Adenosine

IV Compatibilities

Solution: dextrose 5% in LR, D5W, LR, NS

IV Administration

Adenocard: given as a rapid injection (1-3 sec) by peripheral IV route directly into vein or into IV line close (proximal) to patient & is followed by rapid NS flush after each inj (20 mL for adults, 5 mL or more for peds)

Place pt in mild reverse Trendelenburg position before giving drug

Record rhythm strip during administration

Draw up (separate syringes)

• Adenosine dose
• Flush
• Attach BOTH syringes to IV injection port nearest to patient

Clamp IV tubing above injection port

Avoid drug traveling retrograde

Push adenosine AS FAST AS POSSIBLE (1-3 sec)

WHILE KEEPING PRESSURE ON ADENOSINE SYRINGE PLUNGER, push NS flush as fast as possible

Unclamp IV tubing

Preferred method using a stopcock

• Have Adenosine in one port & NS flush in other port
• Simply open stopcock to Adenosine & push
• Close stopcock & open port to NS & push Eliminates possibility of Adenosine traveling retrograde

May be given via central line or intraosseus

Adenoscan: given by continuous peripheral IV infusion for 6 min

Storage

Store at controlled room temperature of 15-30°C

Do not refrigerate; possible crystal formation

Solution must be clear prior to administration

Contraindications

• Known hypersensitivity to adenosine.1 2

• Second- or third-degree AV block (except in patients with a functioning artificial pacemaker).1 2

• Sinus node disease (e.g., sick sinus syndrome, symptomatic bradycardia [except in those with a functioning artificial pacemaker]).1 2 14

• Known or suspected bronchoconstrictive or bronchospastic lung disease (e.g., asthma).2 22

Warnings/Precautions

Cardiovascular and Cerebrovascular Effects

Serious cardiovascular and cerebrovascular events, including myocardial ischemic events, rhythm and conduction abnormalities, hypotension, hypertension, and stroke, reported rarely.1 2 32 37 Ensure availability of cardiac resuscitation equipment and trained staff prior to administration.1 2 32

Risk of rare but serious adverse cardiovascular events, including MI and death, in patients receiving adenosine as a cardiac stress testing agent during myocardial perfusion imaging; similar risk also observed with regadenoson, another pharmacologic stress test agent.2 32 33 34 37 38 39

Avoid use in patients with signs or symptoms of acute myocardial ischemia (e.g., unstable angina, cardiovascular instability).2 32

Risk of first-, second-, or third-degree heart block, sinus bradycardia, and, rarely, sinus pause due to the drug's direct depressant effects on SA and AV nodes.1 2 28 Avoid use in patients with sinus node dysfunction or high-grade AV block unless patient has a functioning artificial pacemaker (see Contraindications under Cautions); use caution in patients with preexisting first-degree AV block or bundle branch block.1 2 Discontinue therapy in patients who develop persistent or symptomatic high-level AV block.1 2

When used for termination of PSVT, new arrhythmias (VPCs, atrial premature complexes, atrial fibrillation, sinus bradycardia, sinus tachycardia, skipped beats, and varying degrees of AV nodal block) may occur at the time of conversion to normal sinus rhythm.1 2 7 8 12 28 29 Such arrhythmias generally transient and self-limiting,1 although episodes of asystole, sometimes fatal, have been reported.1 Ventricular fibrillation (both resuscitated and fatal events) also reported.1 29 In most cases, these adverse effects occurred in patients receiving concomitant therapy with digoxin or digoxin and verapamil; a causal relationship, however, not established.1 (See Specific Drugs under Interactions.)

Marked hypotension possible due to potent peripheral vasodilating effects of the drug; risk may be increased in patients with autonomic dysfunction, stenotic valvular heart disease, pericarditis or pericardial effusion, stenotic carotid artery disease with cerebrovascular insufficiency, or hypovolemia.1 2 Discontinue in patients who develop persistent or symptomatic hypotension.2

Clinically important increases in BP also may occur; generally transient, but may persist for several hours.1 2

Cerebrovascular events, including hemorrhagic and ischemic stroke, possibly related to hemodynamic effects of the drug, also reported.2

Respiratory Effects

Risk of dyspnea, bronchoconstriction, bronchospasm, and respiratory compromise.1 2 12 14 22 23

May exacerbate symptoms (e.g., bronchoconstriction) in patients with asthma.1 2 12 22 23 (See Contraindications under Cautions.)

Use with caution in patients with obstructive lung disease not associated with bronchoconstriction (e.g., emphysema, bronchitis).1 2 22 23 Ensure availability of appropriate resuscitative measures.2 Discontinue drug in patients who develop severe respiratory difficulty.1 2

Seizures

Risk of new-onset or recurrent seizures.1 2 Seizure activity, including tonic-clonic (grand mal) seizures, reported; in some cases, prolonged and required emergency management.2

Concomitant use of aminophylline may increase risk of seizures.2 (See Specific Drugs under Interactions.)

Sensitivity Reactions

Risk of hypersensitivity reactions, possibly requiring resuscitative measures; manifestations have included dyspnea, throat tightness, flushing, erythema, and chest discomfort.1 2 (See Contraindications under Cautions.)

