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Wednesday, October 12, 2016

Epivir

Generic Name: lamivudine (Oral route)

la-MIV-ue-deen

Oral route(Tablet;Solution)

Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported. Severe acute exacerbations of hepatitis B have been reported in patients who have hepatitis B infection or are co-infected with hepatitis B virus (HBV) and HIV-1 and have discontinued lamivudine; monitor hepatic function upon discontinuation of therapy. EPIVIR(R) tablets and oral solution (used to treat HIV-1 infection) contain a higher dose of the active ingredient (lamivudine) than EPIVIR-HBV(R) tablets and oral solution (used to treat chronic hepatitis B). Patients with HIV infection should receive only dosage forms appropriate for treatment of HIV-1. EPIVIR-HBV(R) tablets and oral solution contain a lower dose of the same active ingredient (lamivudine) as EPIVIR(R) tablets and oral solution used to treat HIV infection. If treatment with EPIVIR-HBV(R) is prescribed for chronic hepatitis B for a patient with unrecognized or untreated HIV infection, rapid emergence of HIV resistance is likely because of subtherapeutic dose and inappropriate monotherapy .

Commonly used brand name(s)

In the U.S.

Epivir

Epivir A/F

Epivir HBV

In Canada

Heptovir

Available Dosage Forms:

Solution

Tablet

Therapeutic Class: Antiretroviral Agent

Pharmacologic Class: Nucleoside Reverse Transcriptase Inhibitor

Uses For Epivir

Lamivudine is used in the treatment of the infection caused by the human immunodeficiency virus (HIV) or hepatitis B virus. HIV is the virus that causes acquired immune deficiency syndrome (AIDS). Lamivudine is taken together with zidovudine (AZT) or other medications used to treat HIV.

Lamivudine will not cure or prevent HIV infection or AIDS; however, it helps keep HIV from reproducing and appears to slow down the destruction of the immune system. This may help delay the development of problems usually related to AIDS or HIV disease. Lamivudine will not keep you from spreading HIV to other people. People who receive this medicine may continue to have other problems usually related to AIDS or HIV disease. Lamivudine is not a cure for the hepatitis B virus; the long-term effects of the drug on the infection and the liver are unknown at this time.

Lamivudine is available only with your doctor's prescription.

Once a medicine has been approved for marketing for a certain use, experience may show that it is also useful for other medical problems. Although this use is not included in product labeling, lamivudine is used in certain patients with the following medical condition:

Human immunodeficiency virus (HIV) infection due to occupational exposure (possible prevention of)

Before Using Epivir

In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For this medicine, the following should be considered:

Allergies

Tell your doctor if you have ever had any unusual or allergic reaction to this medicine or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully.

Pediatric

Lamivudine can cause serious side effects. In one study, children with advanced AIDS were more likely than children who were less ill to develop pancreatitis (inflammation of the pancreas) and peripheral neuropathy (a problem involving the nerves). Therefore, it is especially important that you discuss with your child's doctor the good that this medicine may do as well as the risks of using it. Your child must be seen frequently and your child's progress carefully followed by the doctor while the child is taking lamivudine.

Geriatric

Lamivudine has not been studied specifically in older people. Therefore, it is not known whether it causes different side effects or problems in the elderly than it does in younger adults. Talk to your doctor first if you have liver, kidney, heart problems or other diseases. Your doctor may need to adjust your dose.

Pregnancy

	Pregnancy Category	Explanation
All Trimesters	C	Animal studies have shown an adverse effect and there are no adequate studies in pregnant women OR no animal studies have been conducted and there are no adequate studies in pregnant women.

Breast Feeding

There are no adequate studies in women for determining infant risk when using this medication during breastfeeding. Weigh the potential benefits against the potential risks before taking this medication while breastfeeding.

Interactions with Medicines

Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are taking this medicine, it is especially important that your healthcare professional know if you are taking any of the medicines listed below. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.

Using this medicine with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

Interferon Alfa

Ribavirin

Zalcitabine

Interactions with Food/Tobacco/Alcohol

Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. Discuss with your healthcare professional the use of your medicine with food, alcohol, or tobacco.

Proper Use of lamivudine

This section provides information on the proper use of a number of products that contain lamivudine. It may not be specific to Epivir. Please read with care.

Take this medicine exactly as directed by your doctor. Do not take more of it, do not take it more often, and do not take it for a longer time than your doctor ordered. Also, do not stop taking lamivudine or zidovudine without checking with your doctor first.

Keep taking lamivudine for the full time of treatment , even if you begin to feel better.

This medicine works best when there is a constant amount in the blood. To help keep the amount constant, do not miss any doses . If you need help in planning the best times to take your medicine, check with your health care professional.

If you are using lamivudine oral suspension, use a specially marked measuring spoon or other device to measure each dose accurately. The average household teaspoon may not hold the right amount of liquid. The lamivudine oral suspension contains sucrose. Tell your doctor if you are diabetic before you start taking this medicine.

Only take medicine that your doctor has prescribed specifically for you. Do not share your medicine with others.

Dosing

The dose of this medicine will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of this medicine. If your dose is different, do not change it unless your doctor tells you to do so.

The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.

For oral dosage forms (oral solution and tablets):
- For treatment of hepatitis B infection:
  - Adults —100 milligrams (mg) once a day.
  - Children younger than 16 years of age—Use and dose must be determined by your doctor.
- For treatment of HIV infection or AIDS:
  - Adults weighing 50 kilograms (kg) (110 pounds) or more—150 milligrams (mg) twice a day together with other HIV medications.
  - Adults weighing less than 50 kg (110 pounds)—2 mg per kg of body weight twice a day together with other HIV medications.
  - Children 3 months to 16 years of age—4 mg per kg of body weight, up to 150 mg per dose, twice a day together with other HIV medications.
  - Children younger than 3 months of age—Use and dose must be determined by your doctor.

Note: Patients that require treatment for both hepatitis B and either AIDS or HIV should follow the dosing schedule for HIV or AIDS

Missed Dose

If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

Storage

Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.

Keep out of the reach of children.

Do not keep outdated medicine or medicine no longer needed.

Precautions While Using Epivir

It is very important that your doctor check your progress at regular visits.

Do not take any other medicines without checking with your doctor first. To do so may increase the chance of side effects from lamivudine.

If you have both HIV and hepatitis B virus (HBV) infections, deterioration of liver disease has occurred when lamivudine treatment is stopped. Discuss any changes in your treatment and medicines with your doctor.

HIV may be acquired from or spread to other people through infected body fluids, including blood, vaginal fluid, or semen. If you are infected, it is best to avoid any sexual activity involving an exchange of body fluids with other people. If you do have sex, always wear (or have your partner wear) a condom (“rubber”). Only use condoms made of latex, and use them every time you have vaginal, anal, or oral sex. The use of a spermicide (such as nonoxynol-9) may also help prevent transmission of HIV if it is not irritating to the vagina, rectum, or mouth. Spermicides have been shown to kill HIV in lab tests. Do not use oil-based jelly, cold cream, baby oil, or shortening as a lubricant—these products can cause the condom to break. Lubricants without oil, such as K-Y Jelly, are recommended. Women may wish to carry their own condoms. Birth control pills and diaphragms will help protect against pregnancy, but they will not prevent someone from giving or getting the AIDS virus. If you inject drugs, get help to stop. Do not share needles or equipment with anyone. In some cities, more than half of the drug users are infected, and sharing even 1 needle or syringe can spread the virus. If you have any questions about this, check with your health care professional.

