|
This information has been developed and provided by an independent third-party source. Merck & Co., Inc. does not endorse and is not responsible for the accuracy of the content, or for practices or
standards of non-Merck sources.
Medication Safety Issues
High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.
Pronunciation
(a DEN oh seen)
U.S. Brand Names
Index Terms
Generic Available
Yes
Canadian Brand Names
Pharmacologic Category
Pharmacologic Category Synonyms
Use: Labeled Indications
Adenocard®: Treatment of paroxysmal supraventricular tachycardia (PSVT) including that associated with accessory bypass tracts (Wolff-Parkinson-White syndrome); when clinically advisable, appropriate vagal maneuvers should be attempted prior to adenosine administration; not effective in atrial flutter, atrial fibrillation, or ventricular tachycardia
Adenoscan®: Pharmacologic stress agent used in myocardial perfusion thallium-201 scintigraphy
Use: Unlabeled/Investigational
Adenoscan®: Acute vasodilator testing in pulmonary artery hypertension
Pregnancy Risk Factor
C
Pregnancy Considerations
Reports of administration during pregnancy have indicated no adverse effects on fetus or newborn attributable to adenosine.
Lactation
Excretion in breast milk unknown
Contraindications
Hypersensitivity to adenosine or any component of the formulation; second- or third-degree AV block or sick sinus syndrome (except in patients with a functioning artificial pacemaker), atrial flutter, atrial fibrillation, and ventricular tachycardia (this drug is not effective in converting these arrhythmias to sinus rhythm). The manufacturer states that Adenoscan® should be avoided in patients with known or suspected bronchoconstrictive or bronchospastic lung disease.
Warnings/Precautions
Concerns related to adverse effects:
• Atrial fibrillation/flutter: There have been reports of atrial fibrillation/flutter in patients with paroxysmal supraventricular tachycardia (PSVT) associated with accessory conduction pathways after adenosine. Does not convert afib/flutter to normal sinus rhythm; risk of serious arrhythmias/hypotension. Not for use in patients with afib/flutter associated with Wolff-Parkinson-White Syndrome.
• Conduction disturbances: Adenosine decreases conduction through the AV node and may produce first-, second-, or third-degree heart block. Patients with pre-existing S-A nodal dysfunction may experience prolonged sinus pauses after adenosine; use caution in patients with first-degree AV block or bundle branch block; avoid use of adenosine for pharmacologic stress testing in patients with high-grade AV block or sinus node dysfunction (unless a functional pacemaker is in place). Rare, prolonged episodes of asystole have been reported, with fatal outcomes in some cases.
• Hypotension: May produce profound vasodilation with subsequent hypotension. When used as a bolus dose (PSVT), effects are generally self-limiting (due to the short half-life of adenosine). However, when used as a continuous infusion (pharmacologic stress testing), effects may be more pronounced and persistent, corresponding to continued exposure. Use infusions with caution in patients with autonomic dysfunction, carotid stenosis (with cerebrovascular insufficiency), uncorrected hypovolemia, pericarditis, pleural effusion and/or stenotic valvular heart disease.
• Proarrhythmic effects: Watch for proarrhythmic effects; monitor and adjust dose to prevent QTc prolongation.
Disease-related concerns:
• Asthma: A limited number of patients with asthma have received adenosine and have not experienced exacerbation of their asthma. Adenosine may cause bronchoconstriction in patients with asthma; should be used cautiously in patients with obstructive lung disease not associated with bronchoconstriction (eg, emphysema, bronchitis).
• Electrolyte imbalance: Correct electrolyte disturbances, especially hypokalemia or hypomagnesemia, prior to use and throughout therapy.
Concurrent drug therapy issues:
• Caffeine: Pharmacologic stress testing: Withhold for five half-lives prior to adenosine use; avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
• Drugs which slow AV conduction: Use with caution in patients receiving other drugs which slow AV conduction (eg, digoxin, verapamil).
• Theophylline: Withhold for five half-lives prior to adenosine use whenever possible (eg, pharmacological stress testing).
Special populations:
• Elderly: Use with caution in the elderly; may be at increased risk of hemodynamic effects, bradycardia, and/or AV block.
Dosage form specific issues:
• Adenocard®: Transient AV block is expected. When used in PSVT, at the time of conversion to normal sinus rhythm, a variety of new rhythms may appear on the ECG. Administer as a rapid bolus, either directly into a vein or (if administered into an I.V. line), as close to the patient as possible (followed by saline flush).
Other warnings/precautions:
• CAST trial: In the Cardiac Arrhythmia Suppression Trial (CAST), recent (>6 days but <2 years ago) myocardial infarction patients with asymptomatic, nonlife-threatening ventricular arrhythmias did not benefit and may have been harmed by attempts to suppress the arrhythmia with flecainide or encainide. An increased mortality or nonfatal cardiac arrest rate (7.7%) was seen in the active treatment group compared with patients in the placebo group (3%). The applicability of the CAST results to other populations is unknown. Antiarrhythmic agents should be reserved for patients with life-threatening ventricular arrhythmias.
