Vasopressin injection is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines.

{ "type": "p", "children": [], "text": "Vasopressin injection is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines." }

Inspect parenteral drug products for particulate matter and discoloration prior to use, whenever solution and container permit.

VasopressinInjection Solution for Dilution, 20 units/mL

Dilute vasopressin injection in normal saline (0.9% sodium chloride) or 5% dextrose in water (D5W) prior to use for intravenous administration. Discard unused diluted solution after 18 hours at room temperature or 24 hours under refrigeration.

<div class="scrollingtable"><table> <caption> <span>Table 1 Preparation of diluted solutions</span> </caption> <col width="22%"/> <col width="1px"/> <col width="1px"/> <col width="1px"/> <thead> <tr class="First"> <th align="center" class="Lrule Rrule Toprule" rowspan="2" valign="top"><span class="Bold">Fluid restriction?</span></th><th align="center" class="Rrule Toprule" rowspan="2" valign="top"><span class="Bold">Final concentration</span></th><th align="center" class="Botrule Rrule Toprule" colspan="2" valign="top"><span class="Bold">Mix</span></th> </tr> <tr class="Last"> <th align="center" class="Botrule Lrule Rrule" valign="top">V <span class="Bold">asopressin Injection</span></th><th align="center" class="Botrule Rrule" valign="top"><span class="Bold">Diluent</span></th> </tr> </thead> <tbody> <tr class="First"> <td class="Botrule Lrule Rrule Toprule" valign="top">  <p class="First">No</p> </td><td class="Botrule Rrule Toprule" valign="top">  <p class="First">0.1 units/mL</p> </td><td class="Botrule Rrule Toprule" valign="top">  <p class="First">2.5 mL (50 units)</p> </td><td class="Botrule Rrule Toprule" valign="top">  <p class="First">500 mL</p> </td> </tr> <tr class="Last"> <td class="Botrule Lrule Rrule" valign="top">  <p class="First">Yes</p> </td><td class="Botrule Rrule" valign="top">  <p class="First">1 unit/mL</p> </td><td class="Botrule Rrule" valign="top">  <p class="First">5 mL (100 units)</p> </td><td class="Botrule Rrule" valign="top">  <p class="First">100 mL</p> </td> </tr> </tbody> </table></div>

In general, titrate to the lowest dose compatible with a clinically acceptable response.

The recommended starting dose is:

Post-cardiotomy shock:0.03 units/minute

Septic Shock:0.01 units/minute

Titrate up by 0.005 units/minute at 10 -to 15-minute intervals until the target blood pressure is reached. There are limited data for doses above 0.1 units/minute for post-cardiotomy shock and 0.07 units/minute for septic shock. Adverse reactions are expected to increase with higher doses.

After target blood pressure has been maintained for 8 hours without the use of catecholamines, taper vasopressin injection by 0.005 units/minute every hour as tolerated to maintain target blood pressure.

Vasopressin injection, USP is a colorless solution for intravenous administration available as 20 units/mL in a single dose vial. To be used after dilution.

{ "type": "p", "children": [], "text": "Vasopressin injection, USP is a colorless solution for intravenous administration available as 20 units/mL in a single dose vial. To be used after dilution." }

Vasopressin injection 1 mL single dose vial does not contain chlorobutanol and is therefore contraindicated only in patients with a known allergy or hypersensitivity to 8-L-arginine vasopressin.

{ "type": "p", "children": [], "text": "Vasopressin injection 1 mL single dose vial does not contain chlorobutanol and is therefore contraindicated only in patients with a known allergy or hypersensitivity to 8-L-arginine vasopressin." }

A decrease in cardiac index may be observed with the use of vasopressin.

Patients may experience reversible diabetes insipidus, manifested by the development of polyuria, a dilute urine, and hypernatremia, after cessation of treatment with vasopressin. Monitor serum electrolytes, fluid status and urine output after vasopressin discontinuation. Some patients may require readministration of vasopressin or administration of desmopressin to correct fluid and electrolyte shifts.

The following adverse reactions associated with the use of vasopressin were identified in the literature. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to estimate their frequency reliably or to establish a causal relationship to drug exposure.

