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U.S. Brand
Names |
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INOmax™ |
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Pharmacological Index |
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Vasodilator, Pulmonary |
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|
Use |
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Treatment of term and near-term (>34 weeks) neonates with hypoxic
respiratory failure associated with pulmonary hypertension; used concurrently
with ventilatory support and other agents |
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Pregnancy Risk
Factor |
|
C |
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Pregnancy/Breast-Feeding
Implications |
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Not indicated for adult use so it has not been studied in pregnancy or
breast-feeding. |
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Contraindications |
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Neonates dependent on right-to-left shunting of blood. |
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Warnings/Precautions |
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Abrupt discontinuation may lead to worsening oxygenation and increasing
pulmonary artery pressure (PAP). Worsening oxygenation and increasing PAP may
occur in patients who do not respond. Doses above 20 ppm should not be used
because of the increased risk of methemoglobinemia and elevated nitrogen dioxide
(NO2) levels. Methemoglobin levels and NO2 should be
monitored. |
|
|
Adverse
Reactions |
|
>10%:
Cardiovascular: Hypotension (13%)
Miscellaneous: Withdrawal syndrome (12%)
1% to 10%:
Dermatologic: Cellulitis (5%)
Endocrine & metabolic: Hyperglycemia (8%)
Genitourinary: Hematuria (8%)
Miscellaneous: Sepsis (7%), infection (6%)
Respiratory: Stridor (5%)
Atelectasis occurred in 9% of patients receiving placebo and in 9% of those
receiving inhaled nitric oxide. |
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Overdosage/Toxicology |
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Elevations in methemoglobin and nitrogen dioxide may be signs of overdose.
Elevated nitrogen dioxide may cause acute lung injury and elevations of
methemoglobin reduce the oxygen delivery capacity of the circulation.
NO2 levels >3 ppm or methemoglobin levels >7% were treated by
reducing the dose of or discontinuing INOmax™.
Methemoglobinemia that does not resolve with dosage reduction or discontinuation
of therapy may require intravenous vitamin C, intravenous methylene blue, or
blood transfusion, depending on the clinical situation. |
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Drug
Interactions |
|
No formal studies have been done. Concurrent use of sodium nitroprusside or
nitroglycerin may result in an increased risk of developing methemoglobinemia.
Monitor closely if used. Has been administered with tolazoline, dopamine,
dobutamine, steroids, surfactant, and high-frequency
ventilation. |
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Stability |
|
Store at 25°C
(77°C) |
|
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Mechanism of
Action |
|
In neonates with persistent pulmonary hypertension, nitric oxide improves
oxygenation. Nitric oxide relaxes vascular smooth muscle by binding to the heme
moiety of cytosolic guanylate cyclase, activating guanylate cyclase and
increasing intracellular levels of cyclic guanosine 3',5'-monophosphate, which
leads to vasodilation. When inhaled, pulmonary vasodilation occurs and an
increase in the partial pressure of arterial oxygen results. Dilation of
pulmonary vessels in well ventilated lung areas redistributes blood flow away
from lung areas where ventilation/perfusion ratios are
poor. |
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Pharmacodynamics/Kinetics |
|
Absorption: Occurs systemically after inhalation.
Metabolism: Nitric oxide combines with hemoglobin that is 60% to 100%
oxygenated. Nitric oxide combines with oxyhemoglobin to produce methemoglobin
and nitrate. Within the pulmonary system, nitric oxide can combine with oxygen
and water to produce nitrogen dioxide and nitrite respectively, which interact
with oxyhemoglobin to then produce methemoglobin and nitrate. When evaluating
nitric oxide doses of 5, 20 and 80 ppm, only at 80 ppm is the methemoglobin
percent ~5% after 8 hours of administration. Methemoglobin levels >7% were
attained only in patients receiving 80 ppm. One patient did not exceed 7% until
40 hours.
Elimination: Nitrate, the primary metabolite, is excreted in the urine and is
cleared at rate approaching the glomerular filtration rate.
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Usual Dosage |
|
Neonates (up to 14 days old): 20 ppm. Treatment should be maintained up to 14
days or until the underlying oxygen desaturation has resolved and the neonate is
ready to be weaned from therapy. In the CINRGI trial, patients whose oxygenation
improved had their dose reduced to 5 ppm at the end of 4 hours of treatment.
Doses above 20 ppm should not be used because of the risk of methemoglobinemia
and elevated NO2. |
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Administration |
|
In the ventilated neonate, precise monitoring of inspired nitric oxide and
NO2 should be instituted using a calibrated analysis device with
alarms. Sample gas for analysis should be drawn before the Y-piece, proximal to
the patient. In addition, oxygen levels should be measured. A backup delivery
system should be available in the event of power failure. |
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Monitoring
Parameters |
|
Respiratory status including arterial blood gases with close attention to
PaO2, methemoglobin, NO2 , vital signs, blood sugar, signs
and symptoms of infection. |
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Dental Health: Local
Anesthetic/Vasoconstrictor
Precautions |
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No information available to require special precautions |
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Dental Health:
Effects on Dental Treatment |
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No effects or complications reported |
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Nursing
Implications |
|
Monitor oxygenation closely. Improvement will typically occur within 30
minutes of initiation. Do not discontinue therapy abruptly. Additional therapies
should be used to maximize oxygen delivery. Monitor for withdrawal reactions
(worsening oxygenation, increased PAP) after
discontinuation. |
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Dosage Forms |
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Aluminum cylinders: 353 L, 1963 L |
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References |
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"Inhaled Nitric Oxide in Full-Term and Nearly Full-term Infants With Hypoxic Respiratory Failure."
The Neonatal Inhaled Nitric Oxide Study Group, N Engl J Med, 1997,
336(9):597-604.
Davidson D, Barefield ES, Kattwinkel J, et al,
"Inhaled Nitric Oxide for the Early Treatment of Persistent Pulmonary Hypertension of the Term Newborn: A Randomized, Double-Masked, Placebo-Controlled, Dose-Response, Multicenter Study: I-NO/PPHN Study Group."
Pediatr, 1998, 101(3 Pt 1):325-34.
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