Epivir Side Effects

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur:

More common—especially in children

Abdominal or stomach pain (severe)

feeling of fullness

nausea

sensation or pins and needles

skin rash

stabbing pain

tingling, burning, numbness, or pain in the hands, arms, feet, or legs

unsteadiness or awkwardness

vomiting

Rare

Abdominal discomfort

decreased appetite

diarrhea

fast, shallow breathing

feeling of fullness

fever, chills, or sore throat

general feeling of discomfort

muscle pain or cramping

nausea

shortness of breath

sleepiness

unusual tiredness or weakness

Incidence not determined

Cough

dark urine

difficulty swallowing

dizziness

fast heartbeat

fever

hives or welts

itching

light-colored stools

puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue

redness of skin

tightness in chest

upper right abdominal pain

wheezing

yellow eyes and skin

Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:

More common

Canker sores

difficulty in moving

discouragement

ear discharge

ear swelling

feeling sad or empty

general feeling of discomfort or illness

irritability

loss of appetite

loss of interest or pleasure

nasal discharge or congestion

pain in joints

sores, ulcers, or white spots on lips or tongue or inside the mouth

stomach pain or cramps

swollen and painful spots on neck, armpit, or groin

swollen joints

trouble concentrating

trouble sleeping

unusually warm skin

weight loss

Less common

Acid or sour stomach

belching

cough

heartburn

indigestion

stomach discomfort or upset

Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

See also: Epivir side effects (in more detail)

Incidence not determined

Body fat redistribution or accumulation

blurred vision

dry mouth

flushed, dry skin

fruit-like breath odor

hair loss

increased hunger or thirst

increased urination

sweating

thinning of hair

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More Epivir resources

Epivir Side Effects (in more detail)
Epivir Use in Pregnancy & Breastfeeding
Drug Images
Epivir Drug Interactions
Epivir Support Group
0 Reviews for Epivir - Add your own review/rating

Epivir Prescribing Information (FDA)

Epivir Consumer Overview

Epivir MedFacts Consumer Leaflet (Wolters Kluwer)

Lamivudine Prescribing Information (FDA)

Lamivudine Monograph (AHFS DI)

Compare Epivir with other medications

Hepatitis B
HIV Infection
Nonoccupational Exposure
Occupational Exposure

enalapril and felodipine

en-AL-a-pril MAL-ee-ate, fe-LOE-di-peen

Oral routeTablet, Extended Release

When used in pregnancy during the second and third trimesters, ACE inhibitors can cause injury and even death to the developing fetus. When pregnancy is detected, enalapril maleate/felodipine should be discontinued as soon as possible .

ACE inhibitors can cause injury or death to the developing fetus when used during the second and third trimesters. Stop therapy as soon as possible when pregnancy is detected .

Commonly used brand name(s):

In the U.S.

Lexxel

Available Dosage Forms:

Tablet, Extended Release

Therapeutic Class: ACE Inhibitor/Calcium Channel Blocker Combination

Pharmacologic Class: Enalapril

Chemical Class: Dihydropyridine

Uses For enalapril and felodipine

Enalapril and felodipine combination belongs to the class of medicines called high blood pressure medicines (antihypertensives). enalapril and felodipine is used to treat high blood pressure (hypertension).

High blood pressure adds to the workload of the heart and arteries. If it continues for a long time, the heart and arteries may not function properly. This can damage the blood vessels of the brain, heart, and kidneys, resulting in a stroke, heart failure, or kidney failure. High blood pressure may also increase the risk of heart attacks. These problems may be less likely to occur if blood pressure is controlled.

The exact way in which enalapril and felodipine works is not known. Enalapril is a type of medicine known as an angiotensin-converting enzyme (ACE) inhibitor. It blocks an enzyme in the body that is necessary in producing a substance that causes blood vessels to tighten. Felodipine is a type of medicine known as a calcium channel blocker. Calcium channel blocking agents affect the movement of calcium into the cells of the heart and blood vessels. The actions of both medicines relax blood vessels, lower blood pressure, and increase the supply of blood and oxygen to the heart.

enalapril and felodipine was available only with your doctor's prescription.

Enalapril and felodipine combination was discontinued by the manufacturer on July 2, 2008.

Before Using enalapril and felodipine

In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For enalapril and felodipine, the following should be considered:

Allergies

Tell your doctor if you have ever had any unusual or allergic reaction to enalapril and felodipine or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully.

Pediatric

Studies on enalapril and felodipine have been done only in adult patients, and there is no specific information comparing use of enalapril and felodipine in children with use in other age groups.

Geriatric

Although enalapril and felodipine has not been shown to cause different side effects or problems in older people than it does in younger adults, blood levels of the felodipine component may be increased in the elderly.

Pregnancy

	Pregnancy Category	Explanation
1st Trimester	C	Animal studies have shown an adverse effect and there are no adequate studies in pregnant women OR no animal studies have been conducted and there are no adequate studies in pregnant women.
2nd Trimester	D	Studies in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy in a life threatening situation or a serious disease, may outweigh the potential risk.
3rd Trimester	D	Studies in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy in a life threatening situation or a serious disease, may outweigh the potential risk.

Breast Feeding

Interactions with Medicines

Using enalapril and felodipine with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

Allopurinol

Amiloride

Amiodarone

Atazanavir

Azathioprine

Canrenoate

Cyclosporine

Dantrolene

Droperidol

Eplerenone

Fentanyl

Interferon Alfa-2a

Mibefradil

Potassium

Spironolactone

Triamterene

Using enalapril and felodipine with any of the following medicines may cause an increased risk of certain side effects, but using both drugs may be the best treatment for you. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

Acebutolol

Aceclofenac

Acemetacin

Alclofenac

Aliskiren

Alprenolol

Amprenavir

Apazone

Aspirin

Atenolol

Azosemide

Bemetizide

Bendroflumethiazide

Benoxaprofen

Benzthiazide

Betaxolol

Bevantolol

Bisoprolol

Bromfenac

Bucindolol

Bufexamac

Bumetanide

Bupivacaine

Buthiazide

Capsaicin

Carprofen

Carteolol

Carvedilol

Celecoxib

Celiprolol

Chlorothiazide

Chlorthalidone

Clometacin

Clomipramine

Clonixin

Clopamide

Cyclopenthiazide

Cyclothiazide

Dalfopristin

Dexketoprofen

Diclofenac

Diflunisal

Dilevalol

Dipyrone

Droxicam

Esmolol

Ethacrynic Acid

Etodolac

Etofenamate

Felbinac

Fenbufen

Fenoprofen

Fentiazac

Floctafenine

Fluconazole

Flufenamic Acid

Flurbiprofen

Furosemide

Gold Sodium Thiomalate

Hydrochlorothiazide

Hydroflumethiazide

Ibuprofen

Indapamide

Indinavir

Indomethacin

Indoprofen

Isoxicam

Itraconazole

Ketoconazole

Ketoprofen

Ketorolac

Labetalol

Levobunolol

Lornoxicam

Magnesium

Meclofenamate

Mefenamic Acid

Meloxicam

Mepindolol

Metformin

Methyclothiazide

Metipranolol

Metolazone

Metoprolol

Nabumetone

Nadolol

Naproxen

Nebivolol

Nelfinavir

Nesiritide

Niflumic Acid

Nimesulide

Oxaprozin

Oxcarbazepine

Oxprenolol

Oxyphenbutazone

Penbutolol

Phenobarbital

Phenylbutazone

Pindolol

Pirazolac

Piretanide

Piroxicam

Pirprofen

Polythiazide

Propranolol

Propyphenazone

Proquazone

Quinethazone

Quinupristin

Rifampin

Rifapentine

Rofecoxib

Saquinavir

Sotalol

St John's Wort

Sulindac

Suprofen

Talinolol

Tenidap

Tenoxicam

Tertatolol

Tiaprofenic Acid

Timolol

Tolmetin

Torsemide

Trichlormethiazide

Trimethoprim

Valdecoxib

Xipamide

Zomepirac

Interactions with Food/Tobacco/Alcohol

Using enalapril and felodipine with any of the following may cause an increased risk of certain side effects but may be unavoidable in some cases. If used together, your doctor may change the dose or how often you use enalapril and felodipine, or give you special instructions about the use of food, alcohol, or tobacco.

