NESIRITIDE
(nes-ir'i-tide)
Natrecor
Classifications: cardiovascular agent; atrial natriuretic peptide hormone
Pregnancy Category: C

Availability

1.5 mg vial

Actions

Nesiritide is a human B-type natriuretic peptide (hBNP), produced by recombinant DNA, which mimics the actions of human atrial natriuretic hormone (ANH). ANH is secreted by the right atrium when atrial blood pressure increases. Nesiritide, like ANH, inhibits antidiuretic hormone (ADH) by increasing urine sodium loss by the kidney and triggering the formation of a large volume of dilute urine.

Therapeutic Effects

Nesiritide binds to a cyclic nucleic acid, which results in smooth muscle cell relaxation. The drug also causes dilation of veins and arteries. It is effective in managing dyspnea at rest in patients with acute congestive heart failure (CHF).

Uses

Acute treatment of decompensated CHF in patients who have dyspnea at rest or with minimal activity.

Contraindications

Hypersensitivity to nesiritide, patients with a systolic blood pressure <90 mm Hg, cardiogenic shock, patients with low cardiac filling pressures, patients who should not receive vasodilators, such as those with significant valvular stenosis, restrictive or obstructive cardiomyopathy, constrictive pericarditis, pericardial tamponade; pregnancy (category C).

Cautious Use

Lactation, concurrent administration of ACE inhibitors or vasodilators. Safety and efficacy in pediatric patients have not been established.

Route & Dosage

Acute Decompensated CHF
Adult: IV 2 mcg/kg bolus administered over 60 s, followed by a continuous infusion of 0.01 mcg/kg/min (0.1 mL/kg/h) (max: 0.03 mcg/kg/min). Monitor blood pressure closely. If hypotension occurs, the dose should be reduced or discontinued. The infusion can subsequently be restarted at a dose that is reduced by 30% (with no bolus administration) after stabilization of hemodynamics.

Administration

Intravenous

PREPARE: Direct: and IV Infusion: Reconstitute one 1.5 mg vial by adding 5 mL of IV solution removed from a 250 mL bag of selected diluent (i.e., D5W, NS, D5/0.45% NaCl, D5/0.2% NaCl). Rock the vial gently so that all surfaces, including the stopper, contact the diluent ensuring complete reconstitution. Do not shake the vial. Add the entire contents of the vial to the 250 mL IV bag to yield approximately 6 mcg/mL. Invert the bag several times to mix completely. Use within 24 h. Prime the IV tubing with 25 mL prior to connecting to the vascular access port.

ADMINISTER: Direct: Withdraw the bolus dose from the prepared infusion bag. Determine dose as follows: bolus volume (mL) = (0.33) x (patient weight in kg). Give the bolus dose over 60 sec through an IV port in the tubing. IV Infusion: Infuse remainder of IV infusion immediately following the bolus dose. Determine the infusion rate as follows: flow rate (mL/h) = (0.1) x (patient weight in kg).

INCOMPATIBILITIES Solution/additive and Y-site: Bumetanide, enalaprilate, ethacrynic acid, furosemide, heparin, hydralazine, insulin.

Store at controlled room temperature at 20°–25° C (68°–77° F) or refrigerated.

Adverse Effects (1%)

Body as a Whole: Headache, back pain, catheter pain, fever, injection site pain, leg cramps. CNS: Insomnia, dizziness, anxiety, confusion, paresthesia, somnolence, tremor. CV: Hypotension, ventricular tachycardia, ventricular extrasystoles, angina, bradycardia, tachycardia, atrial fibrillation, AV node conduction abnormalities. GI: Abdominal pain, nausea, vomiting. Respiratory: Cough, hemoptysis, apnea. Skin: Sweating, pruritus, rash. Special Senses: Amblyopia. Renal: Renal failure in acutely decompensated heart failure patients.

Interactions

Drug: No interaction trials conducted. No clinically significant interactions reported.

Pharmacokinetics

Onset: 15 min. Duration: >60 h depending on dose. Metabolism/Elimination: Cleared from the circulation via the following three independent mechanisms, in order of decreasing importance: 1) binding to cell surface clearance receptors with subsequent cellular internalization and lysosomal proteolysis; 2) proteolytic cleavage of the peptide by endopeptidases, such as neutral endopeptidase, which are present on the vascular luminal surface; and 3) renal filtration. Half-Life: 18 min.

Nursing Implications

Assessment & Drug Effects

Monitor hemodynamic parameters (e.g., BP, PCWP, HR, ECG) throughout therapy. Notify physician immediately if systolic BP <90 mm Hg.
Establish hypotension parameters prior to initiating therapy.
Reduce the dose or withhold the drug if hypotension occurs during administration. Reinitiate therapy infusion only after hypotension is corrected. Subsequent doses following a hypotensive episode are usually reduced by 30% and given without a prior bolus dose.
Lab tests: Baseline and periodic serum creatinine.

Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; Canadian drug name; Prototype drug