Nimbex

Muscle Relaxants, Peripherally Acting

Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Accidental administration of neuromuscular blocking agents can be fatal. Store cisatracurium with the cap and ferrule intact, in a manner that minimizes the possibility of selecting the wrong product.[42614]
Updates for coronavirus disease 2019 (COVID-19): The FDA is allowing cisatracurium 2 mg/mL and 10 mg/mL to be used beyond the labeled in-use time to help ensure access during COVID-related drug shortages. This period should be as short as possible, and for a maximum of 2 hours at room temperature or 4 hours when refrigerated. In-use time is defined as the maximum amount of time allowed to elapse between penetration of a closed-container system or after reconstitution of a lyophilized drug before patient administration.[65833]

Only experienced clinicians, familiar with the use of neuromuscular blocking drugs, should administer or supervise the use of cisatracurium. Adequacy of respiration must be assured through assisted or controlled ventilation.
To avoid distress to the patient, administer cisatracurium only after unconsciousness has been induced. Adequate amnesia, sedation, and analgesia should accompany neuromuscular blockade.
Do not mix cisatracurium with alkaline solutions (e.g., barbiturate solutions such as thiopental) in the same syringe or administer simultaneously during IV infusion through the same needle or the same IV line; cisatracurium has an acidic pH.
The 20 mL vial is only intended for administration as an infusion for use in a single intensive care patient. Do not use the 20 mL vial multiple times because there is a higher risk of infection. The 20 mL vial does not contain a preservative.[42614]
 
Intermittent IV Injection
Dilution is not necessary.
Administer by direct IV injection over 5 to 10 seconds.[42614]
 
Continuous IV Infusion
Dilute with 5% Dextrose Injection, 0.9% Sodium Chloride Injection, 5% Dextrose and 0.9% Sodium Chloride Injection, or Lactated Ringer's and 5% Dextrose Injection to 0.1 mg/mL or with Lactated Ringer's and 5% Dextrose Injection to 0.2 mg/mL. Final concentration range: 0.1 to 0.4 mg/mL.[42614]
ASHP Recommended Standard Concentrations for Adult Continuous Infusions: 2 mg/mL.[64020]
Infuse at a rate based on patient response and requirements.
A peripheral nerve stimulator is recommended to monitor rocuronium's effects. Target response is typically 1 to 2 twitches. Incorrect electrode placement, direct stimulation of muscle due to large electrode size, acute illness, capillary leak, and edema may affect an appropriate assessment. Monitor visual and tactile stimulation on muscle movement as well as heart rate, blood pressure, and mechanical ventilator status during administration.[42614] [52441]
Storage: Diluted solutions may be stored under refrigeration for 24 hours.[42614]

bronchospasm / Rapid / 0.2-1.5
bradycardia / Rapid / 0.4-0.4
laryngospasm / Rapid / Incidence not known
angioedema / Rapid / Incidence not known
anaphylactoid reactions / Rapid / Incidence not known
malignant hyperthermia / Rapid / Incidence not known
muscle paralysis / Delayed / Incidence not known
apnea / Delayed / Incidence not known
acute quadriplegic myopathy syndrome / Delayed / Incidence not known
thrombosis / Delayed / Incidence not known
keratitis / Delayed / Incidence not known
seizures / Delayed / Incidence not known

hypotension / Rapid / 0.2-0.2
sinus tachycardia / Rapid / Incidence not known
wheezing / Rapid / Incidence not known
erythema / Early / Incidence not known
respiratory depression / Rapid / Incidence not known
hypoxia / Early / Incidence not known
myopathy / Delayed / Incidence not known
dyspnea / Early / Incidence not known
skin erosion / Delayed / Incidence not known
conjunctivitis / Delayed / Incidence not known
skin ulcer / Delayed / Incidence not known
tolerance / Delayed / Incidence not known

flushing / Rapid / 0.2-0.2
rash / Early / 0.1-0.1
pruritus / Rapid / Incidence not known
urticaria / Rapid / Incidence not known
weakness / Early / Incidence not known
xerophthalmia / Early / Incidence not known
anxiety / Delayed / Incidence not known

