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EPHEDRINE SULFATE injection


  1. Highlights Of Prescribing Information
  2. Indications And Usage
  3. Dosage And Administration
  4. Dosage Forms And Strengths
  5. Contraindications
  6. Warnings And Precautions
  7. Adverse Reactions
  8. Drug Interactions
  9. 1 Indications And Usage
  10. 2 Dosage And Administration
  11. 3 Dosage Forms And Strengths
  12. 4 Contraindications
  13. 5 Warnings And Precautions
  14. 6 Adverse Reactions
  15. 7 Drug Interactions
  16. 8 Use In Specific Populations
  17. 10 Overdosage
  18. 11 Description
  19. 12 Clinical Pharmacology
  20. 13 Nonclinical Toxicology
  21. 14 Clinical Studies
  22. 16 How Supplied/storage And Handling
  23. 1 Indications And Usage
  24. 2 Dosage And Administration
  25. 3 Dosage Forms And Strengths
  26. 4 Contraindications
  27. 5 Warnings And Precautions
  28. 6 Adverse Reactions
  29. 7 Drug Interactions
  30. 8 Use In Specific Populations
  31. 10 Overdosage
  32. 11 Description
  33. 12 Clinical Pharmacology
  34. 13 Nonclinical Toxicology
  35. 14 Clinical Studies
  36. 16 How Supplied/storage And Handling
  37. Principal Display Panel - 1 Ml Ampule Carton
  38. Ephedrine Sulfateinjection Usp, 50 Mg/ml
  39. Description
  40. Clinical Pharmacology
  41. Indications And Usage
  42. Contraindications
  43. Precautions
  44. Adverse Reactions
  45. Drug Abuse And Dependence
  46. Overdosage
  47. Dosage And Administration
  48. How Supplied
  49. 16 How Supplied/storage And Handling
  50. 50mg/ml Carton

Highlights Of Prescribing Information 

These highlights do not include all the information needed to use EPHEDRINE SULFATE INJECTION safely and effectively. See full prescribing information for EPHEDRINE SULFATE INJECTION.

EPHEDRINE SULFATE injection, for intravenous use
Initial U.S. Approval: 2016

Indications And Usage 

Ephedrine Sulfate Injection is an alpha- and beta-adrenergic agonist and a norepinephrine-releasing agent that is indicated for the treatment of clinically important hypotension occurring in the setting of anesthesia. (1)

Dosage And Administration 

Bolus intravenous injection: 5 to 10 mg as needed, not to exceed 50 mg. Dilute before use. See Full Prescribing Information for instructions on administration and preparation for injection. (2).

Dosage Forms And Strengths 

Injection: 50 mg/mL ephedrine sulfate in an ampule (3)

Injection: 50 mg/mL ephedrine sulfate in a vial (3)

Contraindications 

None (4)

Warnings And Precautions 

  • Pressor Effect with Concomitant Oxytocic Drugs: Pressor effect of sympathomimetic pressor amines is potentiated. (5.1)
  • Tolerance and Tachyphylaxis: Repeated administration of ephedrine may cause tachyphylaxis. (5.2)

Adverse Reactions 

Most common adverse reactions during treatment: nausea, vomiting, and tachycardia. (6).


To report SUSPECTED ADVERSE REACTIONS, contact Akorn, Inc. at 1-800-932-5676 or FDA at 1-800-FDA-1088 or http://www.fda.gov/medwatch.

Drug Interactions 

  • Interactions that Augment the Pressor Effect: Clonidine, oxytocin and oxytocic drugs, propofol, monoamine oxidase inhibitors (MAOIs), and atropine. Monitor blood pressure. (7)
  • Interactions that Antagonize the Pressor Effect: Antagonistic effects with -adrenergic antagonists, -adrenergic antagonists, reserpine, quinidine, mephentermine. Monitor blood pressure. (7)
  • Guanethidine: Ephedrine may inhibit the neuron blockage produced by guanethidine, resulting in loss of antihypertensive effectiveness. Monitor blood pressure and adjust the dosage of pressor accordingly (7).
  • Rocuronium: Ephedrine may reduce the onset time of neuromuscular blockade when used for intubation with rocuronium if administered simultaneously with anesthetic induction. Be aware of this potential interaction. No treatment or other interventions are needed (7).
  • Epidural anesthesia: Ephedrine may decrease the efficacy of epidural blockade by hastening the regression of sensory analgesia. Monitor and treat the patient according to clinical practice (7).
  • Theophylline: Concomitant use of ephedrine may increase the frequency of nausea, nervousness, and insomnia. Monitor patient for worsening symptoms and manage symptoms according to clinical practice (7).
  • Cardiac glycosides: Giving ephedrine with a cardiac glycoside, such as digitalis, may increase the possibility of arrhythmias. Carefully monitor patients on cardiac glycosides who are also administered ephedrine (7).

Revised: 1/2019

1 Indications And Usage  

Ephedrine Sulfate Injection is indicated for the treatment of clinically important hypotension occurring in the setting of anesthesia.

2 Dosage And Administration  

2.1 General Dosage and Administration Instructions

Ephedrine Sulfate Injection must be diluted before administration as an intravenous bolus to achieve the desired concentration. Dilute with normal saline or 5% dextrose in water.

Inspect parenteral drug products visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use if solution is colored or cloudy, or if it contains particulate matter.

2.2 Dosing for the Treatment of Clinically Important Hypotension in the Setting of Anesthesia

The recommended dosages for the treatment of clinically important hypotension in the setting of anesthesia is an initial dose of 5 to 10 mg administered by intravenous bolus. Administer additional boluses as needed, not to exceed a total dosage of 50 mg.

