Adenocard

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Adenocard

Classes

Anti-arrhythmics, Miscellaneous
Diagnostic Agents, Other

Administration
Injectable Administration

Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.

Intravenous Administration

Intravenous injection
Prior to the administration of adenosine for paroxysmal supraventricular tachycardia (PSVT), attempt appropriate vagal maneuvers unless otherwise contraindicated.
Administer undiluted by rapid intravenous bolus (over 1 to 2 seconds).
Inject into the most proximal injection site or central venous line. Stopcock or T-connector method recommended for rapid administration. Follow immediately with a rapid saline flush (at least 5 mL); guidelines recommend a 20 mL flush. May also be given directly into a peripheral vein.
Elevate extremity after administration.
Storage: Vials are for use only; discard any unused portion.
 
Intravenous infusion
Administer only as a continuous peripheral intravenous infusion over 6 minutes as an adjunct to thallium-201 myocardial perfusion scintigraphy.
Inject thallium-201 at the midpoint of the adenosine infusion (i.e., after the first 3 minutes of adenosine infusion). Inject thallium-201 as close to the venous access as possible to prevent an inadvertent increase in the dose of adenosine (the contents of the intravenous tubing) being administered.
Storage: Vials are for single use only; discard any unused portion.

Other Injectable Administration

Intraosseous Administration
NOTE: Adenosine is not FDA-approved for intraosseous administration.
During cardiopulmonary resuscitation, the same dosage of adenosine may be given via the intraosseous route when IV access is unsuccessful or not feasible. Administer a saline flush after the dose.

Adverse Reactions
Severe

AV block / Early / 0.8-3.0
myocardial infarction / Delayed / 0-1.0
bradycardia / Rapid / 0-1.0
ventricular fibrillation / Early / 0-1.0
atrial fibrillation / Early / Incidence not known
cardiac arrest / Early / Incidence not known
torsade de pointes / Rapid / Incidence not known
heart failure / Delayed / Incidence not known
asystole / Rapid / Incidence not known
ventricular tachycardia / Early / Incidence not known
respiratory arrest / Rapid / Incidence not known
bronchospasm / Rapid / Incidence not known
intracranial bleeding / Delayed / Incidence not known
seizures / Delayed / Incidence not known
stroke / Early / Incidence not known

Moderate

dyspnea / Early / 12.0-28.0
hypotension / Rapid / 0-2.0
palpitations / Early / 0-1.0
hypertension / Early / 0-1.0
scotomata / Delayed / 0-1.0
blurred vision / Early / 0-1.0
chest pain (unspecified) / Early / Incidence not known
premature ventricular contractions (PVCs) / Early / Incidence not known
sinus tachycardia / Rapid / Incidence not known
loss of consciousness / Rapid / Incidence not known
infusion-related reactions / Rapid / Incidence not known
erythema / Early / Incidence not known

Mild

flushing / Rapid / 18.0-44.0
headache / Early / 2.0-18.0
dizziness / Early / 2.0-12.0
nausea / Early / 3.0-3.0
paresthesias / Delayed / 2.0-2.0
diaphoresis / Early / 0-1.0
cough / Delayed / 0-1.0
urinary urgency / Early / 0-1.0
nasal congestion / Early / 0-1.0
xerostomia / Early / 0-1.0
otalgia / Early / 0-1.0
metallic taste / Early / 0-1.0
emotional lability / Early / 0-1.0
weakness / Early / 0-1.0
back pain / Delayed / 0-1.0
drowsiness / Early / 0-1.0
tremor / Early / 0-1.0
premature atrial contractions (PACs) / Early / Incidence not known
hyperventilation / Early / Incidence not known
vomiting / Early / Incidence not known
injection site reaction / Rapid / Incidence not known
rash / Early / Incidence not known

