Dobutamine (Dobutrex) is an inotropic drug that increases cardiac contractility resulting in improved stroke volume and cardiac output.

Dobutamine Uses:

• Cardiac decompensation:

  • Short-term management of patients with cardiac decompensation

Guideline recommendations:

• Cardiogenic shock:

  • The 2017 American Heart Association (AHA) scientific statement for the Contemporary Management of Cardiogenic Shock suggest dobutamine to maintain systemic perfusion and maintain end-organ performance in patients with cardiogenic shock.
  • A vasopressor such as norepinephrine (preferred), vasopressin, or dopamine is typically the initial therapy of choice until hemodynamically stable.
  • Once stable, consider adding or switching to an inotrope.
  • However, an inotrope may be the preferred therapy for cardiogenic shock due to acute decompensated heart failure or in other cases when systolic blood pressure >90 mm Hg.

• Inotropic support in advanced heart failure:

  • Bridge therapy in stage D HF unresponsive to guideline-directed medical therapy and device therapy in patients awaiting a heart transplant or mechanical circulatory support;
  • The short-term management of hospitalized patients with severe systolic dysfunction presenting with hypotension and significantly reduced cardiac output;
  • The long-term management (palliative therapy) in select patients with stage D HF non-responsive to guideline-directed medical therapy and device therapy who are not candidates for a heart transplant or mechanical circulatory support.

• Off Label Use of Dobutamine in Adults:

  • Advanced life support
  • Myocardial dysfunction related to sepsis (positive inotropic agent)
  • Stress echocardiography (diagnostic agent)

Adult dose:

Dobutamine Dose in the treatment of Cardiac decompensation:

• Initial dose:

  • 0.5 to 1 mcg/kg/minute;
  • may also start at higher doses (eg, 2.5 mcg/kg/minute) depending on severity of decompensation with titration to desired response.

• Maintenance dose:

  • 2 to 20 mcg/kg/minute.
  • Note: In patients with heart failure, lower doses are preferred to minimize adverse outcomes.

• Maximum dose:

  • 40 mcg/kg/minute.
  • The ACCF/AHA 2013 heart failure guidelines suggest a maximum dose of 20 mcg/kg/minute

Dobutamine Dose in the immediate post-cardiac arrest care settings (Adult Advanced Cardiovascular Life Support (ACLS) guideline recommendation:

• IV infusion: Initial: 5 to 10 mcg/kg/minute;
• titrate to desirable effect

Dobutamine Dose in the treatment of Stress echocardiography (diagnostic agent) (off-label):

• IV infusion:
  • Initial: 5 to 10 mcg/kg/minute;
  • increase at every 3-minute intervals to 20 mcg/kg/minute, then 30 mcg/kg/minute, and then 40 mcg/kg/minute.
  • May co-administer atropine who do not achieve target heart rate

Dose in children:

Dobutamine Dose in the treatment of Hemodynamic support:

• Infants, Children, and Adolescents:

  • Continuous IV or intraosseous infusion:
    • Initial: 0.5 to 1 mcg/kg/minute,
    • up titrate gradually every few minutes until desired response achieved;
    • usual range: 2 to 20 mcg/kg/minute

Dobutamine Pregnancy Risk Category: B

• It should not be used to diagnose stress during pregnancy.
• The same medications are used to treat cardiac arrest in pregnant women as for non-pregnant patients.
• Because of concerns about fetal teratogenicity, it is important to not withhold appropriate medications.
• You may consider using dobutamin in the post-resuscitation period. However, it is important to also consider the effects of inotropic support for the fetus.
• Follow the current guidelines of advanced Cardiovascular Life Support (ACLS) for indications and dosages.

Dobutamine use during breastfeeding:

• Dobutamine may be present in breast milk, but it is unknown.

Dobutamine Dose in Kidney disease:

• There are no dosage adjustments provided in the drug manufacturer's labeling.

Dobutamine Dose in Liver disease:

• There are no dosage adjustments provided in the drug manufacturer's labeling.

Side effects of Dobutamine:

• Cardiovascular:

  • Ventricular Premature Contractions
  • Angina Pectoris
  • Chest Pain
  • Palpitations
  • Hypotension
  • Increased Blood Pressure
  • Increased Heart Rate
  • Localized Phlebitis
  • Ventricular Ectopy (Increased)

• Central Nervous System:

  • Headache
  • Paresthesia

• Dermatologic:

  • Skin Necrosis (Isolated Cases)

• Endocrine & Metabolic:

  • Decreased Serum Potassium (Slight)

• Gastrointestinal:

  • Nausea

• Hematologic & Oncologic:

  • Thrombocytopenia (Isolated Cases)

• Local:

  • Local Inflammation
  • Local Pain (From Infiltration)

• Neuromuscular & Skeletal:

  • Leg Cramps (Mild)

• Respiratory:

  • Dyspnea

• Miscellaneous:

  • Fever

Contraindications to Dobutamine:

• Hypersensitivity/Allergy to dobutamine or sulfites (some contain sodium meta bisulfate), or any component of the formulation;
• Hypertrophic cardiomyopathy (formerly known as Idiopathic hypertrophic Subaortic Steensis [IHSS]).