Grapefruit Juice

Proper Use of enalapril and felodipine

Take enalapril and felodipine exactly as directed by your doctor, at the same time each day. Do not take more of it and do not take it more often than directed.

Swallow the tablets whole, without breaking, crushing, or chewing them.

If felodipine is taken with grapefruit juice, its effects may be increased. Check with your doctor before taking enalapril and felodipine with grapefruit juice.

Dosing

The dose of enalapril and felodipine will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of enalapril and felodipine. If your dose is different, do not change it unless your doctor tells you to do so.

For oral dosage form (tablets):
- For high blood pressure:
  - Adults—1 tablet once a day to start. Your doctor may increase your dose up to 4 tablets once a day if needed, to equal 20 mg enalapril and 10 mg felodipine extended-release.
  - Children—Use and dose must be determined by your doctor.

Missed Dose

If you miss a dose of enalapril and felodipine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

Storage

Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.

Keep out of the reach of children.

Do not keep outdated medicine or medicine no longer needed.

Ask your healthcare professional how you should dispose of any medicine you do not use.

Precautions While Using enalapril and felodipine

It is very important that your doctor check your progress at regular visits. This will allow your doctor to make sure the medicine is working properly, to check for unwanted effects, and to change the dosage if needed.

If you think that you may have become pregnant, check with your doctor immediately. Use of enalapril and felodipine, especially during the second and third trimesters (after the first 3 months) of pregnancy, may cause serious injury or even death to the unborn child.

Do not take any other medicines, potassium supplements, or salt substitutes that contain potassium unless approved or prescribed by your doctor.

Dizziness, lightheadedness, or fainting may occur after the first dose, especially if you have been taking a diuretic (water pill). Make sure you know how you react to the medicine before you drive, use machines, or do other things that could be dangerous if you experience these effects.

Call your doctor if you faint or feel lightheaded while you are taking enalapril and felodipine.

Check with your doctor if you notice any signs of fever, sore throat, or chills. These could be symptoms of an infection developing as a result of low white blood cell counts.

Check with your doctor if you notice difficult breathing or swelling of the face, arms, or legs. These could be symptoms of a serious allergic reaction.

Check with your doctor if you become sick while taking enalapril and felodipine, especially with severe or continuing vomiting or diarrhea. These conditions may cause you to lose too much water, possibly resulting in low blood pressure.

Dizziness, lightheadedness, or fainting may also occur if you exercise or if the weather is hot. Heavy sweating can cause loss of too much water and result in low blood pressure. Use extra care during exercise or hot weather.

Black patients may be less sensitive to the blood pressure-lowering effects of enalapril and felodipine. In addition, the risk of a serious allergic reaction involving swelling of the face, mouth, hands, or feet may be increased.

Before having any kind of surgery (including dental surgery) or emergency treatment, tell the medical doctor or dentist in charge that you are taking enalapril and felodipine.

enalapril and felodipine Side Effects

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur:

Less common

Dizziness, lightheadedness, or fainting

swelling of ankles, feet, or lower legs

Rare

Chills, fever, and sore throat

swelling of face, mouth, hands, or feet

trouble in swallowing or breathing (sudden), accompanied by hoarseness

unusual bleeding or bruising

yellow eyes or skin

Signs and symptoms of too much potassium in the body

Confusion

irregular heartbeat

nervousness

numbness or tingling in the hands, feet, or lips

shortness of breath

weakness or heaviness of legs

More common

Headache

Less common

Cough (dry, persistent)

flushing

swelling of the gums

unusual tiredness

Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

See also: enalapril and felodipine side effects (in more detail)

More enalapril and felodipine resources

Enalapril and felodipine Side Effects (in more detail)
Enalapril and felodipine Use in Pregnancy & Breastfeeding
Enalapril and felodipine Drug Interactions
Enalapril and felodipine Support Group
1 Review for Enalapril and felodipine - Add your own review/rating

Compare enalapril and felodipine with other medications

High Blood Pressure

Epipen Jr

Generic Name: epinephrine (Injection route)

ep-i-NEF-rin

Commonly used brand name(s)

In the U.S.

Adrenaclick

Adrenalin

Adrenalin Chloride

Epipen

Epipen Jr

Twinject

Available Dosage Forms:

Injectable

Solution

Therapeutic Class: Anaphylaxis Agent

Pharmacologic Class: Adrenergic

Chemical Class: Alkylarylamine

Uses For Epipen Jr

Epinephrine injection is used for emergency treatment of severe allergic reactions (including anaphylaxis) to insect bites or stings, medicines, foods, or other substances. It is also used to treat anaphylaxis caused by unknown substances or triggered by exercise.

This medicine is available only with your doctor's prescription.

Before Using Epipen Jr

Allergies

Pediatric

No information is available on the relationship of age to the effects of epinephrine injection in the pediatric population. Safety and efficacy have not been established.

Geriatric

No information is available on the relationship of age to the effects of epinephrine injection in geriatric patients. However, elderly patients are more likely to have age-related heart disease which may require caution in patients receiving epinephrine injection.

Pregnancy

	Pregnancy Category	Explanation
All Trimesters	C	Animal studies have shown an adverse effect and there are no adequate studies in pregnant women OR no animal studies have been conducted and there are no adequate studies in pregnant women.

Breast Feeding

Interactions with Medicines

Using this medicine with any of the following medicines is not recommended. Your doctor may decide not to treat you with this medication or change some of the other medicines you take.

Dihydroergotamine

Isocarboxazid

Linezolid

Phenelzine

Tranylcypromine

Amitriptyline

Amoxapine

Bucindolol

Carteolol

Carvedilol

Clomipramine

Desipramine

Dilevalol

Dothiepin

Doxepin

Entacapone

Halothane

Imipramine

Levobunolol

Lofepramine

Metipranolol

Nadolol

Nortriptyline

Opipramol

Oxprenolol

Penbutolol

Pindolol

Propranolol

Protriptyline

Rasagiline

Sotalol

Tertatolol

Timolol

Trimipramine

Using this medicine with any of the following medicines may cause an increased risk of certain side effects, but using both drugs may be the best treatment for you. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

Labetalol

Interactions with Food/Tobacco/Alcohol

Proper Use of epinephrine

This section provides information on the proper use of a number of products that contain epinephrine. It may not be specific to Epipen Jr. Please read with care.

Use this medicine only as directed by your doctor. Do not take more of it, do not take it more often, and do not take it for a longer time than your doctor ordered.

If you are using this medicine at home, make sure you or any of your family members understand exactly how to give them. Also, tell your doctor if you or your caregiver has severe arthritis of the hands. If you have any questions about this, check with your doctor.

This medicine is injected under your skin or into the muscle of your outer thigh only. Do not inject this medicine into a vein or into the muscle of your buttocks. To do so, may increase the chance of having serious side effects.

This medicine comes with patient instructions. Read and follow these instructions carefully. Ask your doctor if you have any questions.

This medicine comes in an auto-injector syringe and needle kit that contains the correct dose of medicine your doctor has prescribed.

You may need to use more than one injection if your allergic reaction does not get better after the first shot.

Carry this medicine with you at all times for emergency use in case you have a severe allergic reaction.

Dosing

For injection dosage form:
- For allergic reactions:
  - Adults and children weighing above 30 kilograms (66 pounds)—0.3 milligram (mg) injected under the skin or into the muscle of your thigh.
  - Adults and children weighing 15 to 30 kilograms (33 to 66 pounds)—0.15 milligram (mg) injected under the skin or into the muscle of your thigh.

Storage

Keep out of the reach of children.

Do not keep outdated medicine or medicine no longer needed.

Store the injection kits at room temperature, away from heat, moisture, and direct light. Do not store the medicine in the refrigerator or freezer. Keep the auto-injector in its case or tube.

Check the injection kits regularly to make sure that the liquid has not changed its color. Do not use this medicine if the liquid has changed its color, or if there are solids in the liquid.