  • Adjust dosage according to the blood pressure goal (i.e., titrate to effect).

2.3 Prepare a 5 mg/mL Solution for Bolus Intravenous Administration

For bolus intravenous administration, prepare a solution containing a final concentration of 5 mg/mL of Ephedrine Sulfate Injection:

  • Withdraw 50 mg (1 mL of 50 mg/mL) of Ephedrine Sulfate Injection and dilute with 9 mL of 5% Dextrose Injection or 0.9% Sodium Chloride Injection and maintain at room temperature. Discard diluted solution after 24 hours.
  • Withdraw an appropriate dose of the 5 mg/mL solution prior to bolus intravenous administration.

3 Dosage Forms And Strengths  

Ephedrine Sulfate Injection, USP is supplied as 1 mL ampule that contains 50 mg/mL ephedrine sulfate equivalent to 38 mg ephedrine base.

Ephedrine Sulfate Injection, USP is supplied as 1 mL vial that contains 50 mg/mL ephedrine sulfate equivalent to 38 mg ephedrine base.

4 Contraindications  

None

5 Warnings And Precautions  

5.1 Pressor Effect with Concomitant Oxytocic Drugs

Serious postpartum hypertension has been described in patients who received both a vasopressor (i.e., methoxamine, phenylephrine, ephedrine) and an oxytocic (i.e., methylergonovine, ergonovine) [see Drug Interactions (7)]. Some of these patients experienced a stroke. Carefully monitor the blood pressure of individuals who have received both ephedrine and an oxytocic.

5.2 Tolerance and Tachyphylaxis

Data indicate that repeated administration of ephedrine can result in tachyphylaxis. Clinicians treating anesthesia-induced hypotension with Ephedrine Sulfate Injection should be aware of the possibility of tachyphylaxis and should be prepared with an alternative pressor to mitigate unacceptable responsiveness.

5.3 Risk of Hypertension When Used Prophylactically

When used to prevent hypotension, ephedrine has been associated with an increased incidence of hypertension compared with when ephedrine is used to treat hypotension.

6 Adverse Reactions  

The following adverse reactions associated with the use of ephedrine were identified in the clinical literature. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to estimate their frequency reliably or to establish a causal relationship to drug exposure.

Gastrointestinal disorders: Nausea, vomiting

Cardiac disorders: Tachycardia, palpitations (thumping heart), reactive hypertension, bradycardia, ventricular ectopics, R-R variability

Nervous system disorders: Dizziness

Psychiatric disorders: Restlessness

7 Drug Interactions  

Interactions that Augment the Pressor Effect
Oxytocin and oxytocic drugs
Clinical Impact: Serious postpartum hypertension has been described in patients who received both a vasopressor (i.e., methoxamine, phenylephrine, ephedrine) and an oxytocic (i.e., methylergonovine, ergonovine). Some of these patients experienced a stroke.
Intervention: Carefully monitor the blood pressure of individuals who have received both ephedrine and an oxytocic.
Clonidine, propofol, monoamine oxidase inhibitors (MAOIs), atropine
Clinical Impact: These drugs augment the pressor effect of ephedrine.
Intervention: Carefully monitor the blood pressure of individuals who have received both ephedrine and any of these drugs.
Interactions that Antagonize the Pressor Effect
Clinical Impact: These drugs antagonize the pressor effect of ephedrine.
Intervention: Carefully monitor the blood pressure of individuals who have received both ephedrine and any of these drugs.
Examples: -adrenergic antagonists, -adrenergic receptor antagonists, reserpine, quinidine, mephentermine
Other Drug Interactions
Guanethidine
Clinical Impact: Ephedrine may inhibit the neuron blockage produced by guanethidine, resulting in loss of antihypertensive effectiveness.
Intervention: Clinician should monitor patient for blood pressor response and adjust the dosage or choice of pressor accordingly.
Rocuronium
Clinical Impact: Ephedrine may reduce the onset time of neuromuscular blockade when used for intubation with rocuronium if administered simultaneously with anesthetic induction.
Intervention: Be aware of this potential interaction. No treatment or other interventions are needed.
Epidural anesthesia
Clinical Impact: Ephedrine may decrease the efficacy of epidural blockade by hastening the regression of sensory analgesia.
Intervention: Monitor and treat the patient according to clinical practice.
Theophylline
Clinical Impact: Concomitant use of ephedrine may increase the frequency of nausea, nervousness, and insomnia.
Intervention: Monitor patient for worsening symptoms and manage symptoms according to clinical practice.
Cardiac glycosides
Clinical Impact: Giving ephedrine with a cardiac glycoside, such as digitalis, may increase the possibility of arrhythmias.
Intervention: Carefully monitor patients on cardiac glycosides who are also administered ephedrine.

8 Use In Specific Populations  

8.1 Pregnancy

Risk Summary

Limited published data on the use of ephedrine sulfate are insufficient to determine a drug associated risk of major birth defects or miscarriage. However, there are clinical considerations [see Clinical Considerations]. Animal reproduction studies have not been conducted with ephedrine sulfate.

The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.

Clinical Considerations

Fetal/Neonatal adverse reactions

Cases of potential metabolic acidosis in newborns at delivery with maternal ephedrine exposure have been reported in the literature. These reports describe umbilical artery pH of 7.2 at the time of delivery [see Clinical Pharmacology (12.3)]. Monitoring of the newborn for signs and symptoms of metabolic acidosis may be required. Monitoring of infant's acid-base status is warranted to ensure that an episode of acidosis is acute and reversible.

8.2 Lactation

Risk Summary

Limited published literature reports that ephedrine is present in human milk. However, no information is available on the effects of the drug on the breastfed infant or the effects of the drug on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for Ephedrine Sulfate Injection and any potential adverse effects on the breastfed child from Ephedrine Sulfate Injection or from the underlying maternal condition.

8.4 Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

8.5 Geriatric Use

Clinical studies of ephedrine did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.

In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. This drug is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.

8.6 Renal Impairment

Ephedrine and its metabolite are excreted in urine. In patients with renal impairment, excretion of ephedrine is likely to be affected with a corresponding increase in elimination half-life, which will lead to slow elimination of ephedrine and consequently prolonged pharmacological effect and potentially adverse reactions. Monitor patients with renal impairment carefully after the initial bolus dose for adverse events.

10 Overdosage  

Overdose of ephedrine can cause a rapid rise in blood pressure. In the case of an overdose, careful monitoring of blood pressure is recommended. If blood pressure continues to rise to an unacceptable level, parenteral antihypertensive agents can be administered at the discretion of the clinician.

11 Description  

Ephedrine is an alpha- and beta-adrenergic agonist and a norepinephrine-releasing agent. Ephedrine Sulfate Injection, USP is a clear, colorless, sterile solution for intravenous injection. It must be diluted before intravenous administration. The chemical name of ephedrine sulfate is (1R,2S)-(-)-2-methylamine-1-phenylpropan-1-ol sulfate, and the molecular weight is 428.5 g/mol. Its structural formula is depicted below:

Structural Formula

Ephedrine sulfate may darken on exposure to light. It is freely soluble in water and ethanol, very slightly soluble in chloroform, and practically insoluble in ether. Each mL contains ephedrine sulfate 50 mg (equivalent to 38 mg ephedrine base) in water for injection. The pH is adjusted with sodium hydroxide and/or glacial acetic acid, if necessary. The pH range is 4.5 to 7.0.

12 Clinical Pharmacology  

12.1 Mechanism of Action

Ephedrine sulfate is a sympathomimetic amine that directly acts as an agonist at - and -adrenergic receptors and indirectly causes the release of norepinephrine from sympathetic neurons. Pressor effects by direct alpha- and beta-adrenergic receptor activation are mediated by increases in arterial pressures, cardiac output, and peripheral resistance. Indirect adrenergic stimulation is caused by norepinephrine release from sympathetic nerves.

12.2 Pharmacodynamics

Ephedrine stimulates heart rate and cardiac output and variably increases peripheral resistance; as a result, ephedrine usually increases blood pressure. Stimulation of the -adrenergic receptors of smooth muscle cells in the bladder base may increase the resistance to the outflow of urine. Activation of -adrenergic receptors in the lungs promotes bronchodilation.

The overall cardiovascular effect from ephedrine is the result of a balance among -1 adrenoceptor-mediated vasoconstriction, -2 adrenoceptor-mediated vasoconstriction, and -2 adrenoceptor-mediated vasodilatation. Stimulation of the -1 adrenoceptors results in positive inotrope and chronotrope action.

Tachyphylaxis to the pressor effects of ephedrine may occur with repeated administration [see Warnings and Precautions (5.2)].

12.3 Pharmacokinetics

Publications studying pharmacokinetics of oral administration of (-)-ephedrine support that (-)-ephedrine is metabolized into norephedrine. However, the metabolism pathway is unknown. Both the parent drug and the metabolite are excreted in urine. Limited data after IV administration of ephedrine support similar observations of urinary excretion of drug and metabolite. The plasma elimination half-life of ephedrine following oral administration was about 6 hours.

Ephedrine crosses the placental barrier [see Use in Specific Populations (8.1)].

13 Nonclinical Toxicology  

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenesis: Two-year feeding studies in rats and mice conducted under the National Toxicology Program (NTP) demonstrated no evidence of carcinogenic potential with ephedrine sulfate at doses up to 10 mg/kg/day and 27 mg/kg/day (approximately 2 times and 3 times the maximum human recommended dose on a mg/m2 basis, respectively).

Mutagenesis: Ephedrine sulfate tested negative in the in vitro bacterial reverse mutation assay, the in vitro mouse lymphoma assay, the in vitro sister chromatid exchange, and the in vitro chromosomal aberration assay.

Impairment of Fertility: Studies to evaluate the effect of ephedrine on fertility have not been conducted.

14 Clinical Studies  

The evidence for the efficacy of ephedrine injection is derived from the published literature. Increases in blood pressure following administration of ephedrine were observed in 14 studies, including 9 where ephedrine was used in pregnant women undergoing neuraxial anesthesia during Cesarean delivery, 1 study in non-obstetric surgery under neuraxial anesthesia, and 4 studies in patients undergoing surgery under general anesthesia. Ephedrine has been shown to raise systolic and mean blood pressure when administered as a bolus dose following the development of hypotension during anesthesia.

16 How Supplied/storage And Handling  

Ephedrine Sulfate Injection, USP, 50 mg/mL, is a clear, colorless, sterile solution supplied as follows:

NDC 17478-955-10 1 mL clear, glass ampules supplied in packages of 10

This container closure is not made with natural rubber latex.

Store at 20 to 25 C (68 to 77 F), with excursions permitted from 15 C to 30 C (59 F to 86 F) [see USP Controlled Room Temperature]. Protect from light. Store in carton until time of use.

