FULL PRESCRIBING INFORMATION
1 INDICATIONS AND USAGE
Vasopressin injection is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines.
2 DOSAGE AND ADMINISTRATION
2.1 Preparation of Diluted Solutions
Inspect parenteral drug products for particulate matter and discoloration prior to use, whenever solution and container permit.
Vasopressin Injection Solution for Dilution, 20 units/mL and 200 units/10 mL (20 units/mL).
Dilute vasopressin injection in normal saline (0.9% sodium chloride) or 5% dextrose in water (D5W) prior to use for intravenous administration. Discard unused diluted solution after 18 hours at room temperature or 24 hours under refrigeration.
Table 1 Preparation of diluted solutions
|
Fluid restriction? |
Final concentration |
Mix |
|
|
Vasopressin Injection |
Diluent |
||
|
No |
0.1 units/mL |
2.5 mL (50 units) |
500 mL |
|
Yes |
1 unit/mL |
5 mL (100 units) |
100 mL |
2.2 Administration
In general, titrate to the lowest dose compatible with a clinically acceptable response.
The recommended starting dose is:
Post-cardiotomy shock: 0.03 units/minute
Septic Shock: 0.01 units/minute
Titrate up by 0.005 units/minute at 10- to 15-minute intervals until the target blood pressure is reached. There are limited data for doses above 0.1 units/minute for post-cardiotomy shock and 0.07 units/minute for septic shock. Adverse reactions are expected to increase with higher doses.
After target blood pressure has been maintained for 8 hours without the use of catecholamines, taper vasopressin injection by 0.005 units/minute every hour as tolerated to maintain target blood pressure.
3 DOSAGE FORMS AND STRENGTHS
Vasopressin injection, USP is a clear, practically colorless solution for intravenous administration available as 20 units/mL in a single-dose vial and 200 units/10 mL (20 units/mL) in a multiple-dose vial.
4 CONTRAINDICATIONS
Vasopressin injection 1 mL single-dose vial and 10 mL multiple-dose vial are contraindicated in patients with known allergy or hypersensitivity to 8-L-arginine vasopressin or chlorobutanol.
5 WARNINGS AND PRECAUTIONS
5.2 Reversible Diabetes Insipidus
Patients may experience reversible diabetes insipidus, manifested by the development of polyuria, a dilute urine, and hypernatremia, after cessation of treatment with vasopressin. Monitor serum electrolytes, fluid status, and urine output after vasopressin discontinuation. Some patients may require readministration of vasopressin or administration of desmopressin to correct fluid and electrolyte shifts.
6 ADVERSE REACTIONS
The following adverse reactions associated with the use of vasopressin were identified in the literature. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to estimate their frequency reliably or to establish a causal relationship to drug exposure.
Bleeding/lymphatic system disorders: Hemorrhagic shock, decreased platelets, intractable bleeding
Cardiac disorders: Right heart failure, atrial fibrillation, bradycardia, myocardial ischemia
Gastrointestinal disorders: Mesenteric ischemia
Hepatobiliary: Increased bilirubin levels
Renal/urinary disorders: Acute renal insufficiency
Vascular disorders: Distal limb ischemia
Metabolic: Hyponatremia
Skin: Ischemic lesions
Postmarketing Experience
Reversible diabetes insipidus [see Warnings and Precautions (5.2)].
7 DRUG INTERACTIONS
7.1 Catecholamines
Use with catecholamines is expected to result in an additive effect on mean arterial blood pressure and other hemodynamic parameters. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed.
7.2 Indomethacin
Use with indomethacin may prolong the effect of vasopressin injection on cardiac index and systemic vascular resistance. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed [see Clinical Pharmacology (12.3)].
7.3 Ganglionic Blocking Agents
Use with ganglionic blocking agents may increase the effect of vasopressin injection on mean arterial blood pressure. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed [see Clinical Pharmacology (12.3)].
7.4 Drugs Suspected of Causing SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion)
Use with drugs suspected of causing SIADH (e.g., SSRIs, tricyclic antidepressants, haloperidol, chlorpropamide, enalapril, methyldopa, pentamidine, vincristine, cyclophosphamide, ifosfamide, felbamate) may increase the pressor effect in addition to the antidiuretic effect of vasopressin injection. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed.
7.5 Drugs Suspected of Causing Diabetes Insipidus
Use with drugs suspected of causing diabetes insipidus (e.g., demeclocycline, lithium, foscarnet, clozapine) may decrease the pressor effect in addition to the antidiuretic effect of vasopressin injection. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed.