Do not reuse the remaining portion of the medicine that is left in the auto-injector. Throw away the auto-injector after you have used it.

Precautions While Using Epipen Jr

If your symptoms do not improve within a few days or if they become worse, check with your doctor.

Anaphylaxis is a life-threatening reaction and requires immediate medical attention. Check with your doctor right away, or go to an emergency room as soon as possible, even if you feel better after using this medicine.

This medicine may affect blood sugar levels. If you notice a change in the results of your blood or urine sugar tests or if you have any questions, check with your doctor.

Do not inject this medicine into your hands or feet. There is already less blood flow to the hands and feet, and epinephrine could make that worse and cause damage to these tissues. If you accidentally inject epinephrine into your hands or feet, check with your doctor or go to the hospital emergency room right away.

Do not take other medicines unless they have been discussed with your doctor. This includes prescription or nonprescription (over-the-counter [OTC]) medicines and herbal or vitamin supplements.

Epipen Jr Side Effects

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur:

Incidence not known

Abnormal or decreased touch sensation

arm, back or jaw pain

bleeding, blistering, burning, coldness, discoloration of the skin, feeling of pressure, hives, infection, inflammation, itching, lumps, numbness, pain, rash, redness, scarring, soreness, stinging, swelling, tenderness, tingling, ulceration, or warmth at the injection site

blurred vision

chest pain or discomfort

chest tightness or heaviness

dizziness

fainting fast, irregular, pounding, or racing heartbeat or pulse

fear or nervousness

headache

nausea or vomiting

paleness of the skin

pounding in the ears

restlessness

shakiness in the legs, arms, hands, or feet

shortness of breath

slow or fast heartbeat

stroke

sweating

trembling or shaking of the hands or feet

troubled breathing

unusual tiredness or weakness

wheezing

Get emergency help immediately if any of the following symptoms of overdose occur:

Symptoms of overdose

Agitation

coldness of the skin

coma

confusion

decreased urine output

depression

drowsiness

hostility

irritability

lethargy

lightheadedness, dizziness, or fainting

muscle twitching

pounding, slow heartbeat

rapid weight gain

rapid, deep breathing

seizures

stomach cramps

stupor

swelling of the face, ankles, or hands

Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

See also: Epipen Jr side effects (in more detail)

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Adams-Stokes Syndrome
Allergic Reactions
Asthma, acute
Asystole
AV Heart Block
COPD, Acute
Electromechanical Dissociation
Shock

Epinephrine

Class: alpha- and beta-Adrenergic Agonists
VA Class: AU100
CAS Number: 51-43-4
Brands: Adrenalin Chloride, EpiPen Auto-Injector, EpiPen Jr., Primatene

Introduction

Epinephrine is an endogenous catecholamine that is the active principle of the adrenal medulla; epinephrine acts directly on both α- and β-adrenergic receptors.

Uses for Epinephrine

Bronchospasm

Has been used as as a quick-relief bronchodilator for symptomatic treatment of acute symptoms and exacerbations of bronchial asthma and reversible bronchospasm associated with chronic bronchitis, emphysema, and other obstructive pulmonary diseases.^a ¹⁶⁰ ¹⁶² ¹⁶⁶ ¹⁶⁸ However, generally should be used only when selective β₂-agonists are not readily available, since excessive cardiac stimulation (e.g., increased heart rate, myocardial irritability, increased oxygen demand) can occur with nonselective agents, particularly at high doses.¹⁶⁰ ¹⁶² ¹⁷⁴ ^d

Orally inhaled selective β₂-agonists currently are recommended for prehospital management of asthma exacerbations (e.g., in emergency medicine facilities and/or ambulances) and for acute asthma management in emergency rooms and hospitals.¹⁶⁰ ¹⁶¹ ¹⁶² Reserve sub-Q epinephrine for severe exacerbations when selective agents are not readily available or are ineffective.¹⁶⁰ ¹⁶¹ ¹⁶² ¹⁷⁴ ^d No proven advantage of systemically administered (e.g., sub-Q) epinephrine therapy over orally inhaled therapy for the acute management of asthma exacerbations.¹⁶⁰ ¹⁶² Parenteral epinephrine may be particularly useful in treating anaphylaxis and angioedema coexisting with asthma.¹⁷⁴

Nebulized bronchodilator therapy generally should be reserved for patients who are unable to coordinate inhalation via an MDI because of their age, agitation, or exacerbation severity.¹⁶⁰

Regular, daily use of a short-acting, inhaled β-agonist generally is no longer recommended for maintenance therapy of asthma.¹⁶⁰ Current asthma guidelines emphasize long-term control with anti-inflammatory agents (e.g., corticosteroids), and concomitant anti-inflammatory therapy with an inhaled corticosteroid is recommended whenever inhaled β-agonist bronchodilators are used for maintenance.¹³⁰ ¹³¹ ¹³² ¹³⁸ ¹⁴⁰ ¹⁴¹ ¹⁴⁷ ¹⁴⁸

Sensitivity Reactions

Drug of choice in the emergency treatment of severe acute anaphylactic reactions, including anaphylactic shock, which can be profound and life-threatening.^a ¹⁶¹ ¹⁶³ ¹⁶⁴ ^d

May relieve anaphylactic symptoms (e.g., urticaria, pruritus, angioedema, wheezing, dyspnea, hypotension, swelling of the lips, eyelids, and tongue) caused by reactions to drugs, contrast media, sera, insect stings or bites, foods (e.g., milk, eggs, fish, shellfish, peanuts, tree nuts), latex, or other allergens as well as idiopathic or exercise-induced anaphylaxis.^a ¹⁶¹ ¹⁶³ ^d

Give to all patients with signs of shock, airway swelling, or definite breathing difficulty.¹⁶¹ ^d Drug of choice for the treatment of both vasodilation/hypotension and cardiac arrest associated with anaphylaxis.¹⁶¹ ^d

Parenteral administration (IM route favored)^d is preferred for the treatment of anaphylaxis.^a ^d Administer IV if anaphylaxis appears to be severe with immediate life-threatening manifestations.¹⁶¹ ^d Absorption and subsequent achievement of peak plasma concentrations after sub-Q injection is slower and may be substantially delayed in patients with shock.¹⁶¹ ^d

High IV doses (i.e., rapid progression to high dose) should be used without hesitation in any patient in full cardiac arrest.¹⁶¹ ^d

If necessary, institute other measures for management of cardiac arrhythmias, laryngeal edema, or bronchospasm.^a Once adequate ventilation is ensured, maintenance of BP in anaphylactic shock should be achieved with other pressor agents (e.g., norepinephrine, metaraminol).^a

Close monitoring critical; fatal overdose of epinephrine reported.^d

Risk of paradoxical response to epinephrine in patients receiving β-adrenergic blocking agents; consider glucagon and/or ipratropium for treatment of anaphylaxis in these patients.^d Increased incidence and severity of anaphylaxis in patients receiving β-adrenergic blocking agents.^d

CPR and Cardiac Arrhythmias

Used for its α-adrenergic stimulatory effects to increase blood flow in ACLS during CPR.^a ¹⁶¹ ^d The principal beneficial effects in patients with cardiac arrest result from increases in aortic diastolic blood pressure and in myocardial and cerebral blood flow during resuscitation.^a ¹⁶¹ ^d The value and safety of the β-adrenergic effects are controversial because they may increase myocardial work and reduce subendocardial perfusion.¹⁶¹ ^d

A drug of choice and a high priority for ACLS in cardiac arrest to facilitate return of spontaneous circulation (ROSC); generally used after failure of artificial ventilation, external or internal cardiac compression, and initial defibrillation to restore effective circulation.^a ¹⁶¹ ^d

Cardiac arrest: May be administered IV, intraosseously, or intracardially or by direct instillation into the tracheobronchial tree via an endotracheal tube to restore cardiac rhythm as an adjunct in the management of cardiac arrest.^a ¹⁶¹ ¹⁶⁹ ¹⁷⁰ ^d

Asystole: Restores cardiac electrical activity in asystole and, in some cases, restores myocardial contractility in electromechanical dissociation.^a ¹⁶¹

Impending pulseless electrical activity: May produce beneficial vasopressor effects in patients who are not in cardiac arrest but who have other indications for vasopressor therapy¹⁶¹ (e.g., in those with severe bradycardia and hypotension who are close to pulseless electrical activity or even asystole).^a

Bradycardia: Treatment of symptomatic bradycardia unresponsive to atropine, as a temporizing measure while awaiting availability of a pacemaker (e.g., out-of-hospital setting) or if pacing ineffective.^d

Drug-induced cardiovascular emergencies or altered vital signs: May consider use in bradycardia or shock associated with β-adrenergic or calcium-channel blocking agent or tricyclic antidepressant toxicity.^d

Anesthesia accidents: May be useful in treating cardiac arrest following anesthesia accidents, but should be used with extreme caution, if at all, in patients receiving cyclopropane or halogenated hydrocarbon general anesthetics.^a (See General Anesthetics under Interactions.)