For single use only. Discard unused portion.

novaplusTM+

Manufactured by: Akorn, Inc.
Lake Forest, IL 60045

Novaplus is a registered trademark of Vizient, Inc.

NEH00N Rev. 05/18

Principal Display Panel Text for Container Label:

NDC 17478-955-10

Ephedrine Sulfate

Injection, USP

50 mg/

mL

For Intravenous Use

Must Dilute Before Use

1 mL Single Dose Ampule

Rx ONLY

Principal Display Panel Text for Container Label

Principal Display Panel Text for Carton Label:

NDC 17478-955-10

Ephedrine Sulfate Injection, USP

50 mg/

mL

For Intravenous Use

Must Dilute Before Use

1 mL Single Dose Ampules Discard Unused Portions.

10 Ampules (1 mL each)

novaplusTM+ Rx ONLY

Principal Display Panel Text for Carton Label
EPHEDRINE SULFATE
ephedrine sulfate injection
Product Information
Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:17478-955
Route of Administration INTRAVENOUS
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
Ephedrine Sulfate (UNII: U6X61U5ZEG) (Ephedrine - UNII:GN83C131XS) Ephedrine Sulfate 50 mg in 1 mL
Inactive Ingredients
Ingredient Name Strength
Water (UNII: 059QF0KO0R)
Sodium Hydroxide (UNII: 55X04QC32I)
Acetic Acid (UNII: Q40Q9N063P)
Packaging
# Item Code Package Description Marketing Start Date Marketing End Date
1 NDC:17478-955-10 10 in 1 CARTON 10/26/2017
1 1 mL in 1 AMPULE; Type 0: Not a Combination Product
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
NDA NDA208609 10/26/2017
Labeler - Akorn, Inc. (062649876)
Establishment
Name Address ID/FEI Business Operations
Akorn, Inc. 063434679 PACK(17478-955) , LABEL(17478-955)
Establishment
Name Address ID/FEI Business Operations
Akorn, Inc. 155135783 MANUFACTURE(17478-955) , ANALYSIS(17478-955) , STERILIZE(17478-955)

Revised: 6/2018 Akorn, Inc.

1 Indications And Usage 

Ephedrine Sulfate Injection is indicated for the treatment of clinically important hypotension occurring in the setting of anesthesia.

2 Dosage And Administration 

2.1 General Dosage and Administration Instructions

Ephedrine Sulfate Injection must be diluted before administration as an intravenous bolus to achieve the desired concentration. Dilute with normal saline or 5% dextrose in water.

Inspect parenteral drug products visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use if solution is colored or cloudy, or if it contains particulate matter.

2.2 Dosing for the Treatment of Clinically Important Hypotension in the Setting of Anesthesia

The recommended dosages for the treatment of clinically important hypotension in the setting of anesthesia is an initial dose of 5 to 10 mg administered by intravenous bolus. Administer additional boluses as needed, not to exceed a total dosage of 50 mg.

  • Adjust dosage according to the blood pressure goal (i.e., titrate to effect).

2.3 Prepare a 5 mg/mL Solution for Bolus Intravenous Administration

For bolus intravenous administration, prepare a solution containing a final concentration of 5 mg/mL of Ephedrine Sulfate Injection:

  • Withdraw 50 mg (1 mL of 50 mg/mL) of Ephedrine Sulfate Injection and dilute with 9 mL of 5% Dextrose Injection or 0.9% Sodium Chloride Injection and maintain at room temperature. Discard diluted solution after 24 hours.
  • Withdraw an appropriate dose of the 5 mg/mL solution prior to bolus intravenous administration.

3 Dosage Forms And Strengths 

Ephedrine Sulfate Injection, USP is supplied as 1 mL ampule that contains 50 mg/mL ephedrine sulfate equivalent to 38 mg ephedrine base.

Ephedrine Sulfate Injection, USP is supplied as 1 mL vial that contains 50 mg/mL ephedrine sulfate equivalent to 38 mg ephedrine base.

4 Contraindications 

None

5 Warnings And Precautions 

5.1 Pressor Effect with Concomitant Oxytocic Drugs

Serious postpartum hypertension has been described in patients who received both a vasopressor (i.e., methoxamine, phenylephrine, ephedrine) and an oxytocic (i.e., methylergonovine, ergonovine) [see Drug Interactions (7)]. Some of these patients experienced a stroke. Carefully monitor the blood pressure of individuals who have received both ephedrine and an oxytocic.

5.2 Tolerance and Tachyphylaxis

Data indicate that repeated administration of ephedrine can result in tachyphylaxis. Clinicians treating anesthesia-induced hypotension with Ephedrine Sulfate Injection should be aware of the possibility of tachyphylaxis and should be prepared with an alternative pressor to mitigate unacceptable responsiveness.

5.3 Risk of Hypertension When Used Prophylactically

When used to prevent hypotension, ephedrine has been associated with an increased incidence of hypertension compared with when ephedrine is used to treat hypotension.

6 Adverse Reactions 

The following adverse reactions associated with the use of ephedrine were identified in the clinical literature. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to estimate their frequency reliably or to establish a causal relationship to drug exposure.