{ "type": "p", "children": [], "text": "The following adverse reactions associated with the use of vasopressin were identified in the literature. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to estimate their frequency reliably or to establish a causal relationship to drug exposure." }

Bleeding/lymphatic system disorders: Hemorrhagic shock, decreased platelets, intractable bleeding

{ "type": "p", "children": [], "text": "Bleeding/lymphatic system disorders: Hemorrhagic shock, decreased platelets, intractable bleeding" }

Cardiac disorders: Right heart failure, atrial fibrillation, bradycardia, myocardial ischemia

{ "type": "p", "children": [], "text": "Cardiac disorders: Right heart failure, atrial fibrillation, bradycardia, myocardial ischemia" }

Gastrointestinal disorders: Mesenteric ischemia

{ "type": "p", "children": [], "text": "Gastrointestinal disorders: Mesenteric ischemia" }

Hepatobiliary: Increased bilirubin levels

{ "type": "p", "children": [], "text": "Hepatobiliary: Increased bilirubin levels" }

Renal/urinary disorders: Acute renal insufficiency

{ "type": "p", "children": [], "text": "Renal/urinary disorders: Acute renal insufficiency" }

Vascular disorders: Distal limb ischemia

{ "type": "p", "children": [], "text": "Vascular disorders: Distal limb ischemia" }

Metabolic: Hyponatremia

{ "type": "p", "children": [], "text": "Metabolic: Hyponatremia" }

Skin: Ischemic lesions

{ "type": "p", "children": [], "text": "Skin: Ischemic lesions" }

Postmarketing Experience

{ "type": "p", "children": [], "text": "\nPostmarketing Experience\n" }

Reversible diabetes insipidus [see Warnings and Precautions ( 5.2)] .

{ "type": "p", "children": [], "text": "Reversible diabetes insipidus\n \n [see Warnings and Precautions (\n \n 5.2)]\n \n .\n\n " }

Use with catecholaminesis expected to result in an additive effect on mean arterial blood pressure and other hemodynamic parameters. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed.

Use with indomethacinmay prolong the effect of vasopressin injection on cardiac index and systemic vascular resistance. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed [see Clinical Pharmacology (12.3)].

Use with ganglionic blocking agentsmay increase the effect of vasopressin injection on mean arterial blood pressure. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed [see Clinical Pharmacology (12.3)].

Use with drugs suspected of causing SIADH(e.g., SSRIs, tricyclic antidepressants, haloperidol, chlorpropamide, enalapril, methyldopa, pentamidine, vincristine, cyclophosphamide, ifosfamide, felbamate) may increase the pressor effect in addition to the antidiuretic effect of vasopressin injection. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed.

Use with drugs suspected of causing diabetes insipidus(e.g., demeclocycline, lithium, foscarnet, clozapine) may decrease the pressor effect in addition to the antidiuretic effect of vasopressin injection. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed.

Risk Summary

There are no available data on vasopressin injection use in pregnant women to inform a drug associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Animal reproduction studies have not been conducted with vasopressin.

Clinical Considerations

Dose adjustments during pregnancy and the postpartum period:Because of increased clearance of vasopressin in the second and third trimester, the dose of vasopressin injection may need to be increased [see Dosage and Administration (2.2) and Clinical Pharmacology ( 12.3)] .

Maternal adverse reactions: Vasopressin injection may produce tonic uterine contractions that could threaten the continuation of pregnancy.

There are no data on the presence of vasopressin injection in either human or animal milk, the effects on the breastfed infant, or the effects on milk production.

Safety and effectiveness of vasopressin injection in pediatric patients with vasodilatory shock have not been established.

Clinical studies of vasopressin did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy [see Warnings and Precautions (5), Adverse Reactions (6), and Clinical Pharmacology (12.3)] .

Overdosage with vasopressin injection can be expected to manifest as consequences of vasoconstriction of various vascular beds (peripheral, mesenteric, and coronary) and as hyponatremia. In addition, overdosage may lead less commonly to ventricular tachyarrhythmias (including Torsade de Pointes), rhabdomyolysis, and non-specific gastrointestinal symptoms.

{ "type": "p", "children": [], "text": "Overdosage with vasopressin injection can be expected to manifest as consequences of vasoconstriction of various vascular beds (peripheral, mesenteric, and coronary) and as hyponatremia. In addition, overdosage may lead less commonly to ventricular tachyarrhythmias (including Torsade de Pointes), rhabdomyolysis, and non-specific gastrointestinal symptoms." }

Direct effects will resolve within minutes of withdrawal of treatment.

{ "type": "p", "children": [], "text": "Direct effects will resolve within minutes of withdrawal of treatment." }

Vasopressin is a polypeptide hormone. Vasopressin injection, USP is a sterile, aqueous solution of synthetic arginine vasopressin for intravenous administration.

{ "type": "p", "children": [], "text": "Vasopressin is a polypeptide hormone. Vasopressin injection, USP is a sterile, aqueous solution of synthetic arginine vasopressin for intravenous administration." }

The 1 mL solution contains vasopressin, USP 20 units/mL, 1.36 mg sodium acetate trihydrate and Water for Injection, USP. Sodium hydroxide and hydrochloric acid are included to adjust to a pH of ⁓3.8.

