Atracurium is a parenteral, intermediate-acting, nondepolarizing, neuromuscular blocking agent (NMBA) indicated as an adjunct to general anesthesia to facilitate tracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation. The majority of atracurium is metabolized via spontaneous degradation (Hofmann elimination); the remainder undergoes ester hydrolysis by nonspecific plasma esterases. Because Hofmann elimination occurs independently of enzymes or organ function, there is no prolongation of the effect of atracurium in patients with renal or hepatic failure. These characteristics have made atracurium infusions attractive in the intensive care unit, where multiorgan dysfunction is more common. Rapid injection of atracurium at intubating doses has been associated with histamine release and hypotension.
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.
-Accidental administration of neuromuscular blocking agents can be fatal. Store atracurium with the cap and ferrule intact, in a manner that minimizes the possibility of selecting the wrong product.
Intravenous Administration
-Only experienced clinicians, familiar with the use of neuromuscular blocking drugs, should administer or supervise the use of atracurium. Adequacy of respiration must be assured through assisted or controlled ventilation.
-To avoid distress to the patient, administer atracurium only after unconsciousness has been induced. Adequate amnesia, sedation, and analgesia should accompany neuromuscular blockade.
-Do not mix atracurium with alkaline solutions (e.g., barbiturate solutions such as thiopental) in the same syringe or administer simultaneously during IV infusion through the same needle or through the same IV line; atracurium has an acidic pH.
Intermittent IV Injection
-No further dilution necessary.
-Administer by direct IV injection.
-In patients with cardiac disease, asthma, or sensitivity to release of histamine or other mediators, use a lower initial atracurium dosage and administer slowly over 1 minute or in divided doses.
Continuous IV Infusion
-Dilute with 0.9% Sodium Chloride Injection, 5% Dextrose Injection, or 5% Dextrose and 0.9% Sodium Chloride Injection to a concentration of 0.2 mg/mL or 0.5 mg/mL; more concentrated solutions have reduced stability.
-A peripheral nerve stimulator is recommended to monitor atracurium's effects. Target response is typically 1 to 2 twitches. Incorrect electrode placement, direct stimulation of muscle due to large electrode size, acute illness, capillary leak, and edema may affect an appropriate assessment. Monitor visual and tactile stimulation on muscle movement as well as heart rate, blood pressure, and mechanical ventilator status during administration.
-Storage: Diluted solutions may be stored under refrigeration or at room temperature for 24 hours.
Dose-dependent skin flushing (5%) was reported in clinical trials with atracurium. Skin flush was reported in 1% of patients receiving atracurium 0.3 mg/kg or less, 8.7% of patients receiving 0.31 to 0.5 mg/kg, and 29.2% of patients receiving 0.6 mg/kg or more.
During clinical trials (n = 875), hypotension requiring treatment was reported in 5 patients. Of the 5 patients who required treatment for hypotension, 3 had a history of significant cardiovascular disease. Vital sign (i.e., mean arterial pressure (MAP), heart rate) changes more than 30% were observed after administration of atracurium in clinical trials. MAP increase (2.1%) was reported in 1.9% of patients receiving atracurium 0.3 mg/kg or less, 2.8% of patients receiving 0.31 to 0.5 mg/kg, and 0% of patients receiving 0.6 mg/kg or more; MAP decrease (1.9%) was reported in 1.1% of patients receiving atracurium 0.3 mg/kg or less, 2.1% of patients receiving 0.31 to 0.5 mg/kg, and 14.3% of patients receiving 0.6 mg/kg or more. Heart rate increase (2.1%) was reported in 1.6% of patients receiving atracurium 0.3 mg/kg or less, 2.8% of patients receiving 0.31 to 0.5 mg/kg, and 4.8% of patients receiving 0.6 mg/kg or more; heart rate decrease (0.6%) was reported in 0.8% of patients receiving atracurium 0.3 mg/kg or less and 0% of patients receiving 0.31 to 0.5 mg/kg or 0.6 mg/kg or more. Sinus tachycardia and bradycardia have been reported in clinical practice with atracurium. Since atracurium has no clinically significant effects on heart rate in the recommended dosage range, it will not counteract the bradycardia produced by many anesthetic agents or vagal stimulation. As a result, bradycardia during anesthesia may be more common with atracurium than with other muscle relaxants.
