Adenosine is a parenteral pharmacologic stress agent indicated as an adjunct to thallium-201 myocardial perfusion scintigraphy in patients unable to exercise adequately and antiarrhythmic indicated for conversion to sinus rhythm of paroxysmal supraventricular tachycardia (PSVT), including that associated with accessory bypass tracts (Wolff-Parkinson-White Syndrome). It is an endogenous nucleoside occurring in all cells of the body. When clinically advisable, appropriate vagal maneuvers (e.g., Valsalva maneuver), should be attempted before adenosine administration for cardioversion. Adenosine does not convert atrial flutter, atrial fibrillation, or ventricular tachycardia to normal sinus rhythm. The safety and efficacy of adenosine administered by the intracoronary route have not been established. Fatal and nonfatal cardiac arrest, sustained ventricular tachycardia, and myocardial infarction have occurred after adenosine administration. Adenosine can also cause dyspnea, bronchoconstriction, and respiratory compromise. Appropriate resuscitative measures should be available.
General Administration Information
For storage information, see the specific product information within the How Supplied section.
Route-Specific Administration
Injectable Administration
-Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Intravenous Administration
Intravenous injection
-Prior to the administration of adenosine for paroxysmal supraventricular tachycardia (PSVT), attempt appropriate vagal maneuvers unless otherwise contraindicated.
-Administer undiluted by rapid intravenous bolus (over 1 to 2 seconds).
-Inject into the most proximal injection site or central venous line. Stopcock or T-connector method recommended for rapid administration. Follow immediately with a rapid saline flush (at least 5 mL); guidelines recommend a 20 mL flush. May also be given directly into a peripheral vein.
-Elevate extremity after administration.
-Storage: Vials are for use only; discard any unused portion.
Intravenous infusion
-Administer only as a continuous peripheral intravenous infusion over 6 minutes as an adjunct to thallium-201 myocardial perfusion scintigraphy.
-Inject thallium-201 at the midpoint of the adenosine infusion (i.e., after the first 3 minutes of adenosine infusion). Inject thallium-201 as close to the venous access as possible to prevent an inadvertent increase in the dose of adenosine (the contents of the intravenous tubing) being administered.
-Storage: Vials are for single use only; discard any unused portion.
Other Injectable Administration
Intraosseous Administration
NOTE: Adenosine is not FDA-approved for intraosseous administration.
-During cardiopulmonary resuscitation, the same dosage of adenosine may be given via the intraosseous route when IV access is unsuccessful or not feasible. Administer a saline flush after the dose.
Fatal and nonfatal cardiac arrest, sustained ventricular tachycardia (requiring resuscitation), and myocardial infarction (less than 1%) have occurred after adenosine infusion for cardiac stress testing. Transient or prolonged episodes of asystole have been reported with fatal outcomes in some cases. Rarely, ventricular fibrillation has been reported after adenosine administration, including both resuscitated and fatal events. At the time of conversion to normal sinus rhythm, a variety of new rhythms may appear on the electrocardiogram. They generally last only a few seconds without intervention, and may take the form of premature ventricular contractions (PVCs), premature atrial contractions (PACs), atrial fibrillation, sinus bradycardia (less than 1%), sinus tachycardia, skipped beats, and varying degrees of AV block. Such findings were seen in 55% of patients receiving adenosine for cardioversion. Atrial fibrillation typically began 1.5 to 3 minutes after initiation of adenosine, lasted for 15 seconds to 6 hours, and spontaneously converted to normal sinus rhythm. Adenosine can induce clinically significant increases in systolic and diastolic blood pressure. Most increases resolved spontaneously within several minutes, but in some cases, hypertension lasted for several hours. Flushing (18% to 44%) was among the most common adverse reactions reported with adenosine use in clinical trials. Other cardiovascular adverse reactions reported with adenosine during clinical trials include chest discomfort (40%), chest pain (unspecified), arrhythmias (1%), ventricular arrhythmia (less than 1%), first-degree AV block (3%), second-degree AV block (3%), third-degree AV block (less than 1%), palpitations (less than 1%), sinus exit block (less than 1%), sinus pause (less than 1%), ST-segment depression (3%), T-wave changes (less than 1%), hypertension (systolic blood pressure more than 200 mmHg) (less than 1%), hypotension (2% or less), and diaphoresis (less than 1%). Heart failure and torsade de pointes (TdP) were reported with postmarketing experience with adenosine. Discontinue adenosine in any patient who develops persistent or symptomatic high-grade AV block. Do not administer additional doses in patients who develop high-grade AV block after a single adenosine dose. Because of the very short half-life of adenosine, these effects are generally self-limiting. Discontinue adenosine in any patient who develops persistent or symptomatic hypotension.
