(ep i NEF rin)
- Racemic Epinephrine
- Racepinephrine HCL
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Nebulization Solution, Inhalation:
Asthmanefrin Refill: 2.25% (1 ea) [contains edetate disodium]
Asthmanefrin Starter Kit: 2.25% (1 ea [DSC]) [contains edetate disodium]
Micronefrin: 2.25% (15 mL [DSC])
Nebulization Solution, Inhalation [preservative free]:
S2: 2.25% (1 ea) [sulfite free; contains edetate disodium]
Brand Names: U.S.
- Asthmanefrin Refill [OTC]
- Asthmanefrin Starter Kit [OTC] [DSC]
- Micronefrin [OTC] [DSC]
- S2 [OTC]
- Alpha/Beta Agonist
Stimulates alpha-, beta1-, and beta2-adrenergic receptors resulting in relaxation of smooth muscle of the bronchial tree, cardiac stimulation (increasing myocardial oxygen consumption), and dilation of skeletal muscle vasculature; small doses can cause vasodilation via beta2-vascular receptors; large doses may produce constriction of skeletal and vascular smooth muscle
Does not cross blood-brain barrier
Taken up into the adrenergic neuron and metabolized by monoamine oxidase and catechol-o-methyltransferase; circulating drug hepatically metabolized
Urine (as inactive metabolites, metanephrine, and sulfate and hydroxy derivatives of mandelic acid; small amounts as unchanged drug)
Onset of Action
Bronchodilation: Inhalation: ~1 minute
Use: Labeled Indications
OTC labeling: Treatment of bronchospasm associated with bronchial asthma
Off Label Uses
Based on recommendations from the American Academy of Pediatrics epinephrine may be used for the emergency treatment of croup in pediatric patients [AAP [Hegenbarth 2008]].
Oral inhalation (OTC labeling): Concurrent use or within 2 weeks of MAO inhibitors
Bronchospasm, relief of mild asthma symptoms: Nebulization: Racemic epinephrine (2.25% solution): OTC labeling: Hand-bulb nebulizer: Add 0.5 mL to nebulizer; 1 to 3 inhalations, may repeat dose after at least 3 hours if needed. Do not exceed 12 inhalations in 24 hours.
Refer to adult dosing.
Bronchospasm, relief of mild asthma symptoms: Children ≥4 years and Adolescents: Nebulization: Racemic epinephrine (2.25% solution): OTC labeling: Hand-bulb nebulizer: Add 0.5 mL to nebulizer; 1 to 3 inhalations; may repeat dose after at least 3 hours if needed. Do not exceed 12 inhalations in 24 hours. Note: Not recommended for routine management and treatment of asthma (GINA 2015; NAEPP 2007)
Croup (laryngotracheobronchitis), airway edema (off-label use): Infants, Children, and Adolescents: Nebulization: Note: Typically relief of symptoms occurs within 10 to 30 minutes and lasts 2 to 3 hours; patients should be observed for rapid symptom recurrence and possible repeat treatment.
Racemic epinephrine (2.25% solution): 0.05 to 0.1 mL/kg (maximum dose: 0.5 mL) diluted in 2 mL NS, may repeat dose every 20 minutes; others have reported use of 0.5 mL as a fixed dose for all patients; use lower end of dosing range for younger infants (Hegenbarth 2008; Rosekrans 1998; Rotta 2003; Wright 2002)
L-epinephrine (using parenteral 1 mg/mL solution): 0.5 mL/kg of 1 mg/mL solution (maximum dose: 5 mL) diluted in NS, may repeat dose every 20 minutes; Note: Racemic epinephrine 10 mg = 5 mg L-epinephrine (Hegenbarth 2008)
Dosing: Renal Impairment
There are no dosage adjustment provided in manufacturer's labeling.
Dosing: Hepatic Impairment
There are no dosage adjustment provided in manufacturer's labeling.
Oral inhalation: S2, Asthmanefrin: If using jet nebulizer, must be diluted with 3 to 5 mL NS. If using handheld rubber bulb nebulizer, dilution is not required.
Oral inhalation: If using jet nebulizer: Administer diluted over ~15 minutes. If using handheld rubber bulb nebulizer, dilution is not required.
S2, Asthmanefrin: Store between 2°C to 20°C (36°F to 68°F). Protect from light.
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
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
Cannabinoid-Containing Products: May enhance the tachycardic effect of Sympathomimetics. Exceptions: Cannabidiol. Monitor therapy
Chloroprocaine: May enhance the hypertensive 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
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
Guanethidine: May enhance the arrhythmogenic effect of Sympathomimetics. Guanethidine may enhance the hypertensive effect of Sympathomimetics. Monitor therapy
Inhalational Anesthetics: May enhance the arrhythmogenic effect of EPINEPHrine (Oral Inhalation). Monitor therapy
Iobenguane I 123: Sympathomimetics may diminish the therapeutic effect of Iobenguane I 123. Avoid combination
Monoamine Oxidase Inhibitors: May enhance the hypertensive effect of EPINEPHrine (Oral Inhalation). Avoid combination
Promethazine: May diminish the therapeutic effect of EPINEPHrine (Oral Inhalation). 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. 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
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
There are no adverse reactions listed in the manufacturer's labeling.
• Cardiovascular disease: Use with caution in patients with cardiovascular diseases (eg, arrhythmias, coronary artery disease, hypertension).
• Seizures: Use with caution in patients with a history seizure disorder
• Thyroid disease: Use with caution in patients with thyroid 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.
• Self medication (OTC use): Prior to self-medication, patients should contact healthcare provider. The product should only be used in persons with a diagnosis of asthma. If symptoms are not relieved in 20 minutes or become worse do not continue to use the product - seek immediate medical assistance. The product should not be used more frequently or at higher doses than recommended unless directed by a health care provider. This product should not be used in patients who have required hospitalization for asthma or if a patient is taking prescription medication for asthma. Use with caution in patients with prostate enlargement or urinary retention. Do not use if you have taken a MAO inhibitor (certain drugs used for depression, Parkinson disease, or other conditions) within 2 weeks.
FEV1, peak flow, and/or other pulmonary function tests; blood pressure, heart rate; CNS stimulation; serum glucose, serum potassium; asthma symptoms
Epinephrine crosses the placenta following injection (Sandler 1964). Uncontrolled asthma is associated with adverse events on pregnancy (increased risk of perinatal mortality, pre-eclampsia, preterm birth, low birth weight infants). The occasional use of inhaled epinephrine when needed for asthma exacerbations is not expected to cause adverse fetal events. However, when treatment of asthma is needed during pregnancy, other agents are preferred (NAEPP 2005).
• 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 dizziness, anxiety, tremors, or insomnia. Have patient report immediately to prescriber signs of severe cerebrovascular disease (change in strength on one side is greater than the other, difficulty speaking or thinking, change in balance, or vision changes), angina, tachycardia, abnormal heartbeat, severe headache, or seizures (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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