Common Brand Names

Adenocard, Adenoscan

Dea Class

Rx

Description

Parenteral pharmacologic stress agent and antiarrhythmic
Used for adjunct to thallium-201 myocardial perfusion scintigraphy in patients unable to exercise adequately and for conversion to sinus rhythm of paroxysmal supraventricular tachycardia (PSVT)
Associated with cardiac arrest, sustained ventricular tachycardia, myocardial infarction, bronchoconstriction, and respiratory compromise; appropriate resuscitative measures should be available

Dosage And Indications
For the treatment of paroxysmal supraventricular tachycardia (PSVT), including that associated with Wolff-Parkinson-White (WPW) syndrome. Intravenous or Intraosseous† dosage Adults

6 mg IV/IO as a single dose. If conversion does not occur within 1 to 2 minutes, administer 12 mg IV/IO as a single dose.[29325] [45649] May repeat the 12 mg dose once if needed.[29325]

Children and Adolescents weighing 50 kg or more


6 mg IV/IO as a single dose. If conversion does not occur within 1 to 2 minutes, administer 12 mg IV/IO as a single dose.[29325] [45649] [64934] May repeat the 12 mg dose once if needed.[29325]

Infants, Children, and Adolescents weighing less than 50 kg

0.1 mg/kg/dose IV/IO as a single dose. If conversion does not occur within 1 to 2 minutes, administer 0.2 mg/kg/dose IV/IO as a single dose. [64934] The FDA-approved dosage is 0.05 to 0.1 mg/kg/dose IV as a single dose. If conversion does not occur within 1 to 2 minutes, increase the dose by 0.05 to 0.1 mg/kg/dose and repeat up to 0.3 mg/kg (Max: 12 mg/dose).[29325] However, studies have shown that initial doses of 0.05 mg/kg/dose and 0.1 mg/kg/dose terminate the arrhythmia in less than 10% and less than 37% of pediatric patients who received these doses, respectively. The median effective dose was approximately 0.2 mg/kg in infants and 0.1 to 0.15 mg/kg in children, leading some experts to recommend higher initial doses of 0.2 mg/kg/dose.[52002] [52003] [56507] [56508]

Neonates

0.1 mg/kg/dose IV/IO as a single dose. If conversion does not occur within 1 to 2 minutes, administer 0.2 mg/kg/dose IV/IO as a single dose. [64934] The FDA-approved dosage is 0.05 to 0.1 mg/kg/dose IV as a single dose. If conversion does not occur within 1 to 2 minutes, increase the dose by 0.05 to 0.1 mg/kg/dose and repeat up to 0.3 mg/kg.[29325] However, studies have shown that initial doses of 0.05 mg/kg/dose and 0.1 mg/kg/dose terminate the arrhythmia in less than 10% and less than 37% of pediatric patients who received these doses, respectively. The median effective dose was approximately 0.2 mg/kg in neonates and infants, leading some experts to recommend higher initial doses of 0.2 mg/kg/dose.[52002] [52003] [56507] [56508]

For use in coronary artery disease diagnosis (i.e., stress echocardiography) in patients unable to exercise adequately as an adjunct to thallium-201 myocardial perfusion imaging. Continuous Intravenous Infusion dosage (Adenoscan) Adults

140 mcg/kg/minute continuous IV infusion for 6 minutes for a total dose of 0.84 mg/kg (Max: 60 mg).

For acute vasodilator testing in pulmonary hypertension diagnosis†. Intravenous dosage Adults

50 mcg/kg/minute IV titrated by 50 mcg/kg/minute every 2 minutes up to a maximum of 250 mcg/kg/minute. Guidelines suggest that patients with pulmonary arterial hypertension undergo acute vasoreactivity testing with a short-acting agent in the absence of contraindications, including low systemic blood pressure, low systemic cardiac output, or the presence of functional class (FC) IV symptoms. Acute vasoreactivity is defined as a fall in mean pulmonary artery pressure (mPAP) more than 10 mmHg, to an mPAP less than 40 mmHg, with an unchanged or increased cardiac output.

