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EPHEDrine (Systemic)

Medically reviewed by Drugs.com. Last updated on Sep 18, 2020.

Pronunciation

(e FED rin)

Index Terms

  • Ephedrine Sulfate

Dosage Forms

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

Solution, Injection, as sulfate:

Generic: 50 mg/mL (1 mL [DSC])

Solution, Injection, as sulfate [preservative free]:

Generic: 50 mg/mL (1 mL)

Solution, Intravenous, as sulfate:

Akovaz: 50 mg/mL (1 mL)

Generic: 50 mg/mL (1 mL)

Solution, Intravenous, as sulfate [preservative free]:

Emerphed: 5 mg/mL (10 mL)

Generic: 50 mg/mL (1 mL)

Tablet, Oral, as sulfate:

Bronkaid Max: 25 mg [dye free]

Brand Names: U.S.

  • Akovaz
  • Bronkaid Max [OTC]
  • Emerphed

Pharmacologic Category

  • Alpha/Beta Agonist

Pharmacology

Releases tissue stores of norepinephrine and thereby produces an alpha- and beta-adrenergic stimulation; longer-acting and less potent than epinephrine

Metabolism

Minimally hepatic; metabolites include p-hydroxyephedrine, p-hydroxynorephedrine, norephedrine.

Excretion

Urine (primarily unchanged; dependent upon urinary pH with greatest excretion in acid pH).

Onset of Action

IM: Within 10 to 20 minutes.

Duration of Action

Pressor/cardiac effects: SubQ: 1 hour.

Half-Life Elimination

Dependent upon urinary pH; Urine pH 5: ~3 hours; Urine pH 6.3: ~6 hours.

Special Populations: Renal Function Impairment

Elimination half-life may be increased.

Use: Labeled Indications

Hypotension, anesthesia-induced: Treatment of anesthesia-induced hypotension.

Off Label Uses

Postoperative nausea and vomiting (prevention)

Data from two randomized controlled studies suggests that patients given post-operative ephedrine had lower postoperative nausea and vomiting (PONV) scores early in the post-operative period without significant hemodynamic changes [Rothenberg 1991], [Hagemann 2000]. Additional trials may be necessary to further define the role of ephedrine in this setting.

Based on the Society of Ambulatory Anesthesia (SAMBA) guidelines for the management of PONV, ephedrine is a recommended pharmacologic antiemetic among other agents for prophylaxis in adults at moderate to severe risk for PONV. Other agents include 5HT3 antagonists (eg, ondansetron, granisetron), steroids (eg, dexamethasone), phenothiazines (eg, promethazine, prochlorperazine), butyrophenones (eg, droperidol, haloperidol), antihistamines (eg, dimenhydrinate), and anticholinergics (eg, transdermal scopolamine) [SAMBA [Gan 2007]].

Contraindications

There are no contraindications listed in the manufacturer’s labeling.

Dosing: Adult

Hypotension, anesthesia-induced: IV: Initial: 5 to 10 mg; repeat as needed to maintain BP (maximum total cumulative dose: 50 mg).

Postoperative nausea and vomiting (prevention) (off-label use): IM: 0.5 mg/kg at the end of surgery (Hagemann 2000; SAMBA [Gan 2007]).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Geriatric

Initiate at lower end of dosing range. Refer to adult dosing.

Dosing: Pediatric

Hypotension, anesthesia-induced: Limited data available: Use the lowest effective dose:

Infants, Children, and Adolescents: Slow IV push: 0.1 to 0.3 mg/kg/dose; usual adult dose: 5 to 25 mg/dose; repeat as needed to maintain blood pressure; maximum dose: 25 mg/dose; maximum total dose: 50 mg (Atchabahian 2013; Taguchi 1996).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Reconstitution

IV: Using a 50 mg/mL vial, withdraw 50 mg and dilute with 9 mL of D5W or NS to final concentration of 5 mg/mL. Premixed vials requiring no further dilution are also available.