{ "type": "p", "children": [], "text": "The 1 mL solution contains vasopressin, USP 20 units/mL, 1.36 mg sodium acetate trihydrate and Water for Injection, USP. Sodium hydroxide and hydrochloric acid are included to adjust to a pH of ⁓3.8." }

The chemical name of vasopressin is Cyclo (1-6) L-Cysteinyl-L-Tyrosyl-L-PhenylalanylL-Glutaminyl-L-Asparaginyl-L-Cysteinyl-L-Prolyl-L-Arginyl-L-Glycinamide. It is a white to off white powder/flakes, freely soluble in water. The structural formula is:

{ "type": "p", "children": [], "text": "The chemical name of vasopressin is Cyclo (1-6) L-Cysteinyl-L-Tyrosyl-L-PhenylalanylL-Glutaminyl-L-Asparaginyl-L-Cysteinyl-L-Prolyl-L-Arginyl-L-Glycinamide. It is a white to off white powder/flakes, freely soluble in water. The structural formula is:" }

Molecular Formula: C 46H 65N 15O 12S 2                Molecular Weight: 1084.24 u

{ "type": "p", "children": [], "text": "Molecular Formula: C\n \n 46H\n \n 65N\n \n 15O\n \n 12S\n \n 2                Molecular Weight: 1084.24 u\n\n " }

One mg is equivalent to 530 units.

{ "type": "p", "children": [], "text": "One mg is equivalent to 530 units." }

Vasopressin causes vasoconstriction by binding to V 1receptors on vascular smooth muscle coupled to the Gq/11-phospholipase C-phosphatidyl-inositol-triphosphate pathway, resulting in the release of intracellular calcium. In addition, vasopressin stimulates antidiuresis via stimulation of V 2receptors which are coupled to adenyl cyclase.

At therapeutic doses exogenous vasopressin elicits a vasoconstrictive effect in most vascular beds including the splanchnic, renal and cutaneous circulation. In addition, vasopressin at pressor doses triggers contractions of smooth muscles in the gastrointestinal tract mediated by muscular V 1-receptors and release of prolactin and ACTH via V 3receptors. At lower concentrations typical for the antidiuretic hormone vasopressin inhibits water diuresis via renal V 2receptors. In addition, vasopressin has been demonstrated to cause vasodilation in numerous vascular beds that are mediated by V 2, V 3, oxytocin and purinergic P2 receptors.

In patients with vasodilatory shock vasopressin in therapeutic doses increases systemic vascular resistance and mean arterial blood pressure and reduces the dose requirements for norepinephrine. Vasopressin tends to decrease heart rate and cardiac output. The pressor effect is proportional to the infusion rate of exogenous vasopressin. The pressor effect reaches its peak within 15 minutes. After stopping the infusion the pressor effect fades within 20 minutes. There is no evidence for tachyphylaxis or tolerance to the pressor effect of vasopressin in patients.

Vasopressin plasma concentrations increase linearly with increasing infusion rates from 10 to 200 μU/kg/min. Steady state plasma concentrations are achieved after 30 minutes of continuous intravenous infusion.

Distribution

Vasopressin does not appear to bind plasma protein. The volume of distribution is 140 mL/kg.

Elimination

At infusion rates used in vasodilatory shock (0.01 to 0.1 units/minute), the clearance of vasopressin is 9 to 25 mL/min/kg in patients with vasodilatory shock. The apparent t 1/2of vasopressin at these levels is ≤10 minutes.

Metabolism

Serine protease, carboxipeptidase and disulfide oxido-reductase cleave vasopressin at sites relevant for the pharmacological activity of the hormone. Thus, the generated metabolites are not expected to retain important pharmacological activity.

Excretion

Vasopressin is predominantly metabolized and only about 6% of the dose is excreted unchanged into urine.

Specific Populations

Pregnancy: Because of a spillover into blood of placental vasopressinase, the clearance of exogenous and endogenous vasopressin increases gradually over the course of a pregnancy. During the first trimester of pregnancy, the clearance is only slightly increased. However, by the third trimester the clearance of vasopressin is increased about 4-fold and at term up to 5-fold. After delivery, the clearance of vasopressin returns to preconception baseline within two weeks.

Drug Interactions

Indomethacin more than doubles the time to offset for vasopressin’s effect on peripheral vascular resistance and cardiac output in healthy subjects [see Drug Interactions (7.2)].

The ganglionic blocking agent tetra-ethylammonium increases the pressor effect of vasopressin by 20% in healthy subjects [see Drug Interactions (7.3)].

Halothane, morphine, fentanyl, alfentanyl and sufentanyl do not impact exposure to endogenous vasopressin. 

