Rx Update: December 2001

Nesiritide

Mary Ross, R.Ph., M.B.A.
Peer Review Status: Internally Reviewed

Nesiritide (Natrecor® - Scios) is a recombinant form of a natriuretic peptide indicated for the treatment of acutely decompensated chronic heart failure with dyspnea at rest or with minimal activity. Nesiritide reduces both preload and afterload by venous and arterial dilation, increases cardiac output, and increases diuresis and sodium excretion.

Nesiritide should not be used as primary therapy in patients with cardiogenic shock or in patients with a systolic blood pressure < 90 mm Hg. It should be used with caution in patients with low cardiac filling pressures, significant valvular stenosis, restrictive or obstructive cardiomyopathy, constrictive pericarditis, pericardial tamponade, and other conditions where cardiac output depends on venous return.

The most common adverse reactions reported with nesiritide include dose-dependent hypotension, dizziness, lightheadedness, and diaphoresis. If a patient on nesiritide becomes hypotensive, the dose can be reduced or discontinued until the patient is normotensive. Fluids or position changes can help reverse the hypotension. Once blood pressure normalizes, the infusion can be restarted at a 30% reduced rate. Concomitant use of angiotensin converting enzyme inhibitors (e.g., captopril, benazepril) may increase the risk of symptomatic hypotension (SBP < 90 mm Hg and syncope).

Nesiritide is incompatible with heparin, insulin, ethacrynate sodium, bumetanide, enalaprilat, hydralazine, and furosemide. Concomitant administration of heparin through a separate catheter is acceptable. Nesiritide should be administered through a peripheral IV or a central catheter that is not heparin-coated.

Nesiritide is available as a 1.5 mg vial. The powder is reconstituted and further diluted with 250 ml of D5W or NS to a final concentration of 6 mcg/ml. Nesiritide is administered as an IV bolus followed by a continuous infusion. The bolus should be administered from the diluted IV bag; it should not be given undiluted from the vial. The bolus dose is 2 mcg/kg administered over 60 seconds through tubing primed with 25 ml of normal saline. The infusion immediately follows the bolus at a rate of 0.01 mcg/kg/min. The initial flow rate for a nesiritide infusion can be calculated by the following equation: flow rate (ml/hr)= 0.1 x patient weight (kg). The duration of therapy is usually 24 to 48 hours. If needed, infusion rate increases should be made no more frequently than every 3 hours, and should not exceed 0.03 mcg/kg/min. Patients should be monitored for hypotension frequently during nesiritide therapy.

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