Heart block: Has been used in the treatment of syncope and/or bradycardia resulting from AV nodal block, but has largely been replaced by isoproterenol.^a Electrical cardiac pacemakers have largely replaced drug therapy in third-degree AV nodal block (complete heart block).^a

Radiographic Uses

Has been given intra-arterially† as an adjunct to radiographic contrast media in arteriography†.^a

GI and Renal Hemorrhage

Has been administered intra-arterially† via the celiac artery, inferior mesenteric artery, or superior mesenteric artery to control hemorrhage in patients with severe GI bleeding†.^a

Has been administered intra-arterially† via the renal artery to control hemorrhage in patients with renal arterial bleeding†.^a

Radiation Nephritis

Has been injected into a renal artery prior to and during irradiation of the abdominal area to protect the kidney from radiation nephritis†.^a

Adjunct to Local Anesthesia

May be added to solutions of some local anesthetics to decrease the rate of their vascular absorption (to localize and prolong the duration of anesthesia and decrease the risk of systemic toxicity).^a

Superficial Bleeding

May be applied topically to control superficial bleeding from arterioles or capillaries in the skin, mucous membranes, or other tissues.^a Bleeding from larger vessels is not controllable by topical application.^a

Cardiogenic, Hemorrhagic, and Traumatic Shock

Should not be used in cardiogenic shock (because it increases myocardial oxygen demand) or in hemorrhagic or traumatic shock.^a

Premature Labor

Has been used to relax uterine musculature and inhibit uterine contractions in premature labor† (tocolysis); however, the cardiovascular and other adverse effects limit its usefulness.^a (See Pregnancy under Cautions.) Other β-agonists (e.g., terbutaline) preferred.¹⁶⁵ ¹⁷³

Hypoglycemia

Has been used parenterally to correct hypoglycemia† in insulin shock; however, dextrose and/or glucagon is more effective.^a

Epinephrine Dosage and Administration

Administration

Administer by sub-Q, IM, or IV injection or by IV infusion.^a ¹⁶⁰ ¹⁶¹ ¹⁶² ¹⁶³ ¹⁶⁴ ¹⁶⁹ ^d Also may be administered intra-arterially† (e.g., for radiography, for local control of bleeding).^a

In extreme cardiac emergencies, may be administered intracardially, via an endotracheal tube, or by intraosseous infusion†.^a ¹⁶¹ ¹⁶⁹ ¹⁷⁰ Although endotracheal administration of epinephrine is possible, IV or intraosseous† administration is preferred because of more predictable drug delivery and pharmacologic effect.^d

Rapid IV injection (bolus dose) or endotracheal administration of epinephrine may cause failure of exhaled carbon dioxide detectors (used to confirm endotracheal tube placement in the trachea during cardiac arrest) despite adequate placement (i.e., false-negative reading).^d Use a second method to confirm tube placement.^d

For bronchodilation, administer by oral inhalation via a metered-dose inhaler (MDI), nebulization, or intermittent positive-pressure breathing (IPPB) apparatus or inject sub-Q or IM.^a ¹⁶⁰ ¹⁶² ¹⁶⁶ ¹⁶⁸

Apply topically to the skin and mucous membranes for local hemostasis.^a

Sub-Q Injection

Injections containing 1 mg/mL preferably are administered sub-Q.^a ¹⁶⁰ ¹⁶² ¹⁶⁹ However, absorption and subsequent achievement of peak plasma concentrations is slower and may be substantially delayed if shock is present.^a ¹⁶¹ ^d

IM Injection

Injections containing 1 mg/mL also may be injected IM, but IM injection into the buttocks should be avoided.^a ¹⁶⁰ ¹⁶¹ ¹⁶² ¹⁶⁹ ¹⁷² ^d

For self-medication, instruct patients and their caregivers about proper administration techniques using the auto-injector provided by the manufacturer.¹⁶³ ¹⁶⁴ ^d First aid providers should be familiar with the auto-injector in order to assist patients having an anaphylactic reaction with self-medication, and they should be able to administer the auto-injector, if a patient is unable to self-administer, provided that state law permits it and valid prescription exists.^d

Technique for Using Auto-injector

Inject the age-appropriate dose IM only into the anterolateral aspect of the thigh.¹⁶³ ¹⁶⁴

The patient should grasp the prefilled auto-injector with the black tip pointed downward; the grey activation cap should be removed.¹⁶⁴ Point the black tip toward the outer thigh, swing and jab it firmly into the outer thigh so that the auto-injector is perpendicular (90° angle) to the thigh, and hold firmly in the thigh for several seconds until the dose is delivered.¹⁶⁴ Administer through clothing if necessary.¹⁶³ Massage injection area for several seconds.¹⁶⁴ If the needle is not exposed at the black tip, repeat administration.¹⁶⁴

Never put thumb, fingers, or hand over the black tip.¹⁶⁴

Do not remove the grey activation cap until ready to use.¹⁶⁴

The auto-injector is overfilled and most of the solution (90%) will remain after injection of the age-approriate dose and cannot be reused.¹⁶⁴

After use, bend the needle back against a hard surface.¹⁶⁴ Then, deliver the used auto-injector to a health-care provider for proper disposal.¹⁶⁴

IV Administration

Emergency situations: Inject very slowly IV as a dilute solution or infuse slowly IV.^a When injected peripherally, 1–2 minutes generally are required to reach central circulation.¹⁶¹ ^d

Severe asthma or anaphylaxis: IV therapy may be necessary (e.g., for severe anaphylactic shock with immediate life-threatening manifestations) when drug absorption from sub-Q or IM injection is likely to be impaired.^a ^d

CPR: When a vein has not been cannulated prior to the arrest, a peripheral vein (antecubital or external jugular in adults and the largest most accessible vein that does not interrupt resuscitation in pediatric patients) is preferred since central venous access requires interruption of chest compressions, is technically more difficult, and is associated with an increased risk of complications.¹⁶¹ Venous access can be challenging in infants and children during an emergency, whereas intraosseous access can be easily achieved.^d Limit the time attempting venous access; if reliable access cannot be achieved quickly, establish intraosseous access.^d

If a central venous catheter is already in place at the time of arrest, it can be used because of more rapid onset (in adults), more secure access to circulation, and avoidance of tissue infiltration.¹⁶¹ ^d Tissue infiltration may lead to local ischemia, tissue injury, and ulceration.^d Avoid central venous line placement in patients who are candidates for pharmacologic reperfusion (e.g., with thrombolytic therapy).¹⁶¹ ^d

Dilution

Prepare infusion solutions containing 2 or 4 mcg/mL by adding 1 mg to 500 or 250 mL of a compatible IV solution, respectively.^a ¹⁰¹ ^d

Prepare solutions containing 0.05 mg/mL by adding 0.5 mg (0.5 mL of a 1:1000 injection) to 10 mL of 0.9% sodium chloride injetion.¹⁶⁹