No formal carcinogenicity or fertility studies with vasopressin have been conducted in animals. Vasopressin was found to be negative in the in vitrobacterial mutagenicity (Ames) test and the in vitroChinese hamster ovary (CHO) cell chromosome aberration test. In mice, vasopressin has been reported to have an effect on function and fertilizing ability of spermatozoa.

No toxicology studies were conducted with vasopressin.

Increases in systolic and mean blood pressure following administration of vasopressin were observed in 7 studies in septic shock and 8 in post-cardiotomy vasodilatory shock.

{ "type": "p", "children": [], "text": "Increases in systolic and mean blood pressure following administration of vasopressin were observed in 7 studies in septic shock and 8 in post-cardiotomy vasodilatory shock." }

Store between 2°C and 8°C (36°F and 46°F). Do not freeze.

Vials may be held up to 12 months upon removal from refrigeration to room temperature storage conditions (20°C to 25°C [68°F to 77°F], see USP Controlled Room Temperature), anytime within the labeled shelf life. Once removed from refrigeration, unopened vial should be marked to indicate the revised 12 months expiration date. If the manufacturer's original expiration date is shorter than the revised expiration date, then the shorter date must be used. Do not use vasopressin injection, USP beyond the manufacturer's expiration date stamped on the vial.

The storage conditions and expiration periods are summarized in the following table.

<div class="scrollingtable"><table frame="border" rules="all"> <tbody class="Headless"> <tr class="First" valign="middle"> <td></td><td align="center">Unopened <br/> Refrigerated 2°C to 8°C (36°F to 46°F) </td><td align="center">Unopened Room Temperature 20°C to 25°C (68°F to 77°F) <br/> Do not store above 25°C (77°F) </td><td>Opened (After First Pun cture)</td> </tr> <tr class="Last"> <td>1 mL Vial</td><td align="center">Until manufacturerexpiration date</td><td>12 months or until manufacturer expiration date,whichever is earlier</td><td align="center">N/A</td> </tr> </tbody> </table></div>

Rx Only

{ "type": "p", "children": [], "text": "Rx Only" }

Distributor: Dr. Reddy’s Laboratories, Inc.

{ "type": "p", "children": [], "text": "Distributor:\n \n Dr. Reddy’s Laboratories, Inc.\n" }

Princeton, NJ 08540

{ "type": "p", "children": [], "text": "Princeton, NJ 08540" }

Made in India

{ "type": "p", "children": [], "text": "\nMade in India\n" }

Revised: 07/2024

{ "type": "p", "children": [], "text": "Revised: 07/2024 \n \n" }

NDC 71872-7334-1

{ "type": "p", "children": [], "text": "NDC 71872-7334-1" }

Vasopressin Injection, USP

{ "type": "p", "children": [], "text": "Vasopressin Injection, USP" }

20 Units per mL

{ "type": "p", "children": [], "text": "20 Units per mL" }

1 x 1 mL Single-Dose Vial

{ "type": "p", "children": [], "text": "1 x 1 mL Single-Dose Vial" }

RX Only

{ "type": "p", "children": [], "text": "RX Only" }

Vasopressin injection is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines.

{ "type": "p", "children": [], "text": "Vasopressin injection is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines. " }

Inspect parenteral drug products for particulate matter and discoloration prior to use, whenever solution and container permit.

Vasopressin Injection Solution for Dilution, 20 units/mL

Dilute Vasopressin injection in normal saline (0.9% sodium chloride) or 5% dextrose in water (D5W) prior to use for intravenous administration. Discard unused diluted solution after 18 hours at room temperature or 24 hours under refrigeration.

<div class="scrollingtable"><table width="100%"> <caption> <span>Table 1 Preparation of diluted solutions </span> </caption> <col width="25%"/> <col width="25%"/> <col width="26%"/> <col width="25%"/> <tbody class="Headless"> <tr class="First"> <td class="Botrule Lrule Rrule Toprule" rowspan="2" valign="top"> <p class="First">Fluid restriction?</p> </td><td class="Botrule Rrule Toprule" rowspan="2" valign="top"> <p class="First">Final concentration </p> </td><td align="center" class="Botrule Rrule Toprule" colspan="2" valign="top"> <p class="First">Mix </p> </td> </tr> <tr> <td class="Botrule Rrule" valign="top"> <p class="First">Vasopressin injection </p> </td><td align="center" class="Botrule Rrule" valign="top"> <p class="First">Diluent </p> </td> </tr> <tr> <td class="Botrule Lrule Rrule" valign="top"> <p class="First">No </p> </td><td class="Botrule Rrule" valign="top"> <p class="First">0.1 units/mL </p> </td><td class="Botrule Rrule" valign="top"> <p class="First">2.5 mL (50 units) </p> </td><td class="Botrule Rrule" valign="top"> <p class="First">500 mL </p> </td> </tr> <tr class="Last"> <td class="Botrule Lrule Rrule" valign="top"> <p class="First">Yes </p> </td><td class="Botrule Rrule" valign="top"> <p class="First">1 unit/mL </p> </td><td class="Botrule Rrule" valign="top"> <p class="First">5 mL (100 units) </p> </td><td class="Botrule Rrule" valign="top"> <p class="First">100 mL </p> </td> </tr> </tbody> </table></div>

In general, titrate to the lowest dose compatible with a clinically acceptable response.