Notice:

• Patients with uncontrolled hypertension (>200/110mm Hg), severe aortic and atrial tachyarrhythmias, recent MI (1 week), patients with unstable angina, patients with uncontrolled ventricular responses, patients with ventricular tachycardia with uncontrolled ventricular response, patients with a history of ventricular dilation or large aortic andortic aneurysms, patients on beta-blockers, where dobutamine's inotropic effects to dobutamine are reduced.

Warnings and precautions

• Arrhythmias:

  • There have been reports of ventricular arrhythmias including supraventricular arrhythmias and non-sustainedventricular tachycardia.
  • Pay attention to arrhythmias in patients suffering from acute heart failure.
  • Before you start, ensure that your ventricular rate in atrial fibrillation/flutter is under control.
  • It can increase the rate of ventricular response. Protect heart transplant candidates against sudden cardiac death by taking appropriate precautions

• Blood pressure effects:

  • A patient might experience an increase in blood pressure due to an augmented cardiac output. However, it is possible for a patient to become hypotensive.

• Heart failure complications:

  • Patients with heart failure diagnosed by the New York Heart Association Class III/IV have a higher risk of death and hospitalization.

• Tachycardia

  • Could cause heart rate increases due to dose.

• Ventricular ectopy

  • May increase the severity of ventricular ectopy (dose-related).

• Aortic stenosis

  • Ineffective therapy in the presence severe aortic obstruction.

• Electrolyte imbalance:

  • To minimize arrhythmias, it is important to correct electrolyte disturbances (hypokalemia and hypomagnesemia) before starting therapy.

• Hypovolemia:

  • To optimize hemodynamics, you can correct hypovolemia first if necessary.

• Post: Active myocardial ischemia (post)

  • Patients with active myocardial injury or recent myocardial damage should be cautious.
  • It can also increase myocardial oxygen need.

Dobutamine: Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Monitoring parameters:

• Blood pressure,
• ECG,
• heart rate,
• CVP, RAP, MAP;
• serum glucose,
• renal function; urine output;
• if pulmonary artery catheter is in place, monitor CI, PCWP, and SVR;
• ScvO or SvO
• Consult individual institutional policies and procedures.

How to administer Dobutamine?

• Always administer via infusion device;
• administer into a large vein.

Mechanism of action of Dobutamine:

• Dobutamine, a racemic mix, stimulates beta adrenergic receptors in myocardial beta-1 cells primarily by (+) enantiomer. Some alpha receptor agonism is caused by (-) Enantiomer.
• This results in increased contractility, heart rate, and stimulation of both beta -receptors and the vasculature.
• Both beta and alpha-adrenergic nerve receptors can be activated.
• However, the effects beta receptor activation may equal or slightly exceed the effects alpha receptors stimulation.
• This results in vessels dilation in addition to the inotropic, chronotropic, and inotropic actions.
• It reduces wedge pressure and central venous pressure, but has very little or no effect on the pulmonary vascular resistance.

The onset of action:

• IV: 1 to 10 minutes

Peak effect:

• 10 to 20 minutes

Metabolism:

• In tissues and hepatically to inactive metabolites

Half-life elimination:

• 2 minutes

Excretion:

• Urine (as metabolites)

International Brands of Dobutamine:

• DOBUTamine SDZ
• Butamine
• Cardiject
• Cardiotone
• Cardomin
• Dexdobu
• Dobamin
• Dobtan
• Dobu-Hameln
• Dobucard
• Dobuject
• Dobumarc
• Dobumin
• Dobunex
• Doburan
• Dobusafe
• Dobutamin Hexal
• Dobutamin-Ratiopharm
• Dobutamine Aguettant
• Dobutamine Hydrochloride
• Dobutamine Panpharma
• Dobutel
• Dobutrex
• Dominic
• Doxa
• Duvig
• Easydobu
• Gendobu
• Inomin
• Inotop
• Inotrex
• Inotrop
• Myofast
• Posiject
• Pusogard
• Utamine

Dobutamine Brand Names in Pakistan: