Label: NOREPINEPHRINE BITARTRATE IN SODIUM CHLORIDE- norepinephrine bitartrate injection, solution
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NDC Code(s):
44567-640-01,
44567-640-10,
44567-641-01,
44567-641-10, view more44567-642-01, 44567-642-10
- Packager: WG Critical Care, LLC
- Category: HUMAN PRESCRIPTION DRUG LABEL
- DEA Schedule: None
- Marketing Status: New Drug Application
Drug Label Information
Updated July 31, 2023
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HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use NOREPINEPHRINE BITARTRATE IN SODIUM CHLORIDE INJECTION safely and effectively. See full prescribing information for NOREPINEPHRINE BITARTRATE IN SODIUM CHLORIDE INJECTION.
NOREPINEPHRINE BITARTRATE IN SODIUM CHLORIDE injection, for intravenous use
Initial U.S. Approval: 1950INDICATIONS AND USAGE
Norepinephrine Bitartrate in Sodium Chloride Injection is a catecholamine indicated for restoration of blood pressure in adult patients with acute hypotensive states. (1)
DOSAGE AND ADMINISTRATION
DOSAGE FORMS AND STRENGTHS
CONTRAINDICATIONS
None. (4)
WARNINGS AND PRECAUTIONS
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- Tissue Ischemia: Avoid extravasation into tissues, which can cause local necrosis. (5.1)
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- Hypotension After Abrupt Discontinuation: Sudden cessation of the infusion rate may result in marked hypotension. Reduce the Norepinephrine Bitartrate in Sodium Chloride Injection infusion rate gradually. (5.2)
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- Cardiac Arrhythmias: Norepinephrine Bitartrate in Sodium Chloride Injection may cause arrhythmias. Monitor cardiac function in patients with underlying heart disease. (5.3)
ADVERSE REACTIONS
Most common adverse reactions are ischemic injury, bradycardia, anxiety, transient headache, respiratory difficulty, and extravasation necrosis at injection site. (6)
To report SUSPECTED ADVERSE REACTIONS, contact WG Critical Care, LLC at 1-866-562-4708, or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
DRUG INTERACTIONS
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- Monoamine oxidase inhibitors (MAOI) or tricyclic antidepressants of the triptyline or imipramine types may result in hypertension. (7.1, 7.2)
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- Antidiabetics: Norepinephrine can decrease insulin sensitivity and raise blood glucose. (7.3)
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- Cyclopropane and halothane anesthetics increase cardiac autonomic irritability. (7.4)
USE IN SPECIFIC POPULATIONS
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- Elderly patients may be at greater risk of developing adverse reactions. (8.5)
See 17 for PATIENT COUNSELING INFORMATION.
Revised: 7/2023
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Table of Contents
FULL PRESCRIBING INFORMATION: CONTENTS*
1 INDICATIONS AND USAGE
2 DOSAGE AND ADMINISTRATION
2.1 Important Dosage and Administration Instructions
2.2 Dosage
2.4 Drug Incompatibilities
3 DOSAGE FORMS AND STRENGTHS
4 CONTRAINDICATIONS
5 WARNINGS AND PRECAUTIONS
5.1 Tissue Ischemia
5.2 Hypotension after Abrupt Discontinuation
5.3 Cardiac Arrhythmias
6 ADVERSE REACTIONS
7 DRUG INTERACTIONS
7.1 MAO-Inhibiting Drugs
7.2 Tricyclic Antidepressants
7.3 Antidiabetics
7.4 Halogenated Anesthetics
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
8.2 Lactation
8.4 Pediatric Use
8.5 Geriatric Use
10 OVERDOSAGE
11 DESCRIPTION
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
12.2 Pharmacodynamics
12.3 Pharmacokinetics
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
16 HOW SUPPLIED/STORAGE AND HANDLING
17 PATIENT COUNSELING INFORMATION
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- Sections or subsections omitted from the full prescribing information are not listed.
- 1 INDICATIONS AND USAGE
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2 DOSAGE AND ADMINISTRATION
2.1 Important Dosage and Administration Instructions
Correct Hypovolemia
Address hypovolemia before initiation of Norepinephrine Bitartrate in Sodium Chloride Injection therapy. If the patient does not respond to therapy, suspect occult hypovolemia [see Warnings and Precautions (5.1)].