The recommended starting dose is:

Post-cardiotomy shock: 0.03 units/minute

Septic Shock: 0.01 units/minute

Titrate up by 0.005 units/minute at 10- to 15-minute intervals until the target blood pressure is reached. There are limited data for doses above 0.1 units/minute for postcardiotomy shock and 0.07 units/minute for septic shock. Adverse reactions are expected to increase with higher doses.

After target blood pressure has been maintained for 8 hours without the use of catecholamines, taper vasopressin injection by 0.005 units/minute every hour as tolerated to maintain target blood pressure.

Vasopressin injection, USP is a clear, practically colorless solution available as 20 units/mL in a single dose vial. To be used after dilution.

{ "type": "p", "children": [], "text": "Vasopressin injection, USP is a clear, practically colorless solution available as 20 units/mL in a single dose vial. To be used after dilution. " }

Vasopressin injection 1 mL single dose vial does not contain chlorobutanol and is therefore contraindicated only in patients with a known allergy or hypersensitivity to 8-L-arginine vasopressin.

{ "type": "p", "children": [], "text": "\nVasopressin injection 1 mL single dose vial does not contain chlorobutanol and is therefore contraindicated only in patients with a known allergy or hypersensitivity to 8-L-arginine vasopressin. \n" }

A decrease in cardiac index may be observed with the use of vasopressin.

Patients may experience reversible diabetes insipidus, manifested by the development of polyuria, a dilute urine, and hypernatremia, after cessation of treatment with vasopressin. Monitor serum electrolytes, fluid status and urine output after vasopressin discontinuation. Some patients may require readministration of vasopressin or administration of desmopressin to correct fluid and electrolyte shifts.

The following adverse reactions associated with the use of vasopressin were identified in the literature. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to estimate their frequency reliably or to establish a causal relationship to drug exposure.

{ "type": "p", "children": [], "text": "The following adverse reactions associated with the use of vasopressin were identified in the literature. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to estimate their frequency reliably or to establish a causal relationship to drug exposure. " }

Bleeding/lymphatic system disorders: Hemorrhagic shock, decreased platelets, intractable bleeding

{ "type": "p", "children": [], "text": "Bleeding/lymphatic system disorders: Hemorrhagic shock, decreased platelets, intractable bleeding " }

Cardiac disorders: Right heart failure, atrial fibrillation, bradycardia, myocardial ischemia

{ "type": "p", "children": [], "text": "Cardiac disorders: Right heart failure, atrial fibrillation, bradycardia, myocardial ischemia " }

Gastrointestinal disorders: Mesenteric ischemia

{ "type": "p", "children": [], "text": "Gastrointestinal disorders: Mesenteric ischemia " }

Hepatobiliary: Increased bilirubin levels

{ "type": "p", "children": [], "text": "Hepatobiliary: Increased bilirubin levels " }

Renal/urinary disorders: Acute renal insufficiency

{ "type": "p", "children": [], "text": "Renal/urinary disorders: Acute renal insufficiency " }

Vascular disorders: Distal limb ischemia

{ "type": "p", "children": [], "text": "Vascular disorders: Distal limb ischemia " }

Metabolic: Hyponatremia

{ "type": "p", "children": [], "text": "Metabolic: Hyponatremia " }

Skin: Ischemic lesions

{ "type": "p", "children": [], "text": "Skin: Ischemic lesions " }

Postmarketing Experience

{ "type": "p", "children": [], "text": "\nPostmarketing Experience\n" }

Reversible diabetes insipidus [see Warnings and Precautions (5.2)].

{ "type": "p", "children": [], "text": "\nReversible diabetes insipidus [see Warnings and Precautions (5.2)].\n" }

Use with catecholamines is expected to result in an additive effect on mean arterial blood pressure and other hemodynamic parameters. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed.

Use with indomethacin may prolong the effect of Vasopressin injection on cardiac index and systemic vascular resistance. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed [see Clinical Pharmacology (12.3)].

Use with ganglionic blocking agents may increase the effect of Vasopressin injection on mean arterial blood pressure. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed [see Clinical Pharmacology (12.3)].

