Nalbuphine

Nalbuphine
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

Nalbuphine is an analgesic opioid that is FDA approved for the {{{indicationType}}} of general anesthesia; Adjunct, pain (moderate to severe), pain (moderate to severe), including preoperative, postoperative, and obstetrical analgesia.. Common adverse reactions include dermatologic: diaphoresis (up to 9% ), gastrointestinal: nausea and vomiting (6% ), xerostomia (4% ), neurologic: dizziness (up to 5% ), headache (3% ), sedated (36% ), vertigo (up to 5% ).

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

• General anesthesia; Adjunct: induction, 0.3-3 mg/kg IV over 10-15 min.
• General anesthesia; Adjunct: maintenance, 0.25-0.5 mg/kg in single IV administrations, as needed.
• Pain (Moderate to Severe): 10 mg subQ, IM or IV for a 70 kg individual repeated every 3 Bold textto 6 hours as needed; max single dose is 20 mg/dose; MAX total daily dose is 160 mg/day.

*   Pain (Moderate to Severe), Including preoperative, postoperative, and obstetrical analgesia: 10 mg subQ, IM or IV for a 70 kg individual repeated every 3 to 6 hours as needed; max single dose is 20 mg/dose; MAX total daily dose is 160 mg/day.

• Shivering, Postanesthesia: 0.08 mg/kg IV

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information about Off-Label Guideline-Supported Use of Nalbuphine in adult patients.

Non–Guideline-Supported Use

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

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

• Safety and effectiveness not established in patients under 18 years of age

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information about Off-Label Guideline-Supported Use of Nalbuphine in pediatric patients.

Non–Guideline-Supported Use

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

Contraindications

Nalbuphine hydrochloride injection should not be administered to patients who are hypersensitive to nalbuphine hydrochloride, or to any of the other ingredients in nalbuphine hydrochloride injection.

Warnings

Nalbuphine hydrochloride injection should be administered as a supplement to general anesthesia only by persons specifically trained in the use of intravenous anesthetics and management of respiratory effects of potent opioids.

Naloxone hydrochloride injection, resuscitative and intubation equipment and oxygen should be readily available.

Drug Abuse

Caution should be observed in prescribing nalbuphine for emotionally unstable patients, or for individuals with a history of opioid abuse. Such patients should be closely supervised when long term therapy is contemplated (see DRUG ABUSE AND DEPENDENCE).

Use in Ambulatory Patients

Nalbuphine may impair the mental or physical abilities required for the performance of potentially dangerous tasks such as driving a car or operating machinery. Therefore, nalbuphine hydrochloride injection should be administered with caution to ambulatory patients who should be warned to avoid such hazards.

Use in Emergency Procedures

Maintain patient under observation until recovered from nalbuphine effects that would affect driving or other potentially dangerous tasks.

Use in Pregnancy (Other Than Labor)

Severe fetal bradycardia has been reported when nalbuphine is administered during labor. Naloxone may reverse these effects. Although there are no reports of fetal bradycardia earlier in pregnancy, it is possible that this may occur. This drug should be used in pregnancy only if clearly needed, if the potential benefit outweighs the risk to the fetus, and if appropriate measures such as fetal monitoring are taken to detect and manage any potential adverse effect on the fetus.

Use During Labor and Delivery

The placental transfer of nalbuphine is high, rapid, and variable with a maternal to fetal ratio ranging from 1:0.37 to 1:6. Fetal and neonatal adverse effects that have been reported following the administration of nalbuphine to the mother during labor include fetal bradycardia, respiratory depression at birth, apnea, cyanosis, and hypotonia. Some of these events have been life-threatening. Maternal administration of naloxone during labor has normalized these effects in some cases. Severe and prolonged fetal bradycardia has been reported. Permanent neurological damage attributed to fetal bradycardia has occurred. A sinusoidal fetal heart rate pattern associated with the use of nalbuphine has also been reported. Nalbuphine should be used during labor and delivery only if clearly indicated and only if the potential benefit outweighs the risk to the infant. Newborns should be monitored for respiratory depression, apnea, bradycardia and arrhythmias if nalbuphine has been used.

Head Injury and Increased Intracranial Pressure

The possible respiratory depressant effects and the potential of potent analgesics to elevate cerebrospinal fluid pressure (resulting from vasodilation following CO2 retention) may be markedly exaggerated in the presence of head injury, intracranial lesions or a pre-existing increase in intracranial pressure. Furthermore, potent analgesics can produce effects which may obscure the clinical course of patients with head injuries. Therefore, nalbuphine hydrochloride injection should be used in these circumstances only when essential, and then should be administered with extreme caution.

Impaired Respiration: At the usual adult dose of 10 mg/70 kg, nalbuphine hydrochloride causes some respiratory depression approximately equal to that produced by equal doses of morphine. However, in contrast to morphine, respiratory depression is not appreciably increased with higher doses of nalbuphine. Respiratory depression induced by nalbuphine can be reversed by naloxone hydrochloride when indicated. Nalbuphine hydrochloride injection should be administered with caution at low doses to patients with impaired respiration (e.g., from other medication, uremia, bronchial asthma, severe infection, cyanosis or respiratory obstructions).

