Esmolol hydrochloride 10 mg/ml solution for injection
Each vial of 10 ml solution for injection contains 100 mg esmolol hydrochloride.
1 ml aqueous solution contains 10 mg esmolol hydrochloride (10 mg/ml).
For the full list of excipients, see section 6.1.
Solution for injection
The solution is clear and colourless.
Esmolol hydrochloride is indicated for supraventricular tachycardia (except for pre- excitation syndromes) and for the rapid control of the ventricular rate in patients with atrial fibrillation or atrial flutter in perioperative, postoperative, or other circumstances where short-term control of the ventricular rate with a short-acting agent is desirable.
Esmolol hydrochloride is also indicated for tachycardia and hypertension occuring in the perioperative phase and non-compensatory sinus tachycardia where, in the the physician’s judgement the rapid heart rate requires specific intervention.
Esmolol hydrochloride is not intended for use in chronic settings.
Esmolol hydrochloride 10 mg/ml solution for injectionEsmolol hydrochloride 10 mg/ml solution for injectionin a vial with 10 ml is a clear solution ready for intravenous use. The concentration of this product is 10 mg/ml esmolol hydrochloride.
In addition, a concentrate for solution for infusion in a concentration of 2500 mg/10 ml (250 mg/ml) is available in an ampoule. This product must be diluted before use.
The dosage of esmolol should be titrated individually. A starting dose is required, followed by a maintenance dosage.
The effective dose of esmolol hydrochloride is within the range of 50 to 200 micrograms/kg/min, although doses as high as 300 micrograms /kg/min have been used. In a few patients the average effective dosage of 25 micrograms /kg/min has been adequate.
Flow Chart for Initiation and Maintenance of Treatment
As the desired heart rate or safety endpoint (e.g. lowered blood pressure) is approached, OMIT the loading infusion and reduce the incremental dose in the maintenance infusion from 50 micrograms/kg/min to 25 micrograms/kg/min or lower.
If necessary, the interval between the titration steps may be increased from 5 to 10 minutes.
NB: Maintenance doses above 200 micrograms/kg/min have not been shown to have significantly increased benefits, and the safety of doses above 300 micrograms/kg/min has not been studied.
In the event of an adverse reaction, the dosage of esmolol may be reduced or discontinued. Pharmacological adverse reactions should resolve within 30 minutes.
If a local infusion site reaction develops, an alternative infusion site should be used and caution should be taken to prevent extravasation.
The administration of esmolol infusions for longer than 24 hours has not been thoroughly evaluated. Infusion durations greater than 24 hours should only be used with caution.
Conversion table: microg/kg/min → ml/min (esmolol diluted to 10 mg/ml strength)
|500||50||100||150||200||250 g/kg/min||300 g/kg/min|
|1 minute only|
|Conversion table: microg/kg/min → ml/h (esmolol diluted to 10 mg/ml strength)|
|500||50||100||150||200||250 g/kg/min||300 g/kg/min|
|1 minute only|
Abrupt discontinuation of esmolol in patients has not been reported to produce the withdrawal effects which may occur with abrupt withdrawal of beta -blockers following chronic use in coronary artery disease (CAD) patients. However, caution should still be used in discontinuing esmolol infusions abruptly in CAD patients.
PERIOPERATIVE TACHYCARDIA AND HYPERTENSION
When treating tachycardia and/or hypertension in the perioperative setting, the following dose regimens may be used.
a) For the intraoperative treatment – during anaesthesia when immediate control is required, a bolus injection of 80 mg is given over 15 to 30 seconds, followed by a 150 micrograms/kg/min infusion. Titrate the infusion rate as required up to 300 micrograms/kg/ min.
b) Upon awakening from anaesthesia administer an infusion of 500 micrograms/kg/min for up to 4 minutes followed by an infusion of 300 micrograms/kg/min.
c) For postoperative situations when time for titration is available, give the 500 micrograms/kg/min loading dose over one minute before each titration step to produce a rapid onset of action. Use titration steps of 50, 100, 150, 200, 250 and 300 micrograms/kg/min given over four minutes, stopping at the desired therapeutic effect.