Gastrointestinal disorders: Nausea, vomiting

Cardiac disorders: Tachycardia, palpitations (thumping heart), reactive hypertension, bradycardia, ventricular ectopics, R-R variability

Nervous system disorders: Dizziness

Psychiatric disorders: Restlessness

7 Drug Interactions 

Interactions that Augment the Pressor Effect
Oxytocin and oxytocic drugs
Clinical Impact: Serious postpartum hypertension has been described in patients who received both a vasopressor (i.e., methoxamine, phenylephrine, ephedrine) and an oxytocic (i.e., methylergonovine, ergonovine). Some of these patients experienced a stroke.
Intervention: Carefully monitor the blood pressure of individuals who have received both ephedrine and an oxytocic.
Clonidine, propofol, monoamine oxidase inhibitors (MAOIs), atropine
Clinical Impact: These drugs augment the pressor effect of ephedrine.
Intervention: Carefully monitor the blood pressure of individuals who have received both ephedrine and any of these drugs.
Interactions that Antagonize the Pressor Effect
Clinical Impact: These drugs antagonize the pressor effect of ephedrine.
Intervention: Carefully monitor the blood pressure of individuals who have received both ephedrine and any of these drugs.
Examples: -adrenergic antagonists, -adrenergic receptor antagonists, reserpine, quinidine, mephentermine
Other Drug Interactions
Guanethidine
Clinical Impact: Ephedrine may inhibit the neuron blockage produced by guanethidine, resulting in loss of antihypertensive effectiveness.
Intervention: Clinician should monitor patient for blood pressure response and adjust the dosage or choice of pressor accordingly.
Rocuronium
Clinical Impact: Ephedrine may reduce the onset time of neuromuscular blockade when used for intubation with rocuronium if administered simultaneously with anesthetic induction.
Intervention: Be aware of this potential interaction. No treatment or other interventions are needed.
Epidural anesthesia
Clinical Impact: Ephedrine may decrease the efficacy of epidural blockade by hastening the regression of sensory analgesia.
Intervention: Monitor and treat the patient according to clinical practice.
Theophylline
Clinical Impact: Concomitant use of ephedrine may increase the frequency of nausea, nervousness, and insomnia.
Intervention: Monitor patient for worsening symptoms and manage symptoms according to clinical practice.
Cardiac glycosides
Clinical Impact: Giving ephedrine with a cardiac glycoside, such as digitalis, may increase the possibility of arrhythmias.
Intervention: Carefully monitor patients on cardiac glycosides who are also administered ephedrine.

8 Use In Specific Populations 

8.1 Pregnancy

Risk Summary

Limited published data on the use of ephedrine sulfate are insufficient to determine a drug associated risk of major birth defects or miscarriage. However, there are clinical considerations [see Clinical Considerations]. Animal reproduction studies have not been conducted with ephedrine sulfate.

The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.

Clinical Considerations

Fetal/Neonatal adverse reactions

Cases of potential metabolic acidosis in newborns at delivery with maternal ephedrine exposure have been reported in the literature. These reports describe umbilical artery pH of 7.2 at the time of delivery [see Clinical Pharmacology (12.3)]. Monitoring of the newborn for signs and symptoms of metabolic acidosis may be required. Monitoring of infant's acid-base status is warranted to ensure that an episode of acidosis is acute and reversible.

8.2 Lactation

Risk Summary

Limited published literature reports that ephedrine is present in human milk. However, no information is available on the effects of the drug on the breastfed infant or the effects of the drug on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for Ephedrine Sulfate Injection and any potential adverse effects on the breastfed child from Ephedrine Sulfate Injection or from the underlying maternal condition.

8.4 Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

8.5 Geriatric Use

Clinical studies of ephedrine did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.

In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. This drug is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.

8.6 Renal Impairment

Ephedrine and its metabolite are excreted in urine. In patients with renal impairment, excretion of ephedrine is likely to be affected with a corresponding increase in elimination half-life, which will lead to slow elimination of ephedrine and consequently prolonged pharmacological effect and potentially adverse reactions. Monitor patients with renal impairment carefully after the initial bolus dose for adverse events.

10 Overdosage 

Overdose of ephedrine can cause a rapid rise in blood pressure. In the case of an overdose, careful monitoring of blood pressure is recommended. If blood pressure continues to rise to an unacceptable level, parenteral antihypertensive agents can be administered at the discretion of the clinician.

11 Description 

Ephedrine is an alpha-and beta-adrenergic agonist and a norepinephrine-releasing agent. Ephedrine Sulfate Injection, USP is a clear, colorless, sterile solution for intravenous injection. It must be diluted before intravenous administration. The chemical name of ephedrine sulfate is (1R,2S)-(-)-2-methylamine-1-phenylpropan-1-ol sulfate, and the molecular weight is 428.5 g/mol. Its structural formula is depicted below:

Chemical Structure

Ephedrine sulfate may darken on exposure to light. It is freely soluble in water and ethanol, very slightly soluble in chloroform, and practically insoluble in ether. Each mL contains ephedrine sulfate 50 mg (equivalent to 38 mg ephedrine base) in water for injection. The pH is adjusted with sodium hydroxide and/or glacial acetic acid, if necessary. The pH range is 4.5 to 7.0.

12 Clinical Pharmacology 

12.1 Mechanism of Action

Ephedrine sulfate is a sympathomimetic amine that directly acts as an agonist at -and -adrenergic receptors and indirectly causes the release of norepinephrine from sympathetic neurons. Pressor effects by direct alpha-and beta-adrenergic receptor activation are mediated by increases in arterial pressures, cardiac output, and peripheral resistance. Indirect adrenergic stimulation is caused by norepinephrine release from sympathetic nerves.

12.2 Pharmacodynamics

Ephedrine stimulates heart rate and cardiac output and variably increases peripheral resistance; as a result, ephedrine usually increases blood pressure. Stimulation of the -adrenergic receptors of smooth muscle cells in the bladder base may increase the resistance to the outflow of urine. Activation of -adrenergic receptors in the lungs promotes bronchodilation.