Impaired Renal or Hepatic Function: Because nalbuphine is metabolized in the liver and excreted by the kidneys, nalbuphine hydrochloride should be used with caution in patients with renal or liver dysfunction and administered in reduced amounts.

Myocardial Infarction: As with all potent analgesics, nalbuphine hydrochloride should be used with caution in patients with myocardial infarction who have nausea or vomiting.

Biliary Tract Surgery: As with all opioid analgesics, nalbuphine hydrochloride should be used with caution in patients about to undergo surgery of the biliary tract since it may cause spasm of the sphincter of Oddi.

Cardiovascular System: During evaluation of nalbuphine hydrochloride injection, in anesthesia, a higher incidence of bradycardia has been reported in patients who did not receive atropine pre-operatively.

Adverse Reactions

Clinical Trials Experience

The most frequent adverse reaction in 1066 patients treated with nalbuphine hydrochloride injection was sedation 381 (36%). Less frequent reactions were: sweaty/clammy 99 (9%), nausea/vomiting 68 (6%), dizziness/vertigo 58 (5%), dry mouth 44 (4%), and headache 27 (3%).

Other adverse reactions which occurred (reported incidence of 1% or less) were:

CNS Effects: Nervousness, depression, restlessness, crying, euphoria, floating, hostility, unusual dreams, confusion, faintness, hallucinations, dysphoria, feeling of heaviness, numbness, tingling, unreality. The incidence of psychotomimetic effects, such as unreality, depersonalization, delusions, dysphoria and hallucinations has been shown to be less than that which occurs with pentazocine.

Cardiovascular: Hypertension, hypotension, bradycardia, tachycardia.

Gastrointestinal: Cramps, dyspepsia, bitter taste.

Respiratory: Depression, dyspnea, asthma.

Dermatologic: Itching, burning, urticaria.

Miscellaneous: Speech difficulty, urinary urgency, blurred vision, flushing and warmth.

Allergic Reactions: Anaphylactic/anaphylactoid and other serious hypersensitivity reactions have been reported following the use of nalbuphine and may require immediate, supportive medical treatment. These reactions may include shock, respiratory distress, respiratory arrest, bradycardia, cardiac arrest, hypotension, or laryngeal edema. Some of these allergic reactions may be life-threatening. Other allergic-type reactions reported include stridor, bronchospasm, wheezing, edema, rash, pruritus, nausea, vomiting, diaphoresis, weakness, and shakiness.

Postmarketing Experience

Due to the nature and limitations of spontaneous reporting, causality has not been established for the following adverse events received for nalbuphine hydrochloride injection: abdominal pain, pyrexia, depressed level or loss of consciousness, somnolence, tremor, anxiety, pulmonary edema, agitation, seizures, and injection site reactions such as pain, swelling, redness, burning, and hot sensations. Death has been reported from severe allergic reactions to nalbuphine hydrochloride treatment. Fetal death has been reported where mothers received nalbuphine hydrochloride during labor and delivery.

Drug Interactions

Although nalbuphine possesses opioid antagonist activity, there is evidence that in nondependent patients it will not antagonize an opioid analgesic administered just before, concurrently, or just after an injection of nalbuphine hydrochloride. Therefore, patients receiving an opioid analgesic, general anesthetics, phenothiazines, or other tranquilizers, sedatives, hypnotics, or other CNS depressants (including alcohol) concomitantly with nalbuphine may exhibit an additive effect. When such combined therapy is contemplated, the dose of one or both agents should be reduced.

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): B Pregnancy Category B: Reproduction studies have been performed in rats by subcutaneous administration of nalbuphine up to 100 mg/kg/day, or 590 mg/m2/day which is approximately 6 times the MRHD, and in rabbits by intravenous administration of nalbuphine up to 32 mg/kg/day, or 378 mg/m2/day which is approximately 4 times the MRHD. The results did not reveal evidence of developmental toxicity, including teratogenicity, or harm to the fetus. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

Non-teratogenenic Effects:

Neonatal body weight and survival rates were reduced at birth and during lactation when

nalbuphine was subcutaneously administered to female and male rats prior to mating and throughout gestation and lactation or to pregnant rats during the last third of gestation and throughout lactation at doses approximately 4 times the maximum recommended human dose.
Pregnancy Category (AUS): There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Nalbuphine in women who are pregnant.