Although rare, severe anaphylactic or anaphylactoid reactions to neuromuscular blocking agents (NMBAs), including atracurium, have been reported; some cases have been fatal. Immediate availability of appropriate emergency treatment for anaphylaxis is advised because of the potential life-threatening severity of a reaction. Rapid injection of atracurium at intubating doses has been associated with histamine release and hypotension. Rare hypersensitivity reactions (e.g., angioedema, bronchospasm, wheezing, flushing, rash, erythema, urticaria, pruritus, hypotension, sinus tachycardia) related to histamine release have been reported after atracurium administration. In clinical trials (n = 875), erythema (0.6%) was reported in 0.6% of patients receiving atracurium 0.3 mg/kg or less, 0.5% of patients receiving 0.31 to 0.5 mg/kg, and 0% of patients receiving 0.6 mg/kg or more, and itching (0.2%) was reported in 0.4% of patients receiving atracurium 0.3 mg/kg or less and 0% of patients receiving 0.31 to 0.5 mg/kg or 0.6 mg/kg or more. Hives (0.1%) were reported in 0.2% of patients receiving atracurium 0.3 mg/kg or less and 0% of patients receiving 0.31 to 0.5 mg/kg or 0.6 mg/kg or more. Wheezing and/or bronchial secretions (0.2%) were reported in 0.2% of patients receiving atracurium 0.3 mg/kg or less, 0.3% of patients receiving 0.31 to 0.5 mg/kg, and 0% of patients receiving 0.6 mg/kg or more. Atracurium was discontinued in 1 patient who required treatment for bronchial secretions; treatment was required for 1 patient who experienced wheezing. Bronchospasm, laryngospasm, rash, and urticaria have been reported in clinical practice with atracurium.
Malignant hyperthermia can be precipitated by many drugs used in anesthetic practice, including halogenated anesthetics and depolarizing neuromuscular blocking agents (e.g., succinylcholine). Reports of malignant hyperthermia have been rare in cases where atracurium has been used. In a clinical study of malignant hyperthermia-susceptible patients, atracurium did not trigger this syndrome. However, because of the potentially fatal outcome, consider all patients undergoing anesthesia with administration of neuromuscular blocking agents, such as atracurium, at risk.
Atracurium is used for the purpose of inducing temporary paralysis; however, some of its most serious adverse effects are extensions of its therapeutic use. Careful monitoring of physiologic parameters and response to a peripheral nerve stimulator is recommended during continuous infusions or repeated dosing. Though paralysis may be used to facilitate mechanical ventilation, hypoxia may result from inadequate ventilation and/or a deterioration in pulmonary mechanics associated with prolonged paralysis. Excessive doses or prolonged exposure to neuromuscular blocking agents (NMBAs) can cause skeletal muscle weakness, and patients may consequentially experience prolonged apnea, dyspnea, respiratory depression, and/or profound muscular weakness (muscle paralysis). Prolonged block and dyspnea been observed in clinical practice with atracurium. Muscle weakness in critically ill patients is multifactorial; however, prolonged recovery is most often related to excessive dosing of neuromuscular blockers or use of these agents in patients with hepatic or renal dysfunction. These patients may take hours to days to recover due to long-term accumulation of the drug and its metabolites. Perhaps the most devastating complication of neuromuscular blockade, acute quadriplegic myopathy syndrome (AQMS), presents as acute paresis, myonecrosis with increased creatine phosphokinase (CPK), and abnormal electromyography (EMG). After drug discontinuation, patients present with flaccid paralysis, decreased deep tendon reflexes, and respiratory insufficiency. Sensory function and extraocular movement are preserved, and there are no abnormal cerebrospinal fluid findings. Prolonged rehabilitation as well as chronic ventilatory support are often needed in patients with AQMS. Recovery may take weeks to months. To reduce the risk of prolonged recovery and AQMS, periodic screening of CPK during ongoing neuromuscular blockage may be helpful. Though periodic interruption of therapy is often not feasible and there is no direct evidence showing that it reduces the incidence of AQMS, daily 'drug holidays' may be considered for patients who will tolerate an interruption in therapy.
Patients receiving atracurium are at risk for developing xerophthalmia, leading to keratitis, conjunctivitis, and corneal abrasion because muscle paralysis inhibits eyelid movement and complete closure. Prophylactic eye care is essential; use artificial tears or ophthalmic ointment at regular intervals during neuromuscular blockade. Additionally, paralyzed patients with prolonged immobility are at risk for skin erosion, skin ulcer (pressure sore), and deep vein thrombosis (DVT). Frequent repositioning, physical therapy, and sequential compression devices (if age appropriate) are indicated. The use of special mattresses may be considered.
