Adult Dosing

Supraventricular tachycardia

• Loading dose: 500 mcg/kg/min IV over 1 min
• Maintenance dose: 50 mcg/kg/min IV, may increase maint. dose by 50 mcg/kg/min q4 mins
• Note:Dosage needs to be titrated, using ventricular rate as guide
• Max: 300 mcg/kg/min maint dose; maintenance doses > 200 mcg/kg/min rarely more effective
• If more rapid slowing of ventricular response is needed, give 500 mcg/kg/min IV x 1 min before each maintenance dose up to a total of 3 loading doses. If required, maintenance dose alone may be incremented a fourth time (No loading dose)
• Esmolol infusion may be used upto 24 hrs (max 48 hrs)

Intraoperative hypertension/ tachycardia

Rapid control

• Loading dose: 80 mg IV over 30 secs
• Maintenance dose(if required): 150 mcg/kg/min IV, may increase dose by 50 mcg/kg/min PRN
• Max: 300 mcg/kg/min maint dose

Postoperative hypertension/ tachycardia

Gradual control

• Loading dose: 500 mcg/kg/min IV over 1 min
• Maintenance dose: 50 mcg/kg/min IV, may increase maint. dose by 50 mcg/kg/min q4 mins
• Max: 300 mcg/kg/min maint dose
• If more response is needed, give 500 mcg/kg/min IV x 1 min before each maintenance dose up to a total of 3 loading doses

Hypertensive Emergency [Non-FDA approved]

• Load 250-500 mcg/kg over 1 min, then initiate infusion at 50-100 mcg/kg/min
• If desired response is not achieved, repeat IV loading dose and increase IV infusion every 5 minutes gradually to a maximum of 200-300 mcg/kg/min (increments generally 50 mcg/kg/min every 5 minutes)

Pediatric Dosing

• Safety and effectiveness in pediatric patients have not been established

[Outline]

• Adult Dosing
• Pediatric Dosing

• Supraventricular tachycardia
• Intraoperative and postoperative tachycardia and/or hypertension

• Hypersensitivity
• Sinus bradycardia
• Cardiogenic shock
• Uncompensated heart failure
• AV Block, 2nd or 3rd degree
• Hypertension, hyperthermia-associated

• N/A

Renal Dose Adjustment

• Renal impairment: Use with caution, elevated metabolite levels in ESRD. Dose adjustments not defined
• Hemodialysis: No supplement

Hepatic Dose Adjustment

• Hepatic impairment: Dose adjustments not defined

• 20-50% of patients treated with esmolol have experienced hypotension. Hypotension can occur at any dose but is dose-related. Doses > 200 mcg/kg/min are not recommended
• Use of beta-blockers in CHF may result in further depression of myocardial contractility, and precipitate more severe failure. Withdraw drug at first sign or symptom of impending cardiac failure
• Carefully monitor heart rate and blood pressure during administration
• Do not use for treatment of hypertension in patients in whom the increased blood pressure is primarily due to the vasoconstriction associated with hypothermia
• Avoid use in bronchospastic disease. If used, carefully titrate to obtain lowest possible dose. Stop infusion immediately in case of bronchospasm
• Beta-blockers can precipitate or aggravate symptoms of arterial insufficiency in patients with peripheral vascular disease
• Beta-blockers may mask some of the manifestations of hypoglycemia, particularly tachycardia. Use cautiously in diabetes mellitus
• Concurrent use of catecholamine depletor may have an additive effect

Cautions: Use cautiously in

• Renal impairment
• Hypotension
• Bronchospastic disease
• PVD
• Diabetes mellitus
• Thyrotoxicosis
• Pregnancy
• Lactation
• To convert to other antiarrhythmic therapy after control has been achieved with esmolol, reduce infusion rate of esmolol by 50% 30 min after administration of first dose of the alternative agent. If after the second dose of the alternative agent a satisfactory response is maintained for 1 hour, then discontinue esmolol

Brevibloc interacts with :

	Aricept
	Aricept ODT
	Donepezil
	Exelon
	Galantamine
	Razadyne
	Razadyne ER
	Rivastigmine

Pregnancy Category:C

Breastfeeding: It is not known if esmolol is excreted in human breast milk. Due to extremely short half-life, it would not be expected to cause any adverse effects in breastfed infants. This information is based upon LactMed database (available at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT last accessed 28 May 2010). Manufacturer advises caution.

• CV: Asymptomatic or Symptomatic Hypotension(diaphoresis,dizziness), peripheral ischemia, bradycardia, CHF, cold extremities, pallor, flushing, chest pain, syncope, second or third-degree heart block
• CNS: Dizziness, somnolence, confusion, headache, agitation, insomnia, fatigue, depression, lethargy, drowsiness, forgetfulness
• RESP: Bronchospasm, shortness of breath, wheezing, nasal congestion, rhonchi, rales
• GI: Nausea, vomiting, diarrhea, dyspepsia, constipation, abdominal discomfort, dry mouth
• DERM: Sweating
• HEMA: Agranulocytosis, thrombocytopenia purpura
• MISC: Weight changes, muscle weakness, inflammation at infusion site

• Mechansim of action: Selectively blocks stimulation of beta1(myocardial)-adrenergic receptors
• Extensively metabolized by erythrocytes
• Excreted in urine: 71-88% (<1% unchanged)
• Half-life: 9 mins

US Trade Name(s)

• Brevibloc

US Availability

esmolol (generic)

• INJ: 10 mg/mL
• INJ: 250 mg/mL

Brevibloc

• INJ: 10 mg/mL (10 mL vial)
• INJ: 10 mg/ mL (250 mL Premixed Injection bag)
• INJ: 20 mg/mL (100 mL Double strength premixed injection bag)

Canadian Trade Name(s)

• Brevibloc

Canadian Availability

Brevibloc

• INJ: 10 mg/mL (10 mL vials)
• INJ: 10 mg/mL (250 mL infusion bags)

UK Trade Name(s)

• Brevibloc

UK Availability

Brevibloc

• INJ: 10 mg/mL (10 mL vials)
• INJ: 10 mg/mL (250 mL infusion bags)

Australian Trade Name(s)

• Brevibloc

Australian Availability

Brevibloc

• INJ: 10 mg/mL (10 mL vials)

[Outline]

Cardiovascular

Antiarrhythmic Agents

Group II Antiarrhythmics