The overall cardiovascular effect from ephedrine is the result of a balance among -1 adrenoceptor-mediated vasoconstriction, -2 adrenoceptor-mediated vasoconstriction, and -2 adrenoceptor-mediated vasodilatation. Stimulation of the -1 adrenoceptors results in positive inotrope and chronotrope action.

Tachyphylaxis to the pressor effects of ephedrine may occur with repeated administration [see Warnings and Precautions (5.2)].

12.3 Pharmacokinetics

Publications studying pharmacokinetics of oral administration of (-)-ephedrine support that (-)-ephedrine is metabolized into norephedrine. However, the metabolism pathway is unknown. Both the parent drug and the metabolite are excreted in urine. Limited data after IV administration of ephedrine support similar observations of urinary excretion of drug and metabolite. The plasma elimination half-life of ephedrine following oral administration was about 6 hours.

Ephedrine crosses the placental barrier [see Use in Specific Populations (8.1)].

13 Nonclinical Toxicology 

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenesis: Two-year feeding studies in rats and mice conducted under the National Toxicology Program (NTP) demonstrated no evidence of carcinogenic potential with ephedrine sulfate at doses up to 10 mg/kg/day and 27 mg/kg/day (approximately 2 times and 3 times the maximum human recommended dose on a mg/m2 basis, respectively).

Mutagenesis: Ephedrine sulfate tested negative in the in vitro bacterial reverse mutation assay, the in vitro mouse lymphoma assay, the in vitro sister chromatid exchange, and the in vitro chromosomal aberration assay.

Impairment of Fertility: Studies to evaluate the effect of ephedrine on fertility have not been conducted.

14 Clinical Studies 

The evidence for the efficacy of ephedrine injection is derived from the published literature. Increases in blood pressure following administration of ephedrine were observed in 14 studies, including 9 where ephedrine was used in pregnant women undergoing neuraxial anesthesia during Cesarean delivery, 1 study in non-obstetric surgery under neuraxial anesthesia, and 4 studies in patients undergoing surgery under general anesthesia. Ephedrine has been shown to raise systolic and mean blood pressure when administered as a bolus dose following the development of hypotension during anesthesia.

16 How Supplied/storage And Handling 

Ephedrine Sulfate Injection, USP, 50 mg/mL, is a clear, colorless, sterile solution supplied as follows:

NDC 17478-415-10 1 mL clear, glass ampules supplied in packages of 10 (NDC 17478-415-01).

NDC 17478-517-01 1 mL single-dose Vials supplied in packages of 10.

This container closure is not made with natural rubber latex.

Store at 20 to 25 C (68 to 77 F), with excursions permitted from 15 to 30 C (59 to 86 F) [see USP Controlled Room Temperature]. Protect from light. Store in carton until time of use.

For single use only. Discard unused portion.

Manufactured by: Akorn, Inc.
Lake Forest, IL 60045

EH00N Rev. 01/19

Principal Display Panel - 1 Ml Ampule Carton 

NDC 17478-415-10

Ephedrine Sulfate Injection, USP

50 mg/mL

For Intravenous Use
Must Dilute Before Use

1 mL Single Dose Ampules - Discard Unused Portion.
10 Ampules (1 mL each)

Rx only AKORN

PRINCIPAL DISPLAY PANEL - 1 mL Ampule Carton

PRINCIPAL DISPLAY PANEL - 10 x 1 mL Ampule Carton

NDC 17478-517-01

Ephedrine Sulfate Injection, USP

50 mg/mL

For Intravenous Use

Must Dilute Before Use

10 x 1 mL Single-dose Vials

Rx only Akorn Logo

PRINCIPAL DISPLAY PANEL - 10 x 1 mL Ampule Carton
EPHEDRINE SULFATE
ephedrine sulfate injection
Product Information
Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:17478-415
Route of Administration INTRAVENOUS
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
Ephedrine Sulfate (UNII: U6X61U5ZEG) (Ephedrine - UNII:GN83C131XS) Ephedrine Sulfate 50 mg in 1 mL
Inactive Ingredients
Ingredient Name Strength
Water (UNII: 059QF0KO0R)
Sodium Hydroxide (UNII: 55X04QC32I)
Acetic Acid (UNII: Q40Q9N063P)
Packaging
# Item Code Package Description Marketing Start Date Marketing End Date
1 NDC:17478-415-10 10 in 1 CARTON 03/01/2017
1 NDC:17478-415-01 1 mL in 1 AMPULE; Type 0: Not a Combination Product
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
NDA NDA208609 03/01/2017
EPHEDRINE SULFATE
ephedrine sulfate injection
Product Information
Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:17478-517
Route of Administration INTRAVENOUS
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
Ephedrine Sulfate (UNII: U6X61U5ZEG) (Ephedrine - UNII:GN83C131XS) Ephedrine Sulfate 50 mg in 1 mL
Inactive Ingredients
Ingredient Name Strength
Water (UNII: 059QF0KO0R)
Sodium Hydroxide (UNII: 55X04QC32I)
Acetic Acid (UNII: Q40Q9N063P)
Packaging
# Item Code Package Description Marketing Start Date Marketing End Date
1 NDC:17478-517-01 10 in 1 CARTON 07/03/2017
1 1 mL in 1 VIAL, SINGLE-DOSE; Type 0: Not a Combination Product
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
NDA NDA208609 03/01/2017
Labeler - Akorn, Inc. (062649876)
Establishment
Name Address ID/FEI Business Operations
Akorn, Inc. 063434679 PACK(17478-415, 17478-517) , LABEL(17478-415, 17478-517)
Establishment
Name Address ID/FEI Business Operations
Akorn, Inc. 155135783 MANUFACTURE(17478-415, 17478-517) , ANALYSIS(17478-415, 17478-517) , STERILIZE(17478-415, 17478-517)

Revised: 11/2017 Akorn, Inc.

