Medically reviewed by Drugs.com. Last updated on May 7, 2019.
(MAN i tole)
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Osmitrol: 5% (1000 mL); 10% (500 mL); 15% (500 mL); 20% (250 mL, 500 mL)
Generic: 20% (250 mL [DSC], 500 mL); 25% (50 mL)
Solution, Intravenous [preservative free]:
Generic: 25% (50 mL [DSC])
Resectisol: 5% (2000 mL)
Brand Names: U.S.
- Diuretic, Osmotic
- Genitourinary Irrigant
Produces an osmotic diuresis by increasing the osmotic pressure of glomerular filtrate, which inhibits tubular reabsorption of water and electrolytes and increases urinary output . Mechanism of action in reduction of intracranial pressure (ICP) is less clear. However, it is thought that mannitol reduces ICP by reducing blood viscosity which transiently increases cerebral blood flow and oxygen transport and constricts pial arterioles. This in turn reduces cerebral blood volume and ICP. Furthermore, mannitol reduces ICP by withdrawing water from the brain parenchyma and excretes water in the urine (Allen 1998; BTF [Carney 2016]).
17 L; remains confined to extracellular space (except in extreme concentrations); does not penetrate the blood-brain barrier (generally, penetration is low)
Minimally hepatic to glycogen
Urine (~80% as unchanged drug)
Onset of Action
Diuresis: 1 to 3 hours; Reduction in intracranial pressure: ~15 to 30 minutes
Duration of Action
Reduction in intracranial pressure: 3 to 6 hours
0.5 to 2.5 hours; 6 to 36 hours in renal failure
Use: Labeled Indications
Injection: Reduction of increased intracranial pressure (associated with cerebral edema and/or brain mass); reduction of increased intraocular pressure
Genitourinary irrigation solution: Irrigation in transurethral prostatic resection or other transurethral surgical procedures
Off Label Uses
Improve renal transplant function
Injection: Hypersensitivity to mannitol or any component of the formulation; severe renal disease (anuria); severe dehydration/hypovolemia; active intracranial bleeding except during craniotomy; progressive heart failure or pulmonary congestion after mannitol administration; severe pulmonary edema or congestion
Genitourinary irrigation solution: Anuria
Intracranial pressure (ICP), cerebral edema, reduction (off-label dosing): IV: 0.25 to 1 g/kg/dose; may repeat every 6 to 8 hours as needed (BTF [Carney 2016]; Grape 2012). Some suggest maintaining serum osmolality <320 mOsm/kg (Rabinstein 2006). However, this value is routinely exceeded without ill effect. A better marker for mannitol toxicity may be the serum osmol gap (or osmolal gap) and the target is <18 to 20 (Erstad 2016; García-Morales 2004).
Intraocular pressure (IOP), reduction: IV: 1.5 to 2 g/kg administered over 30 to 60 minutes 1 to 1.5 hours prior to surgery
IOP (traumatic hyphema), reduction: IV: 1.5 g/kg administered over 45 minutes twice daily for IOP >35 mm Hg; may administer every 8 hours in patients with extremely high pressure (Crouch 1999)
Donor: 12.5 g (with adequate hydration) prior to nephrectomy; may repeat (Morris 2008)
Recipient: 50 g before kidney revascularization (Sprung 2000; Tiggeler 1984; van Valenberg 1987; Weimar 1983)
Transurethral irrigation: Use 5% urogenital solution as required for irrigation.
Refer to adult dosing. Consider initiation at lower end of dosing range.
Note: The manufacturer's labeling recommends a test dose prior to starting IV mannitol therapy in patients with marked oliguria or suspected renal insufficiency.
Acute renal failure (oliguria): Infants, Children, and Adolescents: IV: Initial: 0.5 to 1 g/kg/dose infused over 2 to 6 hours; usual range: 0.25 to 2 g/kg/dose; may repeat dose every 4 to 6 hours; do not repeat dose if oliguria persists. Note: Although FDA-labeled indications, the use of mannitol for the prevention of acute renal failure and/or promotion of diuresis is not routinely recommended (Kellum 2008).