Ensure availability of appropriate personnel and resuscitative equipment.2

Specific Populations

Category C.1 2

Because of its rapid onset and brief duration of action, adenosine may have advantages over other antiarrhythmic agents (e.g., verapamil, digoxin) in the acute treatment of PSVT in pregnant women in whom vagal maneuvers have failed.24 25 26 28 Use with caution because hypotension may compromise placental (fetal) blood flow.28

Not known whether adenosine is distributed into milk.7 30 Discontinue nursing or the drug.2 Some clinicians suggest that breast-feeding may be possible because of the drug’s short half-life.28 30

Safety and efficacy (as adjunct to thallium stress test) not established in children ≤18 years of age.2

Safety and efficacy (as antiarrhythmic for PSVT) not established in pediatric patients; however, IV adenosine has been used for the treatment of PSVT in neonates, infants, children, and adolescents1 24 and some clinicians consider it a drug of choice for SVT in pediatric patients.24

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults.1 2 Use with caution since increased sensitivity cannot be ruled out;2 some geriatric patients may have diminished cardiac or nodal dysfunction, concomitant disease, or drug therapy that may alter hemodynamic function and result in severe bradycardia or AV block.1

Hepatic function not required for therapeutic effect or inactivation; hepatic dysfunction not expected to alter efficacy or tolerability.1 2

Renal function not required for therapeutic effect or inactivation; renal dysfunction not expected to alter efficacy or tolerability.1 2

Common Adverse Effects

For termination of PSVT: Facial flushing,1 4 8 10 13 14 24 shortness of breath/dyspnea,1 4 10 13 14 24 chest pressure,1 4 8 24 nausea,1 headache,1 lightheadedness,1 dizziness,1 10 numbness,1 tingling in the arms.1

As an adjunct to thallium stress test: Facial flushing,2 9 17 chest discomfort,2 17 dyspnea or urge to breathe deeply,2 9 17 headache,2 9 17 throat/neck/jaw discomfort,2 9 GI discomfort,2 9 lightheadedness/dizziness,2 9 17 upper extremity discomfort,2 9 ST-segment depression,2 8 first- or second-degree AV block,2 9 paresthesia,2 9 hypotension,2 nervousness,2 9 arrhythmias.2

Elimination

Metabolism

Rapidly metabolized intracellularly to inactive metabolites.1 2

Elimination Route

Cleared by cellular uptake, primarily by erythrocytes and vascular endothelial cells.1 2

Half-life

<10 seconds.1 2

• Importance of informing patients about serious adverse effects associated with adenosine, such as MI, arrhythmias, cardiac arrest, heart block, substantial changes in BP, bronchoconstriction, hypersensitivity reactions, seizures, and stroke.1 2 24

• Importance of patients informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs (e.g., aminophylline, theophylline), caffeine-containing foods or beverages,27 as well as any concomitant illnesses (e.g., asthma, COPD).1 2

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1 2

• Importance of informing patients of other important precautionary information.1 2 (See Cautions.)

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.
• Flushing.
• Headache.
• Belly pain.

These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.

You may report side effects to the FDA at 1-800-FDA-1088. You may also report side effects at http://www.fda.gov/medwatch.

Adenosine Injection is indicated as an adjunct to thallium-201 myocardial perfusion scintigraphy in patients unable to exercise adequately.

Effects of Other Drugs on Adenosine

Effects of Adenosine on Other Drugs

Adenosine injection has been given with other cardioactive drugs (such as beta adrenergic blocking agents, cardiac glycosides, and calcium channel blockers) without apparent adverse interactions, but its effectiveness with these agents has not been systematically evaluated. Because of the potential for additive or synergistic depressant effects on the SA and AV nodes, however, Adenosine should be used with caution in the presence of these agents [see Warnings and Precautions (5.2)].

• 9-Beta-D-Ribofuranosyladenine
• Adenosine Phosphate

Rapid IV push (over 1 to 2 seconds) via peripheral line, followed by a normal saline flush:

Paroxysmal supraventricular tachycardia (Adenocard): Infants and Children: IV:

Manufacturer's labeling:

Children <50 kg: Initial: 0.05 to 0.1 mg/kg (maximum initial dose: 6 mg). If conversion of PSVT does not occur within 1 to 2 minutes, may increase dose by 0.05 to 0.1 mg/kg. May repeat until sinus rhythm is established or to a maximum single dose of 0.3 mg/kg or 12 mg. Follow each dose with normal saline flush.

Children ≥50 kg: Refer to adult dosing.

Pediatric advanced life support (PALS, 2010): Treatment of SVT: IV, I.O.: Initial: 0.1 mg/kg (maximum initial dose: 6 mg); if not effective within 1 to 2 minutes, administer 0.2 mg/kg (maximum single dose: 12 mg). Follow each dose with ≥5 mL normal saline flush.

Store between 15°C and 30°C (59°F and 86°F). Do not refrigerate; crystallization may occur (may dissolve by warming to room temperature).

Adenosine may be found in some form under the following brand names:

• Adenocard

• Adenoscan

• My-O-Den

Adenosine is available in the following forms:

• Injectable Solution
• Prefilled Syringe
• Topical Cream