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DOPamine

Pronunciation

Pronunciation

(DOE pa meen)

Index Terms

  • Dopamine HCl
  • Dopamine HCl/D5W
  • Dopamine Hydrochloride
  • Intropin

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous, as hydrochloride:

Generic: 0.8 mg/mL (250 mL, 500 mL); 1.6 mg/mL (250 mL, 500 mL); 3.2 mg/mL (250 mL); 40 mg/mL (5 mL, 10 mL); 80 mg/mL (5 mL); 160 mg/mL (5 mL)

Pharmacologic Category

  • Adrenergic Agonist Agent
  • Inotrope

Pharmacology

Stimulates both adrenergic and dopaminergic receptors, lower doses are mainly dopaminergic stimulating and produce renal and mesenteric vasodilation, higher doses also are both dopaminergic and beta1-adrenergic stimulating and produce cardiac stimulation and renal vasodilation; large doses stimulate alpha-adrenergic receptors

Metabolism

Renal, hepatic, plasma; 75% to inactive metabolites by monoamine oxidase and 25% to norepinephrine (active)

Excretion

Urine (as metabolites)

Clearance: Neonates: Varies and appears to be age related; prolonged clearance with combined hepatic and renal impairment

Onset of Action

Adults: Within 5 minutes

Duration of Action

Adults: <10 minutes

Half-Life Elimination

~2 minutes

Use: Labeled Indications

Adjunct in the treatment of shock (eg, MI, open heart surgery, renal failure, cardiac decompensation) that persists after adequate fluid volume replacement

American College of Cardiology/American Heart Association heart failure (HF) guideline recommendations (ACCF/AHA [Yancy 2013]): To maintain systemic perfusion and preserve end-organ performance in patients with cardiogenic shock; bridge therapy in stage D HF unresponsive to guideline-directed medical therapy and device therapy in patients awaiting heart transplant or mechanical circulatory support; short-term management of hospitalized patients with severe systolic dysfunction presenting with low blood pressure and significantly depressed cardiac output; long-term management (palliative therapy) in select patients with stage D HF unresponsive to guideline-directed medical therapy and device therapy who are not candidates for heart transplant or mechanical circulatory support.

Low-dose dopamine may be considered in combination with diuretic therapy to facilitate diuresis and preserve renal function and renal blood flow in those with acute decompensated HF (ACCF/AHA [Yancy 2013]. Data published after the release of these guidelines confirm prior evidence that the use of low-dose dopamine does not improve renal function or congestive symptoms when used in combination with diuretic therapy in this population (Chen 2013; Triposkiadis 2014).

Use: Unlabeled

Symptomatic bradycardia or heart block unresponsive to atropine or pacing

Contraindications

Hypersensitivity to sulfites (commercial preparation contains sodium bisulfite); pheochromocytoma; uncorrected tachyarrhythmias; ventricular fibrillation

Dosing: Adult

Hemodynamic support: IV infusion:

Manufacturer's labeling: Dosage range: 2 to 20 mcg/kg/minute; titrate to desired response (maximum: 50 mcg/kg/minute; however, doses >20 mcg/kg/minute may not have a beneficial effect on blood pressure and may increase the risk of tachyarrhythmias); infusion may be gradually increased by 5- to 10-mcg/kg/minute increments until optimal response is obtained

ACLS guideline recommendations (to treat hypotension especially if associated with symptomatic bradycardia in the immediate post-cardiac arrest care setting): Initial: 5 to 10 mcg/kg/minute; titrate to effect (AHA [Peberdy 2010])

Note: If dosages >20 to 30 mcg/kg/minute are needed, a more direct-acting vasopressor may be more beneficial (ie, epinephrine, norepinephrine).

Hemodynamic effects of dopamine are dose dependent (however, this is relative and there is overlap of clinical effects between dosing ranges):

Low-dose: 1 to 5 mcg/kg/minute, results in increased renal blood flow and urine output

Intermediate-dose: 5 to 10 mcg/kg/minute, results in increased renal blood flow, heart rate, cardiac contractility, and cardiac output

High-dose: >10 mcg/kg/minute, alpha-adrenergic effects begin to predominate, resulting in vasoconstriction, increased blood pressure, in addition to increased heart rate, cardiac contractility, and cardiac output due to beta-adrenergic effects.