IM: For postoperative nausea and vomiting (off-label use), dilute with NS (Hagemann 2000).

Administration

IV: Administer as an IV bolus. Verify formulation prior to administration; available in vials requiring further dilution and also premixed vials (requiring no further dilution).

IM: For postoperative nausea and vomiting (off-label use), administer IM (Hagemann 2000; SAMBA [Gan 2007]).

Storage

Store at 25°C (77°F); excursions are permitted between 15°C and 30°C (59°F and 86°F). Discard any unused portion.

Drug Interactions

Alkalinizing Agents: May increase the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Monitor therapy

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

Atropine (Systemic): May enhance the therapeutic effect of EPHEDrine (Systemic). 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

Bretylium: May enhance the therapeutic effect of Alpha-/Beta-Agonists (Direct-Acting). Monitor therapy

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

Carbonic Anhydrase Inhibitors: May increase the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Monitor therapy

Cardiac Glycosides: EPHEDrine (Systemic) may enhance the arrhythmogenic effect of Cardiac Glycosides. Monitor therapy

Chloroprocaine: May enhance the hypertensive effect of Alpha-/Beta-Agonists. Monitor therapy

CloNIDine: May enhance the therapeutic effect of EPHEDrine (Systemic). Monitor therapy

CloZAPine: May diminish the therapeutic effect of Alpha-/Beta-Agonists. Monitor therapy

Cocaine (Topical): 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

DexAMETHasone (Systemic): EPHEDrine (Systemic) may decrease the serum concentration of DexAMETHasone (Systemic). Monitor therapy

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

Droxidopa: EPHEDrine (Systemic) may enhance the hypertensive effect of Droxidopa. 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

FentaNYL: Alpha-/Beta-Agonists (Indirect-Acting) may decrease the serum concentration of FentaNYL. Specifically, fentanyl nasal spray serum concentrations may decrease and onset of effect may be delayed. Monitor therapy

Guanethidine: May enhance the arrhythmogenic effect of Sympathomimetics. Guanethidine may enhance the hypertensive effect of Sympathomimetics. Monitor therapy

Hyaluronidase: May enhance the vasoconstricting effect of Alpha-/Beta-Agonists. Management: Avoid the use of hyaluronidase to enhance dispersion or absorption of alpha-/beta-agonists. Use of hyaluronidase for other purposes in patients receiving alpha-/beta-agonists may be considered as clinically indicated. Consider therapy modification

Inhalational Anesthetics: EPHEDrine (Systemic) may enhance the arrhythmogenic effect of Inhalational Anesthetics. Avoid combination

Iobenguane Radiopharmaceutical Products: Alpha-/Beta-Agonists (Indirect-Acting) may diminish the therapeutic effect of Iobenguane Radiopharmaceutical Products. Management: Discontinue all drugs that may inhibit or interfere with catecholamine transport or uptake for at least 5 biological half-lives before iobenguane administration. Do not administer these drugs until at least 7 days after each iobenguane dose. 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

Monoamine Oxidase Inhibitors: May enhance the hypertensive effect of Alpha-/Beta-Agonists (Indirect-Acting). While linezolid is expected to interact via this mechanism, management recommendations differ from other monoamine oxidase inhibitors. Refer to linezolid specific monographs for details. Exceptions: Linezolid. Avoid combination

Oxytocin: May enhance the hypertensive effect of EPHEDrine (Systemic). Monitor therapy

Ozanimod: May enhance the hypertensive effect of Sympathomimetics. Management: Concomitant use of ozanimod with sympathomimetic agents is not recommended. If combined, monitor patients closely for the development of hypertension, including hypertensive crises. Consider therapy modification

Procarbazine: May enhance the adverse/toxic effect of Sympathomimetics. Management: Consider alternatives to this combination when possible. Procarbazine prescribing information states that this combination should be avoided. Consider therapy modification

Propofol: May enhance the therapeutic effect of EPHEDrine (Systemic). Monitor therapy