Test dose (to assess adequate renal function): IV: 0.2 g/kg (maximum dose: 12.5 g) over 3 to 5 minutes to produce a urine flow of at least 1 mL/kg/hour for 1 to 3 hours
Intracranial pressure (ICP), reduction: Infants, Children, and Adolescents: IV: Usual range: 0.25 to 1 g/kg/dose infused over 20 to 30 minutes; repeat as needed to maintain serum osmolality <300 to 320 mOsm/kg (BTF [Carney 2016]; Hegenbarth 2008; Kochanek 2012). Note: The manufacturer's labeling allows for higher single doses up to 2 g/kg/dose.
Intraocular pressure (IOP), reduction: Infants, Children, and Adolescents: IV: 1 to 2 g/kg/dose or 30 to 60 g/m2/dose infused over 30 to 60 minutes administered 1 to 1.5 hours prior to surgery
IOP (traumatic hyphema), reduction: Infants, Children, and Adolescents: IV: 1.5 g/kg/dose infused over 45 minutes twice daily for IOP >35 mm Hg; may administer every 8 hours in patients with extremely high pressure (Crouch 1999)
IV: Concentration and rate of administration depends on indication/severity, or may be adjusted to urine flow. For cerebral edema or elevated ICP, administer over 30 to 60 minutes. Inspect for crystals prior to administration. If crystals are present, redissolve by warming solution. Use filter-type administration set (≤5 micron) for infusion solutions containing mannitol ≥20% (WHO 2011). Do not administer with blood. Crenation and agglutination of red blood cells may occur if administered with whole blood.
Vesicant (at concentrations >5%); ensure proper catheter or needle position prior to and during IV infusion. Avoid extravasation of IV infusions. Administration into a large central vein is recommended.
Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote; remove needle/cannula; apply dry cold compresses (Hurst 2004; Reynolds 2014); elevate extremity.
Hyaluronidase: Intradermal or SubQ: Inject a total of 1 to 1.7 mL (15 units/mL) as five separate 0.2 to 0.3 mL injections (using a tuberculin syringe) into area of extravasation at the leading edge in a clockwise manner (Reynolds 2014) or SubQ: Administer multiple 0.5 to 1 mL injections of a 15 units/mL solution around the periphery of the extravasation (Kumar 2003).
Irrigation: Administer using only the appropriate transurethral urologic instrumentation.
Injection: Store at controlled room temperature; do not freeze. Crystallization of solution may occur at low temperatures; do not use solutions that contain crystals. To dissolve crystals in plastic containers, heat solution up to 70°C (158°F), with agitation; do not immerse in water or microwave (may contaminate or damage product); allow solution to return to room or body temperature before use. To dissolve crystals in vials/bottles, warm vial in hot water at 80°C (176°F) and periodically shake vigorously or vial may be autoclaved at 121°C (250°F) for 20 minutes at 15 psi. Allow solution to return to room or body temperature before use.
Irrigation: Store at room temperature of 25°C (77°F); excursions permitted up to 40°C. Avoid excessive heat; do not warm above 150°F (66°C). Do not freeze.
Amikacin (Oral Inhalation): May enhance the nephrotoxic effect of Mannitol (Systemic). Avoid combination
Aminoglycosides: Mannitol (Systemic) may enhance the nephrotoxic effect of Aminoglycosides. Avoid combination
Diacerein: May enhance the therapeutic effect of Diuretics. Specifically, the risk for dehydration or hypokalemia may be increased. Monitor therapy
Opioid Agonists: May enhance the adverse/toxic effect of Diuretics. Opioid Agonists may diminish the therapeutic effect of Diuretics. Monitor therapy
Sodium Phosphates: Diuretics may enhance the nephrotoxic effect of Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be enhanced. Management: Consider avoiding this combination by temporarily suspending treatment with diuretics, or seeking alternatives to oral sodium phosphate bowel preparation. If the combination cannot be avoided, hydrate adequately and monitor fluid and renal status. Consider therapy modification
Tobramycin (Oral Inhalation): Mannitol (Systemic) may enhance the nephrotoxic effect of Tobramycin (Oral Inhalation). Avoid combination
May cause false positive results for blood ethylene glycol concentrations. High mannitol concentrations may cause false low results for inorganic phosphorus blood concentrations if assay based on the conversion of phosphate (orthophosphate) to the phosphomolybdate complex is used.