Nimbex

Rx

Parenteral, intermediate-acting, nondepolarizing, neuromuscular blocking agent (NMBA)
Used for an adjunct to general anesthesia to facilitate tracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation
Minimal histamine release

0.15 to 0.2 mg/kg/dose IV. Doses up to 0.4 mg/kg have been used. Onset of intubating conditions is 2 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.15 to 0.2 mg/kg/dose IV. Doses up to 0.4 mg/kg have been used. Onset of intubating conditions is 2 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.1 to 0.15 mg/kg/dose IV. Onset of intubating conditions is about 3 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.15 mg/kg/dose IV. Onset of intubating conditions is about 2 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.15 to 0.2 mg/kg IV once, followed by 0.03 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Generally, the first maintenance dose is required 40 to 50 minutes and 50 to 60 minutes after initial doses of 0.15 mg/kg and 0.2 mg/kg, respectively. For shorter or longer duration of action, smaller or larger doses may be administered. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[42614]

0.15 to 0.2 mg/kg IV once, followed by 3 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Dosage range: 0.5 to 10.2 mcg/kg/minute. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.15 to 0.2 mg/kg IV once, followed by 3 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Dosage range: 0.5 to 10.2 mcg/kg/minute. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.15 mg/kg IV once, followed by 1 to 3 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.15 to 0.2 mg/kg IV once, followed by 0.03 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Generally, the first maintenance dose is required 40 to 50 minutes and 50 to 60 minutes after initial doses of 0.15 mg/kg and 0.2 mg/kg, respectively. For shorter or longer duration of action, smaller or larger doses may be administered. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[42614]

0.15 to 0.2 mg/kg IV once, followed by 0.03 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Generally, the first maintenance dose is required 40 to 50 minutes and 50 to 60 minutes after initial doses of 0.15 mg/kg and 0.2 mg/kg, respectively. For shorter or longer duration of action, smaller or larger doses may be administered. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[42614]

0.15 to 0.2 mg/kg IV once, followed by 3 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Dosage range: 1 to 3 mcg/kg/minute. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.15 to 0.2 mg/kg IV once, followed by 3 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Dosage range: 1 to 3 mcg/kg/minute. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.1 to 0.15 mg/kg IV once, followed by 3 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Dosage range: 1 to 3 mcg/kg/minute. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

Limited data; 0.06 to 0.12 mg/kg/hour continuous IV infusion. Guidelines suggest neuromuscular blocking agents may be used to manage overt shivering in therapeutic hypothermia.

15 mg IV once, followed by 37.5 mg/hour continuous IV infusion for 48 hours.[56349] Alternately, 0.2 mg/kg or 50 mg IV once, followed by 5 mcg/kg/minute continuous IV infusion with increase by 20% when train-of-four response is 1 or more for 48 hours.[59212] [59217] Guidelines recommend a short course (48 hours or less) of neuromuscular blockade for patients with early, sepsis-induced ARDS with a PaO2/FiO2 less than 150 mmHg.[61770]

†Indicates off-label use

Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.

Consider extending the interval between administering cisatracurium and attempting intubation by at least 1 minute to achieve adequate intubation conditions; the time to 90% neuromuscular blockade was 1 minute slower in patients with end-stage renal disease than in patients with normal renal function.

Acebutolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Acetazolamide: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Amide local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Aminoglycosides: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Atorvastatin: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Benazepril: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Celecoxib: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Olmesartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amphotericin B lipid complex (ABLC): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Amphotericin B liposomal (LAmB): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Amphotericin B: (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Atenolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Atenolol; Chlorthalidone: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bacitracin: (Minor) Concomitant use of neuromuscular blockers and systemic bacitracin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Beta-blockers: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Betaxolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bismuth Subcitrate Potassium; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bisoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Botulinum Toxins: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Brimonidine; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Calcium Acetate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Famotidine; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Magnesium Hydroxide; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Chloride: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Gluconate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium; Vitamin D: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium-channel blockers: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Capreomycin: (Minor) Concomitant use of neuromuscular blockers and capreomycin may prolong neuromuscular blockade. A partial neuromuscular blockade was demonstrated after large intravenous doses of capreomycin.
Carbamazepine: (Moderate) Monitor for a more rapid recovery from neuromuscular blockade than expected during concurrent use of carbamazepine and cisatracurium. When administering neuromuscular blockade via continuous infusion, infusion rate requirements may be higher. Chronic carbamazepine administration may cause neuromuscular blockade resistance.
Carbonic anhydrase inhibitors: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Carteolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Carvedilol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Chromium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Clevidipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Colistimethate, Colistin, Polymyxin E: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Colistin: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Corticosteroids: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Cyclosporine: (Moderate) Concomitant use of neuromuscular blockers and cyclosporine may prolong neuromuscular blockade.
Demeclocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Desflurane: (Moderate) Consider administering less frequent or lower cisatracurium maintenance bolus doses for long surgical procedures using desflurane administered with nitrous oxide/oxygen at the 1.25 MAC level for at least 30 minutes. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration. Concomitant use of cisatracurium and desflurane may prolong neuromuscular blockade. No adjustment to the initial cisatracurium maintenance bolus dose should be necessary when cisatracurium is administered shortly after initiation of desflurane.
Dextromethorphan; Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Diltiazem: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Donepezil: (Moderate) A higher cisatracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as donepezil.
Donepezil; Memantine: (Moderate) A higher cisatracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as donepezil.
Dorzolamide; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Doxapram: (Minor) Doxapram may temporarily mask the residual effects of neuromuscular blockers.
Doxycycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Esmolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Ester local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Felodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Folic Acid, Vitamin B9: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Fosphenytoin: (Moderate) Concomitant use of neuromuscular blockers and fosphenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Galantamine: (Moderate) A higher cisatracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as galantamine.
Indapamide: (Moderate) Concomitant use of neuromuscular blockers and indapamide may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Irinotecan Liposomal: (Moderate) Irinotecan may antagonize the neuromuscular blocking effects of cisatracurium due to anticholinesterase activity.
Irinotecan: (Moderate) Irinotecan may antagonize the neuromuscular blocking effects of cisatracurium due to anticholinesterase activity.
Isoflurane: (Moderate) Consider administering less frequent or lower cisatracurium maintenance bolus doses for long surgical procedures using isoflurane administered with nitrous oxide/oxygen at the 1.25 MAC level for at least 30 minutes. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration. Isoflurane anesthesia prolonged the clinically effective duration of action of initial and maintenance cisatracurium doses and decreased the average cisatracurium infusion rate requirement by as much as 30% to 40%. No adjustment to the initial cisatracurium maintenance bolus dose should be necessary when cisatracurium is administered shortly after initiation of isoflurane.
Isradipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Ketorolac: (Minor) There have been postmarketing reports of a possible interaction between ketorolac and nondepolarizing neuromuscular blockers, such as cisatracurium, that resulted in apnea.
Labetalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Levamlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Levobunolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Lincosamides: (Moderate) Use neuromuscular blockers and lincosamides with caution. Concomitant use of neuromuscular blockers and lincosamides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lithium: (Moderate) Concomitant use of neuromuscular blockers and lithium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Loop diuretics: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Magnesium: (Moderate) Concomitant use of neuromuscular blockers and magnesium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Methazolamide: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Metoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Minocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Nadolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Nebivolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Nebivolol; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Neostigmine: (Moderate) A higher cisatracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as neostigmine. Intravenous neostigmine is indicated for reversal of the effects of nondepolarizing neuromuscular blockers, such as cisatracurium.
Neostigmine; Glycopyrrolate: (Moderate) A higher cisatracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as neostigmine. Intravenous neostigmine is indicated for reversal of the effects of nondepolarizing neuromuscular blockers, such as cisatracurium.
Nicardipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nifedipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nimodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nisoldipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Omadacycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Perindopril; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Phenytoin: (Moderate) Concomitant use of neuromuscular blockers and phenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Physostigmine: (Moderate) A higher cisatracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as physostigmine.
Pindolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Piperacillin; Tazobactam: (Moderate) Concomitant use of cisatracurium and piperacillin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Polymyxin B: (Major) Avoid concomitant use of systemic polymyxin B and neuromuscular blockers due to the risk of respiratory depression. The neurotoxicity of polymyxin B may can result in neuromuscular blockade, especially when given soon after neuromuscular blockers. If signs of respiratory paralysis appear, assist respiration and discontinue drug therapy.
Procainamide: (Moderate) A lower neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant procainamide use due to procainamide effects on reducing acetylcholine release. Concomitant use of neuromuscular blockers and procainamide may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Propranolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Propranolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Pyridostigmine: (Moderate) A higher cisatracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as pyridostigmine. Intravenous pyridostigmine is indicated for reversal of the effects of nondepolarizing neuromuscular blockers, such as cisatracurium.
Pyridoxine, Vitamin B6: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Quinine: (Major) Avoid concomitant use of neuromuscular blockers and quinine. Quinine may enhance the action of neuromuscular blockers. In 1 patient who received a neuromuscular blocker during an operative procedure, subsequent administration of quinine 1,800 mg 3 hours later resulted in respiratory depression.
Ranitidine: (Moderate) Ranitidine may cause resistance to cisatracurium-induced neuromuscular blockade, due to pharmacodynamic alterations at the acetylcholine receptor. In vitro studies demonstrate that therapeutic serum concentrations of ranitidine inhibit acetylcholinesterase, thus increasing the amount of acetylcholine available to compete at the neuromuscular junction and reverse the neuromuscular blockade. The inhibition of acetylcholinesterase is likely dose-related. Resistance to nondepolarizing neuromuscular blockers was reported occasionally with intravenous ranitidine dosages that were slightly higher than those given clinically, but not frequently with oral therapy.
Rivastigmine: (Moderate) A higher cisatracurium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as rivastigmine.
Sarecycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Sevoflurane: (Moderate) Consider administering less frequent or lower cisatracurium maintenance bolus doses for long surgical procedures using sevoflurane administered with nitrous oxide/oxygen at the 1.25 MAC level for at least 30 minutes. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration. Concomitant use of cisatracurium and sevoflurane may prolong neuromuscular blockade. No adjustment to the initial cisatracurium maintenance bolus dose should be necessary when cisatracurium is administered shortly after initiation of sevoflurane.
Sotalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Stiripentol: (Moderate) Monitor for excessive sedation and somnolence during coadministration of stiripentol and cisatracurium. CNS depressants can potentiate the effects of stiripentol.
Succinylcholine: (Moderate) The use of succinylcholine before cisatracurium administration may decrease the time to onset of maximum neuromuscular blockade but has no effect on the duration of neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Telmisartan; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Tetracyclines: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Theophylline, Aminophylline: (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant aminophylline use. Aminophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition. (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant theophylline use. Theophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition.
Thiazide diuretics: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Trandolapril; Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Vancomycin: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.

