Ephedrine (Akovaz) is a stimulant drug that is used in the treatment of peri-operative hypotension (anesthesia-induced hypotension). It is also used as off-label medicine for the treatment of postoperative nausea and vomiting.

Ephedrine Uses:

• Anesthesia-induced hypotension:

  • It is indicated in the treatment of anesthesia-induced hypotension.

Note:

• The ephedrine for treatment of different conditions like acute bronchospasm, Stokes-Adams syndrome (e.g. presyncope/syncope) with complete heart block, narcolepsy, depression, or myasthenia gravis is not being used nowadays.
• More effective agents available for these conditions.

• Off Label Use of Ephedrine in Adults:

  • prevention of postoperative nausea and vomiting

Ephedrine (Akovaz) dose in Adults

Ephedrine (Akovaz) dose in the treatment of anesthesia-induced hypotension:

• IV: 5 - 25 mg/dose IV push slowly; can be repeated accordingly to maintain blood pressure
• Maximum total dose: 50 mg

Dose in the prevention of postoperative nausea and vomiting (off-label):

• IM: 0.5 mg per kg at the end of surgery.

Ephedrine Dose in Children:

Dose in the treatment of anesthesia-induced hypotension:

Note: Use the smallest effective dose:

• Infants, Children, and Adolescents ≤15 years: Limited data available:

  • Slow IV push: 0.1 to 0.3 mg/kg/dose, can be repeated accordingly to maintain blood pressure;
  • maximum dose: 25 mg per dose;
  • Maximum total dose: 50 mg

• Adolescents >15 years:

  • IV: 5 to 25 mg/dose slow IV push repeat according to the requirement to maintain blood pressure;
  • Maximum total dose: 50 mg

Pregnancy Risk Factor C

• There are currently no studies on animal reproduction.
• It can also cross the placental boundary.
• It is used to treat and prevent hypotension caused by spinal anesthesia during delivery in women who are having a cesarean section.
• Combining oxytocin with severe postpartum hypertension can lead to stroke and even serious postpartum hypertension.
• After the mother's use, neonates have been diagnosed with metabolic acidosis.

Use during breastfeeding:

• Breast milk contains the drug.
• According to the manufacturer the decision to use breastfeeding mothers should be made after considering the risks and benefits to the mother.

Dose in Kidney disease:

No dose adjustments listed in the manufacturer's labeling. Caution is advised

Dose in Liver disease:

No dose adjustments listed in the manufacturer's labeling.

Side effects of Ephedrine (Akovaz):

• Cardiovascular:

  • Angina Pectoris
  • Bradycardia
  • Cardiac Arrhythmia
  • Hypertension
  • Palpitations
  • Pulse Irregularity
  • Tachycardia
  • Ventricular Ectopy
  • Visceral Vasoconstriction (Renal)

• Central Nervous System:

  • Anxiety
  • Confusion
  • Delirium
  • Dizziness
  • Hallucination
  • Headache
  • Insomnia
  • Intracranial Hemorrhage
  • Nervousness
  • Precordial Pain
  • Restlessness
  • Tension
  • Vertigo

• Dermatologic:

  • Diaphoresis
  • Pallor

• Gastrointestinal:

  • Anorexia
  • Nausea
  • Vomiting

• Genitourinary:

  • Dysuria
  • Oliguria
  • Urinary Retention (Males With Prostatism)

• Neuromuscular & Skeletal:

  • Tremor
  • Vesicle Sphincter Spasm
  • Weakness

• Respiratory:

  • Dyspnea

• Miscellaneous:

  • Tachyphylaxis

Contraindications to Ephedrine (Akovaz):

• Hypersensitivity to any component ephedrine, or other sympathomimetics
• Angle-closure glaucoma
• Myocardial sensitizing agents such as halothane, cyclopropane or halothane can be co-administered. cyclopropane, halothane

Warnings and precautions

• Cardiovascular effects

  • High blood pressure can cause intracranial hemorhage.
  • It can cause potentially fatal arrhythmias in patients with heart disease or those who are taking myocardium sensitizing medications.

• Urine output

  • Due to constriction in the renal blood vessels, there may be a decrease in urine output.

• Cardiovascular disease

  • Ephedrine should not be used in situations where vasopressor medications are contraindicated. Angina pectoris and coronary artery disease are all possible side effects.
  • If necessary, use caution.

• Diabetes:

  • Avoid Ephedrine in situations where vasopressor drugs are contraindicated.

• Prostatic hyperplasia/urinary restriction:

  • Caution is advised in cases of prostatic hyperplasia or urinary stricture

• Renal impairment

  • Increased elimination half-life could occur. Use caution if you have renal impairment
  • You should monitor for signs of renal impairment.

• Thyroid dysfunction:

  • Avoid Ephedrine in situations where vasopressors drugs might be contraindicated.
  • Use caution when treating thyroid dysfunction.

• Vasomotor symptoms:

  • Use caution if you have unstable vasomotor symptoms

Ephedrine (systemic): Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Monitoring parameters:

• Blood pressure,
• pulse
• respiratory symptoms
• Monitor patients with renal impairment for adverse reactions.

How to administer Ephedrine (Akovaz)?

Administer slow IV push as a diluted solution. For post-operative nausea and vomiting (off-label use), Use IM route

Mechanism of action of Ephedrine (Akovaz):

It releases tissue stores of norepinephrine and produces alpha- or beta-adrenergic stimulation. It is longer-acting and less potent as compared to epinephrine.

At the beginning:IM:

• In between 10 and 20 minutes.

Duration:

• Pressor/cardiac effects: SubQ: 1 hour

Absorption: IV:

• Rapid, complete

Metabolism:

• It is minimally metabolized in the liver; metabolites include p-hydroxyephedrine, p-hydroxynorephedrine, norephedrine

Half-life elimination:

• Dependent upon urinary pH;
  • Urine pH 5: about 3 hours;
  • Urine pH 6.3: about 6 hours

Excretion:

• Urine (primarily in unchanged form; depends upon urinary pH with the greatest excretion in acid pH)

International Brand Names of Ephedrine:

• Akovaz
• Efedrin
• Efedrin NAF
• Efedrina
• Efipres
• Ephedrine Hydrochloride
• Ephedrine Sulfate Inj
• Epherit
• Forasm
• Kemiphedrine
• Muchan
• Sulfato de Efedrina
• Sulfato de Efedrina Klinos
• Sulfidrin
• Sympathodrine
• Tabellae Ephedrini
• Unifedrine
• Vasodrin
• Vitadrine

Ephedrine Brands Names in Pakistan: