TM Owner Hospira, Inc. (a Pfizer company)
Levophed 1mg/mL Injection
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Indications & Clinical Uses
- Levophed 1mg/mL is a concentrated solution of norepinephrine bitartrate, a potent alpha- and beta-adrenergic vasopressor given only in hospital, usually in an intensive care or emergency setting.
- It is indicated to restore blood pressure in adults with acute hypotensive states, for example septic shock, cardiogenic shock, or severe low blood pressure after trauma, spinal anaesthesia or drug reactions.
- Each single-dose vial contains 4 mg in 4 mL, equal to 1 mg/mL of norepinephrine base.
- The concentrate must never be injected undiluted or given as a bolus.
- It is diluted first, typically one vial into 1,000 mL of a dextrose-containing solution to give 4 micrograms/mL, and delivered as a controlled continuous intravenous infusion through a pump with constant blood-pressure monitoring.
- Dextrose protects the drug from oxidation, so dilution in sodium chloride alone is not recommended.
Side Effects
- Because Levophed (norepinephrine) is used in critically ill patients, most reactions are dose-related consequences of intense blood-vessel tightening: reduced blood flow to skin, fingers, toes and organs, pale or mottled skin, reflex slowing of the heart, irregular heartbeats, anxiety, headache and breathing difficulty.
- The current US prescribing information carries NO boxed warning; the extravasation caution now sits in Warnings and Precautions rather than in a box.
- The most important local problem remains extravasation: leakage of the infusion out of the vein causes severe tissue damage and necrosis.
- Staff watch the site constantly and, if leakage occurs, promptly infiltrate the area with 5 to 10 mg of phentolamine mesylate in 10 to 15 mL of sodium chloride 0.9%.
- The solution contains sodium metabisulfite, which can trigger allergic or asthmatic reactions in susceptible people.
Precautions & Warnings
- Levophed is for intravenous infusion only and must never be given as an undiluted bolus or by any other route.
- Infuse into a large vein, preferably through a central line, and avoid leg veins in older patients or anyone with vascular disease.
- Blood pressure is measured continuously, or every two minutes until stable, and the rate titrated to a target pressure.
- Correct blood volume depletion where possible, because norepinephrine cannot compensate for uncorrected hypovolaemia.
- Take particular care in people with sulfite sensitivity or asthma.
- Prolonged infusion can deplete plasma volume.
- The infusion is tapered rather than stopped abruptly.
- Discard the solution if it is brown or contains a precipitate.
- Vials are stored at 20°C to 25°C in the original carton to protect from light.
- Use in pregnancy and in children is decided case by case by the treating team.
Avoid Interactions
- The pressor effect of Levophed (norepinephrine) is greatly increased and prolonged by monoamine oxidase inhibitors and by tricyclic antidepressants such as amitriptyline, imipramine and nortriptyline, and also by antihistamines, guanethidine and methyldopa; these combinations can cause severe, prolonged high blood pressure and need careful dose reduction and monitoring.
- Cyclopropane and halogenated hydrocarbon anaesthetics increase cardiac irritability and can precipitate ventricular tachycardia or fibrillation.
- Alpha-blocking drugs and some antipsychotics can blunt or reverse the blood-pressure response, reducing efficacy.
- At pharmacy and bedside level, norepinephrine is unstable in alkaline solutions and should not be mixed with oxidising agents; dilution in a dextrose-containing solution is preferred to plain saline.
- The intensive care team needs a full list of the patient's usual medicines, including antidepressants and supplements, before the infusion is started.
References
Frequently Asked Questions
Levophed (norepinephrine bitartrate) is a hospital vasopressor used to raise blood pressure in adults with acute hypotensive states such as septic or cardiogenic shock. It tightens blood vessels and supports the heart. It is given in intensive care or emergency settings with continuous blood-pressure monitoring.
Levophed (norepinephrine) is given only as a continuous intravenous infusion through a pump, never as a bolus. The 4 mg in 4 mL vial is diluted, usually into 1,000 mL of a dextrose-containing solution to make 4 micrograms/mL, and infused into a large vein, preferably a central line.
Levophed (norepinephrine) commonly causes effects of strong blood-vessel tightening: pale, cold or mottled skin, reduced blood flow to fingers and toes, slow or irregular heartbeat, anxiety, headache and breathing difficulty. The most serious local problem is leakage from the vein, which can destroy surrounding tissue.
Levophed (norepinephrine) combined with monoamine oxidase inhibitors or tricyclic antidepressants can cause severe, prolonged high blood pressure. Halogenated and cyclopropane anaesthetics raise the risk of dangerous heart rhythms. Tell the team about all your usual medicines, and about any sulfite sensitivity or asthma.
No. The current US prescribing information for Levophed (norepinephrine) has no boxed warning; the extravasation caution that once appeared in a box now sits in Warnings and Precautions. It still matters: if the infusion leaks into tissue, staff infiltrate the area with 5 to 10 mg phentolamine promptly.
During a Levophed (norepinephrine) infusion your blood pressure is checked continuously, or every two minutes until stable, and the rate is adjusted to a target pressure. Nurses inspect the drip site constantly for leakage or blanching. Heart rhythm, fluid status and circulation in the limbs are watched throughout.
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