Administration
Norepinephrine Bitartrate in Sodium Chloride Injection is a ready to administer product that requires no further dilution prior to infusion. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
Infuse Norepinephrine Bitartrate in Sodium Chloride Injection into a large vein. Avoid infusions into the veins of the leg in the elderly or in patients with occlusive vascular disease of the legs [see Warnings and Precautions (5.1)]. Avoid using a catheter-tie-in technique.
2.2 Dosage
After an initial dosage of 8 to 12 mcg per minute via intravenous infusion, assess patient response and adjust dosage to maintain desired hemodynamic effect. Monitor blood pressure every two minutes until the desired hemodynamic effect is achieved, and then monitor blood pressure every five minutes for the duration of the infusion.
Typical maintenance intravenous dosage is 2 to 4 mcg per minute.
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3 DOSAGE FORMS AND STRENGTHS
Injection:
Norepinephrine Bitartrate in Sodium Chloride is a clear, colorless solution, available as:
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- 4 mg/250 mL (16 mcg per mL) of norepinephrine (free base), single-dose bags
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- 8 mg/250 mL (32 mcg per mL) of norepinephrine (free base), single-dose bags
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- 16 mg/250 mL (64 mcg per mL) of norepinephrine (free base), single-dose bags
- 4 CONTRAINDICATIONS
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5 WARNINGS AND PRECAUTIONS
5.1 Tissue Ischemia
Administration of Norepinephrine Bitartrate in Sodium Chloride Injection to patients who are hypotensive from hypovolemia can result in severe peripheral and visceral vasoconstriction, decreased renal perfusion and reduced urine output, tissue hypoxia, lactic acidosis, and reduced systemic blood flow despite "normal" blood pressure. Address hypovolemia prior to initiating Norepinephrine Bitartrate in Sodium Chloride Injection [see Dosage and Administration (2.1)]. Avoid Norepinephrine Bitartrate in Sodium Chloride Injection in patients with mesenteric or peripheral vascular thrombosis, as this may increase ischemia and extend the area of infarction.
Gangrene of the extremities has occurred in patients with occlusive or thrombotic vascular disease or who received prolonged or high dose infusions. Monitor for changes to the skin of the extremities in susceptible patients.
Extravasation of Norepinephrine Bitartrate in Sodium Chloride Injection may cause necrosis and sloughing of surrounding tissue. To reduce the risk of extravasation, infuse into a large vein, check the infusion site frequently for free flow, and monitor for signs of extravasation [see Dosage and Administration (2.1)].
Emergency Treatment of Extravasation
To prevent sloughing and necrosis in areas in which extravasation has occurred, infiltrate the ischemic area as soon as possible, using a syringe with a fine hypodermic needle with 5 to 10 mg of phentolamine mesylate in 10 to 15 mL of 0.9% Sodium Chloride Injection in adults.
Sympathetic blockade with phentolamine causes immediate and conspicuous local hyperemic changes if the area is infiltrated within 12 hours.
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6 ADVERSE REACTIONS
The following adverse reactions are described in greater detail in other sections:
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- Tissue Ischemia [see Warnings and Precautions (5.1)]
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- Hypotension [see Warnings and Precautions (5.2)]
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- Cardiac Arrhythmias [see Warnings and Precautions (5.3)]
The most common adverse reactions are hypertension and bradycardia.
The following adverse reactions can occur:
Nervous system disorders: Anxiety, headache
Respiratory disorders: Respiratory difficulty, pulmonary edema
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7 DRUG INTERACTIONS
7.1 MAO-Inhibiting Drugs
Co-administration of Norepinephrine Bitartrate in Sodium Chloride Injection with monoamine oxidase (MAO) inhibitors or other drugs with MAO-inhibiting properties (e.g., linezolid) can cause severe, prolonged hypertension.
If administration of Norepinephrine Bitartrate in Sodium Chloride Injection cannot be avoided in patients who recently have received any of these drugs and in whom, after discontinuation, MAO activity has not yet sufficiently recovered, monitor for hypertension.
