Adenosine
Pronunciation
(a DEN oh seen)
U.S. Brand Names
Adenocard®; Adenoscan®
Synonyms
9-Beta-D-ribofuranosyladenine
Generic Available
Yes
Canadian Brand Names
Adenocard®
Use
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
Pregnancy Risk Factor
C
Pregnancy Implications
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
Patients with pre-existing S-A nodal dysfunction may experience prolonged sinus pauses after adenosine. There have been reports of atrial fibrillation/flutter in patients with PSVT associated with accessory conduction pathways after adenosine. Adenosine decreases conduction through the AV node and may produce a short-lasting first-, second-, or third-degree heart block. Because of the very short half-life, the effects are generally self-limiting. Rare, prolonged episodes of asystole have been reported, with fatal outcomes in some cases. At the time of conversion to normal sinus rhythm, a variety of new rhythms may appear on the ECG. 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, and should be used cautiously in patients with obstructive lung disease not associated with bronchoconstriction (eg, emphysema, bronchitis).
Adverse Reactions
>10%:
Cardiovascular: Facial flushing (18%), palpitation, chest pain, hypotension
Central nervous system: Headache
Respiratory: Dyspnea (12%)
Miscellaneous: Diaphoresis
1% to 10%:
Central nervous system: Dizziness
Gastrointestinal: Nausea (3%)
Neuromuscular & skeletal: Paresthesia, numbness
Respiratory: Chest pressure (7%)
<1% (Limited to important or life-threatening): Hypotension, lightheadedness, headache, dizziness, intracranial pressure, hyperventilation
Overdosage/Toxicology
Since adenosine half-life is <10 seconds, adverse effects are rapidly self-limiting. Treatment of prolonged effects requires individualization. Theophylline and other methylxanthines are competitive inhibitors of adenosine and may have a role in reversing its toxic effects.
Drug Interactions
Carbamazepine may increase heart block.
Dipyridamole potentiates effects of adenosine; reduce dose of adenosine.
Theophylline and caffeine (methylxanthines) antagonize adenosine's effects; may require increased dose of adenosine.
Ethanol/Nutrition/Herb Interactions
Food: Avoid food or drugs with caffeine. Adenosine's therapeutic effect may be decreased if used concurrently with caffeine.
Stability
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 to 0.1 mg/kg. If conversion of PSVT does not occur within 1-2 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.
50 kg: Refer to Adults 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®: 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.
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
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 (not in lower arm, hand, lower leg, or foot); follow each bolus with normal saline flush.
Note:
Preliminary results in adults suggest adenosine may be administered via central line at lower doses (eg, adults initial dose: 3 mg)
Monitoring Parameters
ECG monitoring, heart rate, blood pressure
Patient Education
Adenosine is administered in emergencies, patient education should be appropriate to the situation.
Nursing Implications
Be alert for possible exacerbation of asthma in asthmatic patients
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. 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.
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
May rarely see anxiety
Mental Health: Effects on Psychiatric Treatment
Use caution with carbamazepine and tricyclic antidepressants, may increase heart block
Dosage Forms
Injection, solution [preservative free]: 3 mg/mL (2 mL)
Adenocard®: 3 mg/mL (2 mL, 4 mL)
Adenoscan®: 3 mg/mL (20 mL, 30 mL)
References
"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.
International Brand Names
Adenocard® (BR, CA); Adenocor® (AU, BE, BG, DK, ES, FI, GB, HU, IE, IL, LU, NL, NO, NZ, PL, RO, RU, SG, TH, ZA); Adenoject® (IN); Adenoscan® (AT, AU, DE, ES); Adénoscan® (FR); Adenoscan® (GB, IT); Adenosina Biol® (AR); Adenosin Ebewe® (AT, CZ, PL); Adenosin Item® (DE, DK, SE); Adenosin® (NO); Adényl® (FR); Adrekar® (AT, DE); Euritisin® (AR); Fosfobion® (RO); Krenosin® (CH, FR, IT, LU); Soladen® (PL); Tricor® (CL)
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