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Neomycin

Pronunciation

Pronunciation

(nee oh MYE sin)

Index Terms

  • Neomycin Sulfate

Dosage Forms

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

Tablet, Oral, as sulfate:

Generic: 500 mg

Pharmacologic Category

  • Ammonium Detoxicant
  • Antibiotic, Aminoglycoside

Pharmacology

Interferes with bacterial protein synthesis by binding to 30S ribosomal subunits

Absorption

Oral, percutaneous: Poor (3%)

Distribution

97% of an orally administered dose remains in the GI tract. Absorbed neomycin distributes to tissues and concentrates in the renal cortex. With repeated doses, accumulation also occurs in the inner ear.

Excretion

Feces (97% of oral dose as unchanged drug); urine (30% to 50% of absorbed drug as unchanged drug)

Time to Peak

1 to 4 hours

Protein Binding

0% to 30%

Use: Labeled Indications

Hepatic coma (portal-systemic encephalopathy): Adjunctive therapy in hepatic coma.

Surgical (perioperative) prophylaxis: Adjunctive therapy as part of a regimen for the suppression of the normal bacterial bowel flora (eg, preoperative bowel preparation),given concomitantly with enteric-coated erythromycin base.

Contraindications

Hypersensitivity to the neomycin or any component of the formulation; intestinal obstruction; patients with inflammatory or ulcerative GI disease. Patients with a history of hypersensitivity or serious toxic reaction to other aminoglycosides may have a cross-sensitivity to neomycin.

Dosing: Adult

Surgical (perioperative) prophylaxis: Oral:

Manufacturer's labeling: 1 g at 1 PM, 2 PM, and 11 PM on the day preceding 8 AM surgery as an adjunct to mechanical cleansing of the bowel and oral erythromycin

Alternative recommendation: 1 g at 1 PM, 2 PM, and 11 PM on the day preceding 8 AM surgery combined with mechanical cleansing of the large intestine and oral erythromycin or metronidazole, and IV antibiotics on the day of surgery (Bratzler, 2013)

Hepatic encephalopathy: Oral: 4 to 12 g daily divided every 4 to 6 hours for 5 to 6 days

Chronic hepatic insufficiency: Oral: 4 g daily for an indefinite period

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Surgical (perioperative) prophylaxis: Children and Adolescents: Oral: 15 mg/kg/dose for 3 doses administered over 10 hours (eg, at 1 PM, 2 PM, and 11 PM) on the the day preceding surgery; maximum dose: 1,000 mg; (Bratzler, 2013); used as an adjunct to mechanical cleansing of the intestine and in combination with erythromycin base or metronidazole and perioperative IV antibiotics

Dosing: Renal Impairment

There are no dosage adjustments provided in manufacturer’s labeling; however, dosage reduction or discontinuation of therapy should be considered if a patient develops renal insufficiency. The risk of nephro- and/or ototoxicity is increased in patients with renal impairment.

Dosing: Hepatic Impairment

There are no dosage adjustments provided in manufacturer’s labeling.

Storage

Store at 20ºC to 25ºC (68ºF to 77ºF).

Drug Interactions

AbobotulinumtoxinA: Aminoglycosides may enhance the neuromuscular-blocking effect of AbobotulinumtoxinA. Monitor therapy

Acarbose: Neomycin may enhance the adverse/toxic effect of Acarbose. Neomycin may decrease the metabolism of Acarbose. Monitor therapy

Amphotericin B: May enhance the nephrotoxic effect of Aminoglycosides. Monitor therapy

Arbekacin: May enhance the nephrotoxic effect of Aminoglycosides. Arbekacin may enhance the ototoxic effect of Aminoglycosides. Monitor therapy

Bacitracin (Systemic): Neomycin may enhance the nephrotoxic effect of Bacitracin (Systemic). Avoid combination

BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Monitor therapy

Bisphosphonate Derivatives: Aminoglycosides may enhance the hypocalcemic effect of Bisphosphonate Derivatives. Monitor therapy

Capreomycin: May enhance the neuromuscular-blocking effect of Aminoglycosides. Monitor therapy

CARBOplatin: Aminoglycosides may enhance the ototoxic effect of CARBOplatin. Especially with higher doses of carboplatin. Monitor therapy

Cardiac Glycosides: Aminoglycosides may decrease the serum concentration of Cardiac Glycosides. This effect has only been demonstrated with oral aminoglycoside administration. Monitor therapy