Prepare a 1:10,000 solution (0.1 mg/mL) by diluting 1 mL of a commercially available 1:1000 injection (1 mg/mL) with 10 mL of water for injection or 0.9% sodium chloride injection.^a Alternatively, a commercially available 1:10,000 (0.1 mg/mL) injection can be used.¹⁷⁰

Prepare a 1:100,000 solution (0.01 mg/mL) by diluting 0.1 mL of a commercially available 1:1000 injection (1 mg/mL) with 10 mL of 0.9% sodium chloride injection.^a

Rate of Administration

Severe asthma or anaphylaxis: Inject IV slowly (e.g., over 5–10 minutes) or administer by rapid IV injection (i.e., bolus).^a ¹⁰¹

Alternatively in adults, infuse IV at an initial rate of 1 mcg/minute, increasing to 4 mcg/minute as needed.^a

In children after an initial 1-mcg/kg IV bolus, infuse IV at an initial rate of 0.1 mcg/kg per minute, increasing gradually up to 1.5 mcg/kg per minute as needed.¹⁰¹

CPR: Inject doses by IV push in adults, repeating at 3- to 5-minute intervals as needed;¹⁶¹ ¹⁷⁰ ^d follow each dose injected peripherally with a 20-mL flush of IV fluid to ensure distribution into the central compartment;¹⁶¹ ^d if injected IV in an extremity, elevate the extremity for 10–20 seconds.^d

In children, infuse IV at an initial rate of 0.1 mcg/kg per minute, increasing gradually to a maximum of 1 mcg/kg per minute as needed for CPR.^a ^d

Bradycardia or hypotension (i.e., nonarrest rate): In adults, infuse IV at an initial rate of 1 mcg/minute, titrating to hemodynamic response at rates ranging from 2–10 mcg/minute.¹⁶¹ ^d Assess intravascular volume and support as needed.^d

In children, infuse IV at a rate of 0.1–0.2 mcg/kg per minute for refractory bradycardia.¹⁶¹

Intra-arterial Administration

Injections have been administered intra-arterially† for local effects (e.g., to control local bleeding, prevent radiation nephritis, as an adjunct to arteriography).^a

Rate of Administration

GI hemorrhage: 8–20 mcg/minute infused into the celiac or inferior or superior mesenteric artery†.^a

Renal hemorrhage: 10 mcg/minute infused into the renal artery†.^a

Radiation nephritis: 3–7.6 mcg/minute infused into the renal artery†.^a

Adjunct to arteriography: 8–12 mcg/minute infused into the celiac or superior mesenteric artery†.^a

Intracardiac Injection

Limit intracardiac injection to personnel well trained in the technique and generally use only during open cardiac massage or when other routes of administration are persistently inaccessible.^a ¹⁶¹ ¹⁷⁰

Inject into the left ventricular chamber.¹⁷⁰

Follow intracardiac administration by external cardiac massage to ensure entry of the drug into the coronary circulation.^a

Suspensions must not be administered intracardially.^a

Administration Risks

Hazards include coronary artery laceration, cardiac tamponade, pneumothorax, and the need to interrupt external chest compressions and ventilation during the period of administration.^a ¹⁶¹

Endotracheal Administration

Limit endotracheal administration to personnel well trained in the technique.^a ¹⁶¹

In intubated patients, doses can be instilled directly into the bronchial tree via the endotracheal tube.¹⁷⁰

Pass a catheter beyond the tip of the tracheal tube, stop chest compressions, inject the drug solution directly into the tracheal tube, follow immediately with several quick insufflations to create a rapidly absorbed aerosol, and then resume compressions.¹⁶¹ ^d

For pediatric patients, flush with a minimum of 5 mL of 0.9% sodium chloride injection after each dose.^d

For pediatric patients, administration via a tracheal tube is preferred to a catheter or feeding tube because these latter 2 methods often are cumbersome and depend on finding the correct-size catheter to place through the tracheal tube.¹⁶¹

Dilution

Adults: Dilute dose in 5–10 mL of 0.9% sodium chloride or sterile water.^a ^d Systemic absorption may be increased by diluting in sterile water instead of 0.9% sodium chloride;^a ^d however, sterile water may have a more negative effect on arterial oxygen pressure (PaO₂) than sodium chloride.^a Alternatively, a commercially available 1:10,000 (0.1 mg/mL) injection may be administered undiluted via the endotracheal tube.¹⁷⁰

Intraosseous Administration

When IV administration is not possible, epinephrine may be given by intraosseous administration for emergency uses such as CPR.¹⁶¹ ^d

Limit intraosseous administration to personnel well trained in the technique.^a ¹⁶¹

Place a cannula in a noncollapsible marrow venous plexus; such access often can be achieved in 30–60 seconds.¹⁶¹

Use a rigid needle, preferably a specially designed intraosseous or Jamshidi-type bone marrow needle; a styleted needle is preferred to prevent obstruction of the needle with cortical bone.¹⁶¹

Insert the intraosseous needle into the anterior tibial bone marrow; alternatively, the distal femur, medial malleolus, or anterior superior iliac spine can be used.¹⁶¹

In older children and adults, intraosseous cannulas also have been inserted successfully into the distal radius or ulna as well as the proximal tibia.¹⁶¹

Successful intraosseous placement outside the hospital (e.g., by emergency medical services) generally is more difficult in older than in younger children.¹⁶¹

Onset of action and systemic concentrations are comparable to those achieved with central venous administration.¹⁶¹ ^d

Administration Risks

Complications are uncommon (less than 1% of patients), and include tibial fracture, lower-extremity compartment syndrome, extravasation, and osteomyelitis; careful technique can minimize the risk.¹⁶¹ Local effects on bone marrow and bone growth appear to be minimal.¹⁶¹ Risk of microscopic pulmonary fat and bone marrow emboli does not appear to be increased.¹⁶¹

Oral Inhalation

Epinephrine base or hydrochloride may be administered via oral inhalation using a nebulizer, aerosol (metered-dose inhaler [MDI]), or intermittent positive-pressure breathing (IPPB) apparatus.^a ¹⁶⁶ ¹⁶⁸

For nebulization, use a glass or plastic nebulizer capable of delivering a very fine mist and that works effectively with a very small volume of solution.¹⁶⁸ Place the dose in the nebulizer reservoir and then place the nozzle just inside the partially opened mouth.¹⁶⁸ Squeeze the bulb once or twice, inhaling deeply to draw the vaporized solution into the lungs.¹⁶⁸ Rinse mouth with water immediately to prevent oropharyngeal dryness.¹⁶⁸

Solutions intended for oral inhalation are more concentrated than those intended for injection and must not be administered parenterally.^a ¹⁶⁸

Do not administer oral inhalation solutions intranasally.¹⁶⁸

Topical Administration

Apply solutions topically as a spray or on cotton or gauze to the skin, mucous membranes, or other tissues.^a

Dosage

Available as epinephrine and epinephrine hydrochloride; dosage expressed in terms of epinephrine.^a ¹⁶³ ¹⁶⁶ ¹⁶⁸

Pediatric Patients

Bronchospasm

Treatment of Acute Exacerbations of Asthma

Oral Inhalation

Children ≥4 years of age: 220 mcg (1 inhalation) of epinephrine via an MDI, repeated once if necessary after at least 1 minute; do not administer subsequent doses for at least 3 hours.^a ¹⁶⁶

Children ≥4 years of age: After placing approximately 10 drops of 1% (1:100) epinephrine in the nebulizer reservoir, administer 1–3 deep inhalations via the hand-bulb.^a ¹⁶⁸ Do not repeat more often than every 3 hours; use the least number of inhalations producing relief.^a ¹⁶⁸