Cisatracurium/Cisatracurium Besylate/Nimbex Intravenous Inj Sol: 1mL, 2mg, 10mg

Specific maximum dosage information is not available. Dosage must be individualized based on clinical response.

Muscle contraction is initiated by an action potential traveling from the central nervous system to the nerve terminal. At the nerve terminal, the action potential causes an influx of calcium, initiating the release of acetylcholine (ACh) into the synaptic cleft. ACh binds to ACh receptors on the muscle fiber's motor end-plate causing a conformational change that briefly opens sodium ion channels. When an adequate number of ACh receptors are activated, membrane potential decreases and voltage-dependent sodium ion channels of adjacent muscle membranes activate, transmitting the action potential throughout the muscle fiber and resulting in muscle contraction.[52452] Nondepolarizing neuromuscular blocking agents (NMBAs) such as cisatracurium produce skeletal muscle paralysis by competing with ACh for cholinergic receptor sites at the motor end-plate.[52486] Neuromuscular blockade progresses in a predictable order, beginning with muscles associated with fine movements (e.g., eyes, face, and neck), followed by muscles of the limbs, chest, and abdomen and, finally, the diaphragm. Larger doses increase the chance of respiratory depression associated with relaxation of the intercostal muscles and the diaphragm. Muscle tone returns in the reverse order.[52503]

