Norepinephrine

Norepinephrine is indicated for blood pressure control in certain acute hypotensive states (e.g., pheochromocytomectomy, sympathectomy, poliomyelitis, spinal anesthesia, myocardial infarction, septicemia, blood transfusion, and drug reactions).

• Norepinephrine is also indicated as an adjunct in the treatment of cardiac arrest and profound hypotension.
• Norepinephrine is available under the following different brand names: Levarterenol, and Levophed.

Adult and Pediatric Dosage Forms and Strengths

Injectable solution

• 1 mg/mL

Dosage Considerations – Should be Given as Follows:

Acute Hypotension

Adult

• Initial: 8-12 mcg/minute intravenous (IV) infusion; titrate to effect
• Maintenance: 2-4 mcg/minute IV infusion

Pediatric

• Initial: 0.05-0.1 mcg/kg/minute intravenous (IV) infusion; titrate to effect
• Maximum: 1-2 mcg/kg/minute

Cardiac Arrest

Adult

• Initial: 8-12 mcg/minute intravenous (IV) infusion; titrate to effect
• Maintenance: 2-4 mcg/minute IV infusion

Pediatric

• Initial: 0.05-0.1 mcg/kg/minute intravenous (IV) infusion; titrate to effect
• Maximum: 1-2 mcg/kg/minute

Sepsis and Septic Shock

• Adult: 0.01-3 mcg/kg/minute intravenous (IV) infusion
• Pediatric: 0.05-0.1 mcg/kg/minute IV infusion; titrate to effect; not to exceed 2 mcg/kg/minute

Beta Blocker Toxicity (Off-label)

• Should be titrated to age-appropriate blood pressure

Calcium Channel Blocker Toxicity (Off-label)

• Should be titrated to age-appropriate blood pressure

Tricyclic Antidepressant Toxicity (Off-label)

• Should be titrated to age-appropriate blood pressure

Common side effects of norepinephrine include:

• Slow heart rate
• High blood pressure (hypertension)
• Irregular heartbeats (arrhythmias)
• Confusion
• Anxiety
• Shortness of breath, with or without respiratory difficulty
• Headache
• Nausea and vomiting
• Sweating
• Tremor
• Restlessness
• Urinary retention
• Leakage of intravenous (IV) fluid
• Gangrene
• Dizziness
• Weakness
• Redness and swelling at the injection site

Serious side effects of norepinephrine include:

• Pain or burning where the injection is given
• Sudden numbness/weakness/cold feeling in your body
• Blue lips or fingernails
• Urinating less than usual or not at all
• Trouble breathing
• Dangerously high blood pressure (severe headache, blurred vision, buzzing in your ears, anxiety, confusion, chest pain, shortness of breath, irregular heartbeats, seizure)

This is not a complete list of side effects and other serious side effects may occur. Call your doctor for information and medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

If your doctor has directed you to use this medication for your condition, your doctor or pharmacist may already be aware of any possible drug interactions or side effects and may be monitoring you for them. Do not start, stop, or change the dosage of this medicine or any medicine before getting further information from your doctor, healthcare provider, or pharmacist first.

• Severe interactions of norepinephrine include:
  • isocarboxazid
  • linezolid
  • phenelzine
  • procarbazine
  • selegiline transdermal
  • tranylcypromine
• Norepinephrine has serious interactions with at least 34 different drugs.
• Norepinephrine has moderate interactions with at least 261 different drugs.
• Mild Interactions of norepinephrine include:
  • bendroflumethiazide
  • bumetanide
  • chlorothiazide
  • chlorthalidone
  • cyclopenthiazide
  • desmopressin
  • ethacrynic acid
  • eucalyptus
  • furosemide
  • hydrochlorothiazide
  • indapamide
  • methyclothiazide
  • metolazone
  • noni juice
  • sage
  • torsemide

This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist. Check with your physician if you have health questions or concerns.

Warnings

• Antidote for extravasation ischemia: To prevent sloughing and necrosis in areas where extravasation has taken place, infiltrate areas promptly with 10-15 mL of saline solution containing 5-10 mg of phentolamine mesylate for injection.
• Use a syringe with a fine hypodermic needle, with the solution being infiltrated liberally throughout the area, which is easily identified by its cold, hard, pallid appearance.
• This medication contains norepinephrine. Do not take Levarterenol or Levophed if you are allergic to norepinephrine or any ingredients contained in this drug.
• Keep out of reach of children. In case of overdose, get medical help or contact a Poison Control Center immediately.

Contraindications

• Hypersensitivity
• Low blood pressure (hypotension) due to blood volume deficit
• Peripheral vascular thrombosis (except for lifesaving procedures)
• Concomitant use with some general anesthetics: Chloroform, trichloroethylene, cyclopropane, halothane

Effects of Drug Abuse

• No information available

Short-Term Effects

• See "What Are Side Effects Associated with Using Norepinephrine?"

Long-Term Effects

• See "What Are Side Effects Associated with Using Norepinephrine?"

Cautions

• Mesenteric or peripheral vascular thrombosis.
• Avoid infusion site extravasation.
• Not for use in profound hypoxia.
• Sulfite allergy due to the presence of metabisulfite.
• Monitor blood pressure.
• Extreme caution in concurrent monoamine oxidase inhibitor (MAOI) use.

Pregnancy and Lactation

• Use norepinephrine with caution during pregnancy if the benefits outweigh the risks. Animal studies show risk and human studies are not available or neither animal nor human studies were done.
• It is not known if norepinephrine is excreted into breast milk; avoid use during breastfeeding.