Ephedrine Sulfateinjection Usp, 50 Mg/ml  

For IM, IV or SC Use

Rx only

Description  

Ephedrine Sulfate Injection, USP is a sterile solution of 50 mg ephedrine sulfate in Water for Injection.

Ephedrine occurs as fine, white, odorless crystals or powder and darkens on exposure to light. It is freely soluble in water and sparingly soluble in alcohol.

The chemical name of ephedrine sulfate is (C10H15NO)2 H2SO4 benzenemethanol -[l - (methylamino) ethyl] - sufate (2:1) (salt). Its molecular weight is 428.54. The structural formula is:

Structural Formula

Clinical Pharmacology  

Ephedrine sulfate is a potent sympathomimetic that stimulates both and receptors and has clinical uses related to both actions. Its peripheral actions, which it owes in part to the release of norepinephrine, simulate responses that are obtained when adrenergic nerves are stimulated. These include an increase in blood pressure, stimulation of heart muscle, constriction of arterioles, relaxation of the smooth muscle of the bronchi and gastrointestinal tract, and dilation of the pupils. In the bladder, relaxation of the detrusor muscle is not prominent, but the tone of the trigone and vesicle sphincter is increased.

Ephedrine sulfate also has a potent effect on the CNS. It stimulates the cerebral cortex and subcortical centers, which accounts for its use in narcolepsy.

The cardiovascular responses reported in man include moderate tachycardia, unchanged or augmented stroke volume, enhanced cardiac output, variable alterations in peripheral resistance and usually a rise in blood pressure. The action of ephedrine is more prominent on the heart than on the blood vessels. Ephedrine sulfate increases the flow of coronary, cerebral and muscle blood.

In patients with myasthenia gravis, administration of Ephedrine Sulfate Injection, USP produces a real but modest increase in motor power. The exact mechanism by which ephedrine sulfate affects skeletal muscle contractions is unknown.

Indications And Usage  

Ephedrine Sulfate Injection, USP is indicated in the treatment of allergic disorders, such as bronchial asthma The drug has long been used as a pressor agent, particularly during spinal anesthesia when hypotension frequently occurs. In Stokes-Adams syndrome with complete heart block, ephedrine has a value similar to that of epinephrine. It is indicated as a central nervous system stimulant in narcolepsy and depressive states. It is also used in myasthenia gravis.

Contraindications  

Allergic reactions to ephedrine sulfate are rare. The hypersensitivity, if known, is a specific contraindication. Patients hypersensitive to other sympathomimetics may also be hypersensitive to ephedrine sulfate.

Precautions  

GENERAL - Special care should be used when administering Ephedrine Sulfate Injection, USP to patients with heart disease, angina pectoris, diabetes, hyperthyroidism, prostatic hypertrophy or hypertension and to patients receiving digitalis. Prolonged use may produce a syndrome resembling an anxiety state. Tolerance to ephedrine sulfate may develop, but temporary discontinuance to the drug restores its original effectiveness.

DRUG INTERACTIONS - Concurrent use of ephedrine sulfate with general anesthetics, especially cyclopropane or halogenated hydrocarbons or digitalis glycosides may cause cardiac arrhythmias, since these medications may sensitize the myocardium to the effects of ephedrine sulfate.

Therapeutic doses of ephedrine sulfate can inhibit the hypotensive effect of guanethidine, bethanidine, and debrisoquin by displacing the adrenergic blockers from their site of action in the sympathetic neurons. The effect in man is seen as a relative or a complete blockade of the antihypertensive drug by a sudden rise in blood pressure. Concomitant use of Ephedrine Sulfate Injection, USP and oxytocics may cause severe hypotension.

Monoamine oxidase inhibitors may potentiate the pressor effect of ephedrine sulfate, possibly resulting in a hypertensive crisis. Ephedrine Sulfate Injection, USP should not be administered during or within 14 days following the administration of MAO inhibitors.

PREGNANCY CATEGORY C - Animal reproduction studies have not been conducted with Ephedrine Sulfate Injection. USP Also, it is not known whether the drug can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Ephedrine Sulfate Injection, USP should be given to a pregnant woman only if clearly indicated.

It is not known what effect Ephedrine Sulfate Injection, USP may have on the newborn or on the child's later growth and development when the drug is administered to the mother just before or during labor.

NURSING MOTHERS - Ephedrine sulfate is excreted in breast milk. Use by nursing mothers is not recommended because of the higher than usual risks for infants.

Adverse Reactions  

With large doses of ephedrine sulfate most patients will experience nervousness, insomnia, vertigo, headache, tachycardia, palpitation and sweating. Some patients have nausea, vomiting and anorexia. Vesical sphincter spasm may occur and result in difficult and painful urination. Urinary retention may develop in males with prostatism.

Precordial pain and cardiac arrhythmias may occur following administration of Ephedrine Sulfate Injection, USP

Drug Abuse And Dependence  

Prolonged abuse of Ephedrine Sulfate Injection, USP can lead to symptoms of paranoid schizophrenia. When this occurs, patients exhibit such physical signs as tachycardia, poor nutrition and hygiene, fever, cold sweat and dilated pupils.