Adenosine is a respiratory stimulant, and intravenous administration has been shown to increase minute ventilation and reduce arterial PCO2, causing respiratory alkalosis. Dyspnea/shortness of breath (12% to 28%), chest pressure (7%), hyperventilation, head pressure (less than 1%), and cough (less than 1%) have been reported with adenosine use during clinical trials. Bronchospasm, throat tightness, and respiratory arrest have been reported with postmarketing experience with adenosine. Discontinue adenosine in any patient who develops severe respiratory difficulties.
Genitourinary adverse reactions reported with adenosine in less than 1% of patients during clinical trials include vaginal pressure and urinary urgency.
Blurred vision, xerostomia, otalgia, nasal congestion, scotomata, and tongue discomfort have been reported in less than 1% of patients receiving adenosine.
Gastrointestinal discomfort (13%), throat, neck, or jaw discomfort (15%), nausea (3%), tightness in throat, groin pressure (less than 1%), and metallic taste (less than 1%) have been reported with adenosine use during clinical trials. Nausea and vomiting have been reported with postmarketing experience with adenosine.
New-onset or recurrence of convulsive seizures has occurred after adenosine injection. Some seizures are prolonged and require emergency management. Hemorrhagic and ischemic cerebrovascular accidents (e.g., stroke, intracranial bleeding) have also been reported with adenosine use and may be associated with the hemodynamic effects of adenosine. Headache (2% to 18%), lightheadedness/dizziness (2% to 12%), paresthesias (2%), numbness (1%), apprehension, nervousness (2%), burning sensation, heaviness in arms, upper extremity discomfort (4%), lower extremity discomfort (less than 1%), neck and back pain (less than 1%), weakness (less than 1%), drowsiness (less than 1%), tremor (less than 1%), and emotional lability (less than 1%) have been reported with adenosine use during clinical trials. Headache and dizziness were more common during infusion for cardiac stress testing than injection for cardioversion. Loss of consciousness has been reported with postmarketing experience with adenosine.
Hypersensitivity (dyspnea, throat tightness, flushing, erythema, rash, and chest discomfort), injection site reaction, and infusion-related reactions (i.e., pain) have been reported from postmarketing experience with adenosine for cardiac stress testing. Symptomatic treatment may be required for hypersensitivity reactions. Resuscitative measures may be necessary if symptoms progress.
Adenosine is contraindicated in patients with known adenosine hypersensitivity. Dyspnea, throat tightness, flushing, erythema, rash, and chest discomfort have occurred after adenosine administration. Symptomatic treatment may be required. Have personnel and appropriate treatment available. Resuscitative measures may be necessary if symptoms progress.
Adenosine will not effectively terminate atrioventricular node-independent tachycardias (e.g., atrial flutter, ectopic atrial tachycardia, atrial fibrillation). Do not administer for wide QRS complex tachycardia unless it is clear the underlying rhythm is not atrial fibrillation or atrial flutter with associated antegrade accessory pathway conduction. Adenosine can be life-threatening for atrial fibrillation with an antegrade accessory pathway. Adenosine is also not effective in converting ventricular tachycardia to normal sinus rhythm.