Inotropic support in advanced heart failure: IV infusion: 5 to 15 mcg/kg/minute; lower doses are preferred (ACCF/AHA [Yancy 2013]).

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Hemodynamic support: IV infusion:

Manufacturer's labeling: Dosage range: 2 to 20 mcg/kg/minute, titrate to desired response (maximum: 50 mcg/kg/minute; however, doses >20 mcg/kg/minute may not have a beneficial effect on blood pressure and may increase the risk of tachyarrhythmias). Infusion may be gradually increased by 5- to 10-mcg/kg/minute increments until optimal response is obtained.

Pediatric Advanced Life Support (PALS) guideline recommendation (to maintain cardiac output and for postresuscitation stabilization): IV or I.O.: Dose range: 2 to 20 mcg/kg/minute (AHA [Kleinman 2010])

Hemodynamic effects of dopamine are dose dependent (however, this is relative and there is overlap of clinical effects between dosing ranges):

Low-dose: 1 to 5 mcg/kg/minute, results in increased renal blood flow and urine output

Intermediate-dose: 5 to 10 mcg/kg/minute, results in increased renal blood flow, heart rate, cardiac contractility, and cardiac output

High-dose: >10 mcg/kg/minute, alpha-adrenergic effects begin to predominate, resulting in vasoconstriction, increased blood pressure in addition to increased heart rate, cardiac contractility, and cardiac output due to beta-adrenergic effects.

Administration

Administer as a continuous infusion with the use of an infusion pump. Administer into large vein to prevent the possibility of extravasation (central line administration); monitor continuously for free flow; use infusion device to control rate of flow; administration into an umbilical arterial catheter is not recommended; when discontinuing the infusion, gradually decrease the dose of dopamine (sudden discontinuation may cause hypotension). Vials (concentrated solution) must be diluted prior to use.

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. Initiate phentolamine (or alternative) antidote. Apply dry warm compresses (Hurst 2004).

Phentolamine: Dilute 5-10 mg in 10-15 mL NS and administer into extravasation site as soon as possible after extravasation (AHA [Peberdy 2010])

Alternatives to phentolamine:

Nitroglycerin topical 2% ointment (based on limited case reports in neonates/infants): Apply 4 mm/kg as a thin ribbon to the affected areas; may repeat after 8 hours if needed (Wong 1992) or apply a 1-inch strip on the affected site (Denkler 1989)

Terbutaline (based on limited case reports): Infiltrate extravasation area using a solution of terbutaline 1 mg diluted to 10 mL in NS (large extravasation site; administration volume varied from 3-10 mL) or 1 mg diluted in 1 mL NS (small/distal extravasation site; administration volume varied from 0.5-1 mL) (Stier 1999)

Compatibility

Stable in D5LR, D51/2NS, D5NS, D5W, D10W, LR, mannitol 20%, NS; incompatible with sodium bicarbonate 5%, and alkaline solutions or iron salts.

Y-site administration: Incompatible with acyclovir, amphotericin B cholesteryl sulfate complex, indomethacin, insulin (regular), thiopental.

Compatibility in syringe: Incompatible with pantoprazole.

Storage

Protect from light. Solutions that are darker than slightly yellow should not be used.

Drug Interactions

Alpha1-Blockers: May diminish the vasoconstricting effect of Alpha-/Beta-Agonists. Similarly, Alpha-/Beta-Agonists may antagonize Alpha1-Blocker vasodilation. Monitor therapy

AtoMOXetine: May enhance the hypertensive effect of Sympathomimetics. AtoMOXetine may enhance the tachycardic effect of Sympathomimetics. Monitor therapy

Benzylpenicilloyl Polylysine: Alpha-/Beta-Agonists may diminish the diagnostic effect of Benzylpenicilloyl Polylysine. Management: Consider use of a histamine skin test as a positive control to assess a patient's ability to mount a wheal and flare response. Consider therapy modification

