Embedded Files
Pharmacologic Category
Dosing: Adult
Hypotension, anesthesia-induced: IV: Initial: 5 to 10 mg; repeat as needed to maintain BP (maximum total cumulative dose: 50 mg).
Postoperative nausea and vomiting (prevention) (off-label use): IM: 0.5 mg/kg at the end of surgery (Hagemann 2000; SAMBA [Gan 2007]).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
* See Dosage and Administration in AHFS Essentials for additional information.
Dosing: Geriatric
Initiate at lower end of dosing range. Refer to adult dosing.
Dosing: Renal Impairment: Adult
There are no dosage adjustments provided in the manufacturer's labeling; use with caution.
Dosing: Hepatic Impairment: Adult
There are no dosage adjustments provided in the manufacturer's labeling.
Dosing: Pediatric
Hypotension, anesthesia-induced: Limited data available: Use the lowest effective dose:
Infants, Children, and Adolescents: Slow IV push: 0.1 to 0.3 mg/kg/dose; usual adult dose: 5 to 25 mg/dose; repeat as needed to maintain blood pressure; maximum dose: 25 mg/dose; maximum total dose: 50 mg (Atchabahian 2013; Taguchi 1996).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Dosing: Renal Impairment: Pediatric
There are no dosage adjustments provided in the manufacturer's labeling; use with caution.
Dosing: Hepatic Impairment: Pediatric
There are no dosage adjustments provided in the manufacturer's labeling.
Calculations
Use: Labeled Indications
Hypotension, anesthesia-induced: Treatment of anesthesia-induced hypotension.
* See Uses in AHFS Essentials for additional information.
Use: Off-Label: Adult
Postoperative nausea and vomiting (prevention)Level of Evidence [B, G]
Data from two randomized controlled studies suggests that patients given post-operative ephedrine had lower postoperative nausea and vomiting (PONV) scores early in the post-operative period without significant hemodynamic changes Ref. Additional trials may be necessary to further define the role of ephedrine in this setting.
Based on the Society of Ambulatory Anesthesia (SAMBA) guidelines for the management of PONV, ephedrine is a recommended pharmacologic antiemetic among other agents for prophylaxis in adults at moderate to severe risk for PONV. Other agents include 5HT3 antagonists (eg, ondansetron, granisetron), steroids (eg, dexamethasone), phenothiazines (eg, promethazine, prochlorperazine), butyrophenones (eg, droperidol, haloperidol), antihistamines (eg, dimenhydrinate), and anticholinergics (eg, transdermal scopolamine) Ref.
Level of Evidence Definitions
Level of Evidence Scale
Class and Related Monographs
Administration: IM
For postoperative nausea and vomiting (off-label use), administer IM (Hagemann 2000; SAMBA [Gan 2007]).
Administration: IV
Administer as an IV bolus. Verify formulation prior to administration; available in vials requiring further dilution and also premixed vials (requiring no further dilution).
Administration: Injectable Detail
pH: 4.5 to 7
Administration: Pediatric
Parenteral: IV: Administer by slow IV push.
Storage/Stability
Store at 25°C (77°F); excursions are permitted between 15°C and 30°C (59°F and 86°F). Discard any unused portion.
Preparation for Administration: Adult
IV: Using a 50 mg/mL vial, withdraw 50 mg and dilute with 9 mL of D5W or NS to final concentration of 5 mg/mL. Premixed vials requiring no further dilution are also available.
IM: For postoperative nausea and vomiting (off-label use), dilute with NS (Hagemann 2000).
Preparation for Administration: Pediatric
Parenteral: IV: Dilution to a concentration of 5 or 10 mg/mL has been used for doses of 5 to 25 mg; in a pediatric hypotension trial, ephedrine doses of 0.1 mg/kg and 0.2 mg/kg were diluted to 1 mg/mL and 2 mg/mL, respectively (Taguchi 1996).
Compatibility
See Trissel’s IV Compatibility Database
Open Trissel's IV Compatibility
Medication Patient Education with HCAHPS Considerations
What is this drug used for?
