Atracurium

Atracurium
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2]

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Overview

Atracurium is a skeletal muscle relaxant and neuromuscular blocking drugs that is FDA approved for the {{{indicationType}}} of induction of neuromuscular blockade, adjunct to general anesthesia, to facilitate endotracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation. Common adverse reactions include dermatologic: flushing (1% to 29.2% ).

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

• Dosage must be individualized

• Induction of neuromuscular blockade, Adjunct to general anesthesia, to facilitate endotracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation:

• Initial

• 0.4 to 0.5 mg/kg IV bolus

• Induction of neuromuscular blockade, Adjunct to general anesthesia, to facilitate endotracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation

• Maintenance

• 0.08 to 0.1 mg/kg IV bolus 20 to 45 min after initial dose, then every 15 to 25 min as needed
• 5 to 9 mcg/kg/min (range 2 to 15 mcg/kg/min) continuous IV infusion after initial dose, upon early evidence of spontaneous recovery; in ICU, 11 to 13 mcg/kg/min (range 4.5 to 29.5 mcg/kg/min) continuous IV infusion

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Atracurium in adult patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Atracurium in adult patients.

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

• Dosage must be individualized

Infants (age 1 month to 2 yr)

• Induction of neuromuscular blockade, Adjunct to general anesthesia, to facilitate endotracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation, under halothane anesthesia,

• Initial, 0.3 to 0.4 mg/kg IV

Age 2 yr and older

• Induction of neuromuscular blockade, Adjunct to general anesthesia, to facilitate endotracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation

• Initial, 0.4 to 0.5 mg/kg IV bolus

Age 1 month and older

• Induction of neuromuscular blockade, Adjunct to general anesthesia, to facilitate endotracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation

• Maintenance, 0.08 to 0.1 mg/kg IV bolus 20 to 45 min after initial dose, then every 15 to 25 min as needed; children may require maintenance doses more frequently than adults

Age 1 month and older

• Induction of neuromuscular blockade, Adjunct to general anesthesia, to facilitate endotracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation

• Maintenance, 5 to 9 mcg/kg/min (range 2 to 15 mcg/kg/min) continuous IV infusion after initial dose, upon early evidence of spontaneous recovery

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Atracurium in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Atracurium in pediatric patients.

Contraindications

Atracurium besylate is contraindicated in patients known to have a hypersensitivity to it. Use of atracurium besylate from multiple dose vials containing benzyl alcohol as a preservative is contraindicated in patients with a known hypersensitivity to benzyl alcohol.

Warnings

ATRACURIUM SHOULD BE USED ONLY BY THOSE SKILLED IN AIRWAY MANAGEMENT AND RESPIRATORY SUPPORT. EQUIPMENT AND PERSONNEL MUST BE IMMEDIATELY AVAILABLE FOR ENDOTRACHEAL INTUBATION AND SUPPORT OF VENTILATION, INCLUDING ADMINISTRATION OF POSITIVE PRESSURE OXYGEN. ADEQUACY OF RESPIRATION MUST BE ASSURED THROUGH ASSISTED OR CONTROLLED VENTILATION. ANTICHOLINESTERASE REVERSAL AGENTS SHOULD BE IMMEDIATELY AVAILABLE.

DO NOT GIVE ATRACURIUM BESYLATE BY INTRAMUSCULAR ADMINISTRATION.

Atracurium has no known effect on consciousness, pain threshold, or cerebration. It should be used only with adequate anesthesia.

Atracurium besylate injection, which has an acid pH, should not be mixed with alkaline solutions (e.g., barbiturate solutions) in the same syringe or administered simultaneously during intravenous infusion through the same needle. Depending on the resultant pH of such mixtures, atracurium may be inactivated and a free acid may be precipitated.

Atracurium besylate injection 10 mL multiple dose vials contain benzyl alcohol. In neonates, benzyl alcohol has been associated with an increased incidence of neurological and other complications which are sometimes fatal. Atracurium besylate 5 mL single use vials do not contain benzyl alcohol (see PRECAUTIONS: Pediatric Use).

Anaphylaxis: Severe anaphylactic reactions to neuromuscular blocking agents, including atracurium besylate, have been reported. These reactions have in some cases been life-threatening and fatal. Due to the potential severity of these reactions, the necessary precautions, such as the immediate availability of appropriate emergency treatment, should be taken. Precautions should also be taken in those individuals who have had previous anaphylactic reactions to other neuromuscular blocking agents since cross-reactivity between neuromuscular blocking agents, both depolarizing and non-depolarizing, has been reported in this class of drugs.

Adverse Reactions

Clinical Trials Experience

Observed in Controlled Clinical Studies: Atracurium was well tolerated and produced few adverse reactions during extensive clinical trials. Most adverse reactions were suggestive of histamine release. In studies including 875 patients, atracurium was discontinued in only one patient (who required treatment for bronchial secretions) and six other patients required treatment for adverse reactions attributable to atracurium (wheezing in one, hypotension in five). Of the five patients who required treatment for hypotension, three had a history of significant cardiovascular disease. The overall incidence rate for clinically important adverse reactions, therefore, was 7/875 or 0.8%.

