Esmolol

Dosage Forms & Strengths

infusion bags

• 2g/100mL
• 2.5g/250mL

injectable solution

• 10mg/mL
• 20mg/mL

Intraoperative Tachycardia/Hypertension

Immediate control

• Initial bolus: 80 mg (~1 mg/kg) IVP over 30 sec, THEN
• 0.15-0.3 mg/kg/min IV infusion PRN 

Postoperative/gradual control

• Load 0.5 mg/kg IV over 1 min, THEN
• 0.05 mg/kg/min IV for 4 min
• If inadequate response in 5 min
• 2nd loading dose of 0.5 mg/kg/min for 1 min, THEN
• 0.1 mg/kg/min IV 

Supraventricular Tachycardia

Load: 0.5 mg/kg IV over 1 min, THEN

Maintenance: Start 0.05 mg/kg/min IV for 4 min, may increase by 0.05 mg/kg up to 0.2 mg/kg/min 

If HR/BP not controlled after 5 min, repeat bolus (ie, 500 mcg/kg/min for 1 min), then initiate infusion of 0.1 mg/kg/min IV

May administer a 3rd bolus if needed, then a maintenance infusion of 0.15 mg/kg/min IV

Higher maintenance doses may be required, up to 0.25-0.3 mg/kg/min

Hypertensive Emergency

Load 0.25-0.5 mg/kg IVP over 1 min, THEN 

0.05-0.1 mg/kg/min IV for 4 min

May repeat loading dose or increase infusion up to 0.3 mg/kg/min if necessary

Renal Impairment

Not necessary to supplement dose; not dialyzable

Additional Information

Less effective than thiazide diuretics in black and geriatric patients

Shown to decrease mortality in hypertension and post-myocardial infarction

Other Indications & Uses

Paroxysmal Atrial Tachycardia, PSVT, ST

Off-label: Acute MI, angina, NSTEMI

Dosage Forms & Strengths

infusion bags

• 2g/100mL
• 2.5g/250mL

injectable solution

• 10mg/mL
• 20mg/mL

Supraventricular Tachycardia (Off-label)

Load with 500-600 mcg/kg IV over 2 min, THEN 200 mcg/kg/min IV infusion (range 50-250 mcg/kg/min) 

Postoperative Hypertension (Off-label)

Load with 500-600 mcg/kg IV over 2 min, THEN 200 mcg/kg/min IV infusion (range 50-250 mcg/kg/min) 

Hypertension

2.5 mg PO qDay; increase dose gradually

Supraventricular tachycardia

Load: 0.5 mg/kg/IV over 1 min, THEN

Maintenance: Start 0.05 mg/kg/min IV for 4 min, may increase by 0.05 mg/kg up to 0.2 mg/kg/min 

If HR/BP not controlled after 5 min, repeat bolus (ie, 0.5 mg/kg/min for 1 min), then initiate infusion of 0.1 mg/kg/min IV

May administer a 3rd bolus if needed, then a maintenance infusion of 0.15 mg/kg/min IV

Higher maintenance doses may be required, up to 0.25-0.3 mg/kg/min

Hypertensive emergency

Load 0.25-0.5 mg/kg IVP over 1 min, THEN

0.05-0.1 mg/kg/min IV for 4 min

May repeat loading dose or increase infusion up to 0.3 mg/kg/min if necessary

Intraoperative tachycardia/hypertension

Immediate control

- Initial bolus: 80 mg (~1 mg/kg) IVP over 30 sec, THEN

- 0.15-0.3 mg/kg/min IV infusion PRN

Postoperative/gradual control

- Load 0.5 mg/kg over 1 min, THEN

- 0.05 mg/kg/min IV for 4 min

- If inadequate response in 5 min

- 2nd loading dose of 0.5 mg/kg/min for 1 min, THEN

- 0.1 mg/kg/min

Included as part of the PRECAUTIONS section.

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

The following adverse reaction rates are based on use of BREVIBLOC (Esmolol Hydrochloride) in clinical trials involving 369 patients with supraventricular tachycardia and over 600 intraoperative and postoperative patients enrolled in clinical trials. Most adverse effects observed in controlled clinical trial settings have been mild and transient. The most important and common adverse effect has been hypotension [see WARNINGS AND PRECAUTIONS]. Deaths have been reported in post-marketing experience occurring during complex clinical states where BREVIBLOC was presumably being used simply to control ventricular rate [see WARNINGS AND PRECAUTIONS].

