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Isoproterenol

Pronunciation

Pronunciation

(eye soe proe TER e nole)

Index Terms

  • Isoprenaline
  • Isoproterenol HCl
  • Isoproterenol Hydrochloride

Dosage Forms

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

Solution, Injection, as hydrochloride:

Isuprel: 0.2 mg/mL (1 mL, 5 mL) [contains disodium edta]

Isuprel: 0.2 mg/mL (1 mL [DSC], 5 mL [DSC]) [contains sodium metabisulfite]

Brand Names: U.S.

  • Isuprel

Pharmacologic Category

  • Beta1- & Beta2-Adrenergic Agonist Agent

Pharmacology

Stimulates beta1- and beta2-receptors resulting in relaxation of bronchial, GI, and uterine smooth muscle, increased heart rate and contractility, vasodilation of peripheral vasculature

Metabolism

Via conjugation in many tissues including hepatic and pulmonary

Excretion

Urine (primarily as sulfate conjugates)

Onset of Action

IV: Immediate

Duration of Action

IV: 10-15 minutes

Half-Life Elimination

2.5-5 minutes

Use: Labeled Indications

Manufacturer’s labeled indications (see "Note"): Mild or transient episodes of heart block that do not require electric shock or pacemaker therapy; serious episodes of heart block and Adams-Stokes attacks (except when caused by ventricular tachycardia or fibrillation); cardiac arrest until electric shock or pacemaker therapy is available; bronchospasm during anesthesia; adjunct to fluid and electrolyte replacement therapy and other drugs and procedures in the treatment of hypovolemic or septic shock and low cardiac output states (eg, decompensated heart failure, cardiogenic shock)

Note: The use of isoproterenol in advanced cardiac life support (ACLS) has largely been supplanted by the use of other adrenergic agents (eg, epinephrine and dopamine). The use of isoproterenol for bronchospasm during anesthesia and cardiogenic, hypovolemic, or septic shock is no longer recommended. See Off-label Use for more appropriate, yet unlabeled, uses.

Use: Unlabeled

Pharmacologic overdrive pacing for refractory torsade de pointes; pharmacologic provocation during tilt table testing for syncope; temporary control of bradycardia in denervated heart transplant patients unresponsive to atropine; ventricular arrhythmias due to AV nodal block; beta-blocker overdose; electrical storm associated with Brugada syndrome

Contraindications

Angina, pre-existing ventricular arrhythmias, tachyarrhythmias; cardiac glycoside intoxication

Dosing: Adult

Note: Patients may exhibit dose-dependent vasodilation due to unopposed beta2-agonism elicited by isoproterenol.

Bradyarrhythmias, AV nodal block, or refractory torsade de pointes: Continuous IV infusion: Usual range: 2-10 mcg/minute; titrate to patient response.

Brugada syndrome with electrical storm (off-label use): IV bolus: Initial: 1-2 mcg, followed by a continuous infusion of 0.15-0.3 mcg/minute for 1 day; may repeat sequence if ventricular tachycardia/fibrillation recurs (Watanabe, 2006; Zipes, 2006).

Tilt table testing for syncope (Benditt, 1996; Brignole, 2004): Continuous IV infusion: Initial: 1 mcg/minute; increase as necessary based on response; maximum dose: 5 mcg/minute. Note: Timing of initiation and dose adjustment during test may be institution-specific.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Note: Patients may exhibit dose-dependent vasodilation due to unopposed beta2-agonism elicited by isoproterenol.

Bradyarrhythmias, AV nodal block, or refractory torsade de pointes: Continuous IV infusion: Usual range: 0.05-2 mcg/kg/minute; titrate to patient response.

Dosing: Renal Impairment

No dosage adjustment provided in manufacturer’s labeling.

Dosing: Hepatic Impairment

No dosage adjustment provided in manufacturer’s labeling.

Administration

IV infusion administration requires the use of an infusion pump.