Adenosine is contraindicated in patients with sinus node disease, such as sick sinus syndrome or symptomatic bradycardia, and in patients with second- or third-degree AV block, except in patients with a functioning artificial pacemaker. Use adenosine with caution in patients with pre-existing first-degree AV block or bundle-branch block. Discontinue adenosine in any patient who develops persistent or symptomatic high-grade AV block. Do not administer additional doses in patients who develop high-grade AV block after a single adenosine dose.
Adenosine is a potent peripheral vasodilator and can induce significant hypotension. The risk of serious hypotension may be higher in patients with autonomic neuropathy, hypovolemia, stenotic valvular heart disease, pericarditis or pericardial effusion, or stenotic carotid artery disease with cerebrovascular insufficiency. Discontinue adenosine in any patient who develops persistent or symptomatic hypotension.
Fatal and nonfatal cardiac arrest, sustained ventricular tachycardia (requiring resuscitation), and myocardial infarction have occurred after adenosine infusion. Avoid use in patients with symptoms or signs of acute myocardial infarction, for example, unstable angina or cardiovascular instability; these patients may be at greater risk of serious cardiovascular reactions to adenosine. Ensure appropriate resuscitative measures are available.
The use of adenosine for myocardial perfusion imaging is contraindicated in patients with bronchoconstrictive or bronchospastic lung disease (e.g., asthma). Avoid adenosine for cardioversion in patients with bronchoconstriction or acute bronchospasm (e.g., asthma). Use adenosine with caution in patients with obstructive lung disease not associated with bronchoconstriction (e.g., emphysema, bronchitis). Adenosine is a respiratory stimulant (probably through activation of carotid chemoreceptors) and intravenous administration has been shown to increase minute ventilation and reduce arterial PCO2, causing respiratory alkalosis. Use of adenosine in patients with asthma has resulted in mild to moderate exacerbation of their symptoms. In addition, respiratory compromise has occurred during adenosine infusion in patients with chronic obstructive pulmonary disease (COPD). Discontinue adenosine if a patient develops severe respiratory difficulties.
Clinical studies of adenosine did not include sufficient numbers of geriatric subjects to determine whether they respond differently compared to younger subjects. In general, use adenosine with caution in geriatric adults since this population may have a diminished cardiac function, nodal dysfunction, or concomitant diseases that may alter hemodynamic function and increase the risk of severe bradycardia or AV block.
When used for cardioversion, reduce the initial adenosine dose to 3 mg in adults with a heart transplant. In the denervated posttransplantation heart, both the sinus and atrioventricular nodes are 3 to 5 times more sensitive to adenosine. In pediatric patients with a transplanted heart, reduce the adenosine dose to one-fifth to one-third the usual dose.
Use adenosine during pregnancy only if clearly needed. It is not known if adenosine can cause fetal harm when administered to a pregnant woman. However, as adenosine is a naturally occurring material and dispersed widely in the body, fetal effects are not anticipated.
It is not known if adenosine is excreted into human milk. Because of the potential for serious adverse reactions from adenosine in nursing infants, interrupt breast-feeding after adenosine administration or do not administer adenosine, taking into account the importance of the drug to the mother.
For the treatment of paroxysmal supraventricular tachycardia (PSVT), including that associated with Wolff-Parkinson-White (WPW) syndrome:
Intravenous or Intraosseous* dosage:
Adults: 6 mg IV/IO as a single dose. If conversion does not occur within 1 to 2 minutes, administer 12 mg IV/IO as a single dose. May repeat the 12 mg dose once if needed.
Children and Adolescents weighing 50 kg or more: 6 mg IV/IO as a single dose. If conversion does not occur within 1 to 2 minutes, administer 12 mg IV/IO as a single dose. May repeat the 12 mg dose once if needed.