Awake, paralyzed patient-anxiety and panic may be the most bothersome adverse effect associated with neuromuscular blockade. Neuromuscular blockers, such as atracurium, do not provide sedation or analgesia and should be administered only after unconsciousness has been induced. It is essential that amnesia, sedation, and analgesia are adequately maintained throughout paralyzation. Depth of sedation is difficult to monitor due to lack of movement with paralyzation. Physiologic parameters such as heart rate or blood pressure may be of use; however, there are many confounding influences on these parameters in critically ill patients.
Patients who receive neuromuscular blocking agents for a prolonged period may develop tachyphylaxis (i.e., tolerance). Prolonged blockade leads to proliferation of acetylcholine receptors at the neuromuscular junction resulting in increased drug requirements. Switch patients who develop tachyphylaxis to atracurium and still require neuromuscular blockade to another agent. Continuous monitoring of neuromuscular transmission with a peripheral nerve stimulator is strongly recommended during continuous infusion or repeated dosing. Target response is typically 1 to 2 twitches. Incorrect electrode placement, direct stimulation of muscle due to large electrode size, acute illness, capillary leak, and edema may affect an appropriate assessment. Monitor visual and tactile stimulation on muscle movement as well as heart rate, blood pressure, and mechanical ventilator status during administration.
Injection site reaction has been observed in clinical practice with atracurium.
Seizures have been reported in intensive care unit patients after long-term infusion of atracurium to support mechanical ventilation. These patients usually had predisposing causes (such as head trauma, cerebral edema, hypoxic encephalopathy, viral encephalitis, uremia). Laudanosine, a major biologically active metabolite of atracurium without neuromuscular blocking activity, produces cerebral excitatory effects (generalized muscle twitching and seizures) at higher doses when administered to several species of animals. The relationship between CNS excitation and laudanosine concentrations in humans has not been established.
Administer atracurium only after unconsciousness has been induced; maintain adequate amnesia and analgesia throughout paralyzation. Neuromuscular blocking agents do not cause sedation or analgesia. Individualize atracurium doses. Use of a peripheral nerve stimulator will permit the most advantageous use of atracurium, minimize the possibility of overdosage or underdosage, and assist in the evaluation of recovery.
Patients with carcinomatosis may be at higher risk of residual paralysis; thus, a lower maximum initial bolus is recommended in these patients. To prevent complications resulting from atracurium-associated residual paralysis, extubation is recommended only after the patient has recovered sufficiently from neuromuscular blockade. Consider use of a reversal agent especially in cases where residual paralysis is more likely to occur.
Atracurium administration requires an experienced clinician who is familiar with its actions and the possible complications that may occur after its use as well as requires a specialized care setting where facilities for intubation, artificial respiration, oxygen therapy, and reversal agents are immediately available. Accidental exposure to a neuromuscular blocking agent may be fatal in a patient for whom it is not intended. Store atracurium with cap and ferrule intact and in a manner that minimizes the possibility of selecting the wrong product. Confirm proper medication selection and clearly communicate the intended dose.
Atracurium is contraindicated in patients known to have an atracurium hypersensitivity. Use atracurium with caution in patients with neuromuscular blocking agent hypersensitivity since cross-reactivity between neuromuscular blocking agents, both depolarizing and non-depolarizing, has been reported. Severe anaphylactic reactions to neuromuscular blocking agents, including atracurium, have been reported. These reactions have been life-threatening and fatal in some cases. Due to the potential severity of these reactions, ensure the necessary precautions, such as the immediate availability of appropriate emergency treatment.
Patients with burns have a decreased sensitivity to atracurium's ability to produce neuromuscular blockade. Resistance to blockade usually develops in patients with burns more than 10% total body surface area approximately 1 week after thermal injury. Increased doses may be required in burn patients; alteration in drug effect may be seen for up to 1 year. In patients with more than 40% total body surface area burns, significant increases in dosage requirements (i.e., 2.5 to 5 times the usual dose) have been reported.
Various physiologic states can alter the expected effects of atracurium; carefully consider each patient's clinical condition when dosing atracurium and monitoring the patient. Cachectic and debilitated patients are more sensitive to neuromuscular blocking agents (NMBAs). Electrolyte imbalance can alter a patient's sensitivity to NMBAs. Hypercalcemia can decrease sensitivity to NMBAs, while most other electrolyte disturbances increase sensitivity (e.g., hypokalemia, hypocalcemia, hypermagnesemia). Use atracurium cautiously in patients with conditions that may lead to electrolyte imbalances, such as adrenal insufficiency. Severe acid/base imbalance may alter a patient's sensitivity to NMBAs: metabolic alkalosis, metabolic acidosis, and respiratory acidosis may enhance neuromuscular blockade and/or prolong recovery time, while respiratory alkalosis reduces the potency of the drug. Dehydration and hypothermia can also increase a patient's sensitivity to NMBAs. In patients undergoing cardiopulmonary bypass with induced hypothermia, the atracurium infusion rate required to maintain adequate surgical relaxation during hypothermia (25 to 28 degrees C) has been shown to be approximately one-half the rate required during normothermia. Consider dosage reduction and a peripheral nerve stimulator to monitor response in patients with severe electrolyte disorders.