Sub-Q

For severe asthma, inject 0.01 mg/kg (0.01 mL/kg of a 1:1000 injection)^a ¹⁶⁰ ¹⁶² or 0.3 mg/m² (0.3 mL/m² of a 1:1000 injection) sub-Q.^a ¹⁶⁹

Single pediatric doses should not exceed 0.3–0.5 mg every 20 minutes as needed for up to 3 consecutive doses.¹⁶⁰ ¹⁶² ^a ¹⁶⁰ ¹⁶² ¹⁶⁹

Neonates: Inject 0.01 mg/kg IV.¹⁷⁰ ¹⁷²

Infants: Inject 0.05 mg IV initially, repeated at 20- to 30-minute intervals as needed.¹⁷⁰ ¹⁷²

Sensitivity Reactions

Anaphylaxis

Inject 0.01 mg/kg (0.01 mL/kg of a 1:1000 injection) (up to 0.5 mg/dose), repeated every 10–20 minutes as needed for up to 3 consecutive doses.¹⁰¹

For self-administration using a prefilled auto-injector (e.g., EpiPen), inject 0.15 or 0.3 mg, depending on body weight; a dose of 0.01 mg/kg generally is recommended.¹⁶³ Clinicians may recommend higher or lower doses depending on individual patient needs and considering the life-threatening nature of anaphylaxis.¹⁶³ The 0.15-mg dose may be more approriate for children <30 kg.¹⁶³ If doses <0.15 mg are considered more appropriate, alternative injectable forms of the drug should be used.¹⁶³ For severe persistent anaphylaxis, repeated doses may be needed.¹⁶³

Sub-Q

Inject 0.01 mg/kg (0.01 mL/kg of a 1:1000 injection) or 0.3 mg/m² (0.3 mL/m² of a 1:1000 injection) sub-Q.^a ¹⁶⁹ Single pediatric doses should not exceed 0.5 mg, repeated as needed at 20-minute to 4-hour intervals depending on the severity of the condition and the response of the patient.^a ¹⁶⁹

In severe anaphylactic shock, IV administration may be necessary since absorption may be impaired with sub-Q or IM administration.^a ¹⁰¹

If necessary, inject an initial dose of 10 mcg/kg (0.1 mL/kg of a 1:10,000 dilution), followed by a continuous IV infusion at an initial rate of 0.1 mcg/kg per minute (using a diluted solution containing 4 mcg/mL); the infusion may be increased as necessary to a maximum of 1.5 mcg/kg per minute to maintain BP.¹⁰¹

Neonates, alternatively: Inject 0.01 mg (10 mcg)/kg.¹⁷⁰ ¹⁷²

Infants, alternatively: Inject 0.05 mg (50 mcg) initially, repeated at 20- to 30-minute intervals as needed.¹⁷⁰ ¹⁷²

CPR and Cardiac Arrhythmias

Bradycardia and Pediatric Advanced Life Support

Neonates: The usual dose is 0.01–0.03 mg/kg (0.1–0.3 mL/kg of a 1:10,000 injection),^d repeated every 3–5 minutes if necessary for CPR or bradycardia.^a ¹⁶¹ Higher IV doses are not recommended¹⁶¹ ^d because of risk of exaggerated hypertension, decreased myocardial function, and worsening neurologic function.^d

Pediatric Patients: The usual initial dose is 0.01 mg/kg (0.1 mL/kg of a 1:10,000 injection), up to a maximum single dose of 1 mg, for CPR or bradycardia,^a ¹⁶¹ ^d ^e repeated every 3–5 minutes as needed.¹⁶¹ ^d Higher IV doses not recommended; use a standard dose for the first and subsequent doses.^d No survival benefit from routine use of high-dose epinephrine; may be harmful, particularly in asphyxia.^d Risk of exaggerated hypertension, decreased myocardial function, and worsening neurologic function with high doses.^d May consider high-dose epinephrine in certain circumstances (e.g., β-adrenergic blocking agent overdose).^d

Pediatric Patients: Alternatively, infuse at an initial rate of 0.1 mcg/kg per minute; increase the rate in increments of 0.1 mcg/kg per minute, if necessary, to a maximum of 1 mcg/kg per minute.^a ^d Low-dose infusions (<0.3 mcg/kg per minute) generally produce predominantly β-adrenergic effects,¹⁶¹ while higher-dose infusions (>0.3 mcg/kg per minute) generally result in α-adrenergic vasoconstriction, but there is substantial interindividual variation in catecholamine response, and infusion dosage should be titrated to the desired effect.^d

Pediatric patients: For refractory bradycardia, consider continuous infusion^d at a rate of 0.1–0.2 mcg/kg per minute.¹⁶¹

Intraosseous

Pediatric patients: The usual initial dose is 0.01 mg/kg (0.1 mL/kg of a 1:10,000 injection), up to a maximum single dose of 1 mg, for CPR or bradycardia,^a ¹⁶¹ ^d ^e repeated every 3–5 minutes as needed.¹⁶¹ ^d Higher intraosseous doses are not recommended; use a standard dose for the first and subsequent doses.^d No survival benefit from routine use of high-dose epinephrine; may be harmful, particularly in asphyxia.^d Risk of exaggerated hypertension, decreased myocardial function, and worsening neurologic function with high doses.^d May consider high-dose epinephrine in certain circumstances (e.g., β-adrenergic blocking agent overdose).^d

Endotracheal

Optimum dose not established.^a ¹⁶¹ ^d

Neonates: IV administration (of 0.01–0.03 mg/kg per dose [0.1–0.3 mL/kg of a 1:10,000 injection])¹⁶¹ is the preferred route.^a ^d If the endotracheal route is used, doses of 0.01 or 0.03 mg/kg will likely be ineffective.^d Although safety and efficacy have not been established, consider endotracheal administration of a higher dose (up to 0.1 mg/kg) while access is being obtained.^a ^d

Pediatric patients: The usual initial dose is 0.1 mg/kg (0.1 mL/kg of a 1:1000 injection), up to a maximum single dose of 10 mg, for CPR or bradycardia,^a ¹⁶¹ ^d ^e repeated every 3–5 minutes as needed.¹⁶¹ ^d

Generally flush the dose with a minimum of 5 mL of 0.9% sodium chloride injection followed by 5 assisted manual ventilations to promote absorption.¹⁶¹ ^a ^d

Intracardiac

Pediatric patients: 0.005–0.01 mg/kg (0.05–0.1 mL/kg of a 1:10,000 injection).^a

Adults

Bronchospasm

Treatment of Acute Exacerbations of Asthma

Oral Inhalation

220 mcg (1 inhalation) of epinephrine via an MDI, repeated once if necessary after at least 1 minute; do not administer subsequent doses for at least 3 hours.^a ¹⁶⁶

After placing approximately 10 drops of 1% (1:100) epinephrine in the nebulizer reservoir, administer 1–3 deep inhalations via the hand-bulb.^a ¹⁶⁸ Do not repeat more often than every 3 hours; the least number of inhalations producing relief should be used.^a ¹⁶⁸

Sub-Q

For severe asthma, the usual initial dose is 0.1–0.5 mg (0.1–0.5 mL of a 1:1000 injection).^a Initial doses should be small and may be increased if necessary, but single doses should not exceed 1 mg.^a

May give at 20-minute to 4-hours intervals depending on the severity of the condition and patient response.^a

Alternatively, may administer 0.01 mg/kg (concentration of 1:1000) divided into 3 doses of approximately 0.3 mg, given at 20-minute intervals.^a ^d

0.1–0.25 mg injected slowly.¹⁷⁰

Sensitivity Reactions

Anaphylaxis

The usual initial dose is 0.1–0.5 mg (0.1–0.5 mL of a 1:1000 injection).^a

For the treatment of reactions caused by drugs that were given IM, epinephrine may be administered at the site of injection of the other drug to minimize further absorption.^a

Initial doses should be small and may be increased if necessary, but single doses should not exceed 1 mg.^a