Use with drugs suspected of causing SIADH (e.g., SSRIs, tricyclic antidepressants, haloperidol, chlorpropamide, enalapril, methyldopa, pentamidine, vincristine, cyclophosphamide, ifosfamide, felbamate) may increase the pressor effect in addition to the antidiuretic effect of Vasopressin injection. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed.

Use with drugs suspected of causing diabetes insipidus (e.g., demeclocycline, lithium, foscarnet, clozapine) may decrease the pressor effect in addition to the antidiuretic effect of Vasopressin injection. Hemodynamic monitoring is recommended; adjust the dose of vasopressin as needed.

Risk Summary

There are no available data on Vasopressin injection use in pregnant women to inform a drug associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Animal reproduction studies have not been conducted.

Clinical Considerations

Dose adjustments during pregnancy and the postpartum period: Because of increased clearance of vasopressin in the second and third trimester, the dose of Vasopressin injection may need to be increased [see Dosage and Administration (2.2) and Clinical Pharmacology (12.3)].

Maternal adverse reactions: Vasopressin injection may produce tonic uterine contractions that could threaten the continuation of pregnancy.

There are no data on the presence of vasopressin injection in either human or animal milk, the effects on the breastfed infant, or the effects on milk production.

Safety and effectiveness of Vasopressin injection in pediatric patients with vasodilatory shock have not been established.

Clinical studies of vasopressin did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy [see Warnings and Precautions (5), Adverse Reactions (6), and Clinical Pharmacology (12.3)].

Overdosage with Vasopressin injection can be expected to manifest as consequences of vasoconstriction of various vascular beds (peripheral, mesenteric, and coronary) and as hyponatremia. In addition, overdosage may lead less commonly to ventricular tachyarrhythmias (including Torsade de Pointes), rhabdomyolysis, and nonspecific gastrointestinal symptoms.

{ "type": "p", "children": [], "text": "Overdosage with Vasopressin injection can be expected to manifest as consequences of vasoconstriction of various vascular beds (peripheral, mesenteric, and coronary) and as hyponatremia. In addition, overdosage may lead less commonly to ventricular tachyarrhythmias (including Torsade de Pointes), rhabdomyolysis, and nonspecific gastrointestinal symptoms. " }

Direct effects will resolve within minutes of withdrawal of treatment.

{ "type": "p", "children": [], "text": "Direct effects will resolve within minutes of withdrawal of treatment." }

Vasopressin is a polypeptide hormone. Vasopressin injection is a sterile, aqueous solution of synthetic arginine vasopressin for intravenous administration.

{ "type": "p", "children": [], "text": "Vasopressin is a polypeptide hormone. Vasopressin injection is a sterile, aqueous solution of synthetic arginine vasopressin for intravenous administration. " }

The 1 mL solution contains vasopressin 20 units/mL, 1.36 mg sodium acetate buffer and Water for Injection, USP. Sodium hydroxide and hydrochloric acid are included to adjust to a pH of 3.8.

{ "type": "p", "children": [], "text": "The 1 mL solution contains vasopressin 20 units/mL, 1.36 mg sodium acetate buffer and Water for Injection, USP. Sodium hydroxide and hydrochloric acid are included to adjust to a pH of 3.8. " }

The chemical name of vasopressin is Cyclo (1-6) L-Cysteinyl-L-Tyrosyl-L-Phenylalanyl-L-Glutaminyl- L-Asparaginyl-L-Cysteinyl-L-Prolyl-L-Arginyl-L-Glycinamide. It is a white to off-white amorphous powder, freely soluble in water. The structural formula is:

{ "type": "p", "children": [], "text": "The chemical name of vasopressin is Cyclo (1-6) L-Cysteinyl-L-Tyrosyl-L-Phenylalanyl-L-Glutaminyl- L-Asparaginyl-L-Cysteinyl-L-Prolyl-L-Arginyl-L-Glycinamide. It is a white to off-white amorphous powder, freely soluble in water. The structural formula is: " }

Vasopressin causes vasoconstriction by binding to V1 receptors on vascular smooth muscle coupled to the Gq/1 1-phospholipase C-phosphatidyl-inositol-triphosphate pathway, resulting in the release of intracellular calcium. In addition, vasopressin stimulates antidiuresis via stimulation of V2 receptors which are coupled to adenyl cyclase.

At therapeutic doses exogenous vasopressin elicits a vasoconstrictive effect in most vascular beds including the splanchnic, renal and cutaneous circulation. In addition, vasopressin at pressor doses triggers contractions of smooth muscles in the gastrointestinal tract mediated by muscular V1-receptors and release of prolactin and ACTH via V3 receptors. At lower concentrations typical for the antidiuretic hormone vasopressin inhibits water diuresis via renal V2 receptors. In addition, vasopressin has been demonstrated to cause vasodilation in numerous vascular beds that are mediated by V2, V3, oxytocin and purinergic P2 receptors.