Replacement of esmolol therapy by alternative drugs
After achieving an adequate control of the heart rate and a stable clinical status, transition to alternative drugs (antiarrhytmics or calcium antagonists) may be accomplished.
When esmolol is replaced by alternative drugs, the physician should carefully consider the labelling of the alternative drug and the dosage of esmolol should be reduced as follows:
1) Within the first hour after the first dose of the alternative drug, the infusion rate of esmolol should be reduced by one-half (50%).
2) After administration of the second dose of the other alternative drug, the patient response should be supervised and if satisfactory control is maintained for the first hour, discontinue the esmolol infusion.
Additional dosing information: as the desired therapeutic effect or a safety endpoint (e.g. lowered blood pressure) is approached, omit the loading dose and reduce the incremental infusion to 12.5 – 25 micrograms/kg/min. Also, if desired, increase the interval between titration steps from five to ten minutes.
Esmolol hydrochloride 10 mg/ml solution for injection should be discontinued when heart rate or blood pressure rapidly approach or exceed a safety limit, and then restarted without a loading infusion at a lower dose after the heart rate or blood pressure has returned to an acceptable level.
Special studies of elderly have not been performed yet. However, an analysis of data of 252 patients over 65 years indicated that no variations in pharmacodynamic effects occurred as compared with data of patients younger than 65 years.
Patients with kidney insufficiency
In patients with renal insufficiency caution is needed when esmolol is administered by infusion, since the acid metabolite is excreted through the kidneys. Excretion of the acid metabolite is significantly decreased in patients with renal disease, with the elimination half-life increased to about tenfold that of normals, and plasma levels considerably elevated.
Patients with liver insufficiency
In case of liver insufficiency no special precautions are necessary since the esterases in the red blood cells have a main role in the esmolol metabolism.
Paediatric population (age under 18 years)
There are limited data available on the use of esmolol hydrochloride in children (see sections 5.1 and 5.2). The available data do not support safety and efficacy in the paediatric population and therefore such use is not recommended.
– hypersensitivity to the active substance or to any of the excipients listed in section 6.1
– severe bradycardia (less than 50 beats per minute)
– “Sick sinus”-syndrome; severe AV-nodal conductance disorders (without pacemaker); 2nd or 3rd degree AV-block
– cardiogenic shock
– severe hypotension
– overt heart failure
– Non-treated phaeochromocytoma
– pulmonary hypertension
– acute asthmatic attack
– metabolic acidosis
It is advised to terminate the infusion gradually because of the risk of rebound tachycardia.
Esmolol hydrochloride should be used with caution in diabetics or in case of hypoglycaemia:
The severity of hypoglycaemia is less than the one observed with less cardio-selective beta-blockers. The beta-blockers can mask the prodromal symptoms of hypoglycaemia such as tachycardia.
Dizziness and sweating, however, may not be affected.
The most frequently observed side effect is hypotension which is rapidly reversible with dosage reduction or discontinuation. In patients with a low systolic blood pressure, extra caution is needed when adjusting the dosage and during maintenance infusion.
It is advised to continuously monitor the blood pressure and ECG in all patients treated with esmolol. In the event of a hypotensive episode, the infusion rate should be reduced or, when necessary, be discontinued.
Due to its negative effect on conduction time, beta-blockers should only be given with caution to patients with first degree heart block.
The elderly should be treated with caution, starting with a lower dosage, but tolerance is usually good in the elderly.
Beta-blockers may increase the number and the duration of anginal attacks in patients with Prinzmetal’s angina due to unopposed alpha-receptor mediated coronary artery vasoconstriction. Non-selective beta-blockers should not be used for these patients and beta 1 selective blockers only with the utmost care.
Sympathetic stimulation is necessary in supporting circulatory function in congestive heart failure, and beta blockade carries the potential hazard of further depressing myocardial contractility and precipitating more severe failure. Continued depression of the myocardium with beta blocking agents over a period of time can, in some cases, lead to cardiac failure. At the first sign or symptom of impending cardiac failure, esmolol should be withdrawn. Although withdrawal may be sufficient because of the short elimination half-life of esmolol, specific treatment may also be considered (see section 4.9).