Infants, Children, and Adolescents weighing less than 50 kg: 0.1 mg/kg/dose IV/IO as a single dose. If conversion does not occur within 1 to 2 minutes, administer 0.2 mg/kg/dose IV/IO as a single dose. The FDA-approved dosage is 0.05 to 0.1 mg/kg/dose IV as a single dose. If conversion does not occur within 1 to 2 minutes, increase the dose by 0.05 to 0.1 mg/kg/dose and repeat up to 0.3 mg/kg (Max: 12 mg/dose). However, studies have shown that initial doses of 0.05 mg/kg/dose and 0.1 mg/kg/dose terminate the arrhythmia in less than 10% and less than 37% of pediatric patients who received these doses, respectively. The median effective dose was approximately 0.2 mg/kg in infants and 0.1 to 0.15 mg/kg in children, leading some experts to recommend higher initial doses of 0.2 mg/kg/dose.
Neonates: 0.1 mg/kg/dose IV/IO as a single dose. If conversion does not occur within 1 to 2 minutes, administer 0.2 mg/kg/dose IV/IO as a single dose. The FDA-approved dosage is 0.05 to 0.1 mg/kg/dose IV as a single dose. If conversion does not occur within 1 to 2 minutes, increase the dose by 0.05 to 0.1 mg/kg/dose and repeat up to 0.3 mg/kg. However, studies have shown that initial doses of 0.05 mg/kg/dose and 0.1 mg/kg/dose terminate the arrhythmia in less than 10% and less than 37% of pediatric patients who received these doses, respectively. The median effective dose was approximately 0.2 mg/kg in neonates and infants, leading some experts to recommend higher initial doses of 0.2 mg/kg/dose.
For use in coronary artery disease diagnosis (i.e., stress echocardiography) in patients unable to exercise adequately as an adjunct to thallium-201 myocardial perfusion imaging:
Continuous Intravenous Infusion dosage (Adenoscan):
Adults: 140 mcg/kg/minute continuous IV infusion for 6 minutes for a total dose of 0.84 mg/kg (Max: 60 mg).
For acute vasodilator testing in pulmonary hypertension diagnosis*:
Intravenous dosage:
Adults: 50 mcg/kg/minute IV titrated by 50 mcg/kg/minute every 2 minutes up to a maximum of 250 mcg/kg/minute. Guidelines suggest that patients with pulmonary arterial hypertension undergo acute vasoreactivity testing with a short-acting agent in the absence of contraindications, including low systemic blood pressure, low systemic cardiac output, or the presence of functional class (FC) IV symptoms. Acute vasoreactivity is defined as a fall in mean pulmonary artery pressure (mPAP) more than 10 mmHg, to an mPAP less than 40 mmHg, with an unchanged or increased cardiac output.
For wide-complex tachycardia diagnosis* and conversion of wide-complex tachycardia of supraventricular origin* in hemodynamically stable patients:
Intravenous or Intraosseous* dosage:
Adults: 6 mg rapid IV/IO bolus followed immediately by a saline flush. If necessary, give a second dose of 12 mg rapid IV/IO bolus followed by a saline flush. May repeat the 12 mg dose once if needed. Reduce the initial dose to 3 mg if given by central access.
Infants, Children, and Adolescents: 0.1 mg/kg (Max: 6 mg) rapid IV/IO bolus followed immediately by a saline flush. If necessary, give a second dose of 0.2 mg/kg (Max: 12 mg) rapid IV/IO bolus followed by a saline flush. Consider adenosine only if the rhythm is regular and the QRS is monomorphic. Do not use in patients with Wolff-Parkinson-White syndrome and wide-complex tachycardia.
Maximum Dosage Limits:
-Adults
12 mg/dose IV, with maximum total dosage up to 30 mg for PSVT; 0.84 mg/kg/dose (Max: 60 mg) IV for coronary artery disease diagnosis.
-Geriatric
12 mg/dose IV, with maximum total dosage up to 30 mg for PSVT; 0.84 mg/kg/dose (Max: 60 mg) IV for coronary artery disease diagnosis.