Tablets:
• It is used to treat asthma.
Injection:
• It is used to treat low blood pressure.
• It may be given to you for other reasons. Talk with the doctor.
All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:
• Dizziness or headache
• Sweating a lot
• Restlessness
• Trouble sleeping
• Feeling nervous and excitable
• Upset stomach or throwing up
• Not hungry
WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:
• High blood pressure like very bad headache or dizziness, passing out, or change in eyesight
• Weakness on 1 side of the body, trouble speaking or thinking, change in balance, drooping on one side of the face, or blurred eyesight
• Chest pain pain or pressure
• Fast, slow, or abnormal heartbeat
• Trouble passing urine
• Shortness of breath
• Seizures
• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.
Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a limited summary of general information about the medicine's uses from the patient education leaflet and is not intended to be comprehensive. This limited summary does NOT include all information available about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not intended to provide medical advice, diagnosis or treatment and does not replace information you receive from the healthcare provider. For a more detailed summary of information about the risks and benefits of using this medicine, please speak with your healthcare provider and review the entire patient education leaflet.
Medication Safety Issues
Sound-alike/look-alike issues:
High alert medication:
Contraindications
There are no contraindications listed in the manufacturer’s labeling.
Warnings/Precautions
Concerns related to adverse effects:
• Cardiovascular effects: May cause hypertension if used prophylactically for hypotension (only indicated for treatment of hypotension).
Disease-related concerns:
• Renal impairment: Use with caution in patients with renal impairment; increased elimination half-life may occur. Carefully monitor patients with renal impairment for adverse reactions.
Special populations:
• Elderly: Use with caution in the elderly.
Other warnings/precautions:
• Tolerance: Tachyphylaxis and tolerance may develop with repeated, prolonged, or excessive administration; temporary cessation of therapy restores its effectiveness.
* See Cautions in AHFS Essentials for additional information.
Geriatric Considerations
Avoid as a bronchodilator. Use caution since it crosses the blood-brain barrier and may cause confusion.
Pregnancy Considerations
Metabolic acidosis has been reported in neonates following maternal use of ephedrine; monitor.
Untreated maternal hypotension during cesarean delivery is associated with adverse events, including maternal nausea and vomiting, and bradycardia and acidosis in the fetus. Ephedrine injection is used at delivery for the prevention and/or treatment of maternal hypotension associated with spinal anesthesia in women undergoing cesarean delivery (ASA 2016). Serious postpartum hypertension and possibly stroke may occur if administered with oxytocic medications.
Breast-Feeding Considerations
Ephedrine is present in breast milk.
According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother.
Briggs' Drugs in Pregnancy & Lactation
Adverse Reactions
Frequency not defined.
Cardiovascular: Angina pectoris, bradycardia, cardiac arrhythmia, hypertension, palpitations, pulse irregularity, tachycardia, ventricular ectopy, visceral vasoconstriction (renal)
Central nervous system: Anxiety, confusion, delirium, dizziness, hallucination, headache, insomnia, intracranial hemorrhage, nervousness, precordial pain, restlessness, tension, vertigo
Dermatologic: Diaphoresis, pallor
Gastrointestinal: Anorexia, nausea, vomiting
Genitourinary: Dysuria, oliguria, urinary retention (males with prostatism)
Neuromuscular & skeletal: Tremor, vesicle sphincter spasm, weakness
Respiratory: Dyspnea
Miscellaneous: Tachyphylaxis
* See Cautions in AHFS Essentials for additional information.
Toxicology
Metabolism/Transport Effects
None known.