QuiNIDine: May diminish the therapeutic effect of EPHEDrine (Systemic). EPHEDrine (Systemic) may diminish the therapeutic effect of QuiNIDine. Monitor therapy

Reserpine: May diminish the therapeutic effect of Alpha-/Beta-Agonists (Indirect-Acting). Monitor therapy

Rocuronium: EPHEDrine (Systemic) may enhance the therapeutic effect of Rocuronium. Monitor therapy

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. Management: If possible, avoid coadministration of direct-acting alpha-/beta-agonists and serotonin/norepinephrine reuptake inhibitors. If coadministered, monitor for increased sympathomimetic effects (eg, increased blood pressure, chest pain, headache). Consider therapy modification

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

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. Management: Avoid, if possible, the use of 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

Urinary Acidifying Agents: May decrease the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Monitor therapy

Test Interactions

Can cause a false-positive amphetamine EMIT assay

Adverse Reactions

Frequency not defined.

Cardiovascular: Angina pectoris, bradycardia, cardiac arrhythmia, hypertension, palpitations, pulse irregularity, tachycardia, ventricular ectopy, visceral vasoconstriction (renal)

Central nervous system: Anxiety, confusion, delirium, dizziness, hallucination, headache, insomnia, intracranial hemorrhage, nervousness, precordial pain, restlessness, tension, vertigo

Dermatologic: Diaphoresis, pallor

Gastrointestinal: Anorexia, nausea, vomiting

Genitourinary: Dysuria, oliguria, urinary retention (males with prostatism)

Neuromuscular & skeletal: Tremor, vesicle sphincter spasm, weakness

Respiratory: Dyspnea

Miscellaneous: Tachyphylaxis

Warnings/Precautions

Concerns related to adverse effects:

• Cardiovascular effects: May cause hypertension if used prophylactically for hypotension (only indicated for treatment of hypotension).

Disease-related concerns:

• Renal impairment: Use with caution in patients with renal impairment; increased elimination half-life may occur. Carefully monitor patients with renal impairment for adverse reactions.

Special populations:

• Elderly: Use with caution in the elderly.

Other warnings/precautions:

• Tolerance: Tachyphylaxis and tolerance may develop with repeated, prolonged, or excessive administration; temporary cessation of therapy restores its effectiveness.

Monitoring Parameters

BP, pulse; monitor patients with renal impairment for adverse reactions.

Pregnancy Considerations

Metabolic acidosis has been reported in neonates following maternal use of ephedrine; monitor.

Untreated maternal hypotension during cesarean delivery is associated with adverse events, including maternal nausea and vomiting, and bradycardia and acidosis in the fetus. Ephedrine injection is used at delivery for the prevention and/or treatment of maternal hypotension associated with spinal anesthesia in women undergoing cesarean delivery (ASA 2016). Serious postpartum hypertension and possibly stroke may occur if administered with oxytocic medications.

Patient Education

What is this drug used for?

Tablets:

• It is used to treat asthma.

Injection:

• It is used to treat low blood pressure.

• It may be given to you for other reasons. Talk with the doctor.

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:

• Dizziness or headache

• Sweating a lot

• Restlessness

• Trouble sleeping

• Feeling nervous and excitable

• Upset stomach or throwing up

• Not hungry

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

• High blood pressure like very bad headache or dizziness, passing out, or change in eyesight

• Weakness on 1 side of the body, trouble speaking or thinking, change in balance, drooping on one side of the face, or blurred eyesight

• Chest pain pain or pressure

• Fast, slow, or abnormal heartbeat

• Trouble passing urine

• Shortness of breath

• Seizures

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a limited summary of general information about the medicine's uses from the patient education leaflet and is not intended to be comprehensive. This limited summary does NOT include all information available about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not intended to provide medical advice, diagnosis or treatment and does not replace information you receive from the healthcare provider. For a more detailed summary of information about the risks and benefits of using this medicine, please speak with your healthcare provider and review the entire patient education leaflet.

Further information

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