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ALERT: U.S. Boxed Warning
The FDA-approved labeling includes a boxed warning. See Warnings/Precautions section and/or refer to product labeling for additional detail.
Medication Safety Issues
Sound-alike/look-alike issues:
DOPamine may be confused with DOBUTamine, Dopram®
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
(DOE pa meen)
Index Terms
Generic Available
Yes
Pharmacologic Category
Use: Labeled Indications
Adjunct in the treatment of shock (eg, MI, open heart surgery, renal failure, cardiac decompensation) which persists after adequate fluid volume replacement
Use: Unlabeled/Investigational
Symptomatic bradycardia or heart block unresponsive to atropine or pacing
Pregnancy Risk Factor
C
Lactation
Excretion in breast milk unknown
Contraindications
Hypersensitivity to sulfites (commercial preparation contains sodium bisulfite); pheochromocytoma; ventricular fibrillation
Warnings/Precautions
Boxed warnings:
• Extravasation: See “Other warnings/precautions” below.
Concerns related to adverse effects:
• Arrhythmias: May cause increases in arrhythmias.
• Tachycardia: May cause increases in heart rate.
• Tissue necrosis: Avoid infiltration - may cause severe tissue necrosis.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with cardiovascular disease, cardiac arrhythmias and/or occlusive vascular disease.
• Myocardial infarct (post): Use with caution in patients post-MI.
Concurrent drug therapy issues:
• Monoamine oxidase inhibitors (MAO-I): Use with extreme caution in patients taking MAO inhibitors; prolong hypertension may result from concurrent use.
Dosage form specific issues:
• Sodium metabisulfite: Product may contain sodium metabisulfite.
Other warnings/precautions:
• Appropriate use: Assure adequate circulatory volume to minimize need for vasoconstrictors. Avoid hypertension; monitor blood pressure closely and adjust infusion rate.
• Extravasation: Avoid extravasation; infuse into a large vein if possible. Avoid infusion into leg veins. Watch I.V. site closely. [U.S. Boxed Warning]: If extravasation occurs, infiltrate the area with diluted phentolamine (5-10 mg in 10-15 mL of saline) with a fine hypodermic needle. Phentolamine should be administered as soon as possible after extravasation is noted.
Adverse Reactions
Frequency not defined.
Most frequent:
Cardiovascular: Ectopic beats, tachycardia, anginal pain, palpitation, hypotension, vasoconstriction
Central nervous system: Headache
Gastrointestinal: Nausea and vomiting
Respiratory: Dyspnea
Infrequent:
Cardiovascular: Aberrant conduction, bradycardia, widened QRS complex, ventricular arrhythmia (high dose), gangrene (high dose), hypertension
Central nervous system: Anxiety
Endocrine & metabolic: Piloerection, serum glucose increased (usually not above normal limits)
Local: Extravasation of dopamine can cause tissue necrosis and sloughing of surrounding tissues
Ocular: Intraocular pressure increased, dilated pupils
Renal: Azotemia, polyuria
Drug Interactions
Cannabinoids: May enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy
COMT Inhibitors: May decrease the metabolism of COMT Substrates. Risk C: Monitor therapy
Sympathomimetics: May enhance the adverse/toxic effect of other Sympathomimetics. Risk C: Monitor therapy
Storage
Protect from light. Solutions that are darker than slightly yellow should not be used.
Compatibility
Stable in D5LR, D51/2NS, D5NS, D5W, D10W, LR, mannitol 20%, NS; incompatible with sodium bicarbonate 5%, and alkaline solutions or iron salts.