Table 3 : Clinical Trial Adverse Reactions (Frequency ≥ 3%)

Clinical Trial Adverse Reactions (Frequency < 3%)

Confusional state and agitation (~2%)

Anxiety, depression and abnormal thinking ( < 1%)

Headache (~ 2%)

Paresthesia, syncope, speech disorder, and lightheadedness ( < 1%)

Convulsions ( < 1%), with one death

Peripheral ischemia (~1%)

Pallor and flushing ( < 1%)

Vomiting (~1%)

Dyspepsia, constipation, dry mouth, and abdominal discomfort ( < 1%)

Urinary retention ( < 1%)

Post-Marketing Experience

In addition to the adverse reactions reported in clinical trials, the following adverse reactions have been reported in the post-marketing experience. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to estimate reliably their frequency or to establish a causal relationship to drug exposure.

Cardiac arrest, Coronary arteriospasm

Angioedema, Urticaria, Psoriasis

Read the entire FDA prescribing information for Brevibloc (Esmolol)

Usual Adult Dose for Atrial Fibrillation:

This drug is administered by continuous IV infusion (with or without a loading dose); additional loading doses and/or titration of the maintenance infusion may be necessary based on desired ventricular response:

Recommended Dosing:
Step 1) Optional loading dose (500 mcg/kg IV over 1 minute), then 50 mcg/kg/min IV for 4 minutes; if the response is adequate, the infusion may be maintained at 50 mcg/kg/min; if the response is inadequate, see step 2.
Step 2) Optional loading dose (500 mcg/kg IV over 1 minute) if necessary, then 100 mcg/kg/min IV for 4 minutes; if the response is adequate, the infusion may be maintained at 100 mcg/kg/min; if the response is inadequate, see step 3.
Step 3) Optional loading dose (500 mcg/kg IV over 1 minute) if necessary, then 150 mcg/kg/min IV for 4 minutes; if the response is adequate, the infusion may be maintained at 150 mcg/kg/min; if the response is inadequate, see step 4.
Step 4) If necessary, increase dose to 200 mcg/kg/min IV

-Maintenance dose: 25 to 200 mcg/kg/min IV
-Maximum dose: 200 mcg/kg/min IV
-Duration: Maintenance infusions may be continued for up to 48 hours

Comment:
-In the absence of loading doses, continuous infusion of a single concentration of this drug reaches steady-state in about 30 minutes.

Use: For the rapid control of ventricular rate in patients with atrial fibrillation or atrial flutter in perioperative, postoperative, or other emergent circumstances where short-term control of ventricular rate with a short-acting agent is desirable; it is also indicated in noncompensatory sinus tachycardia where the rapid heart rate requires specific intervention

Usual Adult Dose for Atrial Flutter:

This drug is administered by continuous IV infusion (with or without a loading dose); additional loading doses and/or titration of the maintenance infusion may be necessary based on desired ventricular response:

Recommended Dosing:
Step 1) Optional loading dose (500 mcg/kg IV over 1 minute), then 50 mcg/kg/min IV for 4 minutes; if the response is adequate, the infusion may be maintained at 50 mcg/kg/min; if the response is inadequate, see step 2.
Step 2) Optional loading dose (500 mcg/kg IV over 1 minute) if necessary, then 100 mcg/kg/min IV for 4 minutes; if the response is adequate, the infusion may be maintained at 100 mcg/kg/min; if the response is inadequate, see step 3.
Step 3) Optional loading dose (500 mcg/kg IV over 1 minute) if necessary, then 150 mcg/kg/min IV for 4 minutes; if the response is adequate, the infusion may be maintained at 150 mcg/kg/min; if the response is inadequate, see step 4.
Step 4) If necessary, increase dose to 200 mcg/kg/min IV

-Maintenance dose: 25 to 200 mcg/kg/min IV
-Maximum dose: 200 mcg/kg/min IV
-Duration: Maintenance infusions may be continued for up to 48 hours

Comment:
-In the absence of loading doses, continuous infusion of a single concentration of this drug reaches steady-state in about 30 minutes.

