predict [2%:200 mcg/kg/minute provide minimal additional effect. For control of postoperative hypertension, as many as one-third of patients may require higher doses (250 to 300 mcg/kg/minute) to control blood pressure; the safety of doses >300 mcg/kg/minute has not been studied. Supraventricular tachycardia (SVT) or noncompensatory sinus tachycardia: IV: Loading dose (optional): 500 mcg/kg over 1 minute; follow with a 50 mcg/kg/minute infusion for 4 minutes; response to this initial infusion rate may be a rough indication of the responsiveness of the ventricular rate. Infusion may be continued at 50 mcg/kg/minute or, if the response is inadequate, titrated upward in 50 mcg/kg/minute increments (increased no more frequently than every 4 minutes) to a maximum of 200 mcg/kg/minute. To achieve more rapid response, following the initial loading dose and 50 mcg/kg/minute infusion, rebolus with a second 500 mcg/kg loading dose over 1 minute, and increase the maintenance infusion to 100 mcg/kg/minute for 4 minutes. If necessary, a third (and final) 500 mcg/kg loading dose may be administered, prior to increasing to an infusion rate of 150 mcg/kg/minute. After 4 minutes of the 150 mcg/kg/minute infusion, the infusion rate may be increased to a maximum rate of 200 mcg/kg/minute (without a bolus dose). The ACC/AHA/HRS supraventricular tachycardia guidelines recommend a maximum dose of 300 mcg/kg/minute (ACC/AHA/HRS [Page 2016]). Note: If a loading dose is not administered, a continuous infusion at a fixed dose reaches steady-state in ~30 minutes. In general, the usual effective dose is 50 to 200 mcg/kg/minute; doses as low as 25 mcg/kg/minute may be adequate. Maintenance infusions may be continued for up to 48 hours. Acute coronary syndromes (when relative contraindications to beta-blockade exist; off-label use): IV: 500 mcg/kg over 1 minute; follow with a 50 mcg/kg/minute infusion; if tolerated and response inadequate, may titrate upward in 50 mcg/kg/minute increments every 5 to 15 minutes to a maximum of 300 mcg/kg/minute (Mitchell 2002); an additional bolus (500 mcg/kg over 1 minute) may be administered prior to each increase in infusion rate (Mooss 1994) Electroconvulsive therapy (off-label use): IV: 1,000 mcg/kg administered 1 minute prior to induction of anesthesia (Weinger 1991) Intubation (off-label use): IV: 1,000 to 2,000 mcg/kg given 1.5 to 3 minutes prior to intubation (Kindler 1996; Levitt 2001; Ugur 2007) Thyrotoxicosis or thyroid storm (off-label use): IV: 50 to 100 mcg/kg/minute (Ross 2016) Guidelines for transfer to oral therapy (beta-blocker, calcium channel blocker): Infusion should be reduced by 50% thirty minutes following the first dose of the alternative agent Manufacturer suggests following the second dose of the alternative drug, patient's response should be monitored and if control is adequate for the first hour, esmolol may be discontinued. Dosing: Geriatric Refer to adult dosing. Dosing: Renal Impairment No dosage adjustment necessary. Not removed by hemo- or peritoneal dialysis. Supplemental dose is not necessary. Dosing: Hepatic Impairment No dosage adjustment necessary. Administration IV: Loading doses may be administered over 30 seconds to 1 minute depending on how urgent the need for effect. Infusion into small veins or through a butterfly catheter should be avoided (can cause thrombophlebitis). Medication port of premixed bags should be used to withdraw only the initial bolus, if necessary (not to be used for withdrawal of additional bolus doses). Vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation. Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity. Storage Clear, colorless to light yellow solution which should be stored at 25 C (77 F); excursions permitted to 15 C to 30 C (59 F to 86 F); do not freeze. Protect from excessive heat. Stable for at least 24 hours (under refrigeration or at controlled room temperature) at a final concentration of 10 mg/mL in D5W, D5LR, D5R, D5 1 / 2 NS, D5NS, LR, 1 / 2 NS, or NS. Drug Interactions Acetylcholinesterase Inhibitors: May enhance the bradycardic effect of Beta-Blockers. Monitor therapy Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Alpha-/Beta-Agonists (Direct-Acting): Beta-Blockers may enhance the vasopressor effect of Alpha-/Beta-Agonists (Direct-Acting). Epinephrine used as a local anesthetic for dental procedures will not likely cause clinically relevant problems. Some beta-adrenoceptor mediated effects of Alpha-/Beta-Agonists (Direct-Acting), including anti-anaphylactic effects of epinephrine, may be diminished by Beta-Blockers. Management: Cardioselective beta-blockers and lower doses of epinephrine may confer a more limited risk. Patients who may require acute subcutaneous epinephrine (e.g., bee sting kits) should probably avoid beta blockers. Consider therapy modification Alpha1-Blockers: Beta-Blockers may enhance the orthostatic hypotensive effect of Alpha1-Blockers. The risk associated with ophthalmic products is probably less than systemic products. Monitor therapy Alpha2-Agonists: May enhance the AV-blocking effect of Beta-Blockers. Sinus node dysfunction may also be enhanced. Beta-Blockers may enhance the rebound hypertensive effect of Alpha2-Agonists. This effect can occur when the Alpha2-Agonist is