Y-site administration: Compatible: Alatrofloxacin, aldesleukin, amifostine, amiodarone, atracurium, aztreonam, cefpirome, ciprofloxacin, cisatracurium, cladribine, clarithromycin, diltiazem, dobutamine, dobutamine with lidocaine, dobutamine with nitroglycerin, dobutamine with sodium nitroprusside, docetaxel, doxorubicin liposome, enalaprilat, epinephrine, esmolol, etoposide, famotidine, fentanyl, fluconazole, foscarnet, gatifloxacin, gemcitabine, granisetron, haloperidol, heparin, hydrocortisone sodium succinate, hydromorphone, inamrinone, labetalol, levofloxacin, lidocaine, lidocaine with nitroglycerin, lidocaine with sodium nitroprusside, linezolid, lorazepam, meperidine, methylprednisolone sodium succinate, metronidazole, midazolam, milrinone, morphine, nicardipine, nitroglycerin, nitroglycerin with sodium nitroprusside, norepinephrine, ondansetron, pancuronium, piperacillin/tazobactam, potassium chloride, propofol, ranitidine, remifentanil, sargramostim, sodium nitroprusside, streptokinase, tacrolimus, theophylline, thiotepa, tirofiban, tolazoline, vecuronium, verapamil, vitamin B complex with C, warfarin, zidovudine. Incompatible: Acyclovir, alteplase, amphotericin B cholesteryl sulfate complex, cefepime, indomethacin, insulin (regular), thiopental. Variable (consult detailed reference): Furosemide, TPN.
Compatibility in syringe: Compatible: Doxapram, heparin, ranitidine.
Compatibility when admixed: Compatible: Aminophylline, atracurium, bretylium, calcium chloride, chloramphenicol, dobutamine, enalaprilat, flumazenil, heparin, hydrocortisone sodium succinate, kanamycin, lidocaine, meropenem, methylprednisolone sodium succinate, nitroglycerin, oxacillin, potassium chloride, propafenone, ranitidine, verapamil. Incompatible: Acyclovir, alteplase, amphotericin B, ampicillin, metronidazole with sodium bicarbonate, penicillin G potassium. Variable (consult detailed reference): Gentamicin.
Mechanism of Action
Stimulates both adrenergic and dopaminergic receptors, lower doses are mainly dopaminergic stimulating and produce renal and mesenteric vasodilation, higher doses also are both dopaminergic and beta1-adrenergic stimulating and produce cardiac stimulation and renal vasodilation; large doses stimulate alpha-adrenergic receptors
Pharmacodynamics/Kinetics
Children: Dopamine has exhibited nonlinear kinetics in children; with medication changes, may not achieve steady-state for ~1 hour rather than 20 minutes
Onset of action: Adults: 5 minutes
Duration: Adults: <10 minutes
Metabolism: Renal, hepatic, plasma; 75% to inactive metabolites by monoamine oxidase and 25% to norepinephrine
Half-life elimination: 2 minutes
Excretion: Urine (as metabolites)
Clearance: Neonates: Varies and appears to be age related; clearance is more prolonged with combined hepatic and renal dysfunction
Dosage
I.V. infusion (administration requires the use of an infusion pump):
Neonates: 1-20 mcg/kg/minute continuous infusion, titrate to desired response.
Children: 1-20 mcg/kg/minute, maximum: 50 mcg/kg/minute continuous infusion, titrate to desired response.
Adults: 1-5 mcg/kg/minute up to 20 mcg/kg/minute, titrate to desired response (maximum: 50 mcg/kg/minute). Infusion may be increased by 1-4 mcg/kg/minute at 10- to 30-minute intervals until optimal response is obtained.
If dosages >20-30 mcg/kg/minute are needed, a more direct-acting pressor may be more beneficial (ie, epinephrine, norepinephrine).
The hemodynamic effects of dopamine are dose dependent:
Low-dose: 1-3 mcg/kg/minute, increased renal blood flow and urine output
Intermediate-dose: 3-10 mcg/kg/minute, increased renal blood flow, heart rate, cardiac contractility, and cardiac output
High-dose: >10 mcg/kg/minute, alpha-adrenergic effects begin to predominate, vasoconstriction, increased blood pressure
Administration: I.V.
Vesicant. Must be diluted prior to use. Do not discontinue suddenly - sudden discontinuation may lead to marked hypotension.