Alternatively, inject 0.3–0.5 mg (0.3–0.5 mL of a 1:1000 injection),¹⁶¹ repeated every 15–20 minutes, as needed.^d

For self-administration using a prefilled auto-injector (e.g., EpiPen), inject 0.3 mg.¹⁶³ Clinicians may recommend higher or lower doses depending on individual patient needs and considering the life-threatening nature of anaphylaxis.¹⁶³

For severe persistent anaphylaxis, repeated doses may be needed.¹⁶³

Sub-Q

Consider the possibility that drug absorption from sub-Q injection may be inadequate in anaphylaxis, particularly with shock.¹⁶¹ ^d

The usual initial dose is 0.1–0.5 mg (0.1–0.5 mL of a 1:1000 injection).^a For the treatment of reactions caused by drugs that were given sub-Q, epinephrine may be administered at the site of injection of the other drug to minimize further absorption.^a

Initial doses should be small and may be increased if necessary, but single doses should not exceed 1 mg.^a

May be given at 20-minute to 4-hours intervals depending on the severity of the condition and patient response.^a

Alternatively, inject 0.3–0.5 mg every 20 minutes as needed for up to 3 doses.¹⁶⁰ ¹⁶²

In severe or life-threatening anaphylaxis, IV administration may be necessary since absorption may be impaired with sub-Q or IM administration.^a ¹⁰¹ ¹⁶¹ ^d

If necessary, inject 0.1–0.25 mg^a ¹⁶¹ ¹⁷² ^d (e.g., 1–2.5 mL of a 1:10,000 injection or dilution) slowly and cautiously (e.g., over 5–10 minutes), and repeat every 5–15 minutes as necessary or follow by a continuous infusion at an initial rate of 1 mcg/minute, increasing the rate to up to 4 mcg/minute as necessary.^a ¹⁶¹ ^d Individual doses up to 0.5 mg also have been used.¹⁶¹

To optimally control administration, some clinicians recommend an initial dose of 0.1 mg (10 mL of a 1:100,000 injection or dilution) given over 5–10 minutes, followed by a continuous infusion as necessary.¹⁰⁰

Alternatively, 0.025–0.05 mg (0.25–0.5 mL of a 1:10,000 injection) be given every 5–15 minutes following initial sub-Q or IM administration of 0.5 mg.^a

CPR and Cardiac Arrhythmias

The optimum dose of epinephrine during CPR remains controversial.¹⁰³ ¹⁰⁴ ¹¹⁵ ¹¹⁶ ¹¹⁷ ¹¹⁸ ¹¹⁹ ¹²⁰ ¹²¹ ¹²² ¹²³ ¹²⁵ ¹²⁶ ¹²⁷ The usual dose of 0.5–1 mg has been questioned since it is not based on body weight¹⁰³ ¹⁰⁴ ¹¹⁷ ¹¹⁹ ¹²⁰ and may be lower than necessary for optimum cardiovascular effects.¹⁰³ ¹⁰⁴ ¹¹⁷ ¹¹⁹ ¹²¹ ¹²⁷

CPR (Cardiac Arrest)

Inject 1 mg every 3–5 minutes.¹⁶¹ ^d

Has been infused at an initial rate of 1 mcg/minute and, increased to 3–4 mcg/minute as needed, via a central line to reduce the risk of extravasation and ensure good bioavailability.¹⁶¹

Higher (>1-mg) doses may be indicated in certain circumstances, (e.g., β-adrenergic or calcium-channel blocking agent overdose).^d

Intraosseous

Intraosseous doses generally are the same as those administered IV.^a ^d

Usually, 1 mg every 3–5 minutes.^d

Endotracheal

Optimum dose not established.^a ¹⁶¹ ^d

If IV or intraosseous access is delayed or cannot be established,^d endotracheal doses 2–2.5 times those administered IV (i.e., 2–2.5 mg) are recommended.^a ¹⁶¹ ^d

Intracardiac

Inject 0.1–1 mg (usually as 1–10 mL of a 1:10,000 injection) into the left ventricular chamber.^a ¹⁶¹ ¹⁷⁰ ¹⁷²

Sub-Q

Following initial IV administration, 0.3 mg may be injected sub-Q.^a

Persistent or Recurrent Ventricular Fibrillation/Tachycardia

Inject 1 mg by rapid injection (IV push) every 3–5 minutes.¹⁶¹ ^d

Pulseless Electrical Activity

Inject 1 mg by rapid injection (IV push) every 3–5 minutes.¹⁶¹ ^d

Asystole

Inject 1 mg by rapid injection (IV push) every 3–5 minutes.¹⁶¹ ^d

Bradycardia:

For symptomatic bradycardia without cardiac arrest, infuse at an initial rate of 1 mcg/minute; subsequent dosage is adjusted according to the patient’s response and generally ranges from 2–10 mcg/minute.^a ¹⁶¹ ^d

Radiographic Use

Arteriography

As an adjunct in arteriography†, 16–24 mL of sodium chloride injection containing 1 mcg of epinephrine per mL has been infused into the celiac or superior mesenteric artery† over 2 minutes; the radiographic contrast medium was administered 7–10 minutes later.

Hemorrhage

GI

Intra-arterial

To control GI bleeding†, infuse into the celiac artery†, inferior mesenteric artery†, or superior mesenteric artery† at a rate of 8–20 mcg/minute for 4 minutes to 3 hours.

Renal

Intra-arterial

To control bleeding from the kidney†, infuse into the renal artery† at a rate of 10 mcg/minute for 10 minutes.^a

Radiation Nephritis

Abdominal Irradiation

Intra-arterial

To prevent radiation nephritis†, infuse into the renal artery† at a rate of 3–7.6 mcg/minute for 4–10 minutes prior to and continued during the period of abdominal irradiation.^a

Adjunct to Local Anesthesia

Local Injection

To localize and prolong the duration of local anesthesia, epinephrine may be used in concentrations of 1:500,000 to 1:50,000; 1:200,000 is used most commonly.^a ¹⁷²

Wednesday, October 12, 2016

Epivir

Commonly used brand name(s)

Uses For Epivir

Before Using Epivir

Allergies

Pediatric

Geriatric

Pregnancy

Breast Feeding

Interactions with Medicines

Interactions with Food/Tobacco/Alcohol

Other Medical Problems

Proper Use of lamivudine

Dosing

Missed Dose

Storage

Precautions While Using Epivir

Epivir Side Effects

More Epivir resources

Compare Epivir with other medications

enalapril and felodipine

Uses For enalapril and felodipine

Before Using enalapril and felodipine

Allergies

Pediatric

Geriatric

Pregnancy

Breast Feeding

Interactions with Medicines

Interactions with Food/Tobacco/Alcohol

Other Medical Problems

Proper Use of enalapril and felodipine

Dosing

Missed Dose

Storage

Precautions While Using enalapril and felodipine

enalapril and felodipine Side Effects

More enalapril and felodipine resources

Compare enalapril and felodipine with other medications

Epipen Jr

Commonly used brand name(s)

Uses For Epipen Jr

Before Using Epipen Jr

Allergies

Pediatric

Geriatric

Pregnancy

Breast Feeding

Interactions with Medicines

Interactions with Food/Tobacco/Alcohol

Other Medical Problems

Proper Use of epinephrine

Dosing

Storage

Precautions While Using Epipen Jr

Epipen Jr Side Effects

More Epipen Jr resources

Compare Epipen Jr with other medications

Epinephrine

Introduction

Uses for Epinephrine

Bronchospasm

Sensitivity Reactions

CPR and Cardiac Arrhythmias

Radiographic Uses

GI and Renal Hemorrhage

Radiation Nephritis

Adjunct to Local Anesthesia

Superficial Bleeding

Cardiogenic, Hemorrhagic, and Traumatic Shock

Premature Labor

Hypoglycemia

Epinephrine Dosage and Administration

Administration

Sub-Q Injection

IM Injection

Technique for Using Auto-injector

IV Administration

Dilution