abruptly withdrawn. Management: Closely monitor heart rate during treatment with a beta blocker and clonidine. Withdraw beta blockers several days before clonidine withdrawal when possible, and monitor blood pressure closely. Recommendations for other alpha2-agonists are unavailable. Exceptions: Apraclonidine. Consider therapy modification Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered. Consider therapy modification Aminoquinolines (Antimalarial): May decrease the metabolism of Beta-Blockers. Monitor therapy Amiodarone: May enhance the bradycardic effect of Beta-Blockers. Possibly to the point of cardiac arrest. Amiodarone may increase the serum concentration of Beta-Blockers. Monitor therapy Amphetamines: May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy Antipsychotic Agents (Phenothiazines): May enhance the hypotensive effect of Beta-Blockers. Beta-Blockers may decrease the metabolism of Antipsychotic Agents (Phenothiazines). Antipsychotic Agents (Phenothiazines) may decrease the metabolism of Beta-Blockers. Monitor therapy Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Monitor therapy Barbiturates: May decrease the serum concentration of Beta-Blockers. Monitor therapy Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Beta2-Agonists: Beta-Blockers (Beta1 Selective) may diminish the bronchodilatory effect of Beta2-Agonists. Of particular concern with nonselective beta-blockers or higher doses of the beta1 selective beta-blockers. Monitor therapy Bradycardia-Causing Agents: May enhance the bradycardic effect of other Bradycardia-Causing Agents. Monitor therapy Bretylium: May enhance the bradycardic effect of Bradycardia-Causing Agents. Bretylium may also enhance atrioventricular (AV) blockade in patients receiving AV blocking agents. Monitor therapy Brigatinib: May diminish the antihypertensive effect of Antihypertensive Agents. Brigatinib may enhance the bradycardic effect of Antihypertensive Agents. Monitor therapy Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Bupivacaine: Beta-Blockers may increase the serum concentration of Bupivacaine. Monitor therapy Calcium Channel Blockers (Nondihydropyridine): May enhance the bradycardic effect of Esmolol. Management: Administration of IV verapamil or diltiazem together with esmolol is contraindicated if one agent is given while the effects of the other are still present. Canadian esmolol labeling specifies that use within 24 hours is contraindicated. Consider therapy modification Cardiac Glycosides: Beta-Blockers may enhance the bradycardic effect of Cardiac Glycosides. Monitor therapy Ceritinib: Bradycardia-Causing Agents may enhance the bradycardic effect of Ceritinib. Management: If this combination cannot be avoided, monitor patients for evidence of symptomatic bradycardia, and closely monitor blood pressure and heart rate during therapy. Avoid combination Cholinergic Agonists: Beta-Blockers may enhance the adverse/toxic effect of Cholinergic Agonists. Of particular concern are the potential for cardiac conduction abnormalities and bronchoconstriction. Management: Administer these agents in combination with caution, and monitor for conduction disturbances. Avoid methacholine with any beta blocker due to the potential for additive bronchoconstriction. Monitor therapy Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Dipyridamole: May enhance the bradycardic effect of Beta-Blockers. Monitor therapy Disopyramide: May enhance the bradycardic effect of Beta-Blockers. Beta-Blockers may enhance the negative inotropic effect of Disopyramide. Monitor therapy Dronedarone: May enhance the bradycardic effect of Beta-Blockers. Dronedarone may increase the serum concentration of Beta-Blockers. This likely applies only to those agents that are metabolized by CYP2D6. Management: Use lower initial beta-blocker doses; adequate tolerance of the combination, based on ECG findings, should be confirmed prior to any increase in beta-blocker dose. Consider therapy modification DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Monitor therapy Ergot Derivatives: Beta-Blockers may enhance the vasoconstricting effect of Ergot Derivatives. Exceptions: Nicergoline. Consider therapy modification Fingolimod: Esmolol may enhance the bradycardic effect of Fingolimod. Avoid combination Floctafenine: May enhance the adverse/toxic effect of Beta-Blockers. Avoid combination Grass Pollen Allergen Extract (5 Grass Extract): Beta-Blockers may enhance the adverse/toxic effect of Grass Pollen Allergen Extract (5 Grass Extract). More specifically, Beta-Blockers may inhibit the ability to effectively treat severe allergic reactions to Grass Pollen Allergen Extract (5 Grass Extract) with epinephrine. Some other effects of epinephrine may be unaffected or even enhanced (e.g., vasoconstriction) during treatment with Beta-Blockers. Consider therapy modification Herbs (Hypertensive Properties): May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy Herbs (Hypotensive Properties): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Monitor therapy Insulins: Beta-Blockers may enhance the hypoglycemic effect of Insulins. Monitor therapy Ivabradine: Bradycardia-Causing Agents may enhance the bradycardic effect of Ivabradine. Monitor therapy Lacosamide: Bradycardia-Causing