Labor and Delivery

The placental transfer of nalbuphine is high, rapid, and variable with a maternal to fetal ratio ranging from 1:0.37 to 1:6. Fetal and neonatal adverse effects that have been reported following the administration of nalbuphine to the mother during labor include fetal bradycardia, respiratory depression at birth, apnea, cyanosis, and hypotonia. Some of these events have been life-threatening. Maternal administration of naloxone during labor has normalized these effects in some cases. Severe and prolonged fetal bradycardia has been reported. Permanent neurological damage attributed to fetal bradycardia has occurred. A sinusoidal fetal heart rate pattern associated with the use of nalbuphine has also been reported. Nalbuphine should be used during labor and delivery only if clearly indicated and only if the potential benefit outweighs the risk to the infant. Newborns should be monitored for respiratory depression, apnea, bradycardia and arrhythmias if nalbuphine has been used.

Nursing Mothers

Limited data suggest that nalbuphine hydrochloride is excreted in maternal milk but only in a small amount (less than 1% of the administered dose) and with a clinically insignificant effect. Caution should be exercised when nalbuphine hydrochloride is administered to a nursing woman.

Pediatric Use

Safety and effectiveness in pediatric patients below the age of 18 years have not been established.

Geriatic Use

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

Gender

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

Race

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

Renal Impairment

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

Hepatic Impairment

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

Females of Reproductive Potential and Males

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

Immunocompromised Patients

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

Administration and Monitoring

Administration

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

Monitoring

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

IV Compatibility

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

Overdosage

There is limited information regarding Nalbuphine overdosage. If you suspect drug poisoning or overdose, please contact the National Poison Help hotline (1-800-222-1222) immediately.

Pharmacology

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

Mechanism of Action

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

Structure

Nalbuphine hydrochloride is a synthetic opioid agonist-antagonist analgesic of the phenanthrene series. It is chemically related to both the widely used opioid antagonist, naloxone, and the potent opioid analgesic, oxymorphone. Chemically nalbuphine hydrochloride is 17-(cyclobutylmethyl)-4,5α-epoxymorphinan-3,6α,14-triol hydrochloride. Nalbuphine hydrochloride molecular weight is 393.91 and is soluble in H2O (35.5 mg/mL at 25ºC) and ethanol (0.8%); insoluble in CHCl3 and ether. Nalbuphine hydrochloride has pKa values of 8.71 and 9.96. The molecular formula is C21H27NO4 • HCl. The structural formula is:

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This image is provided by the National Library of Medicine.

Nalbuphine Hydrochloride Injection is a sterile, nonpyrogenic solution of nalbuphine hydrochloride in water for injection. This product may be administered by subcutaneous, intramuscular or intravenous injection.

Each milliliter (mL) contains nalbuphine hydrochloride 10 mg or 20 mg; sodium citrate, dihydrate 0.47 mg and citric acid, anhydrous 0.63 mg added as buffers and may contain sodium hydroxide and/or hydrochloric acid for pH adjustment; pH 3.7 (3.0 to 4.5). Contains sodium chloride for tonicity adjustment.

Multiple-dose vials contain 1.8 mg/mL methylparaben and 0.2 mg/mL propylparaben added as preservatives. Single-dose products contain no bacteriostat or antimicrobial agent and unused portions must be discarded.

Pharmacodynamics

The onset of action of nalbuphine hydrochloride occurs within 2 to 3 minutes after intravenous administration, and in less than 15 minutes following subcutaneous or intramuscular injection. The plasma half-life of nalbuphine is 5 hours, and in clinical studies, the duration of analgesic activity has been reported to range from 3 to 6 hours.

The opioid antagonist activity of nalbuphine is one-fourth as potent as nalorphine and 10 times that of pentazocine.

Nalbuphine hydrochloride may produce the same degree of respiratory depression as equianalgesic doses of morphine. However, nalbuphine hydrochloride exhibits a ceiling effect such that increases in dose greater than 30 mg do not produce further respiratory depression in the absence of other CNS active medications affecting respiration.

Pharmacokinetics

Nalbuphine hydrochloride is a potent analgesic. Its analgesic potency is essentially equivalent to that of morphine on a milligram basis. Receptor studies show that nalbuphine hydrochloride binds to mu, kappa, and delta receptors, but not to sigma receptors. Nalbuphine hydrochloride is primarily a kappa agonist/partial mu antagonist analgesic.

Nalbuphine hydrochloride by itself has potent opioid antagonist activity at doses equal to or lower than its analgesic dose. When administered following or concurrent with mu agonist opioid analgesics (e.g., morphine, oxymorphone, fentanyl), nalbuphine hydrochloride may partially reverse or block opioid-induced respiratory depression from the mu agonist analgesic. Nalbuphine hydrochloride may precipitate withdrawal in patients dependent on opioid drugs. Nalbuphine hydrochloride should be used with caution in patients who have been receiving mu opioid analgesics on a regular basis.

Nonclinical Toxicology

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

Clinical Studies

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

How Supplied

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

Storage

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

Images

Drug Images

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Patient Counseling Information

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

Precautions with Alcohol

Alcohol-Nalbuphine 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 Nalbuphine Brand Names in the drug label.

Look-Alike Drug Names

There is limited information regarding Nalbuphine 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.