Use neuromuscular blocking agents (NMBAs), including atracurium, with caution in patients with asthma or other pulmonary conditions. The safety of atracurium has not been established in patients with bronchial asthma. NMBAs stimulate histamine release, which could exacerbate asthma. Although atracurium is a less potent histamine releaser than d-tubocurarine or metocurine, the possibility of substantial histamine release in sensitive individuals must be considered. In patients with any history of greater sensitivity to histamine release or other mediators, such as asthma, use a lower initial atracurium dosage and administer slowly or in divided doses. Also, NMBAs cause respiratory muscle paralysis; residual muscle weakness and decreased respiratory function can persist even after drug discontinuation. Use NMBAs with caution in patients with pulmonary disease and conditions associated with low pulmonary function reserve, such as chronic obstructive pulmonary disease (COPD) or neonatal chronic lung disease (CLD). Carefully monitor respiratory status and adequacy of ventilation after drug recovery until the patient is clearly stabilized.
Use atracurium with caution in patients with neuromuscular disease (e.g., myasthenia gravis, myasthenic syndrome [Eaton Lambert syndrome]); prolonged or exaggerated neuromuscular blockade may occur after nondepolarizing agent use. Geriatric patients may be at increased risk for residual neuromuscular block. Additionally, patients with weak muscle tone or severe obesity are at an increased risk for airway and ventilation complications. Consider the use of a small test dose and a peripheral nerve stimulator to monitor response in these patients. Monitor patients carefully until recovery is fully complete. Use ideal body weight or adjusted body weight for dosing in obese and morbidly obese adult patients (body mass index 30 kg/m2 or more). Guidelines for sustained neuromuscular blockade in critically ill children recommend calculating the dose according to IBW.
Use caution when administering atracurium to patients in whom substantial histamine release would be especially hazardous (e.g., patients with clinically significant cardiovascular disease). In patients with significant cardiac disease, use a lower initial atracurium dosage and administer slowly or in divided doses.
Treat patients with a personal or familial history of malignant hyperthermia with extreme caution. Malignant hyperthermia can be precipitated by many drugs used in anesthetic practice, including halogenated anesthetics and depolarizing neuromuscular blocking agents (e.g., succinylcholine). Reports of malignant hyperthermia have been rare in cases in which atracurium has been used. In a clinical study of malignant hyperthermia-susceptible patients, atracurium did not trigger this syndrome.
Atracurium is for intravenous administration only. Do not give atracurium by intramuscular administration.
Use of atracurium from multidose vials containing benzyl alcohol is contraindicated for use in patients with known benzyl alcohol hypersensitivity. Also, excessive amounts of benzyl alcohol in neonates have been associated with hypotension, metabolic acidosis, and kernicterus. A "gasping syndrome" characterized by CNS depression, metabolic acidosis, and gasping respirations has been associated with benzyl alcohol dosages more than 99 mg/kg/day in neonates. The minimum amount of benzyl alcohol at which serious adverse reactions may occur is not known. Consider the daily metabolic load of benzyl alcohol from combined sources. Premature neonates and low-birth-weight neonates may be more likely to develop toxicity.
Use atracurium during pregnancy only if the potential benefit justifies the potential risk to the fetus. There are no adequate and well-controlled studies with atracurium in pregnant women. Atracurium crosses the placenta. It has been shown to be potentially teratogenic in rabbits in doses up to approximately one-half the human dose; there was an increased incidence of certain spontaneously occurring visceral and skeletal anomalies or variations. It is not known whether muscle relaxants administered during labor and vaginal obstetric delivery have immediate or delayed adverse effects on the fetus or increase the likelihood that resuscitation of the newborn will be necessary. The possibility that forceps delivery will be necessary may increase. Atracurium 0.3 mg/kg was administered to 26 pregnant women during delivery by cesarean section. No harmful effects were attributable to atracurium in any of the neonates. Consider the possibility of respiratory depression in the neonate after cesarean section during which a neuromuscular blocking agent has been administered. The action of neuromuscular blocking agents may be enhanced by magnesium salts administered for the management of toxemia in pregnancy. Reduce atracurium dosage, as indicated, in such cases.
