Dobutamine (Dobutrex) - Indication, MOA, Dose, Side effects

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

Risk Factor C (Monitor therapy).

AtoMOXetine Might increase the hypertensive effects of Sympathomimetics. AtoMOXetine could increase the tachycardic effects of Sympathomimetics.
Calcium Salts Might reduce the therapeutic effects of DOBUTamine.
Cannabinoid-Containing Products Sympathomimetics may increase the tachycardic effects of Sympathomimetics. Cannabidiol is an exception.
COMT Inhibitors Could cause a decrease in the metabolism of COMT Substrates. Risk C: Monitor therapy
Doxofylline Doxofylline may be more toxic or harmful if taken with Sympathomimetics.
Guanethidine May increase the arrhythmogenic effects of Sympathomimetics. The hypertensive effects of Sympathomimetics may be enhanced by Guanethidine.
Solriamfetol Sympathomimetics could increase the hypertensive effects of Solriamfetol.
Sympathomimetics May increase the toxic/adverse effects of other Sympathomimetics.
Tedizolid Might increase the hypertensive effects of Sympathomimetics. Tedizolid could increase the tachycardic effects of Sympathomimetics.

Risk Factor D (Consider therapy modifications)

Topical Cocaine Sympathomimetics may increase hypertension. Management: If possible, consider other options to this combination. Concurrent use of this combination can cause significant elevations in blood pressure and heart rate. You should also be aware of any signs of myocardial injury.
Linezolid Sympathomimetics may increase hypertensive effects. Patients receiving linezolid should be reduced in initial doses and closely monitored for an increased pressor response. There are no recommendations for dose adjustments.

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:

Dobutamine (Hcl) Injection 250 mg

Cara-Doba Caraway Pharmaceuticals

Dobutamine (Hcl) Injection 50 mg/ml

Dobex Bio Pharma
Dobuject A.J. & Company.
Dobutamed Mediceena Pharma (Pvt) Ltd.
Dotrex Akhai Pharmaceuticals.

Dobutamine (Hcl) Injection 250 mg/ml

Buta English Pharmaceuticals Industries
Dobutamine Hoffman Health Pakistan Ltd.
Duvig Medinet Pharmaceuticals
Myungmoon Dobutamine Rehmat Pharma

Dobutamine (Hcl) Injection 12.5 mg/ml

Dobutamine Haji Medicine Co.

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