nesiritide


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nesiritide

(ne-sir-i-tide) ,

Natrecor

(trade name)

Classification

Therapeutic: none assigned
Pharmacologic: vasodilators
Pregnancy Category: C

Indications

Acutely decompensated HF in hospitalized patients who have dyspnea at rest or with minimal activity; has been used with digoxin, diuretics, and ACE inhibitors. Should not be used for intermittent outpatient infusion, scheduled repetitive use, as a diuretic or to improve renal function.

Action

Binds to guanyl cyclase receptors in vascular smooth muscle and endothelial cells, producing increased intracellular guanosine 3′5′-cyclic monophosphate (cGMP) and smooth muscle cell relaxation. cGMP acts as a "second messenger" to dilate veins and arteries.

Therapeutic effects

Dose-dependent reduction in pulmonary capillary wedge pressure (PCWP) and systemic arterial pressure in patients with heart failure with resultant decrease in dyspnea.

Pharmacokinetics

Absorption: IV administration results in complete bioavailability.
Distribution: Unknown.
Metabolism and Excretion: Cleared from circulation by binding to cell surface clearance receptors resulting in cellular internalization and proteolysis, proteolytic breakdown by endopeptidases, and renal filtration.
Half-life: 18 min.

Time/action profile (effects on cardiovascular parameters)

ROUTEONSETPEAKDURATION
IV15 min1 hr60 min†
†Longer with higher than recommended doses

Contraindications/Precautions

Contraindicated in: Hypersensitivity;Cardiogenic shock;Systolic BP <100 mm Hg;Low cardiac filling pressure, significant valvular stenosis, restrictive/subtractive cardiomyopathy, constrictive pericarditis/cardiac tamponade, or other conditions in which cardiac output is dependent on venous return.
Use Cautiously in: Heart failure where renal function is dependent on activity of the renin/angiotensin/aldosterone system (may cause azotemia);Cardiogenic shock (should not be used as primary therapy); Obstetric / Lactation / Pediatric: Pregnancy, lactation, or children (safety not established); Geriatric: May have ↑ sensitivity to effects.

Adverse Reactions/Side Effects

Central nervous system

  • anxiety
  • confusion
  • dizziness
  • headache
  • hypotension (dose related)
  • insomnia
  • drowsiness

Ear, Eye, Nose, Throat

  • amblyopia

Respiratory

  • apnea (life-threatening)
  • cough
  • hemoptysis

Cardiovascular

  • hypotension (most frequent)
  • arrhythmias
  • bradycardia

Gastrointestinal

  • abdominal pain
  • nausea
  • vomiting

Genitourinary

  • ↑ serum creatinine
  • renal failure

Dermatologic

  • itching
  • rash
  • sweating

Hematologic

  • anemia

Local

  • injection site reactions

Musculoskeletal

  • back pain
  • leg cramps

Neurologic

  • paresthesia
  • tremor

Miscellaneous

  • allergic reactions (life-threatening)
  • fever

Interactions

Drug-Drug interaction

None reported.

Route/Dosage

Intravenous (Adults) 2 mcg/kg bolus followed by 0.01 mcg/kg/min as a continuous infusion. May ↑ by 0.005 mcg/kg/min every 3 hr up to a maximum infusion rate of 0.03 mcg/kg/min (based on response).

Availability

Powder for injection: 1.5 mg/vial

Nursing implications

Nursing assessment

  • Monitor BP, pulse, ECG, respiratory rate, cardiac index, PCWP, and central venous pressure frequently during administration. May cause hypotension, especially in patients with a BP <100 mm Hg. Reduce dose or discontinue nesiritide if patient develops hypotension. Hypotension may cause renal compromise. Use IV fluids and changes in body position to support BP if symptomatic hypotension occurs. Nesiritide may be restarted at a dose reduced by 30% with no bolus administration once patient is stabilized. Hypotension may be prolonged for hours, requiring a period of monitoring prior to restarting administration.
  • Monitor intake and output and weigh daily. Assess for decrease in signs of HF (dyspnea, rales/crackles, peripheral edema, weight gain).
  • Obtain history for reactions to recombinant peptides; may increase risk of allergic reaction. Observe patient for signs and symptoms of allergic reactions (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notify health care professional immediately if these occur. Keep epinephrine, an antihistamine, IV fluids, pressure amines, and resuscitation equipment close by in the event of an anaphylactic reaction.
  • Lab Test Considerations: Monitor BUN and serum creatinine. May cause ↑ in serum creatinine; ↑ serum creatinine may be dose-related.

Potential Nursing Diagnoses

Decreased cardiac output (Indications)
Activity intolerance (Indications)
Excess fluid volume (Indications)

Implementation

  • high alert: Intravenous vasoactive medications have an increased potential for causing harm. Have second practitioner independently check original order, dose calculations, and infusion pump settings. Administer only in settings where BP can be closely monitored.
    • Prime the IV tubing with an infusion of 25 mL prior to connecting to the patient’s vascular access port and prior to administering bolus or infusion. Flush catheter between administration of nesiritide and other medications. Do not administer through a central heparin-coated catheter as nesiritide binds to heparin. Concomitant administration of a heparin infusion through a separate catheter is acceptable.
  • Intravenous Administration
  • pH: 4.0–6.0.
  • Diluent: Reconstitute 1.5-mg vial of nesiritide by adding 5 mL of diluent removed from a pre-filled 250-mL plastic IV bag containing D5W, 0.9% NaCl, D5/0.45% NaCl, or D5/0.2% NaCl. Do not shake vial; rock gently so all surfaces including stopper are in contact with diluent to ensure complete reconstitution. Withdraw entire content of reconstituted vial and add back to 250-mL plastic IV bag. Invert IV bag several times to ensure complete mixing of solution. Infusion stable for 24 hr. After preparation of infusion bag, withdraw bolus volume from infusion bag. To calculate amount: bolus volume (mL) = 0.33 × patient weight (kg).Concentration: 6 mcg/mL.
  • Rate: Administer bolus over 60 seconds through a port in the IV tubing.
  • Intermittent Infusion: Diluent: See Diluent section under Direct IV section above for preparation instructions for infusion bag. Immediately follow bolus with infusion.Concentration: 6 mcg/mL.
  • Rate: Based on patient's weight (see Route/Dosage section).
  • Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, allopurinol, amifostine, aminophylline, amiodarone, amphotericin B colloidal, amphotericin C lipid complex, amphotericin B liposome, anidulafungin, argatroban, atracurium, azithromycin, aztreonam, bivalirudin, bleomycin, buprenorphine, busulfan, butorphanol, calcium acetate, calcium chloride, calcium gluconate, carboplatin, carmustine, cefazolin, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaoxone, cefuroxime, chloramphenicol, ciprofloxacin, cisatracurium, cisplatin, clindamycin, cyclophosphamide, cyclosporine, cytarabine, dacarbazine, dactinomycin, daunorubicin hydrochloride, dexmedetomidine, dexrazoxane, digoxin, diltiazem, diphenhydramine, docetaxel, dolasetron, doxacurium, doxorubicin, doxorubicin liposomal, doxycycline, droperidol, ephedrine, epirubicin, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fentanyl, filgrastim, fluconazole, fludarabine, fluorouracil, foscarnet, fosphenytoin, ganciclovir, gemcitabine, glycopyrrolate, granisetron, haloperidol, hydrocortisone, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, irinotecan, ketorolac, leucovorin calcium, levofloxacin, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, melphalan, meropenem, mesna, metaraminol, methohexital, methotrexate, methylprednisolone, metoclopramide, metronidazole, midazolam, milrinone, mitomycin, mitoxantrone, moxifloxacin, mycophenolate, nalbuphine, naloxone, nicardipine, nitroglycerin, nitroprusside, octreotide, ondansetron, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, pemetrexed, pentamidine, pentobarbital, pheobarbital, phentolamine, potassium acetate, potassium chloride, potassium phosphates, prochlorperazine, propranolol, quinupristin/dalfopristin, ranitidine, remifentanil, rocuronium, sodium acetate, sodium bicarbonate, sodium phosphates, streptozocin, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, tigecycline, tirofiban, tolazoline, topotecan, torsemide, vancomycin, vasopressin, vecuronium, verapamil, vinblastine, vincristine, vinorelbine, zidovudine, zolendronic acid
  • Y-Site Incompatibility: ampicillin, ampicillin/sulbactam, cefepime, cefoperazone, dantrolene, daptomycin, diazepam, furosemide, insulin, micafungin, nafcillin, pantoprazole, phenytoin, piperacillin/tazobactam, sargramostim, thiopental

Patient/Family Teaching

  • Explain purpose of nesiritide to patient and family.
  • Advise patient to notify health care professional immediately if signs and symptoms of allergic reaction occurs.

Evaluation/Desired Outcomes

  • Improvement in dyspnea and reduction in mean PCWP in patients with decompensated HF.

nesiritide

a vasodilator used to treat acutely decompensated congestive heart failure.

Natrecor

A recombinant brain (B-type) natriuretic peptide given intraveinously to patients with acutely decompensated heart failure and dyspnoea at rest. Natrecor relaxes blood vessels, increases natriuresis and diuresis, and decreases neurohormones. 

Adverse effects
Hypotension, ventricular tachycardia, headache, nausea, back pain, decreased renal function. It has been linked to increased mortality or renal damage; it is to be used only on severely ill patients.

nesiritide

A commercial form of recombinant human natriuretic peptide that has been promoted in the USA. It was approved by the FDA for the treatment of acute, decompensated congestive heart failure. There were reports in mid-2005 of adverse effects on survival and kidney function.
References in periodicals archive ?
Nesiritide in congestive heart failure associated with acute coronary syndromes: a pilot study of safety and efficacy.
Acute study of clinical effectiveness of nesiritide in decompensated heart failure: nesiritide redux.
It includes milrinone, tolvaptan, nesiritide, levosimendan, tezosentan, low-dose dopamine, and ultrafiltration.
Long-term outcome of patients treated with prophylactic nesiritide for the prevention of acute kidney injury following cardiovascular surgery," Clinical Cardiology, vol.
Estas sugerencias se fortalecieron con la publicacion del discutido estudio CARRESS HF, (47) en donde se aleatorizaron 188 pacientes con sindrome cardio renal I a recibir dosis de diureticos escalonada, si habia necesidad de dobutamina, nitroglicerina, nesiritide o soporte ventricular asistido se podia utilizar en este grupo, comparado contra unicamente UF programado a 200ml/hr.
For these two patients, inotropic agents, nesiritide, diuretics, beta blockers, and vasodilators were used in combination.
Mentzer RM, Oz MC, Sladen RN, Graeve AH, Hebeler RF, Luber JM, et al; NAPA Investigators: Effects of perioperative nesiritide in patients with left ventricular dysfunction undergoing cardiac surgery: The NAPA Trial.
Safety and efficacy of outpatient nesiritide in patients with advanced heart failure: results of the second follow-up serial infusions of nesiritide (Fusion II) trial.
Nesiritide ve urodilatin partikul halindeki guanilat siklaz yoluyla etki gostererek vazodilator, natriuretik ve diuretik etki gosterirler (2).
La adecuada seleccion de los pacientes que requieren manejo inotropico es fundamental (14), los diureticos son de utilidad para el manejo de los sintomas de congestion; sin embargo, no disminuyen la mortalidad (15-16) y los vasodilatadores son de gran ayuda por su efecto sobre las resistencias perifericas que caracteristicamente se encuentran elevadas en el perfil hemodinamico de los pacientes con falla cardiaca, la nitroglicerina es el vasodilatador mas utilizado en nuestro medio, sin embargo existen otras alternativas como el nesiritide aunque se discute su modo de administracion ideal (dosis, administracion sin bolo) y su efecto adverso sobre la funcion renal (17-19).
Effect of nesiritide in combination with standard therapy on serum concentrations of natriuretic peptides in patients admitted for decompensated congestive heart failure.
IVCI medications identified by pharmacy as generally seen on the medical-surgical units were reviewed: amiodarone (Cordarone[R]), (Argatroban[R]), diltiazem, dobutamine, dopamine, eptifibatide (Integrilin[R]), furosemide (Lasix[R]), heparin, labetalol (Trandate[R]), lepirudin (Refludan[R]), nesiritide (Natrecor[R]), nitroglycerin, phenylephrine (Neo-Synephrine[R]), procainamide, tirofiban (Aggrastat[R]), and verapamil.