It is unknown if atracurium is excreted into human breast milk. Because many drugs are excreted in human breast milk, use caution when atracurium is administered to a breast-feeding woman. Atracurium undergoes rapid and spontaneous (Hofmann elimination) degradation in the plasma. Atracurium also is poorly absorbed from the gastrointestinal tract. Based on these data, lactation could be allowed as soon as practically feasible after surgery.
General dosing information:
-Guidelines for sustained neuromuscular blockade in critically ill adults recommend against using actual body weight (ABW) and suggest using a consistent weight such as ideal body weight (IBW) or adjusted body weight to calculate neuromuscular blocking agent doses for obese patients. Guidelines for sustained neuromuscular blockade in critically ill children recommend calculating the dose according to IBW.
-Use a peripheral nerve stimulator during continuous infusion or repeated dosing to monitor atracurium's effects. Target response is typically 1 to 2 twitches. Incorrect electrode placement, direct stimulation of muscle due to large electrode size, acute illness, capillary leak, and edema may affect an appropriate assessment. Monitor visual and tactile stimulation on muscle movement as well as heart rate, blood pressure, and mechanical ventilator status during administration.
-Switch patients who develop tachyphylaxis to atracurium and still require paralysis to another agent.
For muscluar relaxation during non-emergent endotracheal intubation:
Intravenous dosage:
Adults: 0.3 to 0.5 mg/kg/dose IV. Onset of intubating conditions is 2 to 2.5 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Children and Adolescents 2 to 17 years: 0.3 to 0.5 mg/kg/dose IV. Onset of intubating conditions is 2 to 2.5 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Infants and Children younger than 2 years: 0.3 to 0.4 mg/kg/dose IV. Onset of intubating conditions is 2 to 2.5 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
For neuromuscular blockade during mechanical ventilation in intensive care patients:
Intermittent Intravenous dosage:
Adults: 0.3 to 0.5 mg/kg IV once, followed by 0.08 to 0.1 mg/kg/dose IV every 15 to 25 minutes as needed; adjust dose and interval to patient's twitch response. Generally, the first maintenance dose is required within 20 to 45 minutes after the initial dose. Higher doses up to 0.2 mg/kg/dose permit dosing at longer intervals. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Children and Adolescents 2 to 17 years: 0.3 to 0.5 mg/kg IV once, followed by 0.08 to 0.1 mg/kg/dose IV every 15 to 25 minutes as needed; adjust dose and interval to patient's twitch response. Generally, the first maintenance dose is required within 20 to 45 minutes after the initial dose. Maintenance doses may be required with slightly greater frequency in children. Higher doses up to 0.2 mg/kg/dose permit dosing at longer intervals. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Infants and Children younger than 2 years: 0.3 to 0.4 mg/kg IV once, followed by 0.08 to 0.1 mg/kg/dose IV every 15 to 25 minutes as needed; adjust dose and interval to patient's twitch response. Generally, the first maintenance dose is required within 20 to 45 minutes after the initial dose. Maintenance doses may be required with slightly greater frequency in infants. Higher doses up to 0.2 mg/kg/dose permit dosing at longer intervals. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Continuous Intravenous Infusion Dosage:
Adults: 0.3 to 0.5 mg/kg IV once, followed by 11 to 13 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Dosage range: 4.5 to 29.5 mcg/kg/minute. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Children and Adolescents 2 to 17 years: 0.3 to 0.6 mg/kg IV once, followed by 11 to 13 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Dosage range: 4.5 to 29.5 mcg/kg/minute. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Infants* and Children younger than 2 years*: 0.3 to 0.6 mg/kg IV once, followed by 5 to 28 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
For neuromuscular blockade during surgery:
Intermittent Intravenous dosage:
Adults: 0.3 to 0.5 mg/kg IV once, followed by 0.08 to 0.1 mg/kg/dose IV every 15 to 25 minutes as needed; adjust dose and interval to patient's twitch response. Generally, the first maintenance dose is required within 20 to 45 minutes after the initial dose. Higher doses up to 0.2 mg/kg/dose permit dosing at longer intervals. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Children and Adolescents 2 to 17 years: 0.3 to 0.5 mg/kg IV once, followed by 0.08 to 0.1 mg/kg/dose IV every 15 to 25 minutes as needed; adjust dose and interval to patient's twitch response. Generally, the first maintenance dose is required within 20 to 45 minutes after the initial dose. Maintenance doses may be required with slightly greater frequency in children. Higher doses up to 0.2 mg/kg/dose permit dosing at longer intervals. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Infants and Children younger than 2 years: 0.3 to 0.4 mg/kg IV once, followed by 0.08 to 0.1 mg/kg/dose IV every 15 to 25 minutes as needed; adjust dose and interval to patient's twitch response. Generally, the first maintenance dose is required within 20 to 45 minutes after the initial dose. Maintenance doses may be required with slightly greater frequency in infants. Higher doses up to 0.2 mg/kg/dose permit dosing at longer intervals. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Continuous Intravenous Infusion dosage:
Adults: 0.3 to 0.5 mg/kg IV once, followed by 9 to 10 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Dosage range: 2 to 15 mcg/kg/minute. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Children and Adolescents 2 to 17 years: 0.3 to 0.5 mg/kg IV once, followed by 9 to 10 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Dosage range: 2 to 15 mcg/kg/minute. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
Infants* and Children younger than 2 years*: 0.4 mg/kg IV once, followed by 6 to 14 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
For the prevention of shaking chills* induced by therapeutic hypothermia after cardiac arrest:
Intravenous dosage:
Adults: Limited data; 0.5 mg/kg/hour continuous IV infusion. Guidelines suggest neuromuscular blocking agents may be used to manage overt shivering in therapeutic hypothermia.