Frequency not defined:
Cardiovascular: Chest pain, cardiac failure, hypertension, hypotension, local thrombophlebitis, peripheral edema, tachycardia
Central nervous system: Chills, dizziness, headache, seizure
Dermatologic: Bullous rash, urticaria
Endocrine & metabolic: Dehydration (secondary to rapid diuresis), dilutional hyponatremia, electrolyte disturbance (increased osmolar gap), fluid and electrolyte disturbance, hypovolemia (secondary to rapid diuresis), hyperglycemia, hyperkalemia (hyperosmolality-induced), hypernatremia, hypervolemia, metabolic acidosis (dilutional), water intoxication
Gastrointestinal: Nausea, vomiting, xerostomia
Hypersensitivity: Hypersensitivity reaction
Local: Local pain
Ophthalmic: Blurred vision
Renal: Acute renal failure, tubular necrosis (adult dose: >200 g/day; serum osmolality >320 mOsm/L), polyuria
Respiratory: Pulmonary edema, rhinitis
Miscellaneous: Fever, tissue necrosis
Concerns related to adverse effects:
• Extravasation: Vesicant (at concentrations >5%); ensure proper catheter or needle position prior to and during IV infusion. Avoid extravasation of IV infusions; may cause compartment syndrome. Administration into a large central vein is recommended.
• Fluid/electrolyte imbalance: May cause hypervolemia and electrolyte disturbances; monitor for new onset or worsening cardiac or pulmonary congestion. Also may cause profound diuresis with fluid and electrolyte loss; close medical supervision and dose evaluation are required. Correct electrolyte disturbances; adjust dose to avoid dehydration.
• Hypersensitivity: Serious hypersensitivity reactions (eg, anaphylaxis), including fatalities, have been reported. Discontinue mannitol immediately if hypersensitivity reaction develops and treat accordingly.
• Nephrotoxicity: May cause renal dysfunction especially with high doses; use caution in patients taking other nephrotoxic agents, with sepsis or preexisting renal disease. To minimize adverse renal effects, adjust to keep serum osmolality less than 320 mOsm/L. Discontinue if evidence of acute tubular necrosis.
• Cerebral edema: In patients being treated for cerebral edema, mannitol may accumulate in the brain (causing rebound increases in intracranial pressure) if circulating for long periods of time as with continuous infusion; intermittent boluses preferred. Cardiovascular status should also be evaluated; do not administer electrolyte-free mannitol solutions with blood. If hypotension occurs, monitor cerebral perfusion pressure to ensure adequate.
• CNS effects: CNS toxicity (eg, coma, confusion, lethargy) may occur; risk may be increased in patients with impaired renal function or with concomitant use of neurotoxic drugs.
• Renal impairment: Use with caution. In patients with severe impairment, do not use until adequacy of renal function and urine flow is established; use 1 to 2 test doses to assess renal response.
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.
Renal function, daily fluid I & O, serum electrolytes, serum and urine osmolality. Monitor infusion site.
For treatment of elevated intracranial pressure, some suggest maintaining serum osmolality <320 mOsm/kg due to the potential risk of acute renal tubular damage (Grape 2012; Rabenstein 2006). However, this value is routinely exceeded without ill effect. A better marker for mannitol toxicity may be the serum osmole gap and the target used by most clinicians is <18 to 20 (Erstad 2016; García-Morales 2004).
Mannitol crosses the placenta (Basso 1977).
Outcome information following surgical use in pregnancy is limited; amniotic fluid volume may be decreased (Handlogten 2015; Kazemi 2014).
• 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 headache, rhinorrhea, nausea, or vomiting. Have patient report immediately to prescriber signs of kidney problems (urinary retention, hematuria, change in amount of urine passed, or weight gain), signs of fluid and electrolyte problems (mood changes, confusion, muscle pain or weakness, abnormal heartbeat, severe dizziness, passing out, tachycardia, increased thirst, seizures, loss of strength and energy, lack of appetite, urinary retention or change in amount of urine passed, dry mouth, dry eyes, or nausea or vomiting), signs of acidosis (confusion, fast breathing, tachycardia, abnormal heartbeat, severe abdominal pain, nausea, vomiting, fatigue, shortness of breath, or loss of strength and energy), signs of skin infection, shortness of breath, severe dizziness, passing out, excessive weight gain, swelling in the arms or legs, angina, tachycardia, blurred vision, vision changes, edema, chills, skin discoloration, or injection site skin breakdown 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.
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More about mannitol
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- During Pregnancy
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- Drug class: miscellaneous diuretics
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