Administration: I.V. Detail
Monitor continuously for free flow. Administration into an umbilical arterial catheter is not recommended; central line administration.
Extravasation management: Due to short half-life, withdrawal of drug is often only necessary treatment. Use phentolamine as antidote. Mix 5 mg with 9 mL of NS; inject a small amount of this dilution into extravasated area. Blanching should reverse immediately. Monitor site. If blanching should recur, additional injections of phentolamine may be needed.
pH: 3.3-3.6
Monitoring Parameters
Blood pressure, ECG, heart rate, CVP, RAP, MAP, urine output; if pulmonary artery catheter is in place, monitor Cl, PCWP, SVR, and PVR
Patient Education
When administered in emergencies, patient education should be appropriate to the situation. If patient is aware, instruct to promptly report chest pain, palpitations, rapid heartbeat, headache, nervousness or restlessness, nausea or vomiting, or respiratory difficulty.
Geriatric Considerations
Has not been specifically studied in the elderly; monitor closely, especially due to increase in cardiovascular disease with age.
Additional Information
Dopamine is most frequently used for treatment of hypotension because of its peripheral vasoconstrictor action. In this regard, dopamine is often used together with dobutamine and minimizes hypotension secondary to dobutamine-induced vasodilation. Thus, pressure is maintained by increased cardiac output (from dobutamine) and vasoconstriction (by dopamine). It is critical neither dopamine nor dobutamine be used in patients in the absence of correcting any hypovolemia as a cause of hypotension.
Low-dose dopamine is often used in the intensive care setting for presumed beneficial effects on renal function. However, there is no clear evidence that low-dose dopamine confers any renal or other benefit. Indeed, dopamine may act on dopamine receptors in the carotid bodies causing chemoreflex suppression. In patients with heart failure, dopamine may inhibit breathing and cause pulmonary shunting. Both these mechanisms would act to decrease minute ventilation and oxygen saturation. This could potentially be deleterious in patients with respiratory compromise and patients being weaned from ventilators.
Anesthesia and Critical Care Concerns/Other Considerations
Low-Dose Dopamine: There is no clear evidence that low-dose dopamine confers any renal benefit. The 2004 ACCM/SCCM Practice Parameters for Hemodynamic Support of Sepsis in Adult Patients recommends against the use of low doses of dopamine to maintain renal function. Low-dose dopamine may increase renal blood flow in some patients requiring norepinephrine. Kellum and Decker (2001) reviewed 58 studies in a meta-analysis focused on determining if low-dose dopamine reduced the severity of acute renal failure, the need for dialysis, or mortality in critically-ill patients. They concluded that the use of low-dose dopamine for the treatment or prevention of acute renal failure cannot be justified. A more recent randomized, double-blind, placebo-controlled trial came to a similar conclusion (Australian and New Zealand Intensive Care Society Clinical Trials Group, 2000). This study enrolled over 300 ICU patients with clinical evidence of renal dysfunction. They were randomized to low-dose dopamine (2 mcg/kg/minute) or placebo. The investigators found no difference in serum creatinine, renal replacement therapy, intensive care length of stay, hospital stay, or mortality between the groups. The 2008 Surviving Sepsis Campaign guidelines also recommend against the use of low-dose dopamine for renal protection (Grade 1A).
Septic Shock: In septic shock, dopamine is effective in increasing mean arterial pressure in patients who remain hypotensive after adequate volume expansion. Undesirable effects include tachycardia, increased pulmonary shunt, and decreased PaO2. As catecholamine stores are depleted, tachyphylaxis may occur. The 2004 ACCM/SCCM Practice Parameters for Hemodynamic Support of Sepsis in Adult Patients recommend either norepinephrine or dopamine as vasopressor therapy. Norepinephrine has a wider dosage range than dopamine.
The 2008 Surviving Sepsis Campaign guidelines recommend using either norepinephrine or dopamine as the first-choice vasopressor agent in adult patients (Grade 1C). Norepinephrine is more potent than dopamine and may be more effective at reversing hypotension in septic shock. In pediatric patients with hypotension refractory to fluid resuscitation, the Surviving Sepsis Campaign guidelines suggest dopamine as the first choice of support (Grade 2C).