Drug Interactions Open Interactions
Alkalinizing Agents: May increase the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy
Alpha1-Blockers: May diminish the vasoconstricting effect of Alpha-/Beta-Agonists. Similarly, Alpha-/Beta-Agonists may antagonize Alpha1-Blocker vasodilation. Risk C: Monitor therapy
AtoMOXetine: May enhance the hypertensive effect of Sympathomimetics. AtoMOXetine may enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy
Atropine (Systemic): May enhance the therapeutic effect of EPHEDrine (Systemic). Risk C: Monitor therapy
Benzylpenicilloyl Polylysine: Alpha-/Beta-Agonists may diminish the diagnostic effect of Benzylpenicilloyl Polylysine. Management: Consider use of a histamine skin test as a positive control to assess a patient's ability to mount a wheal and flare response. Risk D: Consider therapy modification
Bretylium: May enhance the therapeutic effect of Alpha-/Beta-Agonists (Direct-Acting). Risk C: Monitor therapy
Cannabinoid-Containing Products: May enhance the tachycardic effect of Sympathomimetics. Exceptions: Cannabidiol. Risk C: Monitor therapy
Carbonic Anhydrase Inhibitors: May increase the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy
Cardiac Glycosides: EPHEDrine (Systemic) may enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy
Chloroprocaine: May enhance the hypertensive effect of Alpha-/Beta-Agonists. Risk C: Monitor therapy
CloNIDine: May enhance the therapeutic effect of EPHEDrine (Systemic). Risk C: Monitor therapy
CloZAPine: May diminish the therapeutic effect of Alpha-/Beta-Agonists. Risk C: Monitor therapy
Cocaine (Topical): May enhance the hypertensive effect of Sympathomimetics. Management: Consider alternatives to use of this combination when possible. Monitor closely for substantially increased blood pressure or heart rate and for any evidence of myocardial ischemia with concurrent use. Risk D: Consider therapy modification
DexAMETHasone (Systemic): EPHEDrine (Systemic) may decrease the serum concentration of DexAMETHasone (Systemic). Risk C: Monitor therapy
Doxofylline: Sympathomimetics may enhance the adverse/toxic effect of Doxofylline. Risk C: Monitor therapy
Droxidopa: EPHEDrine (Systemic) may enhance the hypertensive effect of Droxidopa. Risk C: Monitor therapy
Ergot Derivatives: May enhance the hypertensive effect of Alpha-/Beta-Agonists. Ergot Derivatives may enhance the vasoconstricting effect of Alpha-/Beta-Agonists. Exceptions: Ergoloid Mesylates; Nicergoline. Risk X: Avoid combination
FentaNYL: Alpha-/Beta-Agonists (Indirect-Acting) may decrease the serum concentration of FentaNYL. Specifically, fentanyl nasal spray serum concentrations may decrease and onset of effect may be delayed. Risk C: Monitor therapy
Guanethidine: May enhance the arrhythmogenic effect of Sympathomimetics. Guanethidine may enhance the hypertensive effect of Sympathomimetics. Risk C: Monitor therapy
Hyaluronidase: May enhance the vasoconstricting effect of Alpha-/Beta-Agonists. Management: Avoid the use of hyaluronidase to enhance dispersion or absorption of alpha-/beta-agonists. Use of hyaluronidase for other purposes in patients receiving alpha-/beta-agonists may be considered as clinically indicated. Risk D: Consider therapy modification
Inhalational Anesthetics: EPHEDrine (Systemic) may enhance the arrhythmogenic effect of Inhalational Anesthetics. Risk X: Avoid combination
Iobenguane Radiopharmaceutical Products: Alpha-/Beta-Agonists (Indirect-Acting) may diminish the therapeutic effect of Iobenguane Radiopharmaceutical Products. Management: Discontinue all drugs that may inhibit or interfere with catecholamine transport or uptake for at least 5 biological half-lives before iobenguane administration. Do not administer these drugs until at least 7 days after each iobenguane dose. Risk X: Avoid combination
Linezolid: May enhance the hypertensive effect of Sympathomimetics. Management: Reduce initial doses of sympathomimetic agents, and closely monitor for enhanced pressor response, in patients receiving linezolid. Specific dose adjustment recommendations are not presently available. Risk D: Consider therapy modification
Monoamine Oxidase Inhibitors: May enhance the hypertensive effect of Alpha-/Beta-Agonists (Indirect-Acting). While linezolid is expected to interact via this mechanism, management recommendations differ from other monoamine oxidase inhibitors. Refer to linezolid specific monographs for details. Exceptions: Linezolid. Risk X: Avoid combination
