OBJECT DRUGS

• Epinephrine (Systemic doses, etc.)

PRECIPITANT DRUGS

Beta-blockers (Nonselective):

• Carteolol (Ocupress)
• Levobunolol (Betagan, etc.)
• Nadolol (Corgard)
• Penbutolol (Levatol)
• Pindolol (Visken)
• Propranolol (Inderal, etc.)
• Sotalol (Betapace, etc.)
• Timolol (Blocadren, etc.)

Comment:

Non-cardioselective beta-blockers markedly increase the pressor response to epinephrine; this effect is not likely with epinephrine doses used for non-systemic effects (e.g., with local anesthetics) unless very large amounts are used. The increased blood pressure may be accompanied by bradycardia and cardiac arrhythmias. Patients prone to anaphylaxis should avoid all beta-blockers if possible (due to poor response to epinephrine should anaphylaxis occur). Ophthalmic use of beta-blockers can result in systemic beta-blockade in some patients.

Class 2: Use Only if Benefit Felt to Outweigh Risk

• Use Alternative: Cardioselective beta-blockers are unlikely to result in hypertensive reactions in patients who receive systemic doses of epinephrine; thus, they are preferable to non-cardioselective beta-blockers if beta-blockers must be used. Cardioselective beta-blockers include acebutolol (Sectral), atenolol (Tenormin), betaxolol (Kerlone), bisoprolol (Zebeta), esmolol (Brevibloc), metoprolol (Lopressor), and nebivolol (Bystolic). Most cardioselective beta-blockers can become nonselective when used in large doses. Also, cardioselective agents that are metabolized by CYP2D6 such as metoprolol and nebivolol can become nonselective in people with reduced CYP2D6 activity, genetically or due to CYP2D6 inhibitors. Mixed alpha/beta blockers such as carvedilol (Coreg) and labetolol (Trandate) appear to be less likely to interact with epinephrine since the alpha-blocking effect tends to counteract the hypertensive effect seen when epinephrine is given with pure beta-blockers.