7.2 Tricyclic Antidepressants
Co-administration of Norepinephrine Bitartrate in Sodium Chloride Injection with tricyclic antidepressants (including amitriptyline, nortriptyline, protriptyline, clomipramine, desipramine, imipramine) can cause severe, prolonged hypertension. If administration of Norepinephrine Bitartrate in Sodium Chloride Injection cannot be avoided in these patients, monitor for hypertension.
7.3 Antidiabetics
Norepinephrine Bitartrate in Sodium Chloride Injection can decrease insulin sensitivity and raise blood glucose. Monitor glucose and consider dosage adjustment of antidiabetic drugs.
7.4 Halogenated Anesthetics
Concomitant use of Norepinephrine Bitartrate in Sodium Chloride Injection with halogenated anesthetics (e.g., cyclopropane, desflurane, enflurane, isoflurane, and sevoflurane) may lead to ventricular tachycardia or ventricular fibrillation. Monitor cardiac rhythm in patients receiving concomitant halogenated anesthetics.
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8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
Risk Summary
Limited published data consisting of a small number of case reports and multiple small trials involving the use of norepinephrine in pregnant women at the time of delivery have not identified an increased risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. There are risks to the mother and fetus from hypotension associated with septic shock, myocardial infarction and stroke which are medical emergencies in pregnancy and can be fatal if left untreated. (see Clinical Considerations). In animal reproduction studies, using high doses of intravenous norepinephrine resulted in lowered maternal placental blood flow. Clinical relevance to changes in the human fetus is unknown since the average maintenance dose is ten times lower (see Data). Increased fetal reabsorptions were observed in pregnant hamsters after receiving daily injections at approximately 2 times the maximum recommended dose on a mg/m3 basis for four days during organogenesis (see Data).
The estimated background risk for major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in the clinically recognized pregnancies is 2–4% and 15–20%, respectively.
Clinical Considerations
Disease-associated maternal and/or embryo/fetal risk
Hypotension associated with septic shock, myocardial infarction, and stroke are medical emergencies in pregnancy which can be fatal if left untreated. Delaying treatment in pregnant women with hypotension associated with septic shock, myocardial infarction and stroke may increase the risk of maternal and fetal morbidity and mortality. Life-sustaining therapy for the pregnant woman should not be withheld due to potential concerns regarding the effects of norepinephrine on the fetus.
Data
Animal Data
A study in pregnant sheep receiving high doses of intravenous norepinephrine (40 mcg/min, at approximately 10 times the average maintenance dose of 2–4 mcg/min in human, on a mg/kg basis) exhibited a significant decrease in maternal placental blood flow. Decreases in fetal oxygenation, urine and lung liquid flow were also observed.
Norepinephrine administration to pregnant rats on Gestation Day 16 or 17 resulted in cataract production in rat fetuses.
In hamsters, an increased number of resorptions (29.1% in study group vs. 3.4% in control group), fetal microscopic liver abnormalities and delayed skeletal ossification were observed at approximately 2 times the maximum recommended intramuscular or subcutaneous dose (on a mg/m2 basis at a maternal subcutaneous dose of 0.5 mg/kg/day from Gestation Day 7–10).
8.2 Lactation
Risk Summary
There are no data on the presence of norepinephrine in either human or animal milk, the effects on the breastfed infant, or the effects on milk production. Clinically relevant exposure to the infant is not expected based on the short half-life and poor oral bioavailability of norepinephrine.
8.5 Geriatric Use
Clinical studies of Norepinephrine Bitartrate in Sodium Chloride Injection 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.
Avoid administration of Norepinephrine Bitartrate in Sodium Chloride Injection into the veins in the leg in elderly patients [see Warnings and Precautions (5.1)].
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10 OVERDOSAGE
Overdosage with Norepinephrine Bitartrate in Sodium Chloride Injection may result in headache, severe hypertension, reflex bradycardia, marked increase in peripheral resistance, and decreased cardiac output.
In case of overdosage, discontinue Norepinephrine Bitartrate in Sodium Chloride Injection until the condition of the patient stabilizes.
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11 DESCRIPTION
Norepinephrine Bitartrate in Sodium Chloride Injection contains the active pharmaceutical ingredient norepinephrine, a catecholamine, in the form of bitartrate salt (monohydrate). Norepinephrine is sometimes referred to as l-arterenol/Levarterenol or l-norepinephrine which differs from epinephrine by the absence of a methyl group on the nitrogen atom.