In patients with vasodilatory shock vasopressin in therapeutic doses increases systemic vascular resistance and mean arterial blood pressure and reduces the dose requirements for norepinephrine. Vasopressin tends to decrease heart rate and cardiac output. The pressor effect is proportional to the infusion rate of exogenous vasopressin. The pressor effect reaches its peak within 15 minutes. After stopping the infusion the pressor effect fades within 20 minutes. There is no evidence for tachyphylaxis or tolerance to the pressor effect of vasopressin in patients.

Vasopressin plasma concentrations increase linearly with increasing infusion rates from 10 to 200 μU/kg/min. Steady state plasma concentrations are achieved after 30 minutes of continuous intravenous infusion.

Distribution

Vasopressin does not appear to bind plasma protein. The volume of distribution is 140 mL/kg.

Elimination

At infusion rates used in vasodilatory shock (0.01 to 0.1 units/minute), the clearance of vasopressin is 9 to 25 mL/min/kg in patients with vasodilatory shock. The apparent t1/2 of vasopressin at these levels is ≤ 10 minutes.

Metabolism

Serine protease, carboxipeptidase and disulfide oxido-reductase cleave vasopressin at sites relevant for the pharmacological activity of the hormone. Thus, the generated metabolites are not expected to retain important pharmacological activity.

Excretion

Vasopressin is predominantly metabolized and only about 6% of the dose is excreted unchanged into urine.

Specific Populations

Pregnancy: Because of a spillover into blood of placental vasopressinase, the clearance of exogenous and endogenous vasopressin increases gradually over the course of a pregnancy. During the first trimester of pregnancy, the clearance is only slightly increased. However, by the third trimester the clearance of vasopressin is increased about 4-fold and at term up to 5-fold. After delivery, the clearance of vasopressin returns to preconception baseline within two weeks.

Drug Interactions

Indomethacin more than doubles the time to offset for vasopressin's effect on peripheral vascular resistance and cardiac output in healthy subjects [see Drug Interactions (7.2)].

The ganglionic blocking agent tetra-ethylammonium increases the pressor effect of vasopressin by 20% in healthy subjects [see Drug Interactions (7.3)].

Halothane, morphine, fentanyl, alfentanyl and sufentanyl do not impact exposure to endogenous vasopressin.

No formal carcinogenicity or fertility studies with vasopressin have been conducted in animals. Vasopressin was found to be negative in the in vitro bacterial mutagenicity (Ames) test and the in vitro Chinese hamster ovary (CHO) cell chromosome aberration test. In mice, vasopressin has been reported to have an effect on function and fertilizing ability of spermatozoa.

No toxicology studies were conducted with vasopressin.

Increases in systolic and mean blood pressure following administration of vasopressin were observed in 7 studies in septic shock and 8 in post-cardiotomy vasodilatory shock.

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Vasopressin injection, USP is a clear, practically colorless solution for intravenous administration available as:

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<div class="scrollingtable"><table width="100%"> <col width="14%"/> <col width="33%"/> <col width="23%"/> <col width="31%"/> <tbody class="Headless"> <tr class="First"> <td align="center" class="Botrule Lrule Rrule Toprule" valign="top"> <p class="First"> <span class="Bold">Product Code</span> </p> </td><td align="center" class="Botrule Rrule Toprule" valign="top"> <p class="First"> <span class="Bold">Unit of Sale</span> </p> </td><td align="center" class="Botrule Rrule Toprule" valign="top"> <p class="First"> <span class="Bold">Strength</span> </p> </td><td align="center" class="Botrule Rrule Toprule" valign="top"> <p class="First"> <span class="Bold">Unit of Use</span> </p> </td> </tr> <tr class="Last"> <td class="Botrule Lrule Rrule" valign="top"> <p class="First">930101 </p> </td><td class="Botrule Rrule" valign="top"> <p class="First">NDC 63323-930-01<br/>A tray of 25 Single Dose Vials </p> </td><td class="Botrule Rrule" valign="top"> <p class="First">20 Units per 1 mL </p> </td><td class="Botrule Rrule" valign="top"> <p class="First">NDC 63323-930-00<br/>1 mL Single Dose Vial </p> </td> </tr> </tbody> </table></div>

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Store between 2°C and 8°C (36°F and 46°F). Do not freeze.