For wide-complex tachycardia diagnosis† and conversion of wide-complex tachycardia of supraventricular origin† in hemodynamically stable patients. Intravenous or Intraosseous† dosage Adults

6 mg rapid IV/IO bolus followed immediately by a saline flush. If necessary, give a second dose of 12 mg rapid IV/IO bolus followed by a saline flush. May repeat the 12 mg dose once if needed.[29325] [45649] Reduce the initial dose to 3 mg if given by central access.[45649]

Infants, Children, and Adolescents

0.1 mg/kg (Max: 6 mg) rapid IV/IO bolus followed immediately by a saline flush. If necessary, give a second dose of 0.2 mg/kg (Max: 12 mg) rapid IV/IO bolus followed by a saline flush. Consider adenosine only if the rhythm is regular and the QRS is monomorphic. Do not use in patients with Wolff-Parkinson-White syndrome and wide-complex tachycardia.[43713]

†Indicates off-label use

Dosing Considerations
Hepatic Impairment

No dosage adjustment is needed.

Renal Impairment

No dosage adjustment is needed.
 
Intermittent hemodialysis
No dosage adjustment is needed.

Drug Interactions

Amlodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Atorvastatin: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Benazepril: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Celecoxib: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Olmesartan: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Valsartan: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Aspirin, ASA; Dipyridamole: (Major) The vasoactive effects of adenosine are potentiated by dipyridamole; smaller doses of adenosine may be effective if used concurrently with dipyridamole. When used for supraventricular tachyarrhythmias in adults, reduce the initial adenosine dose to 3 mg. When possible, withhold dipyridamole for at least 5 half-lives before adenosine use for diagnostic imaging.
Beta-adrenergic blockers: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Caffeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid caffeine-containing foods/beverages for at least 5 half-lives prior to the imaging study.
Calcium-channel blockers: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Carbamazepine: (Major) Carbamazepine increases the degree of heart block produced by adenosine. When used for supraventricular tachyarrhythmias in adults, reduce the initial adenosine dose to 3 mg. When possible, withhold carbamazepine for at least 5 half-lives before adenosine use for diagnostic imaging.
Clevidipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Digoxin: (Moderate) Use adenosine with caution in the presence of digoxin due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes. Concomitant use has rarely been associated with ventricular fibrillation.
Diltiazem: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Dipyridamole: (Major) The vasoactive effects of adenosine are potentiated by dipyridamole; smaller doses of adenosine may be effective if used concurrently with dipyridamole. When used for supraventricular tachyarrhythmias in adults, reduce the initial adenosine dose to 3 mg. When possible, withhold dipyridamole for at least 5 half-lives before adenosine use for diagnostic imaging.
Felodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Inotersen: (Moderate) Use caution with concomitant use of inotersen and adenosine due to the potential risk of bleeding from thrombocytopenia. Consider discontinuation of adenosine in a patient taking inotersen with a platelet count of less than 50,000 per microliter.
Isradipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Levamlodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Methylxanthines: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Nicardipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Nicotine: (Major) Nicotine has been reported to enhance the cardiovascular effects of adenosine; an increase in angina-like chest pains, heart rate or a decrease in blood pressure may be noted. While no special cautions are recommended when adenosine is used therapeutically to treat supraventricular tachycardia, it may be advisable for patients to avoid nicotine products or tobacco prior to electrophysiologic studies or stress testing where adenosine will be administered.
Nifedipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Nimodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Nisoldipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Perindopril; Amlodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Telmisartan; Amlodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Trandolapril; Verapamil: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Verapamil: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.

How Supplied

Adenocard/Adenoscan/Adenosine Intravenous Inj Sol: 1mL, 3mg

Maximum Dosage
Adults

12 mg/dose IV, with maximum total dosage up to 30 mg for PSVT; 0.84 mg/kg/dose (Max: 60 mg) IV for coronary artery disease diagnosis.

Geriatric

12 mg/dose IV, with maximum total dosage up to 30 mg for PSVT; 0.84 mg/kg/dose (Max: 60 mg) IV for coronary artery disease diagnosis.

Adolescents

Weighing 50 kg or more: 12 mg/dose IV/IO, with maximum total dosage up to 30 mg per PSVT episode; safety and efficacy for coronary artery disease diagnosis have not been established.
Weighing less than 50 kg: 0.3 mg/kg/dose IV/IO (Max: 12 mg); safety and efficacy for coronary artery disease diagnosis have not been established.

Children

Weighing 50 kg or more: 12 mg/dose IV/IO, with maximum total dosage up to 30 mg per PSVT episode; safety and efficacy for coronary artery disease diagnosis have not been established.
Weighing less than 50 kg: 0.3 mg/kg/dose IV/IO (Max: 12 mg); safety and efficacy for coronary artery disease diagnosis have not been established.

Infants

0.3 mg/kg/dose IV/IO; safety and efficacy for coronary artery disease diagnosis have not been established.

Neonates

0.3 mg/kg/dose IV/IO; safety and efficacy for coronary artery disease diagnosis have not been established.

Mechanism Of Action

Adenosine slows conduction time through the A-V node, can interrupt the reentry pathways through the A-V node, and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (PSVT), including PSVT associated with Wolff-Parkinson-White Syndrome.
 
Myocardial uptake of thallium-201 is directly proportional to coronary blood flow. Since adenosine significantly increases blood flow in normal coronary arteries with little or no increase in stenotic arteries, adenosine causes relatively less thallium-201 uptake in vascular territories supplied by stenotic coronary arteries (i.e., a greater difference is seen after adenosine between areas served by normal and areas served by stenotic vessels than is seen prior to adenosine). Adenosine causes cardiac vasodilation which increases cardiac blood flow. Adenosine is thought to exert its pharmacological effects through activation of purine receptors (cell-surface A1 and A2 adenosine receptors). Although the exact mechanism by which adenosine receptor activation relaxes vascular smooth muscle is not known, there is evidence to support both inhibition of the slow inward calcium current reducing calcium uptake, and activation of adenylate cyclase through A2 receptors in smooth muscle cells. Adenosine may also lessen vascular tone by modulating sympathetic neurotransmission. The intracellular uptake of adenosine is mediated by a specific transmembrane nucleoside transport system. Once inside the cell, adenosine is rapidly phosphorylated by adenosine kinase to adenosine monophosphate, or deaminated by adenosine deaminase to inosine. These intracellular metabolites of adenosine are not vasoactive.

Pharmacokinetics

Adenosine is administered intravenously. It distributes from the circulation via cellular uptake, primarily by erythrocytes and vascular endothelial cells. This process involves a specific transmembrane nucleoside carrier system that is reversible, nonconcentrative, and bidirectionally symmetrical. Intracellular adenosine is metabolized either via phosphorylation to adenosine monophosphate by adenosine kinase, or via deamination to inosine by adenosine deaminase in the cytosol. Since adenosine kinase has a lower Km and Vmax than adenosine deaminase, deamination plays a significant role only when cytosolic adenosine saturates the phosphorylation pathway. Inosine formed by deamination of adenosine can leave the cell intact or can be degraded to hypoxanthine, xanthine, and ultimately uric acid. Adenosine monophosphate formed by phosphorylation of adenosine is incorporated into the high-energy phosphate pool. While extracellular adenosine is primarily cleared from plasma by cellular uptake with a half-life of less than 10 seconds in whole blood, excessive amounts may be deaminated by an ecto-form of adenosine deaminase.
 
Affected cytochrome P450 isoenzymes and drug transporters: none

Pregnancy And Lactation
Pregnancy

Use adenosine during pregnancy only if clearly needed. It is not known if adenosine can cause fetal harm when administered to a pregnant woman. However, as adenosine is a naturally occurring material and dispersed widely in the body, fetal effects are not anticipated.

It is not known if adenosine is excreted into human milk. Because of the potential for serious adverse reactions from adenosine in nursing infants, interrupt breast-feeding after adenosine administration or do not administer adenosine, taking into account the importance of the drug to the mother.