advised.risperidoneMonitor Closely (2)epinephrine and risperidone both increase QTc interval. Modify Therapy/Monitor Closely. risperidone increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.sacubitril/valsartanMonitor Closely (1)sacubitril/valsartan increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.sageMinor (1)sage increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Minor/Significance Unknown.salicylates (non-asa)Monitor Closely (1)salicylates (non-asa) increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.salmeterolMonitor Closely (3)epinephrine and salmeterol both decrease serum potassium. Use Caution/Monitor. epinephrine and salmeterol both decrease sedation. Use Caution/Monitor. epinephrine and salmeterol both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor.salsalateMonitor Closely (1)salsalate increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.scullcapMonitor Closely (1)scullcap increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.secobarbitalMonitor Closely (1)secobarbital increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.selegilineMonitor Closely (1)selegiline increases effects of epinephrine by pharmacodynamic synergism. Use Caution/Monitor. Avoid concomitant use if possible. Caution is advised.selegiline transdermalContraindicated (1)selegiline transdermal increases effects of epinephrine by pharmacodynamic synergism. Contraindicated. Risk of acute hypertensive episode.serdexmethylphenidate/dexmethylphenidateMonitor Closely (1)epinephrine and serdexmethylphenidate/dexmethylphenidate both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor.sevofluraneSerious - Use Alternative (1)sevoflurane increases toxicity of epinephrine by Mechanism: unknown. Avoid or Use Alternate Drug. Risk of V tach, HTN.shepherd's purseMonitor Closely (1)shepherd's purse increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.sodium sulfate/potassium chloride/magnesium sulfate/polyethylene glycolMonitor Closely (1)epinephrine and sodium sulfate/potassium chloride/magnesium sulfate/polyethylene glycol both decrease serum potassium. Modify Therapy/Monitor Closely.solriamfetolMonitor Closely (1)epinephrine and solriamfetol both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor.sotalolContraindicated (1)epinephrine and sotalol both increase QTc interval. Contraindicated.Monitor Closely (2)sotalol decreases effects of epinephrine by pharmacodynamic antagonism. Use Caution/Monitor. sotalol increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.spironolactoneMonitor Closely (1)spironolactone increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Modify Therapy/Monitor Closely.succinylcholineMonitor Closely (1)succinylcholine increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.sufentanilMonitor Closely (1)sufentanil increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.sulfamethoxazoleMonitor Closely (1)epinephrine and sulfamethoxazole both increase QTc interval. Modify Therapy/Monitor Closely.sulfasalazineMonitor Closely (1)sulfasalazine increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.sulindacMonitor Closely (1)sulindac increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.tapentadolMonitor Closely (1)tapentadol increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.telavancinMonitor Closely (1)epinephrine and telavancin both increase QTc interval. Modify Therapy/Monitor Closely.temazepamMonitor Closely (1)temazepam increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.terbutalineMonitor Closely (3)epinephrine and terbutaline both decrease serum potassium. Use Caution/Monitor. epinephrine and terbutaline both decrease sedation. Use Caution/Monitor. epinephrine and terbutaline both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor.thioridazineMonitor Closely (3)thioridazine, epinephrine. Mechanism: unknown. Use Caution/Monitor. Risk of cardiac arrhythmia or sudden death, more likely w/thioridazine than other phenothiazines. Interaction more likely in certain predisposed pts. only. thioridazine decreases effects of epinephrine by pharmacodynamic antagonism. Use Caution/Monitor. Block pressor response to epinephrine, which may result in severe hypotension and tachycardia. thioridazine increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.Serious - Use Alternative (1)epinephrine and thioridazine both increase QTc interval. Avoid or Use Alternate Drug.thiothixeneMonitor Closely (1)thiothixene increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.Minor (1)thiothixene decreases effects of epinephrine by pharmacodynamic antagonism. Minor/Significance Unknown.timololMonitor Closely (2)timolol decreases effects of epinephrine by pharmacodynamic antagonism. Use Caution/Monitor. timolol increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.Serious - Use Alternative (1)timolol increases effects of epinephrine by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of hypertension and bradycardia. Consider selective beta 1 blocker (e.g., metoprolol).tolcaponeMonitor Closely (1)tolcapone will increase the level or effect of epinephrine by decreasing metabolism. Use