The use of esmolol for control of ventricular response in patients with supraventricular arrhythmias should be undertaken with caution when the patient is compromised hemodynamically or is taking other drugs that decrease any or all of the following: peripheral resistance, myocardial filling, myocardial contractility, or electrical impulse propagation in the myocardium. Despite the rapid onset and offset of the effects of esmolol, several cases of death have been reported in complex clinical states where esmolol was presumably being used to control the ventricular rate.
Patients with bronchospastic disease should, in general, not receive beta-blockers. Because of its relative beta1 selectivity and titratability, esmolol should be used with caution in patients with bronchospastic diseases. However, since beta1 selectivity is not absolute, esmolol should be carefully titrated to obtain the lowest possible effective dose. In the event of bronchospasm, the infusion should be terminated immediately and a beta2 agonist should be administered if necessary.
If the patient already uses a beta2 receptorstimulating agent, it can be necessary to re- evaluate the dose of this agent.
Esmolol should be used with caution in patients with a history of wheezing and asthma.
In patients with psoriasis or a history of psoriasis, the administration of esmolol hydrochloride should be carefully weighed as it should be done in any event.
In patients with peripheral circulatory disorders (Raynaud’s disease or syndrome, intermittent claudication), beta-blockers should be used with great caution as aggravation of these disorders may occur.
Beta-blockers may induce bradycardia. If the pulse rate decreases to less than 50-55 beats per minute at rest and the patient experiences symptoms related to bradycardia, the dosage should be reduced.
Beta-blockers may increase both the sensitivity toward allergens and the seriousness of anaphylactic reactions.
Infusions of concentrations of 20 mg/ml have been associated with significant venous irritation and thrombophlebitis in animals and man. Extravasation of 20 mg/ml may lead to a serious local reaction and possible skin necrosis.
Local reactions have also been reported following infusion of concentrations of 10 mg/ml. Infusion into small veins or through a butterfly catheter should therefore be avoided.
Use in the paediatric population (age under 18 years)
The safety and effectiveness of esmolol hydrochloride in children have not been established.
Calcium antagonists such as verapamil and to a lesser extent diltiazem have a negative influence on contractility and AV-conduction. As with other beta-blocking agents esmolol should be used with caution in combination with verapamil in patients with impaired ventricular function. The combination should not be given to patients with conduction abnormalities and esmolol should not be administered within 48 hours of discontinuing verapamil.
Calcium antagonists such as dihydropyridine derivatives (e.g., nifedipine) may increase the risk of hypotension. In patients with cardiac insufficiency and who are being treated with a calcium antagonist, treatment with beta-blocking agents may lead to cardiac failure. Careful titration of Esmolol hydrochloride 10 mg/ml solution for injection and appropriate haemodynamic monitoring is recommended
Concomitant use of esmolol and class I antiarrhythmic agents (such as disopyramide and quinidine) and also amiodarone can increase the action of both on the AV- conductance time and induce negative inotropic effect.
Concomitant use of esmolol and insulin or oral antidiabetic drugs may intensify the blood sugar lowering effect (especially non-selective beta-blockers). Beta-adrenergic blockade may prevent the appearance of signs of hypoglycemia (tachycardia).
In situation where the patient’s volume status is uncertain or concomitant antihypertensive drugs are utilized, there may be attenuation of the reflex tachycardia and an increase of the risk of hypotension.
Continuation of Beta-blockades reduces the risk of arrhythmia during induction and intubation. The anaesthesiologist should be informed when the patient is receiving a beta-blocking agent in addition to esmolol. The hypotensive effects of inhalation anaesthetic agents may be increased in the presence of esmolol. The dosage of either agent may be modified as needed to maintain the desired haemodynamics.
The combination of Esmolol hydrochloride 10 mg/ml solution for injection with ganglion blocking agents can enhance the hypotensive effect.
NSAIDs may decrease the hypotensive effects of beta-blockers.
Special caution must be taken when using floctafenine or amisulpride concomitantly with beta-blockers.
Concomitant administration of tricyclic antidepressants, barbiturates and phenothiazines as well as other antihypertensive agents may increase the blood pressure lowering effect. Dosing of Esmolol hydrochloride 10 mg/ml solution for injection should be adjusted downward to avoid unexpected hypotension.
Sympathomimetic agents may counteract the effect of beta-adrenergic blocking agents.