Table 1 includes all adverse reaction reported attributable to atracurium during clinical trials with 875 patients.

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This image is provided by the National Library of Medicine.

Most adverse reactions were of little clinical significance unless they were associated with significant hemodynamic changes. Table 2 summarizes the incidences of substantial vital sign changes noted during atracurium clinical trials with 530 patients, without cardiovascular disease, in whom these parameters were assessed.

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Postmarketing Experience

There is limited information regarding Atracurium Postmarketing Experience in the drug label.

Drug Interactions

There is limited information regarding Atracurium Drug Interactions in the drug label.

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): There is no FDA guidance on usage of Atracurium in women who are pregnant.
Pregnancy Category (AUS): There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Atracurium in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of Atracurium during labor and delivery.

Nursing Mothers

There is no FDA guidance on the use of Atracurium in women who are nursing.

Pediatric Use

There is no FDA guidance on the use of Atracurium in pediatric settings.

Geriatic Use

There is no FDA guidance on the use of Atracurium in geriatric settings.

Gender

There is no FDA guidance on the use of Atracurium with respect to specific gender populations.

Race

There is no FDA guidance on the use of Atracurium with respect to specific racial populations.

Renal Impairment

There is no FDA guidance on the use of Atracurium in patients with renal impairment.

Hepatic Impairment

There is no FDA guidance on the use of Atracurium in patients with hepatic impairment.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of Atracurium in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of Atracurium in patients who are immunocompromised.

Administration and Monitoring

Administration

There is limited information regarding Atracurium Administration in the drug label.

Monitoring

There is limited information regarding Atracurium Monitoring in the drug label.

IV Compatibility

There is limited information regarding the compatibility of Atracurium and IV administrations.

Overdosage

There has been limited experience with overdosage of atracurium besylate. The possibility of iatrogenic overdosage can be minimized by carefully monitoring muscle twitch response to peripheral nerve stimulation. Excessive doses of atracurium can be expected to produce enhanced pharmacological effects. Overdosage may increase the risk of histamine release and cardiovascular effects, especially hypotension. If cardiovascular support is necessary, this should include proper positioning, fluid administration, and the use of vasopressor agents if necessary. The patient’s airway should be assured, with manual or mechanical ventilation maintained as necessary. A longer duration of neuromuscular block may result from overdosage and a peripheral nerve stimulator should be used to monitor recovery. Recovery may be facilitated by administration of an anticholinesterase reversing agent such as neostigmine, edrophonium, or pyridostigmine, in conjunction with an anticholinergic agent such as atropine or glycopyrrolate. The appropriate package inserts should be consulted for prescribing information.

Three pediatric patients (3 weeks, 4 and 5 months of age) unintentionally received doses of 0.8 mg/kg to 1 mg/kg of atracurium besylate. The time to 25% recovery (50 to 55 minutes) following these doses, which were 5 to 6 times the ED95 dose, was moderately longer than the corresponding time observed following doses 2 to 2.5 times the atracurium ED95 dose in infants (22 to 36 minutes). Cardiovascular changes were minimal. Nonetheless the possibility of cardiovascular changes must be considered in the case of overdose.

An adult patient (17 years of age) unintentionally received an initial dose of 1.3 mg/kg of atracurium besylate. The time from injection to 25% recovery (83 minutes) was approximately twice that observed following maximum recommended doses in adults (35 to 45 minutes). The patient experienced moderate hemodynamic changes (13% increase in mean arterial pressure and 27% increase in heart rate) which persisted for 40 minutes and did not require treatment.

The intravenous LD50s determined in non-ventilated male and female albino mice and male Wistar rats were 1.9, 2.01 and 1.31 mg/kg, respectively. Deaths occurred within 2 minutes and were caused by respiratory paralysis. The subcutaneous LD50 determined in non-ventilated male Wistar rats was 282.8 mg/kg. Tremors, ptosis, loss of reflexes and respiratory failure preceded death which occurred 45 to 120 minutes after injection.

Pharmacology

There is limited information regarding Atracurium Pharmacology in the drug label.

Mechanism of Action

There is limited information regarding Atracurium Mechanism of Action in the drug label.

Structure

There is limited information regarding Atracurium Structure in the drug label.

Pharmacodynamics

There is limited information regarding Atracurium Pharmacodynamics in the drug label.

Pharmacokinetics

There is limited information regarding Atracurium Pharmacokinetics in the drug label.

Nonclinical Toxicology

There is limited information regarding Atracurium Nonclinical Toxicology in the drug label.

Clinical Studies

There is limited information regarding Atracurium Clinical Studies in the drug label.

How Supplied

There is limited information regarding Atracurium How Supplied in the drug label.

Storage

There is limited information regarding Atracurium Storage in the drug label.

Images

Drug Images

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Package and Label Display Panel

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Patient Counseling Information

There is limited information regarding Atracurium Patient Counseling Information in the drug label.

Precautions with Alcohol

Alcohol-Atracurium interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

There is limited information regarding Atracurium Brand Names in the drug label.

Look-Alike Drug Names

There is limited information regarding Atracurium Look-Alike Drug Names in the drug label.

Drug Shortage Status

Price

References

The contents of this FDA label are provided by the National Library of Medicine.