concerns related to adverse effects:

• CNS effects: Lightheadedness, dizziness, somnolence, and vertigo may occur and may persist for 48-hours post-dose; patients must be cautioned about performing tasks which require mental alertness (eg, operating machinery or driving).

• Hepatotoxicity: [U.S. Boxed Warning]: Oral: Has potential for hepatotoxicity. Higher doses (ie, ≥800 mg/day), even sporadic short courses, may increase the risk of severe hepatic injury although hepatic injury may occur at doses <400 mg/day. Overt hepatitis has been most frequently observed between the third and twelfth month of therapy. Hepatic injury appears to be greater in females, in patients >35 years of age, and in those taking concurrent medications. A higher incidence of fatal hepatic events have been reported in the elderly, although concurrent disease states and concurrent use of hepatotoxic drugs may have contributed. Idiosyncratic and hypersensitivity reactions (sometimes fatal) of the liver have also occurred. Monitor hepatic function at baseline and as clinically indicated during treatment. Discontinue therapy if abnormal liver function tests occur or benefits are not observed within 45 days when utilized for chronic spasticity.

• Muscle weakness: Loss of grip strength, weakness in the legs, dyspnea, respiratory muscle weakness, dysphagia, and decreased inspiratory capacity has occurred with IV dantrolene. Patients should not ambulate without assistance until they have normal strength and balance. Monitor patients for the adequacy of ventilation and for difficulty swallowing/choking.

• Photosensitivity: Oral therapy may cause photosensitivity; discontinue if skin erythema occurs. Use skin protection and avoid prolonged exposure to sunlight; do not use tanning equipment.

Disease-related concerns:

• Cardiovascular disease: Use oral therapy with caution in patients with severely impaired cardiac function due to myocardial disease.

• Hepatic disease: Use oral therapy with caution in patients with history of liver disease or dysfunction.

• Respiratory disease: Use oral therapy with caution in patients with impaired pulmonary function (particularly in obstructive pulmonary disease).

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Dosage form specific issues:

• Extravasation: Alkaline solution; may cause tissue necrosis if extravasated (vesicant); ensure proper needle or catheter placement prior to and during infusion; avoid extravasation.

• Mannitol: Injection may contain mannitol.

• Polysorbate 80: Some dosage forms may contain polysorbate 80 (also known as Tweens). Hypersensitivity reactions, usually a delayed reaction, have been reported following exposure to pharmaceutical products containing polysorbate 80 in certain individuals (Isaksson, 2002; Lucente 2000; Shelley, 1995). Thrombocytopenia, ascites, pulmonary deterioration, and renal and hepatic failure have been reported in premature neonates after receiving parenteral products containing polysorbate 80 (Alade, 1986; CDC, 1984). See manufacturer’s labeling.

Other warnings/precautions:

• Appropriate use: IV dantrolene is not the only therapeutic approach for management of malignant hyperthermia. Supportive measures, including discontinuing trigger agents (eg, anesthetic agents), administering oxygen, utilizing cooling methods, and monitoring blood gases, urinary output, urine color, and electrolytes, must also be utilized and individualized. Administer diuretics to prevent late kidney injury due to myoglobinuria.

Monitoring Parameters

Motor performance should be monitored for therapeutic outcomes; nausea, vomiting, and liver function tests (baseline and at appropriate intervals thereafter) should be monitored for potential hepatotoxicity; intravenous administration requires cardiac, blood pressure, and respiratory monitoring.

Malignant hyperthermia: During and post-acute phase: Per MHAUS protocol, patient should be observed in an ICU for at least 24 hours since recrudescence may occur; monitor for arrhythmias; monitor vital signs (including core temperature), electrolytes, ABG, CK, end tidal CO2 (EtCO2)/capnography, urine output, urine myoglobin

Pregnancy Risk Factor

C

Pregnancy Considerations

Adverse events have been observed in animal reproduction studies. Dantrolene crosses the human placenta. Cord blood concentrations are similar to those in the maternal plasma at term. and dantrolene can be detected in the newborn serum at delivery. Adverse events were not observed in the newborn following maternal doses of 100 mg/day administered orally prior to delivery (Shime, 1988). Uterine atony has been reported following dantrolene injection after delivery; however, this may be due in part to the mannitol contained in the IV preparation (Shin, 1995; Weingarten, 1987). Prophylactic use of dantrolene is not routinely recommended in pregnant women susceptible to MH prior to obstetric surgery, if use is needed, close monitoring of the mother and newborn is recommended (Krause, 2004; Norman, 1995).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience fatigue, flushing, nausea, vomiting, or change in voice. Have patient report immediately to prescriber signs of liver problems (dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or jaundice), signs of infection; loss of strength and energy; shortness of breath; excessive weight gain; swelling of arms or legs; angina; tachycardia; hematuria; black, tarry, or bloody stools; vomiting blood; confusion; depression; severe abdominal pain; urinary retention; change in amount of urine passed; seizures; severe headache; bruising; bleeding; vision changes; severe dizziness; passing out; severe constipation; severe diarrhea; difficulty swallowing; choking; change in speech; or injection site pain or irritation (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

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