Agents may enhance the AV-blocking effect of Lacosamide. Monitor therapy Levodopa: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa. Monitor therapy Lidocaine (Systemic): Beta-Blockers may increase the serum concentration of Lidocaine (Systemic). Monitor therapy Lidocaine (Topical): Beta-Blockers may increase the serum concentration of Lidocaine (Topical). Monitor therapy Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Mepivacaine: Beta-Blockers may increase the serum concentration of Mepivacaine. Monitor therapy Methacholine: Beta-Blockers may enhance the adverse/toxic effect of Methacholine. Avoid combination Methoxyflurane: May enhance the hypotensive effect of Beta-Blockers. Monitor therapy Methylphenidate: May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy Midodrine: Beta-Blockers may enhance the bradycardic effect of Midodrine. Monitor therapy Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Morphine (Systemic): May increase the serum concentration of Esmolol. Monitor therapy Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy NIFEdipine: May enhance the hypotensive effect of Beta-Blockers. NIFEdipine may enhance the negative inotropic effect of Beta-Blockers. Monitor therapy Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Monitor therapy Nonsteroidal Anti-Inflammatory Agents: May diminish the antihypertensive effect of Beta-Blockers. Monitor therapy Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Consider therapy modification Opioids (Anilidopiperidine): May enhance the bradycardic effect of Beta-Blockers. Opioids (Anilidopiperidine) may enhance the hypotensive effect of Beta-Blockers. Monitor therapy Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Monitor therapy Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Propafenone: May increase the serum concentration of Beta-Blockers. Propafenone possesses some independent beta blocking activity. Monitor therapy Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy Regorafenib: May enhance the bradycardic effect of Beta-Blockers. Monitor therapy Reserpine: May enhance the hypotensive effect of Beta-Blockers. Monitor therapy Rifamycin Derivatives: May decrease the serum concentration of Beta-Blockers. Exceptions: Rifabutin. Monitor therapy Rivastigmine: May enhance the bradycardic effect of Beta-Blockers. Avoid combination Ruxolitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Management: Ruxolitinib Canadian product labeling recommends avoiding use with bradycardia-causing agents to the extent possible. Monitor therapy Succinylcholine: Esmolol may enhance the neuromuscular-blocking effect of Succinylcholine. Monitor therapy Sulfonylureas: Beta-Blockers may enhance the hypoglycemic effect of Sulfonylureas. Cardioselective beta-blockers (eg, acebutolol, atenolol, metoprolol, and penbutolol) may be safer than nonselective beta-blockers. All beta-blockers appear to mask tachycardia as an initial symptom of hypoglycemia. Ophthalmic beta-blockers are probably associated with lower risk than systemic agents. Monitor therapy Terlipressin: May enhance the bradycardic effect of Bradycardia-Causing Agents. Monitor therapy Theophylline Derivatives: Beta-Blockers (Beta1 Selective) may diminish the bronchodilatory effect of Theophylline Derivatives. Management: Monitor for reduced theophylline efficacy during concomitant use with any beta-blocker. Beta-1 selective agents are less likely to antagonize theophylline than nonselective agents, but selectivity may be lost at higher doses. Monitor therapy Tofacitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Monitor therapy Yohimbine: May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy Adverse Reactions >10%: Cardiovascular: Decreased blood pressure (20% to 50%), asymptomatic hypotension (dose related: 25%), symptomatic hypotension (dose related: 12%) 1% to 10%: Cardiovascular: Peripheral ischemia (1%) Central nervous system: Dizziness (3%), drowsiness (3%), agitation (2%), confusion (2%), headache (2%) Gastrointestinal: Nausea (7%), vomiting (1%) Local: Infusion site reaction (8%; including inflammation, irritation, and severe reactions associated with extravasation [eg, blistering, necrosis, thrombophlebitis])]} Drug Status Rx Availability Prescription only C Pregnancy Category Risk cannot be ruled out N/A CSA Schedule Not a controlled drug Approval History Drug history at FDA WADA Class Anti-Doping Classification Esmolol Rating No Reviews - Be the first! No Reviews - Be the first! Not Rated - Be the first! Manufacturers Baxter International Inc. Mylan Pharmaceuticals Inc. Fresenius Kabi USA, LLC Drug Class Cardioselective beta blockers Group II antiarrhythmics Related Drugs cardioselective beta blockers metoprolol , atenolol , Toprol-XL , Bystolic group II antiarrhythmics propranolol , Inderal , acebutolol , Inderal LA , Sectral , InnoPran XL High Blood Pressure amlodipine , lisinopril , hydrochlorothiazide , furosemide , losartan , metoprolol , More... Atrial Fibrillation diltiazem , Xarelto , propranolol , digoxin , sotalol , flecainide , More... Supraventricular Tachycardia metoprolol , atenolol , diltiazem , amiodarone , verapamil , More... 2 more conditions...} } sensible
capability Esmolol beat back
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