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
Risk Summary
There are no available data on vasopressin injection use in pregnant women to inform a drug associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Animal reproduction studies have not been conducted with vasopressin.
Clinical Considerations
Dose Adjustments during Pregnancy and the Postpartum Period
Because of increased clearance of vasopressin in the second and third trimester, the dose of vasopressin injection may need to be increased [see Dosage and Administration (2.2) and Clinical Pharmacology (12.3)].
Maternal adverse reactions
Vasopressin injection may produce tonic uterine contractions. Vasopressin receptors are present in human uterine muscles and might not be distinguishable from oxytocin receptors.
8.2 Lactation
Risk Summary
There are no data on the presence of vasopressin injection in either human or animal milk, the effects on the breastfed infant, or the effects on milk production.
8.4 Pediatric Use
Safety and effectiveness of vasopressin injection in pediatric patients with vasodilatory shock have not been established.
8.5 Geriatric Use
Clinical studies of vasopressin did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy [see Warnings and Precautions (5.1, 5.2), Adverse Reactions (6), and Clinical Pharmacology (12.3)].
10 OVERDOSAGE
Overdosage with vasopressin injection can be expected to manifest as consequences of vasoconstriction of various vascular beds (peripheral, mesenteric, and coronary) and as hyponatremia. In addition, overdosage may lead less commonly to ventricular tachyarrhythmias (including Torsade de Pointes), rhabdomyolysis, and non-specific gastrointestinal symptoms.
Direct effects will resolve within minutes of withdrawal of treatment.
11 DESCRIPTION
Vasopressin is a polypeptide hormone. Vasopressin injection is a sterile, aqueous solution of synthetic arginine vasopressin for administration. The 1 mL and 10 mL solution contains vasopressin 20 units/mL, chlorobutanol 5 mg, sodium chloride 9 mg, water for injection, and glacial acetic acid to adjust pH to 3.5.
The chemical name of vasopressin is Cyclo (1-6) L-Cysteinyl-L-Tyrosyl-L-Phenylalanyl-L- Glutaminyl-L-Asparaginyl-L-Cysteinyl-L-Prolyl-L-Arginyl-L-Glycinamide. It is a white to off-white amorphous powder, freely soluble in water. The structural formula is:
Molecular Formula: C46H65N15O12S2 Molecular Weight: 1084.23
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
Vasopressin causes vasoconstriction by binding to V1 receptors on vascular smooth muscle coupled to the Gq/11-phospholipase C-phosphatidyl-inositol-triphosphate pathway, resulting in the release of intracellular calcium. In addition, vasopressin stimulates antidiuresis via stimulation of V2 receptors which are coupled to adenyl cyclase.
12.2 Pharmacodynamics
At therapeutic doses exogenous vasopressin elicits a vasoconstrictive effect in most vascular beds including the splanchnic, renal and cutaneous circulation. In addition, vasopressin at pressor doses triggers contractions of smooth muscles in the gastrointestinal tract mediated by muscular V1-receptors and release of prolactin, ACTH and catecholamines via V3 receptors. At lower concentrations typical for the antidiuretic hormone vasopressin inhibits water diuresis via renal V2 receptors. In addition, vasopressin has been demonstrated to cause vasodilation in numerous vascular beds that is mediated by V2, V3, oxytocin and purinergic P2 receptors.
In patients with vasodilatory shock, vasopressin in therapeutic doses increases systemic vascular resistance and mean arterial blood pressure and reduces the dose requirements for norepinephrine. Vasopressin tends to decrease heart rate and cardiac output. The pressor effect is proportional to the infusion rate of exogenous vasopressin. The pressor effect reaches its peak within 15 minutes. After stopping the infusion, the pressor effect fades within 20 minutes. There is no evidence for tachyphylaxis or tolerance to the pressor effect of vasopressin in patients.
12.3 Pharmacokinetics
Vasopressin plasma concentrations increase linearly with increasing infusion rates from 10 to 200 µU/kg/min. Steady state plasma concentrations are achieved after 30 minutes of continuous intravenous infusion.
Distribution
Vasopressin does not appear to bind plasma protein. The volume of distribution is 140 mL/kg.
Elimination
At infusion rates used in vasodilatory shock (0.01 to 0.1 units/minute), the clearance of vasopressin is 9 to 25 mL/min/kg in patients with vasodilatory shock. The apparent t1/2 of vasopressin at these levels is ≤10 minutes.
Metabolism
Serine protease, carboxipeptidase and disulfide oxido-reductase cleave vasopressin at sites relevant for the pharmacological activity of the hormone. Thus, the generated metabolites are not expected to retain important pharmacological activity.