Maximum Dosage Limits:
Specific maximum dosage information is not available. Dosage must be individualized based on clinical response.
Patients with Hepatic Impairment Dosing
Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.
Patients with Renal Impairment Dosing
Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.
*non-FDA-approved indication
AbobotulinumtoxinA: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Acebutolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Acetazolamide: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Albuterol; Budesonide: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Aliskiren; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Amide local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Amikacin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Amiloride; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Aminoglycosides: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Atorvastatin: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Benazepril: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Celecoxib: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Olmesartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade. (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Amphotericin B lipid complex (ABLC): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Amphotericin B liposomal (LAmB): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Amphotericin B: (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Articaine; Epinephrine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Atenolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Atenolol; Chlorthalidone: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Azelastine; Fluticasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Azilsartan; Chlorthalidone: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Bacitracin: (Minor) Concomitant use of neuromuscular blockers and systemic bacitracin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Beclomethasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Benazepril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Beta-blockers: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Betamethasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Betaxolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bismuth Subcitrate Potassium; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bisoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Botulinum Toxins: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Brimonidine; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Budesonide: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Budesonide; Formoterol: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Budesonide; Glycopyrrolate; Formoterol: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Bumetanide: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Bupivacaine Liposomal: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bupivacaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bupivacaine; Epinephrine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bupivacaine; Lidocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bupivacaine; Meloxicam: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Calcium Acetate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Famotidine; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Magnesium Hydroxide; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Chloride: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Gluconate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium; Vitamin D: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium-channel blockers: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Candesartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Capreomycin: (Minor) Concomitant use of neuromuscular blockers and capreomycin may prolong neuromuscular blockade. A partial neuromuscular blockade was demonstrated after large intravenous doses of capreomycin.
Captopril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Carbamazepine: (Moderate) Monitor for a more rapid recovery from neuromuscular blockade than expected during concurrent use of carbamazepine and atracurium. When administering neuromuscular blockade via continuous infusion, infusion rate requirements may be higher. Chronic carbamazepine administration may cause neuromuscular blockade resistance.
Carbonic anhydrase inhibitors: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Carteolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Carvedilol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Chloroprocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Chlorothiazide: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Chlorthalidone: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Chromium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Ciclesonide: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Clevidipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Clindamycin: (Moderate) Use neuromuscular blockers and lincosamides with caution. Concomitant use of neuromuscular blockers and lincosamides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Cocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Colistimethate, Colistin, Polymyxin E: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Colistin: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Corticosteroids: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Cortisone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Cyclosporine: (Moderate) Concomitant use of neuromuscular blockers and cyclosporine may prolong neuromuscular blockade.
DaxibotulinumtoxinA: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Deflazacort: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Demeclocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Desflurane: (Moderate) Concomitant use of atracurium and desflurane may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration. During maintenance of desflurane anesthesia, the atracurium dose is likely to be reduced compared to that during nitrous oxide/opioid anesthesia. For endotracheal intubation, do not reduce the dose of atracurium. Anesthetic concentrations of desflurane at equilibrium (administered for 15 or more minutes before testing) reduced the ED95 of atracurium by approximately 50% compared to nitrous oxide/opioid anesthesia.
Dexamethasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Dextromethorphan; Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Diltiazem: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Donepezil: (Moderate) A higher atracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as donepezil.
Donepezil; Memantine: (Moderate) A higher atracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as donepezil.
Dorzolamide; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Doxapram: (Minor) Doxapram may temporarily mask the residual effects of neuromuscular blockers.
Doxycycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Enalapril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Eprosartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Esmolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Ester local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Ethacrynic Acid: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Felodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Fludrocortisone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Flunisolide: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Fluticasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Fluticasone; Salmeterol: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Fluticasone; Umeclidinium; Vilanterol: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Fluticasone; Vilanterol: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Formoterol; Mometasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Fosinopril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Fosphenytoin: (Moderate) Concomitant use of neuromuscular blockers and fosphenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Furosemide: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Galantamine: (Moderate) A higher atracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as galantamine.
Gentamicin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Hydrochlorothiazide, HCTZ; Moexipril: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Hydrocortisone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
IncobotulinumtoxinA: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Indapamide: (Moderate) Concomitant use of neuromuscular blockers and indapamide may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Irbesartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Irinotecan Liposomal: (Moderate) Irinotecan may antagonize the neuromuscular blocking effects of atracurium due to anticholinesterase activity.
Irinotecan: (Moderate) Irinotecan may antagonize the neuromuscular blocking effects of atracurium due to anticholinesterase activity.
Isoflurane: (Major) Reduce the initial atracurium dose by approximately one-third (i.e., to 0.25 to 0.35 mg/kg) to adjust for the potentiating effects of isoflurane if atracurium is first administered under steady-state of isoflurane. Isoflurane increases the potency of atracurium and prolongs neuromuscular block by approximately 35%. Recommended initial doses of atracurium may be used to facilitate tracheal intubation before administration of isoflurane.
Isradipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Ketorolac: (Minor) There have been postmarketing reports of a possible interaction between ketorolac and nondepolarizing neuromuscular blockers, such as atracurium, that resulted in apnea.
Labetalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Levamlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Levobunolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Lidocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lidocaine; Epinephrine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lidocaine; Prilocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lincomycin: (Moderate) Use neuromuscular blockers and lincosamides with caution. Concomitant use of neuromuscular blockers and lincosamides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lincosamides: (Moderate) Use neuromuscular blockers and lincosamides with caution. Concomitant use of neuromuscular blockers and lincosamides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lisinopril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Lithium: (Moderate) Concomitant use of neuromuscular blockers and lithium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Loop diuretics: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Losartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Magnesium Salts: (Moderate) Concomitant use of neuromuscular blockers and magnesium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Magnesium: (Moderate) Concomitant use of neuromuscular blockers and magnesium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Mepivacaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Methazolamide: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Methylprednisolone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Metolazone: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Metoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade. (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Minocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Mometasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Nadolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Nebivolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Nebivolol; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Neostigmine: (Moderate) A higher atracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as neostigmine. Intravenous neostigmine is indicated for reversal of the effects of nondepolarizing neuromuscular blockers, such as atracurium.
Neostigmine; Glycopyrrolate: (Moderate) A higher atracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as neostigmine. Intravenous neostigmine is indicated for reversal of the effects of nondepolarizing neuromuscular blockers, such as atracurium.
Nicardipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
NIFEdipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nimodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nisoldipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade. (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Olmesartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Olopatadine; Mometasone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Omadacycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
OnabotulinumtoxinA: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Paromomycin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Perindopril; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Phenytoin: (Moderate) Concomitant use of neuromuscular blockers and phenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Physostigmine: (Moderate) A higher atracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as physostigmine.
Pindolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Piperacillin; Tazobactam: (Moderate) Concomitant use of atracurium and piperacillin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Plazomicin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Polymyxin B: (Major) Avoid concomitant use of systemic polymyxin B and neuromuscular blockers due to the risk of respiratory depression. The neurotoxicity of polymyxin B may can result in neuromuscular blockade, especially when given soon after neuromuscular blockers. If signs of respiratory paralysis appear, assist respiration and discontinue drug therapy.
Prednisolone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Prednisone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Prilocaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Prilocaine; Epinephrine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Procainamide: (Moderate) A lower neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant procainamide use due to procainamide effects on reducing acetylcholine release. Concomitant use of neuromuscular blockers and procainamide may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Propranolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Pyridostigmine: (Moderate) A higher atracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as pyridostigmine. Intravenous pyridostigmine is indicated for reversal of the effects of nondepolarizing neuromuscular blockers, such as atracurium.
Pyridoxine, Vitamin B6: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Quinapril; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Quinine: (Major) Avoid concomitant use of neuromuscular blockers and quinine. Quinine may enhance the action of neuromuscular blockers. In 1 patient who received a neuromuscular blocker during an operative procedure, subsequent administration of quinine 1,800 mg 3 hours later resulted in respiratory depression.