Catecholamine-depleting agents, e.g., reserpine, may have an additive effect when given with beta-blocking agents. Patients treated concurrently with Esmolol hydrochloride 10 mg/ml solution for injection and a catecholamine depletor should therefore be closely observed for evidence of hypotension or marked bradycardia, which may result in vertigo, syncope or postural hypotension.
Concomitant use of clonidine and beta-blockers increase the risk of “rebound” hypertension. When clonidine is used in conjunction with non-selective beta- blockers, such as propranolol, treatment with clonidine should be continued for some time after treatment, when the beta-blocker has been discontinued.
Data from an interaction study between Esmolol hydrochloride 10 mg/ml solution for injection and warfarin showed that concomitant administration of Esmolol hydrochloride 10 mg/ml solution for injection and warfarin does not alter warfarin plasma levels. Esmolol hydrochloride 10 mg/ml solution for injection concentrations, however, were equivocally higher when given with warfarin.
When digoxin and Esmolol hydrochloride 10 mg/ml solution for injection were concomitantly administered intravenously to normal volunteers, there was a 10-20% increase in digoxin blood levels at some time points. The combination of digitalis glycosides and Esmolol hydrochloride 10 mg/ml solution for injection may increase AV conduction time. Digoxin did not affect Esmolol hydrochloride 10 mg/ml solution for injection pharmacokinetics.
When intravenous morphine and Esmolol hydrochloride 10 mg/ml solution for injection interaction was studied in normal subjects, no effect on morphine blood levels was seen. The Esmolol hydrochloride 10 mg/ml solution for injection steady- state blood levels were increased by 46% in the presence of morphine, but no other pharmacokinetic parameters were changed.
The effect of Esmolol hydrochloride 10 mg/ml solution for injection on the duration of suxamethonium chloride-induced neuromuscular blockade has been studied in patients undergoing surgery. The onset of neuromuscular blockade by suxamethonium chloride was unaffected by Esmolol hydrochloride 10 mg/ml solution for injection, but the duration of neuromuscular blockade was prolonged from 5 minutes to 8 minutes.
Although the interactions observed in studies of warfarin, digoxin, morphine or suxamethonium chloride are not of major clinical importance, Esmolol hydrochloride 10 mg/ml solution for injection should be titrated with caution in patients being treated concurrently with warfarin, digoxin, morphine or suxamethonium chloride.
Esmolol is not recommended during pregnancy.
There are insufficient data to determine the possible harmful effects of esmolol during pregnancy. To date, there are no indications for an increased risk on birth defect in humans. Animal studies have shown reproductive toxicity (see section 5.3.). The potential risk for humans is unknown. Based on the pharmacological action, in the later period of pregnancy, side effects on the foetus and neonate (especially hypoglycemia, hypotension and bradycardia) should be taken into account. Beta- blockers reduce the placenta circulation.
If treatment with esmolol is considered necessary, the uteroplacental blood flow and foetal growth should be monitored. The newborn infant must be closely monitored.
It is unknown whether esmolol is excreted in breast milk. Lactation is not advised during the use of esmolol.
In case of an adverse reaction, the dose of esmolol can be reduced or discontinued.
Most of the adverse reactions observed have been mild and transient. The most important adverse reaction is hypotension.
The following terminologies have been used in order to classify the occurrence of undesirable effects:
Very common (≥ 1/10)
Common (≥1/100 to < 1/10)
Uncommon (≥1/1.000 to < 1/100)
Rare (≥ 1/10.000 to < 1/1.000)
Very rare (< 1/10.000)
Not known (cannot be estimated from the available data)
Nervous system disorders
– Common: paraesthesiae, disturbance in attention, dizziness1, somnolence, headache
– Uncommon: convulsions, syncope, dysgeusia, speech disorder
– Uncommon: bradycardia, atrioventricular block
– Very rare: sinus arrest, asystole
– Uncommon: Visual impairment
Respiratory, thoracic and mediastinal disorders
– Uncommon: bronchospasm, wheezing, dyspnoea, nasal congestion, pulmonary oedema, rhonchi, rales
– Common: nausea, vomiting.