Excretion
Vasopressin is predominantly metabolized and only about 6% of the dose is excreted unchanged into urine.
Specific Populations
Pregnancy: Because of a spillover into blood of placental vasopressinase, the clearance of exogenous and endogenous vasopressin increases gradually over the course of a pregnancy. During the first trimester of pregnancy, the clearance is only slightly increased. However, by the third trimester the clearance of vasopressin is increased about 4-fold and at term up to 5-fold. After delivery, the clearance of vasopressin returns to pre-conception baseline within two weeks.
Drug Interactions
Indomethacin more than doubles the time to offset for vasopressin’s effect on peripheral vascular resistance and cardiac output in healthy subjects [see Drug Interactions (7.2)].
The ganglionic blocking agent tetra-ethylammonium increases the pressor effect of vasopressin by 20% in healthy subjects [see Drug Interactions (7.3)].
Halothane, morphine, fentanyl, alfentanyl and sufentanyl do not impact exposure to endogenous vasopressin.
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
No formal carcinogenicity or fertility studies with vasopressin have been conducted in animals. Vasopressin was found to be negative in the in vitro bacterial mutagenicity (Ames) test and the in vitro Chinese hamster ovary (CHO) cell chromosome aberration test. In mice, vasopressin has been reported to have an effect on sperm function, including motility, fertilization and embryonic development.
14 CLINICAL STUDIES
Increases in systolic and mean blood pressure following administration of vasopressin were observed in 7 studies in septic shock and 8 studies in post-cardiotomy vasodilatory shock.
16 HOW SUPPLIED/STORAGE AND HANDLING
Vasopressin injection, USP is a clear, practically colorless solution for intravenous administration available as:
NDC 0517-1020-25: A carton of 25 single-dose vials each containing vasopressin 1 mL at 20 units/mL.
NDC 0517-1030-01: A carton of one multiple-dose vial containing vasopressin 10 mL at 20 units/mL.
Store between 2°C and 8°C (36°F and 46°F). Do not freeze.
Storage is permitted for up to 12 months at controlled room temperature (USP) 20°C to 25°C (68°F to 77°F) within the expiry date. Once removed from refrigeration, mark the unopened vial with the revised 12-month expiration date. Do not return Vasopressin to the refrigerator after it has been stored at room temperature. Discard the product after 12 months at room temperature or at the expiry date, whichever is earlier.
The storage conditions and expiration periods are summarized in the following table.
|
Unopened Refrigerated 2°C to 8°C (36°F to 46°F) |
Unopened Room Temperature 20°C to 25°C (68°F to 77°F) Do not store above 25°C (77°F) |
Opened (After First Puncture) |
|
|
1 mL Vial |
Until manufacturer expiration date |
12 months or until manufacturer expiration date, whichever is earlier |
N/A |
| 10 mL Vial | Until manufacturer expiration date | 12 months or until manufacturer expiration date, whichever is earlier |
30 days |
PRINCIPAL DISPLAY PANEL – Container Label (1 mL)
NDC 0517-1020-01
Rx Only
Vasopressin Injection, USP
20 Units per mL
For Intravenous Infusion
Must be diluted prior to use
1 mL Single-Dose Vial -
Discard Unused Portion
PRINCIPAL DISPLAY PANEL – Carton Labeling (1 mL)
NDC 0517-1020-25
Vasopressin Injection, USP
20 Units per mL
For Intravenous Infusion
Must be diluted prior to use
25 x 1 mL Single Dose Vials
Discard Unused Portion
Rx Only
AMERICAN REGENT, INC.
SHIRLEY, NY 11967
PRINCIPAL DISPLAY PANEL - Container Label (10 mL)
NDC 0517-1030-01
Rx Only
Vasopressin Injection, USP
200 Units per mL 10 mL
(20 Units per mL)
For Intravenous Infusion.
Must be diluted prior to use.
10 mL Multiple-Dose Vial
PRINCIPAL DISPLAY PANEL - Carton Labeling (10 mL)
NDC 0517-1030-01
Rx Only
Vasopressin Injection, USP
200 Units per 10 mL
(20 units per mL)
For Intravenous Infusion.
Must be diluted prior to use.
Store between 2ºC and 8ºC (36ºF and 46ºF).
Vials may be held at 20ºC to 25ºC (68ºF to 77ºF) for up to 12 months.
Do not store above 25ºC (77ºF).
Avoid Freezing.
10 mL Multiple-Dose Vial
AMERICAN REGENT, INC.
SHIRLEY, NY 11967