Cefazedone: May enhance the nephrotoxic effect of Aminoglycosides. Monitor therapy

Cephalosporins (2nd Generation): May enhance the nephrotoxic effect of Aminoglycosides. Monitor therapy

Cephalosporins (3rd Generation): May enhance the nephrotoxic effect of Aminoglycosides. Monitor therapy

Cephalosporins (4th Generation): May enhance the nephrotoxic effect of Aminoglycosides. Monitor therapy

Cephalothin: May enhance the nephrotoxic effect of Aminoglycosides. Monitor therapy

Cephradine: May enhance the nephrotoxic effect of Aminoglycosides. Monitor therapy

CISplatin: May enhance the nephrotoxic effect of Aminoglycosides. Monitor therapy

Colistimethate: Aminoglycosides may enhance the nephrotoxic effect of Colistimethate. Aminoglycosides may enhance the neuromuscular-blocking effect of Colistimethate. Consider therapy modification

CycloSPORINE (Systemic): Aminoglycosides may enhance the nephrotoxic effect of CycloSPORINE (Systemic). Monitor therapy

Distigmine: Aminoglycosides may diminish the therapeutic effect of Distigmine. Monitor therapy

Foscarnet: May enhance the nephrotoxic effect of Aminoglycosides. Avoid combination

Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Monitor therapy

Loop Diuretics: May enhance the adverse/toxic effect of Aminoglycosides. Specifically, nephrotoxicity and ototoxicity. Monitor therapy

Mannitol (Systemic): May enhance the nephrotoxic effect of Aminoglycosides. Avoid combination

Mecamylamine: Aminoglycosides may enhance the neuromuscular-blocking effect of Mecamylamine. Avoid combination

Neuromuscular-Blocking Agents: Aminoglycosides may enhance the respiratory depressant effect of Neuromuscular-Blocking Agents. Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: May decrease the excretion of Aminoglycosides. Data only in premature infants. Monitor therapy

OnabotulinumtoxinA: Aminoglycosides may enhance the neuromuscular-blocking effect of OnabotulinumtoxinA. Monitor therapy

Oxatomide: May enhance the ototoxic effect of Aminoglycosides. Monitor therapy

Penicillins: May decrease the serum concentration of Aminoglycosides. Primarily associated with extended spectrum penicillins, and patients with renal dysfunction. Exceptions: Amoxicillin; Ampicillin; Cloxacillin; Dicloxacillin; Nafcillin; Oxacillin; Penicillin G (Parenteral/Aqueous); Penicillin G Benzathine; Penicillin G Procaine; Penicillin V Potassium. Consider therapy modification

Regorafenib: Neomycin may decrease serum concentrations of the active metabolite(s) of Regorafenib. Monitor therapy

RimabotulinumtoxinB: Aminoglycosides may enhance the neuromuscular-blocking effect of RimabotulinumtoxinB. Monitor therapy

Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Consider therapy modification

SORAfenib: Neomycin may decrease the serum concentration of SORAfenib. Monitor therapy

Tenofovir Products: Aminoglycosides may increase the serum concentration of Tenofovir Products. Tenofovir Products may increase the serum concentration of Aminoglycosides. Monitor therapy

Vancomycin: May enhance the nephrotoxic effect of Aminoglycosides. Monitor therapy

Vitamin K Antagonists (eg, warfarin): Neomycin may enhance the anticoagulant effect of Vitamin K Antagonists. Monitor therapy

Adverse Reactions

>10%:

Central nervous system: Sore mouth

Gastrointestinal: Anorectal pain, diarrhea, mouth irritation, nausea, rectal irritation, vomiting

<1% (Limited to important or life-threatening): Auditory ototoxicity, dyspnea, eosinophilia, nephrotoxicity, neurotoxicity, vestibular ototoxicity

ALERT: U.S. Boxed Warning

Toxicity:

Systemic absorption of neomycin occurs following oral administration, and toxic reactions may occur. Patients treated with neomycin should be under close clinical observation because of the potential toxicity associated with the use of neomycin. Neurotoxicity (including ototoxicity) and nephrotoxicity following the oral use of neomycin sulfate have been reported, even when used in recommended doses. The potential for nephrotoxicity, permanent bilateral auditory ototoxicity, and sometimes vestibular toxicity, is present in patients with healthy renal function when treated with higher doses of neomycin or for longer periods than recommended. Serial, vestibular and audiometric tests, as well as tests of renal function, should be performed (especially in high-risk patients). The risk of nephrotoxicity and ototoxicity is greater in patients with impaired renal function. Ototoxicity is often delayed in onset, and patients developing cochlear damage will not have symptoms during therapy to warn them of developing eighth nerve destruction, and total or partial deafness may occur long after neomycin has been discontinued.