Ranitidine: (Moderate) Ranitidine may cause resistance to atracurium-induced neuromuscular blockade, due to pharmacodynamic alterations at the acetylcholine receptor. In vitro studies demonstrate that therapeutic serum concentrations of ranitidine inhibit acetylcholinesterase, thus increasing the amount of acetylcholine available to compete at the neuromuscular junction and reverse the neuromuscular blockade. The inhibition of acetylcholinesterase is likely dose-related. Resistance to nondepolarizing neuromuscular blockers was reported occasionally with intravenous ranitidine dosages that were slightly higher than those given clinically, but not frequently with oral therapy.
RimabotulinumtoxinB: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Rivastigmine: (Moderate) A higher atracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as rivastigmine.
Ropivacaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Sarecycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Sevoflurane: (Moderate) Reduce the initial atracurium dose by approximately one-third (i.e., to 0.25 to 0.35 mg/kg) to adjust for the potentiating effects of sevoflurane if atracurium is first administered under steady-state of sevoflurane. Recommended initial doses of atracurium may be used to facilitate tracheal intubation before administration of sevoflurane.
Sodium Sulfate; Magnesium Sulfate; Potassium Chloride: (Moderate) Concomitant use of neuromuscular blockers and magnesium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Sotalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Spironolactone; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Stiripentol: (Moderate) Monitor for excessive sedation and somnolence during coadministration of stiripentol and atracurium. CNS depressants can potentiate the effects of stiripentol.
Streptomycin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Succinylcholine: (Major) If succinylcholine is used before atracurium, delay atracurium administration until recovery from succinylcholine-induced neuromuscular blockade begins. With succinylcholine as the intubating agent, use an initial atracurium dose of 0.3 to 0.4 mg/kg for adults under balanced anesthesia. Prior administration of succinylcholine quickens the onset and may increase the depth of the neuromuscular block induced by atracurium. The time to maximum block by atracurium is decreased by 2 to 3 minutes with prior use of succinylcholine.
Telmisartan; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Telmisartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Tetracaine: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Tetracyclines: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Theophylline, Aminophylline: (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant aminophylline use. Aminophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition. (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant theophylline use. Theophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition.
Thiazide diuretics: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Tobramycin: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Torsemide: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Trandolapril; Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Triamcinolone: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Triamterene; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Vancomycin: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Muscle contraction is initiated by an action potential traveling from the central nervous system to the nerve terminal. At the nerve terminal, the action potential causes an influx of calcium, initiating the release of acetylcholine (ACh) into the synaptic cleft. ACh binds to ACh receptors on the muscle fiber's motor end-plate causing a conformational change that briefly opens sodium ion channels. When an adequate number of ACh receptors are activated, membrane potential decreases and voltage-dependent sodium ion channels of adjacent muscle membranes activate, transmitting the action potential throughout the muscle fiber and resulting in muscle contraction. Nondepolarizing neuromuscular blocking agents (NMBAs) such as atracurium produce skeletal muscle paralysis by competing with ACh for cholinergic receptor sites at the motor end-plate. Neuromuscular blockade progresses in a predictable order, beginning with muscles associated with fine movements (e.g., eyes, face, and neck), followed by muscles of the limbs, chest, and abdomen and, finally, the diaphragm. Larger doses increase the chance of respiratory depression associated with relaxation of the intercostal muscles and the diaphragm. Muscle tone returns in the reverse order.
Atracurium is administered intravenously. The dose required to produce 95% suppression of the muscle twitch response (ED95) is about 23 mcg/kg under balanced anesthesia. Peak effect is achieved in 25-30 minutes under balanced anesthesia. If enflurane or isoflurane are used, the potency of atracurium is increased and duration of neuromuscular blockade is increased by 35%. Following doses of 400-500 mcg/kg IV, maximum neuromuscular blockade usually is seen in 3-5 minutes. Recovery of the twitch response is nearly complete 60-70 minutes after injection.
Atracurium is distributed into the extracellular space and not into the fat reserves. It is about 82% protein-bound. Atracurium is metabolized by serum esterases and spontaneous Hofmann elimination to produce laudanosine. This metabolite may possess CNS excitatory activity. Elimination is biphasic. In the initial phase, the plasma half-life of atracurium is 2-3 minutes, and in the terminal phase, the half-life is roughly 20 minutes. Elimination of unchanged drug and metabolites is mainly in the urine, but a small amount is secreted in the bile and lost in the feces. From a single dose, 90% is excreted within 7 hours.
-Special Populations
Hepatic Impairment
Plasma half-life is not altered substantially by hepatic dysfunction.
Renal Impairment
Plasma half-life is not altered substantially by renal dysfunction.