Oxytocin: May enhance the hypertensive effect of EPHEDrine (Systemic). Risk C: Monitor therapy
Ozanimod: May enhance the hypertensive effect of Sympathomimetics. Management: Concomitant use of ozanimod with sympathomimetic agents is not recommended. If combined, monitor patients closely for the development of hypertension, including hypertensive crises. Risk D: Consider therapy modification
Procarbazine: May enhance the adverse/toxic effect of Sympathomimetics. Management: Consider alternatives to this combination when possible. Procarbazine prescribing information states that this combination should be avoided. Risk D: Consider therapy modification
Propofol: May enhance the therapeutic effect of EPHEDrine (Systemic). Risk C: Monitor therapy
QuiNIDine: May diminish the therapeutic effect of EPHEDrine (Systemic). EPHEDrine (Systemic) may diminish the therapeutic effect of QuiNIDine. Risk C: Monitor therapy
Reserpine: May diminish the therapeutic effect of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy
Rocuronium: EPHEDrine (Systemic) may enhance the therapeutic effect of Rocuronium. Risk C: Monitor therapy
Serotonin/Norepinephrine Reuptake Inhibitors: May enhance the tachycardic effect of Alpha-/Beta-Agonists. Serotonin/Norepinephrine Reuptake Inhibitors may enhance the vasopressor effect of Alpha-/Beta-Agonists. Management: If possible, avoid coadministration of direct-acting alpha-/beta-agonists and serotonin/norepinephrine reuptake inhibitors. If coadministered, monitor for increased sympathomimetic effects (eg, increased blood pressure, chest pain, headache). Risk D: Consider therapy modification
Solriamfetol: Sympathomimetics may enhance the hypertensive effect of Solriamfetol. Sympathomimetics may enhance the tachycardic effect of Solriamfetol. Risk C: Monitor therapy
Spironolactone: May diminish the vasoconstricting effect of Alpha-/Beta-Agonists. Risk C: Monitor therapy
Sympathomimetics: May enhance the adverse/toxic effect of other Sympathomimetics. Risk C: Monitor therapy
Tedizolid: May enhance the hypertensive effect of Sympathomimetics. Tedizolid may enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy
Tricyclic Antidepressants: May enhance the vasopressor effect of Alpha-/Beta-Agonists. Management: Avoid, if possible, the use of alpha-/beta-agonists in patients receiving tricyclic antidepressants. If combined, monitor for evidence of increased pressor effects and consider reductions in initial dosages of the alpha-/beta-agonist. Risk D: Consider therapy modification
Urinary Acidifying Agents: May decrease the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy
Test Interactions
Can cause a false-positive amphetamine EMIT assay
Monitoring Parameters
BP, pulse; monitor patients with renal impairment for adverse reactions.
Nursing Physical Assessment/Monitoring
Monitor for hypertension, CNS excitability, urinary retention, dysrhythmias, and respiratory depression.
Dosage Forms: US
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Injection, as sulfate:
Generic: 50 mg/mL (1 mL [DSC])
Solution, Injection, as sulfate [preservative free]:
Generic: 50 mg/mL (1 mL)
Solution, Intravenous, as sulfate:
Akovaz: 50 mg/mL (1 mL)
Generic: 50 mg/mL (1 mL)
Solution, Intravenous, as sulfate [preservative free]:
Emerphed: 5 mg/mL (10 mL)
Generic: 50 mg/mL (1 mL)
Tablet, Oral, as sulfate:
Bronkaid Max: 25 mg [dye free]
Dosage Forms: Canada
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Injection, as sulfate:
Generic: 50 mg/mL (1 mL)
Anatomic Therapeutic Chemical (ATC) Classification
- R03CA02
Generic Available (US)
May be product dependent
Pricing: US
Solution (Akovaz Intravenous)
50 mg/mL (per mL): $33.35
Solution (Emerphed Intravenous)
5 mg/mL (per mL): $3.36
Solution (ePHEDrine Sulfate Injection)
50 mg/mL (per mL): $18.00
Solution (ePHEDrine Sulfate Intravenous)
50 mg/mL (per mL): $34.85 - $59.11
Tablets (Bronkaid Max Oral)
25 mg (per each): $0.18
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Mechanism of Action
Releases tissue stores of norepinephrine and thereby produces an alpha- and beta-adrenergic stimulation; longer-acting and less potent than epinephrine
Pharmacodynamics/Kinetics
Onset: IM: Within 10 to 20 minutes.