Cardiovascular Considerations
Dopamine is most frequently used for treatment of hypotension because of its peripheral vasoconstrictor action. In this regard, dopamine is often used together with dobutamine and minimizes hypotension secondary to dobutamine-induced vasodilation. Thus, pressure is maintained by increased cardiac output (from dobutamine) and vasoconstriction (by dopamine). It is critical neither dopamine nor dobutamine be used in patients in the absence of correcting any hypovolemia as a cause of hypotension.
Low-dose dopamine is often used in the intensive care setting for presumed beneficial effects on renal function. However, there is no clear evidence that low-dose dopamine confers any renal or other benefit. Indeed, dopamine may act on dopamine receptors in the carotid bodies causing chemoreflex suppression. In patients with heart failure, dopamine may inhibit breathing and cause pulmonary shunting. Both these mechanisms would act to decrease minute ventilation and oxygen saturation. This could potentially be deleterious in patients with respiratory compromise and patients being weaned from ventilators.
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
None reported
Mental Health: Effects on Psychiatric Treatment
Dopamine's effects may be enhanced by MAO inhibitors
Nursing: Physical Assessment/Monitoring
Assess other medications patient may be taking for effectiveness and interactions. Infusion pump, continuous cardiac and hemodynamic monitoring, and frequent assessment of I.V. site is required for inpatient therapy. Low-dose home infusion therapy requires frequent monitoring of cardiac and renal status and adverse reactions. Monitor therapeutic effectiveness and adverse reactions. Instruct patient on adverse symptoms to report.
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Infusion, as hydrochloride [premixed in D5W]: 0.8 mg/mL (250 mL, 500 mL); 1.6 mg/mL (250 mL, 500 mL); 3.2 mg/mL (250 mL)
Injection, solution, as hydrochloride: 40 mg/mL (5 mL, 10 mL); 80 mg/mL (5 mL); 160 mg/mL (5 mL) [contains sodium metabisulfite]
References
Bellomo R, Chapman M, Finfer S, et al, “Low-dose Dopamine in Patients With Early Renal Dysfunction: A Placebo-Controlled Randomised Trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group,” Lancet, 2000, 356(9248):2139-43.
Chan TY, “Low-Dose Dopamine in Severe Right Heart Failure and Chronic Obstructive Pulmonary Disease,” Ann Pharmacother, 1995, 29(5):493-6.
Dellinger RP, Carlet JM, Masur H, et al, “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” Crit Care Med, 2004, 32(3):858-73.
Dellinger RP, Levy MM, Carlet JM, et al, “Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008,” Intensive Care Med, 2008, 34(1): 17-60. Available at http://www.survivingsepsis.org/system/files/images/2008_20International_20SSC_20Guidelines_1_.pdf
Johnson RL Jr, “Low-Dose Dopamine and Oxygen Transport by the Lung,” Circulation, 1998, 98(2):97-9.
Kellum JA and Decker J, “Use of Dopamine in Acute Renal Failure: A Meta-Analysis,” Crit Care Med, 2001, 29(8):1526-31.
Martin C, Papazian L, Perrin G, et al, “Norepinephrine or Dopamine for the Treatment of Hyperdynamic Septic Shock?” Chest, 1993, 103(6):1826-31.
“Practice Parameters for Hemodynamic Support of Sepsis in Adult Patients in Sepsis. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine,” Crit Care Med, 1999, 27(3):639-60. Available at: http://www.sccm.org/pdf/Hemodynamic%20Support.pdf. Accessed August 13, 2003.
van de Borne P, Oren R, and Somers VK, “Dopamine Depresses Minute Ventilation in Patients With Heart Failure,” Circulation, 1998, 98(2):126-31.
International Brand Names
Lexi-Comp.com
Last full review/revision August 2008
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