Cisatracurium is administered intravenously. The volume of distribution is limited by its large molecular weight and high polarity. The binding of cisatracurium to plasma proteins has not been successfully studied due to its rapid degradation at physiologic pH. Cisatracurium undergoes organ-independent Hofmann elimination (a pH and temperature-dependent chemical process) to form the monoquaternary acrylate metabolite and laudanosine, neither of which has any neuromuscular blocking activity. The monoquaternary acrylate metabolite undergoes hydrolysis by non-specific plasma esterases to form the monoquaternary alcohol (MQA) metabolite. Laudanosine is further metabolized to desmethyl metabolites which are conjugated with glucuronic acid and excreted in the urine. Mean clearance values for cisatracurium range 4.5—5.7 mL/min/kg in healthy surgical patients. Pharmacokinetic modeling suggests that 80% of the clearance is accounted for by Hofmann elimination and the remaining 20% by renal and hepatic elimination. Approximately 95% of a dose is recovered in the urine (mostly as conjugated metabolites) and 4% in the feces; less than 10—15% of the dose is excreted as unchanged drug. The mean elimination half-life of cisatracurium is 22—29 minutes. The mean elimination half-life for laudanosine is 3.1 hours.

During IV infusions of cisatracurium, peak plasma concentrations of laudanosine and the MQA metabolite are approximately 6% and 11% of the parent compound, respectively. Peak concentrations of laudanosine are significantly lower in healthy surgical patients receiving infusions of cisatracurium than in patients receiving infusions of atracurium (Cmax = 60 ng/mL vs 342 ng/mL). The average ED95 (dose required to produce 95% suppression of the adductor pollicis muscle twitch response to ulnar nerve stimulation) of cisatracurium is 0.05 mg/kg (range: 0.048—0.053) in adults receiving opioid/nitrous oxide/oxygen anesthesia. The average ED95 for atracurium under similar conditions is 0.17 mg/kg. After a cisatracurium dose of 0.1 mg/kg (2 times ED95), time to 90% block is 3.3 minutes (range: 1—8.7 min) and time to 95% recovery is about 64 minutes (range: 25—93 min). In adult patients, the time to maximum block is up to 2 minutes longer for equipotent doses of cisatracurium compared to atracurium. The clinically effective duration of action and rate of spontaneous recovery from equipotent doses of cisatracurium and atracurium are similar. For cisatracurium, the rate of spontaneous recovery of neuromuscular function after infusion is independent of the duration of the infusion and comparable to the rate of recovery following initial doses. In one study in which cisatracurium or vecuronium infusion was administered for up to 6 days during mechanical ventilation in the ICU, patients treated with cisatracurium recovered neuromuscular function following termination of the infusion in about 55 minutes (range: 20—270 min); those treated with vecuronium recovered in 178 minutes (range: 40 min to 33 hours).

There are no data on cisatracurium use in human pregnancy to evaluate for drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Although fetal exposure to benzyl alcohol is unlikely due to rapid metabolism by the pregnant person, consider using a benzyl alcohol-free formulation of cisatracurium in pregnant persons. The 10 mL multiple-dose vials of cisatracurium contain benzyl alcohol. Animal studies in pregnant rats administered cisatracurium during organogenesis at doses equivalent to 0.4- to 12-times the AUC exposure in humans after a bolus dose of 0.2 mg/kg IV revealed no maternal or fetal toxicity or teratogenic effects. The action of neuromuscular blocking agents may be enhanced by magnesium salts administered for the management of toxemia in pregnancy.[42614]

There are no data on the presence of cisatracurium in human milk, the effects on the breast-fed infant, or the effects on milk production. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for cisatracurium and any potential adverse effects on the breast-fed infant from cisatracurium or the underlying maternal condition. Cisatracurium undergoes rapid and spontaneous (Hofmann elimination) degradation in the plasma.[42614] Cisatracurium also is poorly absorbed from the gastrointestinal tract. Based on these data, lactation could be allowed as soon as practically feasible after surgery.[48668] Although fetal exposure to benzyl alcohol is unlikely due to rapid metabolism by the lactating mother, consider using a benzyl alcohol-free formulation of cisatracurium in breast-feeding patients. The 10 mL multiple dose vials of cisatracurium contain benzyl alcohol.[42614]