Some measure of tolerance may develop with prolonged or excessive use but addiction does not occur. Temporary cessation of medication and subsequent readministration restores its effectiveness.

Overdosage  

SYMPTOMS - The principal manifestation of ephedrine sulfate poisoning is convulsions. In acute poisoning the following signs and symptoms may occur: nausea, vomiting, chills, cyanosis, irritability, nervousness, fever, suicidal behavior, tachycardia, dilated pupils, blurred vision, opisthotonos, spasms, convulsions, pulmonary edema, gasping respirations, coma and respiratory failure. Initially, the patient may have hypertension, followed later by hypotension accompanied by anuria.

TREATMENT - If respirations are shallow or cyanosis is present, artificial respiration should be administered. Vasopressors are contraindicated. In cardiovascular collapse blood pressure should be maintained.

ANTIDOTE - For hypertension, 5 mg phentolamine mesylate diluted in saline may be administered slowly intravenously, or 100 mg may be given orally. Convulsions may be controlled by diazepam or paraldehyde. Cool applications and dexamethasone 1 mg/kg, administered slowly intravenously, may control pyrexia.

Dosage And Administration  

ADULTS - The usual parenteral dose is 25 to 50 mg given subcutaneously or intramuscularly. Intravenously, 5 to 25 mg may be administered slowly, repeated in 5 to 10 minutes, if necessary.

CHILDREN - The usual subcutaneous or intramuscular dose is 0.5 mg/kg of body weight or 16.7 mg/square meter of body surface every 4 to 6 hours.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

How Supplied  

Ephedrine Sulfate Injection USP, 50 mg/mL

1 mL ampules in packs of 10, NDC 17478-515-00

STORAGE: Store at 20 to 25 C (68 to 77 F) [see USP Controlled Room Temperature]. Protect from light.

Akorn
Manufactured by: Akorn, Inc.
Lake Forest, IL 60045

ES00N
Rev. 03/10

Principal Display Panel Text for Container Label:

NDC 17478-515-00

Ephedrine Sulfate

Injection, USP

50 mg/mL

1 mL Single Dose Ampule

For IM, IV, or SC use

Mfd. by:

Rx only Akorn, Inc.

Principal Display Panel Text for Container Label

Principal Display Panel Text for Carton Label:

NDC 17478-515-00

Ephedrine Sulfate Injection, USP

50 mg/mL

For IM, IV, or SC use

1 mL Single Dose Ampules

10 Ampules (1 mL each)

Rx only Akorn

Principal Display Panel Text for Carton Label
EPHEDRINE SULFATE
ephedrine sulfate injection
Product Information
Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:17478-515
Route of Administration INTRAMUSCULAR, INTRAVENOUS, SUBCUTANEOUS
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
Ephedrine Sulfate (UNII: U6X61U5ZEG) (Ephedrine - UNII:GN83C131XS) Ephedrine Sulfate 50 mg in 1 mL
Inactive Ingredients
Ingredient Name Strength
WATER (UNII: 059QF0KO0R)
Packaging
# Item Code Package Description Marketing Start Date Marketing End Date
1 NDC:17478-515-00 10 in 1 CARTON
1 1 mL in 1 AMPULE
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
unapproved drug other 04/01/2009
Labeler - Akorn, Inc. (062649876)
Establishment
Name Address ID/FEI Business Operations
Akorn, Inc. 155135783 MANUFACTURE, REPACK, ANALYSIS, LABEL, PACK, RELABEL, STERILIZE

Revised: 1/2012 Akorn, Inc.

16 How Supplied/storage And Handling  

Ephedrine sulfate injection, USP, 50 mg/mL, is supplied as follows:

NDC

Strength

How Supplied

0781-3269-95

50 mg/mL

1 mL fill in 2 mL amber vial; for single use (supplied in packages of 10)

Vial stoppers are not manufactured with natural rubber latex. Store ephedrine sulfate injection, USP, 50 mg/mL, at 20 to 25 C (68 to 77 F) [see USP Controlled Room Temperature]. Store in carton until time of use. For single use only. Discard unused portion.

46238558

Rev. September 2018

Manufactured in Canada by

Avara Boucherville Pharmaceutical Services, Inc. for

Sandoz Inc., Princeton, NJ 08540

50mg/ml Carton  

ephedrine-carton

NDC 0781-3269-95

Ephedrine Sulfate

Injection, USP

50 mg/mL

Must Be Diluted

For Intravenous Use

10 x 1 mL Single Dose Vials

Rx Only

SANDOZ A Novartis Division

EPHEDRINE SULFATE
ephedrine sulfate injection
Product Information
Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:0781-3269
Route of Administration INTRAVENOUS
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
EPHEDRINE SULFATE (UNII: U6X61U5ZEG) (EPHEDRINE - UNII:GN83C131XS) EPHEDRINE SULFATE 50 mg in 1 mL
Inactive Ingredients
Ingredient Name Strength
ACETIC ACID (UNII: Q40Q9N063P)
SODIUM HYDROXIDE (UNII: 55X04QC32I)
WATER (UNII: 059QF0KO0R)
Packaging
# Item Code Package Description Marketing Start Date Marketing End Date
1 NDC:0781-3269-95 10 in 1 CARTON 10/01/2017
1 NDC:0781-3269-71 1 mL in 1 VIAL, SINGLE-DOSE; Type 0: Not a Combination Product
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA209784 10/01/2017
Labeler - Sandoz Inc (110342024)

Revised: 5/2019 Sandoz Inc



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