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Vials may be held up to 12 months upon removal from refrigeration to room temperature storage conditions (20°C to 25°C [68°F to 77°F], [see USP Controlled Room Temperature]), anytime within the labeled shelf life. Once removed from refrigeration, unopened vial should be marked to indicate the revised 12 month expiration date. If the manufacturer's original expiration date is shorter than the revised expiration date, then the shorter date must be used. Do not use Vasopressin injection beyond the manufacturer's expiration date stamped on the vial.

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The storage conditions and expiration periods are summarized in the following table.

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<div class="scrollingtable"><table width="100%"> <col width="16%"/> <col width="42%"/> <col width="42%"/> <tbody class="Headless"> <tr class="First"> <td class="Botrule Lrule Rrule Toprule" valign="top"> <p class="First"></p> </td><td class="Botrule Rrule Toprule" valign="top"> <p class="First">Unopened Refrigerated<br/>2°C to 8°C (36°F to 46°F) </p> </td><td class="Botrule Rrule Toprule" valign="top"> <p class="First">Unopened Room Temperature<br/>20°C to 25°C (68°F to 77°F)<br/>Do not store above 25°C (77°F) </p> </td> </tr> <tr class="Last"> <td class="Botrule Lrule Rrule" valign="top"> <p class="First">1 mL Vial </p> </td><td class="Botrule Rrule" valign="top"> <p class="First">Until manufacturer expiration date </p> </td><td class="Botrule Rrule" valign="top"> <p class="First">12 months or until manufacturer expiration date, whichever is earlier </p> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table width=\"100%\">\n<col width=\"16%\"/>\n<col width=\"42%\"/>\n<col width=\"42%\"/>\n<tbody class=\"Headless\">\n<tr class=\"First\">\n<td class=\"Botrule Lrule Rrule Toprule\" valign=\"top\">\n<p class=\"First\"></p>\n</td><td class=\"Botrule Rrule Toprule\" valign=\"top\">\n<p class=\"First\">Unopened Refrigerated<br/>2°C to 8°C (36°F to 46°F) </p>\n</td><td class=\"Botrule Rrule Toprule\" valign=\"top\">\n<p class=\"First\">Unopened Room Temperature<br/>20°C to 25°C (68°F to 77°F)<br/>Do not store above 25°C (77°F) </p>\n</td>\n</tr>\n<tr class=\"Last\">\n<td class=\"Botrule Lrule Rrule\" valign=\"top\">\n<p class=\"First\">1 mL Vial </p>\n</td><td class=\"Botrule Rrule\" valign=\"top\">\n<p class=\"First\">Until manufacturer expiration date </p>\n</td><td class=\"Botrule Rrule\" valign=\"top\">\n<p class=\"First\">12 months or until manufacturer expiration date, whichever is earlier </p>\n</td>\n</tr>\n</tbody>\n</table></div>" }

451491A

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PACKAGE LABEL- PRINCIPAL DISPLAY PANEL- VASOPRESSIN INJECTION 20 Unit Tray Label

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NDC 63323-930-01        Rx Only

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Vasopressin Injection, USP

{ "type": "p", "children": [], "text": "\nVasopressin\n\nInjection, USP\n" }

20 Units per mL

{ "type": "p", "children": [], "text": "\n20 Units per mL\n" }

For Intravenous Infusion

{ "type": "p", "children": [], "text": "\nFor Intravenous Infusion\n" }

Must be diluted prior to use

{ "type": "p", "children": [], "text": "\nMust be diluted prior to use\n" }

Store between 2°C and 8°C (36°F and 46°F). Vials may be held at 20°C to 25°C (68°F to 77°F) for up to 12 months. Do not store above 25°C (77°F). Avoid freezing.

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25 x 1 mL Single Dose Vials

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PACKAGE LABEL- PRINCIPAL DISPLAY PANEL- VASOPRESSIN INJECTION 20 Unit Vial Label

{ "type": "p", "children": [], "text": "\nPACKAGE LABEL- PRINCIPAL DISPLAY PANEL- VASOPRESSIN INJECTION 20 Unit Vial Label\n" }

NDC 63323-930-00        930101

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Vasopressin Injection, USP

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20 Units per mL

{ "type": "p", "children": [], "text": "\n20 Units per mL\n" }

For Intravenous Infusion

{ "type": "p", "children": [], "text": "For Intravenous Infusion " }

Must be diluted prior to use.

{ "type": "p", "children": [], "text": "\nMust be diluted prior to use.\n" }

Usual Dosage: See insert.

{ "type": "p", "children": [], "text": "Usual Dosage: See insert. " }

Store between 2°C and 8°C (36°Fand 46°F). Do not store above

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25°C (77°F)

{ "type": "p", "children": [], "text": "25°C (77°F) " }

1 mL Single Dose Vial

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Rx Only

{ "type": "p", "children": [], "text": "Rx Only " }