Beta-Blockers: May enhance the vasopressor effect of Alpha-/Beta-Agonists (Direct-Acting). Epinephrine used as a local anesthetic for dental procedures will not likely cause clinically relevant problems. Some beta-adrenoceptor mediated effects of Alpha-/Beta-Agonists (Direct-Acting), including anti-anaphylactic effects of epinephrine, may be diminished by Beta-Blockers. Management: Cardioselective beta-blockers and lower doses of epinephrine may confer a more limited risk. Patients who may require acute subcutaneous epinephrine (e.g., bee sting kits) should probably avoid beta blockers. Consider therapy modification

BuPROPion: May increase the serum concentration of OCT2 Substrates. Monitor therapy

Cannabinoid-Containing Products: May enhance the tachycardic effect of Sympathomimetics. Exceptions: Cannabidiol. Monitor therapy

Cocaine: May enhance the hypertensive effect of Sympathomimetics. Management: Consider alternatives to use of this combination when possible. Monitor closely for substantially increased blood pressure or heart rate and for any evidence of myocardial ischemia with concurrent use. Consider therapy modification

COMT Inhibitors: May decrease the metabolism of COMT Substrates. Monitor therapy

Doxofylline: Sympathomimetics may enhance the adverse/toxic effect of Doxofylline. Monitor therapy

Ergot Derivatives: May enhance the hypertensive effect of Alpha-/Beta-Agonists. Ergot Derivatives may enhance the vasoconstricting effect of Alpha-/Beta-Agonists. Exceptions: Ergoloid Mesylates; Nicergoline. Avoid combination

Hyaluronidase: May enhance the adverse/toxic effect of DOPamine. Management: Avoid the use of hyaluronidase to enhance dispersion or absorption of dopamine. Use of hyaluronidase for other purposes in patients receiving dopamine may be considered as clinically indicated. Consider therapy modification

Inhalational Anesthetics: May enhance the arrhythmogenic effect of DOPamine. Management: Avoid use of dopamine in patients receiving halogenated hydrocarbon anesthetics. If concomitant treatment cannot be avoided, monitor for arrhythmia. Dopamine induced ventricular arrhythmia may be reversible with propranolol based on animal data. Avoid combination

Iobenguane I 123: Sympathomimetics may diminish the therapeutic effect of Iobenguane I 123. Avoid combination

Linezolid: May enhance the hypertensive effect of Sympathomimetics. Management: Reduce initial doses of sympathomimetic agents, and closely monitor for enhanced pressor response, in patients receiving linezolid. Specific dose adjustment recommendations are not presently available. Consider therapy modification

Lurasidone: DOPamine may enhance the hypotensive effect of Lurasidone. Avoid combination

Serotonin/Norepinephrine Reuptake Inhibitors: May enhance the tachycardic effect of Alpha-/Beta-Agonists. Serotonin/Norepinephrine Reuptake Inhibitors may enhance the vasopressor effect of Alpha-/Beta-Agonists. Consider therapy modification

Spironolactone: May diminish the vasoconstricting effect of Alpha-/Beta-Agonists. Monitor therapy

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

Tedizolid: May enhance the hypertensive effect of Sympathomimetics. Tedizolid may enhance the tachycardic effect of Sympathomimetics. Monitor therapy

Tricyclic Antidepressants: May enhance the vasopressor effect of Alpha-/Beta-Agonists (Direct-Acting). Management: Avoid, if possible, the use of direct-acting alpha-/beta-agonists in patients receiving tricyclic antidepressants. If combined, monitor for evidence of increased pressor effects and consider reductions in initial dosages of the alpha-/beta-agonist. Consider therapy modification

Adverse Reactions

Frequency not defined.

Cardiovascular: Angina pectoris, atrial fibrillation, bradycardia, ectopic beats, hypertension, hypotension, palpitations, tachycardia, vasoconstriction, ventricular arrhythmia, ventricular conduction, widened QRS complex on ECG

Central nervous system: Anxiety, headache

Dermatologic: Gangrene (high dose), piloerection

Endocrine & metabolic: Increased serum glucose (usually not above normal limits)

Gastrointestinal: Nausea, vomiting

Genitourinary: Azotemia

Ophthalmic: Increased intraocular pressure, mydriasis

Renal: Polyuria

Respiratory: Dyspnea

Miscellaneous: Tissue necrosis

ALERT: U.S. Boxed Warning

Antidote for peripheral ischemia:

To prevent sloughing and necrosis in ischemic areas, the area should be infiltrated as soon as possible with 10 to 15 mL of sodium chloride 0.9% injection containing phentolamine 5 to 10 mg, an adrenergic blocking agent. Pediatric dosage of phentolamine should be 0.1 to 0.2 mg/kg up to a maximum of 10 mg per dose. A syringe with a fine hypodermic needle should be used, and the solution liberally infiltrated throughout the ischemic area. Sympathetic blockade with phentolamine causes immediate and conspicuous local hyperemic changes if the area is infiltrated within 12 hours. Therefore, phentolamine should be given as soon as possible after the extravasation is noted.