Other factors which increase the risk of toxicity are advanced age and dehydration.

Neuromuscular blockade:

Neuromuscular blockage and respiratory paralysis have been reported following the oral use of neomycin. The possibility of the occurrence of neuromuscular blockage and respiratory paralysis should be considered if neomycin is administered, especially to patients receiving anesthetics; neuromuscular-blocking agents such as tubocurarine, succinylcholine, decamethonium; or massive transfusions of citrate anticoagulated blood. If blockage occurs, calcium salts may reverse these phenomena, but mechanical respiratory assistance may be necessary.

Concurrent therapy:

Concurrent or sequential systemic, oral or topical use of other aminoglycosides, including paromomycin and other potentially nephrotoxic or neurotoxic drugs such as bacitracin, cisplatin, vancomycin, amphotericin B, polymyxin B, colistin and viomycin, should be avoided because the toxicity may be additive.

The concurrent use of neomycin with potent diuretics such as ethacrynic acid or furosemide should be avoided, since certain diuretics by themselves may cause ototoxicity. In addition, when administered intravenously (IV), diuretics may enhance neomycin toxicity by altering the antibiotic concentration in serum and tissue.

Warnings/Precautions

Concerns related to adverse effects:

• Malabsorption: Small amounts of neomycin are absorbed through intact intestinal mucosa; increases in fecal bile acid excretion and reduction of intestinal lactase activity may occur. Oral doses of >12 g/day produce malabsorption of fats, nitrogen, cholesterol, carotene, glucose, xylose, lactose, sodium, calcium, cyanocobalamin and iron.

• Nephrotoxicity: [US Boxed Warning]: May cause nephrotoxicity; usual risk factors include preexisting renal impairment, concomitant nephrotoxic medications, advanced age and dehydration. Discontinue treatment if signs of nephrotoxicity occur; renal damage is usually reversible.

• Neuromuscular blockade and respiratory paralysis: [US Boxed Warning]: May cause neuromuscular blockade and respiratory paralysis; especially when given soon after anesthesia or muscle relaxants.

• Neurotoxicity: [US Boxed Warning]: May cause neurotoxicity; symptoms also include numbness, skin tingling, muscle twitching and seizures. Usual risk factors include preexisting renal impairment and concomitant neuro-/nephrotoxic medications. Discontinue treatment if signs of ototoxicity occur; risk of hearing loss continues after drug withdrawal.

• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.

Disease-related concerns:

• Hearing impairment: Use with caution in patients with preexisting vertigo, tinnitus, or hearing loss.

• Neuromuscular disorders: Use with caution in patients with neuromuscular disorders, including myasthenia gravis and Parkinson disease.

• Renal impairment: Use with caution in patients with preexisting renal insufficiency; dosage modification required.

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.

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC, 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors, 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer’s labeling.

Other warnings/precautions:

• Parenteral administration: More toxic than other aminoglycosides when given parenterally; do not administer parenterally.

• Surgical irrigation: Do not use as surgical irrigation due to significant systemic absorption of the drug.

Monitoring Parameters

Serum creatinine/BUN at baseline and periodically during chronic therapy; audiometry in symptomatic patients

Pregnancy Risk Factor

D

Pregnancy Considerations

Animal reproduction studies have not been conducted. Aminoglycosides cross the placenta. Aminoglycosides may cause fetal harm if administered to a pregnant woman. There are several reports of total irreversible bilateral congenital deafness in children whose mothers received another aminoglycoside (streptomycin) during pregnancy. Although serious side effects to the fetus/infant have not been reported following maternal use of all aminoglycosides, a potential for harm exists. Large oral doses may cause malabsorption of some nutrients in the mother.

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 diarrhea. Have patient report immediately to prescriber signs of renal impairment, severe dizziness, syncope, tinnitus, hearing impairment, asthenia, paresthesia, fasciculations, or change in balance (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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