– Uncommon: dyspepsia, constipation, mouth dryness, abdominal pain
Renal and urinary disorders
– Uncommon: urinary retention
Skin and subcutaneous tissue disorders
– Very common: Diaphoresis
– Uncommon: erythema2, skin discolouration2,
– Very rare: skin necrosis due to extravasation2
– Not known: psoriasis3
Musculoskeletal and connective tissue disorders
– Uncommon: Musculoskeletal pain
Metabolism and nutrition disorders
– Common: anorexia
– Very common: hypotension
– Uncommon: peripheral ischaemia, pallor, flushing
– Very rare: thrombophlebitis2
General disorders and administration site conditions
– Common: asthenia, fatigue, injection site reaction, infusion site reaction, infusion site inflammation, infusion site induration
– Uncommon: chest pain, oedema2 , pain2, infusion site burning, fever and chills
– Common: depression, anxiety, confusional state, agitation
– Uncommon: thinking abnormal
1 Dizziness and diaphoresis are in association with symptomatic hypotension.
2 In association with Injection and Infusion site reactions.
3 Beta blockers as a drug class can cause psoriasis in some situations or worsen it.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
Cases of massive accidental overdoses of esmolol have occurred. Some of these overdoses have been fatal while others resulted in permanent disability. Bolus doses in the range of 625 mg to 2.5 g (12.5-50 mg/kg) have been fatal.
In case of overdose the following symptoms can occur: severe hypotension, sinus bradycardia, atrioventricular block, heart insufficiency, cardiogenic shock, cardiac arrest, bronchospasm, respiratory insufficiency, loss of consciousness to coma, convulsions, nausea, vomiting, hypoglycemia and hyperkalemia.
Because of the short elimination half-life of Esmolol hydrochloride 10 mg/ml solution for injection (approximately 9 minutes), the first step in the management of toxicity should be to discontinue the administration of the drug. The time taken for symptoms to disappear following overdosing will depend on the amount of Esmolol hydrochloride 10 mg/ml solution for injection administered. This may take longer than the 30 minutes seen with discontinuation at therapeutic dose levels. Artificial respiration may be necessary. Based on the observed clinical effects, the following general measures should also be considered:
Bradycardia: atropine or another anticholinergic drug should be given i.v.. When the bradycardia cannot be treated sufficiently a pacemaker may be necessary.
Bronchospasm: nebulised beta-2-sympathomimetics should be given. If this is not sufficient intravenous beta-2-sympathomimetics or aminophylline can be considered.
Symptomatic hypotension: fluids and/or pressor agents should be given i.v..
Cardiovascular depression or cardiac shock: diuretics or sympathomimetics can be administered. The dose of sympathomimetics (depending on the symptoms: dobutamine, dopamine, noradrenaline, isoprenaline, etc.) depends on the therapeutic effect.
In case further treatment is necessary, the following agents can be given i.v.:
– Atropine: 0.5-2 mg
– Inotropic agents
– Calcium ions
Pharmacotherapeutic group: Beta-blocking agents, selective
ATC code: C07AB09
Esmolol is a parenteral administered, cardioselective beta-inhibitor.
In therapeutic doses esmolol does not have intrinsic sympathicomimetic activity (ISA) of importance and no membrane stabilising (local anaesthetic) properties.
Based on the pharmacological properties esmolol has a fast and short action by which the dose can be quickly adjusted:
After a high starting dose a steady state plasma concentration is reached within 5 minutes (without starting dose in 30 minutes). However, the therapeutic effect is sooner obtained than the stabile plasma concentration. The infusion rate can then be adjusted to obtain the desired pharmacological effect.
Esmolol hydrochloride has the known hemodynamic and electrophysiologic effect of beta-blockers:
– Reduction of the heart frequency during rest and exercise
– Reduction of the isoprenaline caused increase of the heart frequency
– Increase of the recovering time of the SA-node
– Delay of the AV-conductance
– Prolonging the AV-interval with normal sinus rhythm and during atrium stimulation without delay in the His-Purkinje tissue
– Prolonging of PQ time, induction of AV block grade II
– Prolonging the functional refractory period of atria and ventricles
– Negative inotrope effect with decreased ejection fraction
– Decrease in blood pressure
An uncontrolled pharmacokinetic/efficacy study was undertaken in 26 paediatric patients aged 2-16 years with supraventricular tachycardia (SVT). A loading dose of 1000 micrograms/kg of esmolol was administered followed by a continuous infusion of 300 micrograms/kg/min. SVT was terminated in 65% of patients within 5 minutes of the commencement of esmolol.
