What is Vasostrict and how is it used?
Vasostrict (vasopressin injection) is a man-made form of a hormone called "anti-diuretic hormone" that is normally secreted by the pituitary gland used to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines.
What are side effects of Vasostrict?
Common side effects of Vasostrict include:
- decreased cardiac output,
- slow heart rate,
- irregular heart beat,
- low levels of sodium in the blood (hyponatremia), and
- inadequate blood supply (ischemia) to the heart, intestines, skin, fingers and toes
Vasopressin is a polypeptide hormone that causes contraction of vascular and other smooth muscles and antidiuresis. Vasostrict is a sterile, aqueous solution of synthetic arginine vasopressin for intravenous administration. The 1 mL solution contains vasopressin 20 units/mL, chlorobutanol, NF 0.5% as a preservative, and Water for Injection, USP adjusted with acetic acid to pH 3.4 – 3.6.
The chemical name of vasopressin is Cyclo (1-6) L-Cysteinyl-L-Tyrosyl-L-Phenylalanyl-LGlutaminyl-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:
One mg is equivalent to 530 units.
Vasostrict® is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines.
DOSAGE AND ADMINISTRATION
Preparation Of Solution
Inspect parenteral drug products for particulate matter and discoloration prior to use, whenever solution and container permit.
Vasostrict® Solution For Dilution, 20 units/mL and 200 units/10 mL (20 units/mL)
Dilute Vasostrict® 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|
|No||0.1 units/mL||2.5 mL (50 units)||500 mL|
|Yes||1 unit/mL||5 mL (100 units)||100 mL|
Vasostrict® Premixed Solution, 40 units/100 mL (0.4 units/mL) and 60 units/100 mL (0.6 units/mL)
This product does not require further dilution prior to 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.
Dosage Forms And Strengths
Vasostrict® (vasopressin injection, USP) is a clear, practically colorless solution available as 20 units/mL in a single dose vial and 200 units/10 mL (20 units/mL) in a multiple dose vial. To be used after dilution.
Vasostrict® is also available premixed as 40 units/100 mL (0.4 units/mL) and 60 units/100 mL (0.6 units/mL) in single dose vials. Ready to use.
Storage And Handling
Vasostrict® (vasopressin injection, USP) is a clear, practically colorless solution for intravenous administration available as:
NDC 42023-164-10: A carton of 10 single dose vials. Each vial contains vasopressin 1 mL at 20 units/mL.
NDC 42023-164-25: A carton of 25 single dose vials. Each vial contains vasopressin 1 mL at 20 units/mL.
NDC 42023-190-01: A carton of 1 multiple dose vial. Each vial contains vasopressin 10 mL at (20 units/mL.
NDC 42023-219-10: A carton of 10 single dose vials. Each vial contains vasopressin 100 mL at 40 units/100 mL (0.4 units/mL).
NDC 42023-220-10: A carton of 10 single dose vials. Each vial contains vasopressin 100 mL at 60 units/100 mL (0.6 units/mL).
Store between 2°C and 8°C (36°F and 46°F). Do not freeze.
Vials may be held up to 12 months upon removal from refrigeration to room temperature storage conditions (20°C to 25°C [68°F to 77°F], USP Controlled Room Temperature), anytime within the labeled shelf life. Once removed from refrigeration, unopened vial should be marked to indicate the revised 12 month expiration date. If the manufacturerâ€™s original expiration date is shorter than the revised expiration date, then the shorter date must be used. Do not use Vasostrict® beyond the manufacturerâ€™s expiration date stamped on the vial.
After initial entry into the 10 mL vial, the remaining contents must be refrigerated. Discard the refrigerated 10 mL vial after 30 days after first puncture.
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|
|100 mL Vial||Until manufacturer expiration date||12 months or until manufacturer expiration date, whichever is earlier||N/A|
Distributed by: Par Pharmaceutical, Chestnut Ridge, NY 10977. Revised: Mar 2021
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.
Gastrointestinal disorders: Mesenteric ischemia
Hepatobiliary: Increased bilirubin levels
Renal/urinary disorders: Acute renal insufficiency
Vascular disorders: Distal limb ischemia
Skin: Ischemic lesions
Reversible diabetes insipidus [see WARNINGS AND PRECAUTIONS]
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.
Use with indomethacin may prolong the effect of Vasostrict® on cardiac index and systemic vascular resistance. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed [see CLINICAL PHARMACOLOGY].
Ganglionic Blocking Agents
Use with ganglionic blocking agents may increase the effect of Vasostrict® on mean arterial blood pressure. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed. [see CLINICAL PHARMACOLOGY].
Drugs Suspected Of Causing SIADH
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 Vasostrict®. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed.
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 Vasostrict®. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed.
Included as part of the PRECAUTIONS section.
Worsening Cardiac Function
A decrease in cardiac index may be observed with the use of vasopressin.
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.
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 function and fertilizing ability of spermatozoa.
Use In Specific Populations
There are no available data on Vasostrict® 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.
Dose Adjustments During Pregnancy And The Postpartum Period
Because of increased clearance of vasopressin in the second and third trimester, the dose of Vasostrict® may need to be increased [see DOSAGE AND ADMINISTRATION and CLINICAL PHARMACOLOGY].
Maternal Adverse Reactions
Vasostrict® may produce tonic uterine contractions that could threaten the continuation of pregnancy.
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.
Safety and effectiveness of Vasostrict® in pediatric patients with vasodilatory shock have not been established.
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, ADVERSE REACTIONS, and CLINICAL PHARMACOLOGY].
Overdosage with Vasostrict® 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.
Vasostrict® 10 mL multiple dose vial is contraindicated in patients with known allergy or hypersensitivity to 8-L-arginine vasopressin or chlorobutanol. The 1 mL single dose vial does not contain chlorobutanol and is therefore contraindicated only in patients with a known allergy or hypersensitivity to 8-L-arginine vasopressin.
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.
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 and ACTH 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 are 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.
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.
Vasopressin does not appear to bind plasma protein. The volume of distribution is 140 mL/kg.
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 t½ of vasopressin at these levels is ≤10 minutes.
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.
Vasopressin is predominantly metabolized and only about 6% of the dose is excreted unchanged into urine.
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 5fold. After delivery, the clearance of vasopressin returns to preconception baseline within two weeks.
Indomethacin more than doubles the time to offset for vasopressinâ€™s effect on peripheral vascular resistance and cardiac output in healthy subjects [see DRUG INTERACTIONS].
The ganglionic blocking agent tetra-ethylammonium increases the pressor effect of vasopressin by 20% in healthy subjects [see DRUG INTERACTIONS].
Halothane, morphine, fentanyl, alfentanyl and sufentanyl do not impact exposure to endogenous vasopressin.
Animal Toxicology And/Or Pharmacology
No toxicology studies were conducted with vasopressin.
Increases in systolic and mean blood pressure following administration of vasopressin were observed in 7 studies in septic shock and 8 in post-cardiotomy vasodilatory shock.
No information provided. Please refer to the WARNINGS AND PRECAUTIONS section.
Report Problems to the Food and Drug Administration
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.