Adverse Reactions
Note: Frequency varies based on use; higher frequency of infusion-related effects, such as flushing and lightheadedness, were reported with continuous infusion (Adenoscan®).
>10%:
Cardiovascular: Facial flushing (18% to 44%)
Central nervous system: Headache (2% to 18%), lightheadedness (2% to 12%)
Neuromuscular & skeletal: Discomfort of neck, throat, jaw (<1% to 15%)
Respiratory: Dyspnea (12% to 28%), chest pressure/discomfort (7% to 40%)
1% to 10%:
Cardiovascular: Hypotension (<1% to 2%), AV block (infusion 6%; third degree <1%), ST segment depression (3%), palpitation, chest pain
Central nervous system: Dizziness, nervousness (2%), apprehension
Gastrointestinal: Nausea (3%)
Neuromuscular & skeletal: Upper extremity discomfort (up to 4%), numbness (up to 2%), paresthesia (up to 2%)
Respiratory: Hyperventilation
Miscellaneous: Diaphoresis
<1% (Limited to important or life-threatening): Back discomfort, burning sensation, blurred vision, intracranial pressure increased, metallic taste, pressure in groin
Postmarketing and/or case reports: Asystole (prolonged), atrial fibrillation, bradycardia, bronchospasm, hypertension (transient), injection site reaction, respiratory arrest, seizure, torsade de pointes, ventricular fibrillation, ventricular tachycardia
Drug Interactions
Dipyridamole: May enhance the therapeutic effect of Adenosine. Dose reduction of adenosine may be needed. Risk D: Consider therapy modification
Nicotine: May enhance the AV-blocking effect of Adenosine. Nicotine may enhance the tachycardic effect of Adenosine. Risk C: Monitor therapy
Theophylline Derivatives: May diminish the therapeutic effect of Adenosine. Risk D: Consider therapy modification
Ethanol/Nutrition/Herb Interactions
Food: Avoid food or drugs with caffeine. Adenosine's therapeutic effect may be decreased if used concurrently with caffeine. Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
Storage
Store at controlled room temperature of 15°C to 30°C (59°F to 86°F). Do not refrigerate; precipitation may occur (may dissolve by warming to room temperature).
Compatibility
Stable in D5LR, D5W, LR, NS.
Mechanism of Action
Slows conduction time through the AV node, interrupting the re-entry pathways through the AV node, restoring normal sinus rhythm
Pharmacodynamics/Kinetics
Onset of action: Rapid
Duration: Very brief
Metabolism: Blood and tissue to inosine then to adenosine monophosphate (AMP) and hypoxanthine
Half-life elimination: <10 seconds
Dosage
Adenocard®: Rapid I.V. push (over 1-2 seconds) via peripheral line:
Infants and Children:
Manufacturer's recommendation:
<50 kg: 0.05-0.1 mg/kg. If conversion of PSVT does not occur within 1-2 minutes, may increase dose by 0.05-0.1 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.
?50 kg: Refer to Adult dosing
Pediatric advanced life support (PALS): Treatment of SVT: I.V., I.O.: 0.1 mg/kg; if not effective, administer 0.2 mg/kg of PSVT; medium dose required: 0.15 mg/kg; maximum single dose: 12 mg. Follow each dose with normal saline flush.
Adults: 6 mg; if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed
Maximum single dose: 12 mg
Follow each I.V. bolus of adenosine with normal saline flush
Note: Preliminary results in adults suggest adenosine may be administered via a central line at lower doses (ie, initial adult dose: 3 mg).
Adenoscan®:
Stress testing: Continuous I.V. infusion via peripheral line: 140 mcg/kg/minute for 6 minutes using syringe or columetric infusion pump; total dose: 0.84 mg/kg. Thallium-201 is injected at midpoint (3 minutes) of infusion.
Acute vasodilator testing (unlabeled use): I.V.: Initial: 50 mcg/kg/minute increased by 50 mcg/kg/minute every 2 minutes to a maximum dose of 500 mcg/kg/minute; acutely assess vasodilator response
Hemodialysis: Significant drug removal is unlikely based on physiochemical characteristics.
Peritoneal dialysis: Significant drug removal is unlikely based on physiochemical characteristics.
Note: Higher doses may be needed for administration via peripheral versus central vein.
Administration: I.V.
For rapid bolus I.V. use only. Administer I.V. push over 1-2 seconds at a peripheral I.V. site as proximal as possible to trunk (ie, not in lower arm, hand, lower leg, or foot). If administered into an I.V. line, administer as close to the patient's heart as possible (followed by saline flush).