The chemical name for norepinephrine bitartrate (monohydrate) is (-)-α-(aminomethyl)-3,4-dihydroxybenzyl alcohol tartrate (1:1) (salt) monohydrate (molecular weight 337.3 g/mol) and has the following structural formula:
Norepinephrine bitartrate (monohydrate) is sparingly soluble in water, very slightly soluble in alcohol and ether, and readily soluble in acids.
Norepinephrine Bitartrate in Sodium Chloride Injection is supplied as a sterile aqueous ready to use solution in 250 mL transparent intravenous bags. Each mL contains 32, 64 or 128 micrograms of norepinephrine bitartrate monohydrate, equivalent to 16, 32, or 64 micrograms of norepinephrine base, respectively. Each mL also contains 9 mg of Sodium Chloride USP as tonicity agent, and may contain Hydrochloric Acid NF and Sodium Hydroxide NF as pH adjusters, for the pH range of 3.4 to 4.0, in Water for Injection.
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12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
Norepinephrine is a peripheral vasoconstrictor (alpha-adrenergic action) and an inotropic stimulator of the heart and dilator of coronary arteries (beta-adrenergic action).
12.2 Pharmacodynamics
The primary pharmacodynamic effects of norepinephrine are cardiac stimulation and vasoconstriction. Cardiac output is generally unaffected, although it can be decreased, and total peripheral resistance is also elevated. The elevation in resistance and pressure result in reflex vagal activity, which slows the heart rate and increases stroke volume. The elevation in vascular tone or resistance reduces blood flow to the major abdominal organs as well as to skeletal muscle. Coronary blood flow is substantially increased secondary to the indirect effects of alpha stimulation. After intravenous administration, a pressor response occurs rapidly and reaches steady state within 5 minutes. The pharmacologic actions of norepinephrine are terminated primarily by uptake and metabolism in sympathetic nerve endings. The pressor action stops within 1–2 minutes after the infusion is discontinued.
12.3 Pharmacokinetics
Absorption
Following initiation of intravenous infusion, the steady state plasma concentration is achieved in 5 min.
Distribution
Plasma protein binding of norepinephrine is approximately 25%. It is mainly bound to plasma albumin and to a smaller extent to prealbumin and alpha 1-acid glycoprotein. The volume of distribution is 8.8 L. Norepinephrine localizes mainly in sympathetic nervous tissue. It crosses the placenta but not the blood-brain barrier.
Elimination
The mean half-life of norepinephrine is approximately 2.4 min. The average metabolic clearance is 3.1 L/min.
Metabolism
Norepinephrine is metabolized in the liver and other tissues by a combination of reactions involving the enzymes catechol-O-methyltransferase (COMT) and MAO. The major metabolites are normetanephrine and 3-methoxyl-4-hydroxy mandelic acid (vanillylmandelic acid, VMA), both of which are inactive. Other inactive metabolites include 3-methoxy-4-hydroxyphenylglycol, 3,4-dihydroxymandelic acid, and 3,4-dihydroxyphenylglycol.
- 13 NONCLINICAL TOXICOLOGY
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16 HOW SUPPLIED/STORAGE AND HANDLING
Norepinephrine Bitartrate in Sodium Chloride Injection is filled in 250 mL transparent intravenous Nexcel bags as:
NDC Configuration
Packaging Configuration
Total Norepinephrine Bitartrate
44567-640-01
1 single-dose bag
4 mg per 250 mL (16 mcg per mL)
44567-640-10
10 bags per carton
44567-641-01
1 single-dose bag
8 mg per 250 mL (32 mcg per mL)
44567-641-10
10 bags per carton
44567-642-01
1 single-dose bag
16 mg per 250 mL (64 mcg per mL)
44567-642-10
10 bags per carton
Each filled bag is packed in an overwrap with a transparent band and oxygen absorber and oxygen indicator placed inside the overwrapping to prevent deterioration of drug product. Product should be used within 7 days of removal from overwrap.
Do not use the product if the oxygen indicator has changed color to green or blue before opening the overwrap. Normal color is yellow or orange.
