Adenosine

Aka: Adenosine, Adenocard

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II. Indications

  1. Chemical conversion of AV Node re-entry Tachycardias
    1. Paroxysmal Supraventricular Tachycardia (PSVT)
    2. Wolff-Parkinson-White Syndrome (WPW Syndrome)
  2. Diagnosis in non-reentry Tachycardias
    1. Atrial Flutter
    2. Atrial Fibrillation
    3. Ventricular Tachycardia

III. Contraindications

  1. Acute Coronary Syndrome
  2. Cardiovascular Instability
  3. Irregular Narrow Complex Tachycardia (pre-excited Atrial Fibrillation)
    1. Risk of degeneration to Ventricular Fibrillation

IV. Mechanism

  1. Endogenous purine Nucleoside
  2. Prolongs refractory period, decreases automaticity and slows conduction within the AV Node
  3. Interrupts AV Nodal Reentry pathways

V. Pharmacokinetics

  1. Activation
    1. Rapidly deaminated to the active metabolite Inosine
    2. Occurs within 30 seconds of IV administration
  2. Deactivation
    1. Rapidly sequestered by Red Blood Cells
    2. Half-Life: <10 seconds

VI. Dosing

  1. General
    1. Rapid IV bolus over 1-3 seconds
    2. Expect brief period of Asystole (under 15 seconds)
    3. Follow dose immediately with saline flush (15-20 cc Normal Saline in adults)
      1. May also combine Adenosine with Normal Saline (15 cc in adults) and push the combined solution
      2. Choi (2003) J Korean Soc Emerg Med 14(3): 224-7 [PubMed]
  2. Child (weight <50 kg)
    1. Initial: 50 to 100 mcg/kg rapid IV push with flush
    2. Next: Increase dose by 50 to 100 mcg/kg rapid IV push every 1 to 2 minutes as needed
    3. Maximum Dose: 300 mcg/kg up to 12 mg
  3. Adult
    1. Initial: 6 mg rapid IV push with flush
    2. Next: 12 mg rapid IV push with flush (may repeat once)
  4. Higher starting dose indications (12 mg in adults)
    1. Caffeine within the last 4 hours
    2. Theophylline
  5. Lower starting dose indications (3 mg in adults)
    1. Carbamazepine
    2. Dipyridamole (Persantine)
    3. Heart Transplant status
    4. Central Line administration (risk of severe Bradycardia and Asystole)

VII. Adverse effects

  1. Transient effects (resolve within 2 minutes)
    1. Flushing
    2. Dyspnea to respiratory distress (esp. in Asthma, COPD)
    3. Chest Pain
  2. Transient Arrhythmias following PSVT conversion
    1. Sinus Bradycardia
    2. Ventricular ectopy

VIII. Drug Interactions

  1. Reduced effect of Adenosine
    1. Theophylline
    2. Methylxanthine (Caffeine, Theobromine)
  2. Potentiated effect of Adenosine
    1. Dipyridamole

IX. Safety

  1. Pregnancy Category C
  2. Unknown Safety in Lactation

X. Resources

  1. Adenosine Injection Solution (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7fd858aa-f4ef-427b-a91c-c860cd27da9d

XI. References

  1. Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 74-5
  2. Hamilton (2020) Tarascon Pocket Pharmacopoeia

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