Administration: I.V. Detail
Do not mix with any other drugs in syringe or solution.
Monitoring Parameters
ECG monitoring, heart rate, blood pressure
Dietary Considerations
Avoid dietary caffeine for 12-24 hours prior to pharmacologic stress testing.
Patient Education
Adenosine is administered in emergencies; patient education should be appropriate to the situation. May cause facial flushing. Report chest pain or pressure, difficulty breathing immediately. Pregnancy precautions: Inform prescriber if you are pregnant.
Geriatric Considerations
Elderly patients may be more sensitive to the effects of this medication.
Anesthesia and Critical Care Concerns/Other Considerations
Short action is an advantage; has prolonged effects in patients taking dipyridamole or carbamazepine and in denervated transplanted hearts; adjust doses or choose alternative agent accordingly.
Adenosine acts via interruption of AV-nodal conduction and, when used for this purpose, requires administration as rapid intravenous push in increasing doses. Because of more direct access when administered through a central line, lower doses of adenosine may be tried in these situations. It is not uncommon to see heart block and sinus pause soon after adenosine administration. May aid in the identification of the arrhythmia by making the atrial fibrillation or flutter electrocardiographic morphology more apparent.
Cardiovascular Considerations
Adenosine may be effective in interrupting re-entrant tachycardias, both AV-nodal re-entrant tachycardias and supraventricular tachycardias secondary to accessory pathways. Adenosine acts via interruption of AV-nodal conduction and, when used for this purpose, requires administration as rapid intravenous push in increasing doses. Because of more direct access when administered through a central line, lower doses of adenosine may be tried in these situations. It is not uncommon to see heart block and sinus pause soon after adenosine administration. Cardiac denervation after cardiac transplantation may cause patients to be hypersensitive to the effects of adenosine. Patients will often experience shortness of breath and/or chest pain having unknown etiology. While adenosine will not convert atrial fibrillation or atrial flutter, the consequent AV-nodal conduction slowing (reduced ventricular rate), in this setting, may aid in the identification of the arrhythmia by making the atrial fibrillation or flutter electrocardiographic morphology more apparent.
Pulmonary Artery Hypertension: Patients with pulmonary artery hypertension who respond acutely to vasodilators have improved survival with the long-term use of a calcium channel blocker.
Dental Health: Effects on Dental Treatment
No significant effects or complications reported
Dental Health: Vasoconstrictor/Local Anesthetic Precautions
No information available to require special precautions
Mental Health: Effects on Mental Status
Dizziness is common; may cause nervousness, anxiety, drowsiness, or emotional instability
Mental Health: Effects on Psychiatric Treatment
Use caution with carbamazepine and tricyclic antidepressants, may increase heart block. Postmarking experience reports seizures as a potential adverse reaction. Psychotropics have the potential to lower seizure threshold. Monitor for seizure activity.
Nursing: Physical Assessment/Monitoring
Assess other medications patient may be taking for effectiveness and interactions. Requires use of infusion pump and continuous cardiac and hemodynamic monitoring during infusion. Monitor for adverse reactions. Note that adenosine could produce bronchoconstriction in patients with asthma.
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution [preservative free]: 3 mg/mL (2 mL, 4 mL)
Adenocard®: 3 mg/mL (2 mL, 4 mL)
Adenoscan®: 3 mg/mL (20 mL, 30 mL)
References
Ellenbogen KA, Thames MD, DiMarco JP, et al, “Electrophysiological Effects of Adenosine in the Transplanted Human Heart. Evidence of Supersensitivity,” Circulation, 1990, 81(3):821-8.
“Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 6: Advanced Cardiovascular Life Support, The American Heart Association in Collaboration With the International Liaison Committee on Resuscitation,” Circulation, 2000, 102(8 Suppl):I86-171.
“Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 10: Pediatric Advanced Life Support, The American Heart Association in Collaboration With the International Liaison Committee on Resuscitation,” Circulation, 2000, 102(8 Suppl):I291-342.
Harrison JK, Greenfield RA, and Wharton JM, “Acute Termination of Supraventricular Tachycardia by Adenosine During Pregnancy,” Am Heart J, 1992, 123(5):1386-8.
McIntosh-Yellin NL, Drew BJ, and Scheinman MM, “Safety and Efficacy of Central Intravenous Bolus Administration of Adenosine for Termination of Supraventricular Tachycardia,” J Am Coll Cardiol, 1993, 22(3):741-5.
Schrader BJ, Inbar S, Kaufmann L, et al, “Comparison of the Effects of Adenosine and Nifedipine in Pulmonary Hypertension,” J Am Coll Cardiol, 1992, 19(5):1060-4.
International Brand Names
Lexi-Comp.com
Last full review/revision August 2008
Content last modified August 2008
| 