Duration: Pressor/cardiac effects: SubQ: 1 hour.
Metabolism: Minimally hepatic; metabolites include p-hydroxyephedrine, p-hydroxynorephedrine, norephedrine.
Half-life elimination: Dependent upon urinary pH; Urine pH 5: ~3 hours; Urine pH 6.3: ~6 hours.
Excretion: Urine (primarily unchanged; dependent upon urinary pH with greatest excretion in acid pH).
Pharmacodynamics/Kinetics: Additional Considerations
Renal function impairment: Elimination half-life may be increased.
Local Anesthetic/Vasoconstrictor Precautions
Use vasoconstrictor with caution since ephedrine may enhance cardiostimulation and vasopressor effects of sympathomimetics such as epinephrine
Effects on Dental Treatment
Key adverse event(s) related to dental treatment: Xerostomia (normal salivary flow resumes upon discontinuation)
Effects on Bleeding
No information available to require special precautions
Index Terms
Ephedrine Sulfate
References
Akovaz (ephedrine sulfate) [prescribing information]. Chesterfield, MO: Avadel Legacy Pharmaceuticals; April 2020.
Atchabahian A, Gupta R, eds. The Anesthesia Guide. San Francisco, CA: The McGraw Hill Companies, Inc; 2013.
Emerphed (ephedrine sulfate) [prescribing information]. Lincolnshire, IL: Nexus Pharmaceuticals Inc; April 2020.
Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2007;105(6):1615-1628.[PubMed 18042859]
Hagemann E, Halvorsen A, Holgersen O, et al. Intramuscular ephedrine reduces emesis during the first three hours after abdominal hysterectomy. Acta Anaesthesiol Scand. 2000;44(1):107-111.[PubMed 10669281]
Hughes SC, Ward MG, Levinson G, et al. Placental transfer of ephedrine does not affect neonatal outcome. Anesthesiology. 1985;63(2):217-219.[PubMed 4025872]
National Asthma Education and Prevention Program (NAEPP), “Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma,” Clinical Practice Guidelines, National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Publication No. 08-4051, 2007. Available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists (ASA) Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2016;124(2):270-300. doi:10.1097/ALN.0000000000000935[PubMed 26580836]
Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43(3):304-377.[PubMed 28101605]
Rothenberg DM, Parnass SM, Litwack K, McCarthy RJ, Newman LM. Efficacy of ephedrine in the prevention of postoperative nausea and vomiting. Anesth Analg. 1991;72(1):58-61.[PubMed 1824585]
Taguchi N, Nishikawa T, Inomata S, Taguchi M, Yamashita S, Naito H. Hemodynamic effects of intravenous ephedrine in infants and children anesthetized with halothane and nitrous oxide. Anesth Analg. 1996;82(3):568-573.[PubMed 8623963]
Brand Names: International
C-Phedrin (BD); Efedrina (ES); Efipres (IN); Ephedrine Hydrochloride (NZ); Ephedrine Sulfate Inj (NZ); Epherit (HU); Ephidin (BD); Epidron (BD); Fedrin (BD); Forasm (KR); Kemiphedrine (EG); Muchan (AR); Nordrine (BD); Sulfato de Efedrina Klinos (VE); Sympathodrine (EG); Tabellae Ephedrini (TW); Tendrin (BZ, CR, DO, GT, HN, MX, NI, PA, SV); Unifedrine (BR); Vasodrin (BD, ID); Vitadrine (LK)
Last Updated 10/15/20
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