In a randomised but uncontrolled dose comparison study, efficacy was assessed in 116 paediatric patients aged 1 week – 7 years with hypertension following repair of coarctation of the aorta. Patients received an initial infusion of either 125 micrograms/kg, 250 micrograms/kg, or 500 micrograms/kg, followed by a continuous infusion of 125 micrograms/kg /min, 250 micrograms/kg /min, or 500 micrograms/kg /min respectively. There was no significant difference in hypotensive effect between the 3 dosage groups. 54% of patients overall required medication other than esmolol to achieve satisfactory blood pressure control. No difference was apparent in this regard between the different dose groups.
The kinetics of esmolol are linear in healthy adults, the plasma concentration is proportional to the dose. If a loading dose is not used then steady-state blood concentrations are reached within 30 minutes with doses of 50 to 300 micrograms/Kg per minute.
The distribution half-life of esmolol hydrochloride is very fast, about 2 minutes. The volume of distribution is 3.4 l/kg.
Esmolol hydrochloride is metabolised by esterases into an acid metabolite (ASL- 8123) and methanol. This occurs through hydrolysis of the ester group by esterases in the red blood cells.
The metabolism of esmolol hydrochloride is independent when the dose is between 50 and 300 micrograms/kg/minute.
Esmolol hydrochloride is 55% bound to human plasma protein compared with only 10% for the acid metabolite.
The elimination half-life after intravenous administration is approximately 9 minutes. The total clearance is 285 ml/kg/minute; this is independent of the circulation of the liver or any other organ. Esmolol hydrochloride is excreted by the kidneys, partly unchanged (less than 2% of the administered amount), partly as acid metabolite that has a weak (less than 0.1% of esmolol) beta-blocking activity. The acid metabolite is excreted in the urine and has a half-life of about 3.7 hours.
A pharmacokinetic study was undertaken in 22 paediatric patients aged 3-16 years. A loading dose of 1000 micrograms/kg of esmolol was administered followed by a continuous infusion of 300 micrograms/kg/min. The observed mean total body clearance was 119 mL/kg/min, the mean volume of distribution 283 mL/kg, and the mean terminal elimination half-life 6.9 min, indicating that esmolol kinetics in children are similar to those in adults. However, large inter-individual variability was observed.
No teratogenic effect has been observed in animal studies. In rabbits, an embryotoxic effect has been observed (increase in fetal resorption) which was probably caused by esmolol. This effect was observed at doses at least 10 times higher than the therapeutic dose. No studies have been done on the effect of esmolol on the fertility and on peri- and postnatal effects. Esmolol was found to be not mutagenic in several in vitro and in vivo test systems. The safety of esmolol has not been examined in long-term studies.
Sodium acetate trihydrate
Acetic acid 99%
Hydrochloric acid 10% (for pH adjustment)
Water for injections
Esmolol hydrochloride 10 mg/ml solution for injection must not be used in combination with sodium carbonate solutions or other medicinal products (e.g. furosemide, diazepam and thiopental) that are chemically incompatible with esmolol.
Chemical and physical in use stability has been demonstrated for 24 hours at 2 to 8 °C.
From a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions are the responsibility of the user and would normally not be longer than 24 hours at 2 to 8 °C unless opening has taken place in controlled and validated aseptic conditions.
Do not store above 25°C.
Keep the vial in the outer carton in order to protect from light.
For storage conditions of the solution see section 6.3.
Each vial of 10 ml solution contains 100 mg esmolol hydrochloride (10 mg/ml).
A clear, colourless glass vial with a chlorobutyl rubber stopper, containing 10 ml solution for injection. The vials are packed in an outer cardboard carton.
Pack size: 5 vials per carton.
The solution should be examined visually for particulate matter and discoloration prior to administration. Only clear and colourless solution should be used.
Any unused solution and the containers should be disposed of in accordance with local requirements.
Orpha-Devel Handels und Vertriebs GmbH
Date of first authorisation: 16/11/2010