-Adolescents
Weighing 50 kg or more: 12 mg/dose IV/IO, with maximum total dosage up to 30 mg per PSVT episode; safety and efficacy for coronary artery disease diagnosis have not been established.
Weighing less than 50 kg: 0.3 mg/kg/dose IV/IO (Max: 12 mg); safety and efficacy for coronary artery disease diagnosis have not been established.
-Children
Weighing 50 kg or more: 12 mg/dose IV/IO, with maximum total dosage up to 30 mg per PSVT episode; safety and efficacy for coronary artery disease diagnosis have not been established.
Weighing less than 50 kg: 0.3 mg/kg/dose IV/IO (Max: 12 mg); safety and efficacy for coronary artery disease diagnosis have not been established.
-Infants
0.3 mg/kg/dose IV/IO; safety and efficacy for coronary artery disease diagnosis have not been established.
-Neonates
0.3 mg/kg/dose IV/IO; safety and efficacy for coronary artery disease diagnosis have not been established.
Patients with Hepatic Impairment Dosing
No dosage adjustment is needed.
Patients with Renal Impairment Dosing
No dosage adjustment is needed.
Intermittent hemodialysis
No dosage adjustment is needed.
*non-FDA-approved indication
Acebutolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Acetaminophen; Aspirin, ASA; Caffeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Acetaminophen; Aspirin, ASA; Caffeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Acetaminophen; Caffeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Acetaminophen; Caffeine; Dihydrocodeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Acetaminophen; Caffeine; Pyrilamine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Amlodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Atorvastatin: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Benazepril: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Celecoxib: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Olmesartan: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Valsartan: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Aspirin, ASA; Butalbital; Caffeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Aspirin, ASA; Caffeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Aspirin, ASA; Caffeine; Orphenadrine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Aspirin, ASA; Dipyridamole: (Major) The vasoactive effects of adenosine are potentiated by dipyridamole; smaller doses of adenosine may be effective if used concurrently with dipyridamole. When used for supraventricular tachyarrhythmias in adults, reduce the initial adenosine dose to 3 mg. When possible, withhold dipyridamole for at least 5 half-lives before adenosine use for diagnostic imaging.
Atenolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Atenolol; Chlorthalidone: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Beta-adrenergic blockers: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Betaxolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Bisoprolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Brimonidine; Timolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Butalbital; Acetaminophen; Caffeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Butalbital; Acetaminophen; Caffeine; Codeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Butalbital; Aspirin; Caffeine; Codeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Caffeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid caffeine-containing foods/beverages for at least 5 half-lives prior to the imaging study. (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Caffeine; Sodium Benzoate: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Calcium-channel blockers: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Carbamazepine: (Major) Carbamazepine increases the degree of heart block produced by adenosine. When used for supraventricular tachyarrhythmias in adults, reduce the initial adenosine dose to 3 mg. When possible, withhold carbamazepine for at least 5 half-lives before adenosine use for diagnostic imaging.
Carteolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Carvedilol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Clevidipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Digoxin: (Moderate) Use adenosine with caution in the presence of digoxin due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes. Concomitant use has rarely been associated with ventricular fibrillation.
Diltiazem: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Dipyridamole: (Major) The vasoactive effects of adenosine are potentiated by dipyridamole; smaller doses of adenosine may be effective if used concurrently with dipyridamole. When used for supraventricular tachyarrhythmias in adults, reduce the initial adenosine dose to 3 mg. When possible, withhold dipyridamole for at least 5 half-lives before adenosine use for diagnostic imaging.
Dorzolamide; Timolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Ergotamine; Caffeine: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Esmolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Felodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Inotersen: (Moderate) Use caution with concomitant use of inotersen and adenosine due to the potential risk of bleeding from thrombocytopenia. Consider discontinuation of adenosine in a patient taking inotersen with a platelet count of less than 50,000 per microliter.
Isradipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Labetalol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Levamlodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Levobunolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Methylxanthines: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Metoprolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Nadolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Nebivolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Nebivolol; Valsartan: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Nicardipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Nicotine: (Major) Nicotine has been reported to enhance the cardiovascular effects of adenosine; an increase in angina-like chest pains, heart rate or a decrease in blood pressure may be noted. While no special cautions are recommended when adenosine is used therapeutically to treat supraventricular tachycardia, it may be advisable for patients to avoid nicotine products or tobacco prior to electrophysiologic studies or stress testing where adenosine will be administered.
NIFEdipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Nimodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Nisoldipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Perindopril; Amlodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Pindolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Propranolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Telmisartan; Amlodipine: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Theophylline, Aminophylline: (Major) Larger doses of adenosine may be required or adenosine may not be effective in the presence of methylxanthines. The effects of adenosine are antagonized by methylxanthines. When used for diagnostic purposes, instruct patients to avoid consumption of methylxanthine-containing products, including caffeinated beverages, for at least 5 half-lives prior to the imaging study.
Timolol: (Moderate) Use adenosine with caution in the presence of beta blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Trandolapril; Verapamil: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Verapamil: (Moderate) Use adenosine with caution in the presence of calcium-channel blockers due to the potential for additive or synergistic depressant effects on the sinoatrial and atrioventricular nodes.
Adenosine slows conduction time through the A-V node, can interrupt the reentry pathways through the A-V node, and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (PSVT), including PSVT associated with Wolff-Parkinson-White Syndrome.
Myocardial uptake of thallium-201 is directly proportional to coronary blood flow. Since adenosine significantly increases blood flow in normal coronary arteries with little or no increase in stenotic arteries, adenosine causes relatively less thallium-201 uptake in vascular territories supplied by stenotic coronary arteries (i.e., a greater difference is seen after adenosine between areas served by normal and areas served by stenotic vessels than is seen prior to adenosine). Adenosine causes cardiac vasodilation which increases cardiac blood flow. Adenosine is thought to exert its pharmacological effects through activation of purine receptors (cell-surface A1 and A2 adenosine receptors). Although the exact mechanism by which adenosine receptor activation relaxes vascular smooth muscle is not known, there is evidence to support both inhibition of the slow inward calcium current reducing calcium uptake, and activation of adenylate cyclase through A2 receptors in smooth muscle cells. Adenosine may also lessen vascular tone by modulating sympathetic neurotransmission. The intracellular uptake of adenosine is mediated by a specific transmembrane nucleoside transport system. Once inside the cell, adenosine is rapidly phosphorylated by adenosine kinase to adenosine monophosphate, or deaminated by adenosine deaminase to inosine. These intracellular metabolites of adenosine are not vasoactive.
Adenosine is administered intravenously. It distributes from the circulation via cellular uptake, primarily by erythrocytes and vascular endothelial cells. This process involves a specific transmembrane nucleoside carrier system that is reversible, nonconcentrative, and bidirectionally symmetrical. Intracellular adenosine is metabolized either via phosphorylation to adenosine monophosphate by adenosine kinase, or via deamination to inosine by adenosine deaminase in the cytosol. Since adenosine kinase has a lower Km and Vmax than adenosine deaminase, deamination plays a significant role only when cytosolic adenosine saturates the phosphorylation pathway. Inosine formed by deamination of adenosine can leave the cell intact or can be degraded to hypoxanthine, xanthine, and ultimately uric acid. Adenosine monophosphate formed by phosphorylation of adenosine is incorporated into the high-energy phosphate pool. While extracellular adenosine is primarily cleared from plasma by cellular uptake with a half-life of less than 10 seconds in whole blood, excessive amounts may be deaminated by an ecto-form of adenosine deaminase.
Affected cytochrome P450 isoenzymes and drug transporters: none
-Special Populations
Hepatic Impairment
Hepatic impairment does not affect the pharmacokinetics of adenosine.
Renal Impairment
Renal impairment does not affect the pharmacokinetics of adenosine.