Caution/Monitor. Tolcapone is a COMT inhibitor. Caution if coadministered with drugs metabolized by COMT. If coadministered, monitor for changes in heart rate, heart rhythm, and blood pressure.tolfenamic acidMonitor Closely (1)tolfenamic acid increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.tolmetinMonitor Closely (1)tolmetin increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.tolvaptanMonitor Closely (1)tolvaptan increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Use Caution/Monitor.topiramateMonitor Closely (1)topiramate increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Modify Therapy/Monitor Closely.torsemideMonitor Closely (1)epinephrine and torsemide both decrease serum potassium. Use Caution/Monitor.Minor (1)epinephrine, torsemide. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Hypokalemia.tramadolMonitor Closely (1)tramadol increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.tranylcypromineContraindicated (1)tranylcypromine increases effects of epinephrine by pharmacodynamic synergism. Contraindicated. Risk of acute hypertensive episode.trazodoneMonitor Closely (2)trazodone increases effects of epinephrine by unknown mechanism. Use Caution/Monitor. trazodone increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.Serious - Use Alternative (2)epinephrine and trazodone both increase QTc interval. Avoid or Use Alternate Drug. trazodone, epinephrine. Other (see comment). Avoid or Use Alternate Drug. Comment: Tricyclic antidepressants increase or decrease effects of sympathomimetics, by blocking reuptake of NE, or blocking uptake of indirect sympathomimetics into the adrenergic neuron.triamtereneMonitor Closely (1)triamterene increases and epinephrine decreases serum potassium. Effect of interaction is not clear, use caution. Modify Therapy/Monitor Closely.triazolamMonitor Closely (1)triazolam increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.triclofosMonitor Closely (1)triclofos increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.trifluoperazineMonitor Closely (3)trifluoperazine, epinephrine. Mechanism: unknown. Use Caution/Monitor. Risk of cardiac arrhythmia or sudden death, more likely w/thioridazine than other phenothiazines. Interaction more likely in certain predisposed pts. only. trifluoperazine decreases effects of epinephrine by pharmacodynamic antagonism. Use Caution/Monitor. Block pressor response to epinephrine, which may result in severe hypotension and tachycardia. trifluoperazine increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.Serious - Use Alternative (1)epinephrine and trifluoperazine both increase QTc interval. Avoid or Use Alternate Drug.trimethoprimMonitor Closely (1)epinephrine and trimethoprim both increase QTc interval. Modify Therapy/Monitor Closely.trimipramineMonitor Closely (2)trimipramine increases effects of epinephrine by unknown mechanism. Use Caution/Monitor. trimipramine increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.Serious - Use Alternative (2)epinephrine and trimipramine both increase QTc interval. Avoid or Use Alternate Drug. trimipramine, epinephrine. Other (see comment). Avoid or Use Alternate Drug. Comment: Tricyclic antidepressants increase or decrease effects of sympathomimetics, by blocking reuptake of NE, or blocking uptake of indirect sympathomimetics into the adrenergic neuron.triprolidineMonitor Closely (1)triprolidine increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.tropisetronMonitor Closely (1)epinephrine and tropisetron both increase QTc interval. Modify Therapy/Monitor Closely.vasopressinMinor (1)epinephrine decreases effects of vasopressin by pharmacodynamic antagonism. Minor/Significance Unknown.venlafaxineMonitor Closely (1)epinephrine and venlafaxine both increase QTc interval. Modify Therapy/Monitor Closely.voriconazoleMonitor Closely (1)epinephrine and voriconazole both increase QTc interval. Modify Therapy/Monitor Closely.xylometazolineMonitor Closely (2)epinephrine and xylometazoline both decrease sedation. Use Caution/Monitor. epinephrine and xylometazoline both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor.yohimbeSerious - Use Alternative (1)yohimbe, epinephrine. Mechanism: pharmacodynamic synergism. Contraindicated. Risk of acute hypertensive episode.yohimbineMonitor Closely (2)epinephrine and yohimbine both decrease sedation. Use Caution/Monitor. epinephrine and yohimbine both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor.ziconotideMonitor Closely (1)ziconotide increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.ziprasidoneMonitor Closely (1)ziprasidone increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.Serious - Use Alternative (1)epinephrine and ziprasidone both increase QTc interval. Avoid or Use Alternate Drug. Frequency Not Defined Angina Anxiety Apprehensiveness Cardiac arrhythmias Dizziness Dyspnea Flushing Headache Hypertension Nausea Nervousness Pallor Palpitations Respiratory difficulties Restlessness Stress cardiomyopathy Sweating Tachycardia Tremor Vasoconstriction Vomiting Weakness Postmarketing Reports Necrotizing fasciitis and myonecrosis caused by