Use: For the rapid control of ventricular rate in patients with atrial fibrillation or atrial flutter in perioperative, postoperative, or other emergent circumstances where short-term control of ventricular rate with a short-acting agent is desirable; it is also indicated in noncompensatory sinus tachycardia where the rapid heart rate requires specific intervention

Usual Adult Dose for Supraventricular Tachycardia:

This drug is administered by continuous IV infusion (with or without a loading dose); additional loading doses and/or titration of the maintenance infusion may be necessary based on desired ventricular response:

Recommended Dosing:
Step 1) Optional loading dose (500 mcg/kg IV over 1 minute), then 50 mcg/kg/min IV for 4 minutes; if the response is adequate, the infusion may be maintained at 50 mcg/kg/min; if the response is inadequate, see step 2.
Step 2) Optional loading dose (500 mcg/kg IV over 1 minute) if necessary, then 100 mcg/kg/min IV for 4 minutes; if the response is adequate, the infusion may be maintained at 100 mcg/kg/min; if the response is inadequate, see step 3.
Step 3) Optional loading dose (500 mcg/kg IV over 1 minute) if necessary, then 150 mcg/kg/min IV for 4 minutes; if the response is adequate, the infusion may be maintained at 150 mcg/kg/min; if the response is inadequate, see step 4.
Step 4) If necessary, increase dose to 200 mcg/kg/min IV

-Maintenance dose: 25 to 200 mcg/kg/min IV
-Maximum dose: 200 mcg/kg/min IV
-Duration: Maintenance infusions may be continued for up to 48 hours

Comment:
-In the absence of loading doses, continuous infusion of a single concentration of this drug reaches steady-state in about 30 minutes.

Use: For the rapid control of ventricular rate in patients with atrial fibrillation or atrial flutter in perioperative, postoperative, or other emergent circumstances where short-term control of ventricular rate with a short-acting agent is desirable; it is also indicated in noncompensatory sinus tachycardia where the rapid heart rate requires specific intervention

Usual Adult Dose for Intra- or Post-op SVT or Hypertension:

For intraoperative and postoperative tachycardia and hypertension it is not always advisable to slowly titrate to a therapeutic effect; therefore 2 dosing options are presented (immediate control and gradual control):

IMMEDIATE CONTROL:
-Administer 1 mg/kg IV as a bolus dose over 30 seconds followed by 150 mcg/kg/min if needed
-Adjust the infusion rate as required to maintain desired heart rate and blood pressure (refer to maximum recommended doses)

GRADUAL CONTROL:
-Administer 500 mcg/kg IV as a bolus dose over 1 minute followed by a maintenance infusion of 50 mcg/kg/min IV for 4 minutes
-Infusion may be continued at 50 mcg/kg/min or, if the response is inadequate, titrated upward in 50 mcg/kg/min increments (increased no more frequently than every 4 minutes) to a maximum of 300 mcg/kg/min; may administer an optional loading dose equal to the initial bolus (500 mcg/kg over 1 minute) prior to each increase in infusion rate

MAXIMUM RECOMMENDED DOSES:
-For the treatment of tachycardia, maintenance infusion dosages greater than 200 mcg/kg/min IV are not recommended; dosages greater than 200 mcg/kg/min IV provide little additional heart rate-lowering effect, and the rate of adverse reactions increases.
-For the treatment of hypertension, higher maintenance infusion dosages (250 to 300 mcg/kg/min) may be required; the safety of doses above 300 mcg/kg/min has not been studied.

Use: For the short-term treatment of tachycardia and hypertension that occur during induction and tracheal intubation, during surgery, on emergence from anesthesia and in the postoperative period, when such specific intervention is considered indicated

• Antiarrhythmic Agent, Class II
• Antihypertensive
• Beta-Blocker, Beta-1 Selective

Blood pressure, MAP, heart rate, continuous ECG, respiratory rate, IV site; serum potassium (especially with renal impairment); consult individual institutional policies and procedures

• 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. Have patient report immediately to prescriber signs of high potassium (abnormal heartbeat, confusion, dizziness, passing out, weakness, shortness of breath, or numbness or tingling feeling), signs of acidosis (confusion, fast breathing, tachycardia, abnormal heartbeat, severe abdominal pain, nausea, vomiting, fatigue, shortness of breath, or loss of strength and energy), dizziness, passing out, sweating a lot, shortness of breath, excessive weight gain, swelling of arms or legs, bradycardia, abnormal heartbeat, or injection site burning, redness, pain, edema, or severe 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.

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.

Commonly reported side effects of esmolol include: dizziness, hypotension, symptomatic hypotension, and diaphoresis. See below for a comprehensive list of adverse effects.

No adjustment recommended.

No adjustment recommended.

Data not available