Store at 20°C to 25°C (68°F to 77°F) [see USP Controlled Room Temperature] in the original carton to protect from light. Do not freeze.
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17 PATIENT COUNSELING INFORMATION
Risk of Tissue Damage
Advise the patient, family, or caregiver to report signs of extravasation urgently [see Warnings and Precautions (5.1)].
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INGREDIENTS AND APPEARANCE
NOREPINEPHRINE BITARTRATE IN SODIUM CHLORIDE
norepinephrine bitartrate injection, solutionProduct Information Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:44567-640 Route of Administration INTRAVENOUS Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength NOREPINEPHRINE BITARTRATE (UNII: IFY5PE3ZRW) (NOREPINEPHRINE - UNII:X4W3ENH1CV) NOREPINEPHRINE 0.016 mg in 1 mL Inactive Ingredients Ingredient Name Strength SODIUM CHLORIDE (UNII: 451W47IQ8X) HYDROCHLORIC ACID (UNII: QTT17582CB) SODIUM HYDROXIDE (UNII: 55X04QC32I) Other Ingredients Ingredient Kind Ingredient Name Quantity Does not contain NATURAL LATEX RUBBER (UNII: 2LQ0UUW8IN) 0 in 1 mL Packaging # Item Code Package Description Marketing Start Date Marketing End Date 1 NDC:44567-640-10 10 in 1 CARTON 10/31/2022 1 NDC:44567-640-01 250 mL in 1 BAG; Type 2: Prefilled Drug Delivery Device/System (syringe, patch, etc.) Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date NDA NDA215700 09/15/2022 NOREPINEPHRINE BITARTRATE IN SODIUM CHLORIDE
norepinephrine bitartrate injection, solutionProduct Information Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:44567-641 Route of Administration INTRAVENOUS Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength NOREPINEPHRINE BITARTRATE (UNII: IFY5PE3ZRW) (NOREPINEPHRINE - UNII:X4W3ENH1CV) NOREPINEPHRINE 0.032 mg in 1 mL Inactive Ingredients Ingredient Name Strength SODIUM CHLORIDE (UNII: 451W47IQ8X) HYDROCHLORIC ACID (UNII: QTT17582CB) SODIUM HYDROXIDE (UNII: 55X04QC32I) Other Ingredients Ingredient Kind Ingredient Name Quantity Does not contain NATURAL LATEX RUBBER (UNII: 2LQ0UUW8IN) 0 in 1 mL Packaging # Item Code Package Description Marketing Start Date Marketing End Date 1 NDC:44567-641-10 10 in 1 CARTON 10/31/2022 1 NDC:44567-641-01 250 mL in 1 BAG; Type 2: Prefilled Drug Delivery Device/System (syringe, patch, etc.) Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date NDA NDA215700 09/15/2022 NOREPINEPHRINE BITARTRATE IN SODIUM CHLORIDE
norepinephrine bitartrate injection, solutionProduct Information Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:44567-642 Route of Administration INTRAVENOUS Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength NOREPINEPHRINE BITARTRATE (UNII: IFY5PE3ZRW) (NOREPINEPHRINE - UNII:X4W3ENH1CV) NOREPINEPHRINE 0.064 mg in 1 mL Inactive Ingredients Ingredient Name Strength SODIUM CHLORIDE (UNII: 451W47IQ8X) HYDROCHLORIC ACID (UNII: QTT17582CB) SODIUM HYDROXIDE (UNII: 55X04QC32I) Other Ingredients Ingredient Kind Ingredient Name Quantity Does not contain NATURAL LATEX RUBBER (UNII: 2LQ0UUW8IN) 0 in 1 mL Packaging # Item Code Package Description Marketing Start Date Marketing End Date 1 NDC:44567-642-10 10 in 1 CARTON 10/31/2022 1 NDC:44567-642-01 250 mL in 1 BAG; Type 2: Prefilled Drug Delivery Device/System (syringe, patch, etc.) Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date NDA NDA215700 09/15/2022 Labeler - WG Critical Care, LLC (829274633) Registrant - WG Critical Care, LLC (829274633) Establishment Name Address ID/FEI Business Operations Inforlife SA 481732753 MANUFACTURE(44567-640, 44567-641, 44567-642)