Compatibility

Stable in dextran 6% in dextrose 5%, dextran 6% in NS, D5LR, D51/4 NS, D2.5W, D51/2NS, D5NS, D5W, D10W, LR, 1/2NS, NS; incompatible with sodium bicarbonate 5% and alkaline solutions.

Y-site administration: Incompatible with aminophylline, pantoprazole.

Compatibility in syringe: Incompatible with pantoprazole

Storage

Store undiluted solution at 20°C to 25°C (68°F to 77°F). Solution should not be used if a color or precipitate is present. Exposure to air, light, or increased temperature may cause a pink to brownish pink color to develop. Stability of parenteral admixture at room temperature (25°C) or at refrigeration (4°C) is 24 hours.

Drug Interactions

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

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

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

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

Highest Risk QTc-Prolonging Agents: QTc-Prolonging Agents (Indeterminate Risk and Risk Modifying) may enhance the QTc-prolonging effect of Highest Risk QTc-Prolonging Agents. Management: Avoid such combinations when possible. Use should be accompanied by close monitoring for evidence of QT prolongation or other alterations of cardiac rhythm. Consider therapy modification

Inhalational Anesthetics: May enhance the arrhythmogenic effect of Isoproterenol. 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

MiFEPRIStone: May enhance the QTc-prolonging effect of QTc-Prolonging Agents (Indeterminate Risk and Risk Modifying). Management: Though the drugs listed here have uncertain QT-prolonging effects, they all have some possible association with QT prolongation and should generally be avoided when possible. Consider therapy modification

Moderate Risk QTc-Prolonging Agents: QTc-Prolonging Agents (Indeterminate Risk and Risk Modifying) may enhance the QTc-prolonging effect of Moderate Risk QTc-Prolonging Agents. 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

Theophylline Derivatives: Isoproterenol may decrease the serum concentration of Theophylline Derivatives. Exceptions: Dyphylline. Monitor therapy

Adverse Reactions

Frequency not defined.

Cardiovascular: Adams-Stokes syndrome, angina pectoris, flushing, hypertension, hypotension, pallor, palpitations, paradoxical bradycardia (with tilt table testing), tachyarrhythmia, ventricular arrhythmia, ventricular premature contractions

Central nervous system: Dizziness, headache, nervousness, restlessness, seizure (Adams-Stokes)

Dermatologic: Diaphoresis

Endocrine & metabolic: Hypokalemia, increased serum glucose

Gastrointestinal: Nausea, vomiting

Neuromuscular & skeletal: Tremor, weakness

Ophthalmic: Blurred vision

Respiratory: Dyspnea, pulmonary edema

Warnings/Precautions

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with cardiovascular disease (eg, coronary artery disease); may increase myocardial oxygen demand resulting in ischemia.

• Diabetes: Use with caution in patients with diabetes mellitus; may transiently increase blood glucose levels.

• Distributive shock: Avoid use in patients with distributive shock; may reduce systemic vascular resistance (SVR) further resulting in hemodynamic compromise.

• Hyperthyroidism: Use with caution in patients with hyperthyroidism; may induce thyroid storm in susceptible individuals.

Special populations:

• Elderly: Use with caution in the elderly.

Dosage form specific issues:

• Sulfites: Contains sulfites; may cause allergic reaction in susceptible individuals.

Other warnings/precautions:

• Appropriate use: Use with extreme caution; not currently a treatment of choice. Excessive or prolonged use may result in decreased effectiveness.

Monitoring Parameters

ECG, heart rate, respiratory rate, arterial blood gas, arterial blood pressure, CVP; serum glucose, serum potassium, serum magnesium

Pregnancy Risk Factor

C

Pregnancy Considerations

Animal reproduction studies have not been conducted by the manufacturer. Use of isoproterenol may interfere with uterine contractions at term (Mahon, 1967).

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 anxiety or nausea. Have patient report immediately to prescriber shortness of breath, angina, tachycardia, arrhythmia, severe dizziness, passing out, severe headache, blurred vision, sweating a lot, or tremors (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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