Clostridia (gas gangrene) Reduced blood flow to digits, hands, or feet with accidental injection to those areas Arrhythmias, including fatal ventricular fibrillation, reported, particularly in patients with underlying cardiac disease or those receiving certain drugs Contraindications There are no contraindications for life-threatening situations Nonanaphylactic shock Narrow-angle glaucoma Coadministration during genral anesthesia with halogenated hydrocarbons or cyclopropane Labor Situations where vasopressors may be contraindicated, including thyrotoxicosis, diabetes Maternal blood pressure in excess of 130/80 mm Hg in hypertension and other cardiovascular disorders Cautions Use caution in patients with cardiac disease, angina (especially with history of CAD) or that are receiving drugs that sensitize the myocardium; treatment may induce cardiac arrhythmias Pulmonary edema may occur as the result of cardiac stimulation and peripheral constriction Decreased urine output may occur as the result of renal blood vessel constriction Use caution in cerebrovascular insufficiency Use with caution in patients with hypertension, diabetes mellitus, thyroid disease, prostatic hypertrophy, geriatric patients, pregnancy, and previous hospitalization for asthma Rapid IV administration, although necessary in pulesless arrest, may cause death from cerebrovascular hemorrhage or cardiac arrhythmias Patients that are sulfite-sensitive, should still be treated during a serious allergic reaction or other emergency even if products available contain sulfites May cause worsening of symptoms in patients with Parkinson disease Avoid extravasation; ensure proper needle or catheter placement prior to and during infusion Correct blood volume depletion before administering any vasopressor Rare cases of serious skin and soft tissue infections, including necrotizing fasciitis and myonecrosis caused by Clostridia (gas gangrene), reported at injection site following injection for anaphylaxis; to decrease risk, do not inject into buttock; advise patients to seek medical care if they develop signs or symptoms of infection, such as persistent redness, warmth, swelling, or tenderness, at epinephrine injection site; cleansing with alcohol does not kill bacterial spores, and therefore, does not lower risk of infection Multiple-dose vial not for ophthalmic use; contains chlorobutanol which may be harmful to corneal endothelium Solutions must be diluted prior to intraocular use; other epinephrine products containing sodium bisulfite have been associated with corneal endothelial damage when used in the eye at undiluted concentrations (1 mg/mL) Autoinjector is to be used in conjunction with immediate medical or hospital care; more than two sequential doses of epinephrine should only be administered under direct medical supervision Extravasation Avoid extravasation; ensure proper needle or catheter placement prior to and during infusion To prevent sloughing and necrosis in areas has extravasation, infiltrate the area with 10-15 mL of 0.9% NaCl solution containing phentolamine 5-10 mg Use a syringe with a fine hypodermic needle, with solution being infiltrated liberally throughout the area, which has a cold, hard, and pallid appearance Phentolamine may cause immediate and conspicuous local hyperemic changes if area is infiltrated within 12 hr Injection related complications Injection into buttock may not provide effective treatment of anaphylaxis Accidental injection into hands, digits, or feet may result in local reactions including injection site coldness, pallor, and hypoesthesia or injury resulting in bruising, discoloration, erythema, bleeding, or skeletal injury To minimize the risk of injection-related injury when administering autoinjector to children or infants, instruct caregivers to firmly hold child’s leg in place and limit movement prior to and during injection Drug interactions overview Coadministration with cardiac glycosides, diuretics, or anti-arrhythmics should be observed carefully for the development of cardiac arrhythmias Effects of epinephrine may be potentiated by tricyclic antidepressants, monoamine oxidase inhibitors, levothyroxine sodium, and certain antihistamines, notably chlorpheniramine, tripelennamine, and diphenhydramine Cardiostimulating and bronchodilating effects of epinephrine are antagonized by beta-adrenergic blocking drugs, such as propranolol Vasoconstricting and hypertensive effects of epinephrine are antagonized by alpha-adrenergic blocking drugs, such as phentolamine Ergot alkaloids may reverse the pressor effects of epinephrine Pregnancy During pregnancy, anaphylaxis can be catastrophic and can lead to hypoxic-ischemic encephalopathy and permanent central nervous system damage or death in the mother and, more commonly, in the fetus or neonate The prevalence of anaphylaxis occurring during pregnancy is reported to be approximately 3 cases per 100,000 deliveries; management of anaphylaxis during pregnancy is similar to management in the general population Epinephrine is the first line-medication of choice for treatment of anaphylaxis; it should be used in the same