Warnings/Precautions

Concerns related to adverse effects:

• Arrhythmias: May cause increases in heart rate, increasing the risk of tachycardia and other tachyarrhythmias including ventricular arrhythmias (Tisdale 1995). In heart transplant candidates, institute appropriate measures to protect patient against risks of sudden cardiac death (Young 2000).

• Extravasation: Vesicant; ensure proper needle or catheter placement prior to and during infusion. Avoid extravasation; infuse into a large vein if possible. Avoid infusion into leg veins. Watch IV site closely. [U.S. Boxed Warning]: If extravasation occurs, infiltrate the area with diluted phentolamine (5 to 10 mg in 10 to 15 mL of saline) with a fine hypodermic needle. Phentolamine should be administered as soon as possible after extravasation is noted to prevent sloughing/necrosis.

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with cardiovascular disease, cardiac arrhythmias and/or occlusive vascular disease.

• Active myocardial ischemia/post–myocardial infarction: Use with caution in patients with active myocardial ischemia or recent myocardial infarction; may increase myocardial oxygen consumption.

• Electrolyte imbalance: Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy to minimize the risk of arrhythmias (ACC/AHA/ESC [Zipes 2006]; Tisdale 1995).

• Shock: The use of dopamine in adult patients with shock (majority of patients had septic shock) demonstrated a higher incidence of adverse events (eg, tachyarrhythmias) (De Backer 2010). Higher 28-day mortality was also seen in patients with septic shock with the use of dopamine as compared to norepinephrine (De Backer 2012; Vasu 2012); the use of norepinephrine may be preferred as the first-line agent in patients with shock. The 2012 Surviving Sepsis Campaign (SSC) guidelines suggest dopamine use as an alternative to norepinephrine only in patients with low risk of tachyarrhythmias and absolute or relative bradycardia (SCCM [Dellinger 2013]).

Concurrent drug therapy issues:

• Monoamine oxidase inhibitors (MAO-I): Use with extreme caution in patients taking MAO inhibitors; prolong hypertension may result from concurrent use.

Dosage form specific issues:

• Sodium metabisulfite: Product may contain sodium metabisulfite.

Other warnings/precautions:

• Appropriate use: Assure adequate circulatory volume to minimize need for vasoconstrictors when used in hemodynamic support. Avoid hypertension; monitor blood pressure closely and adjust infusion rate.

• Long-term therapy: According to the ACCF/AHA 2013 heart failure guidelines, long-term use of intravenous inotropic therapy without a specific indication or for reasons other than palliation is potentially harmful (ACCF/AHA [Yancy 2013]).

Monitoring Parameters

Blood pressure, ECG, heart rate, CVP, RAP, MAP; serum glucose, renal function; urine output; if pulmonary artery catheter is in place, monitor CI, PCWP, SVR, and PVR

Consult individual institutional policies and procedures.

Pregnancy Risk Factor

C

Pregnancy Considerations

Adverse events have been observed in some animal reproduction studies. It is not known if dopamine crosses the placenta. Medications used for the treatment of cardiac arrest in pregnancy are the same as in the non-pregnant woman. Appropriate medications should not be withheld due to concerns of fetal teratogenicity. Dopamine use during the post-resuscitation phase may be considered; however, the effects of vasoactive medications on the fetus should also be considered. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines (Jeejeebhoy [AHA] 2015).

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 nausea or anxiety. Have patient report immediately to prescriber shortness of breath, angina, bradycardia, tachycardia, abnormal heartbeat, severe dizziness, passing out, severe headache, loss of strength and energy, urinary retention, change in amount of urine passed, or severe 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 healthcare 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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