CHAPTER 18

Sympathomimetic
Drugs
Sansan S. Lo s Jack S. Shanewise

Naturally Occurring MPDBM BOFTUIFUJD TPMVUJPOT UP EFDSFBTF TZTUFNJD BCTPSQUJPO

Catecholamines
/BUVSBMMZ PDDVSSJOH DBUFDIPMBNJOFT BSF FQJOFQISJOF,
OPS- FQJOFQISJOF, BOE EPQBNJOF (TFF 5BCMF 18-1 BOE 'JH.
18-1).

Epinephrine
&QJOFQISJOF JT UIF QSPUPUZQF TZNQBUIPNJNFUJD. *U JT
B DJSDVMBUJOH IPSNPOF TZOUIFTJ[FE, TUPSFE, BOE
SFMFBTFE GSPN UIF BESFOBM NFEVMMB. *UT OBUVSBM GVODUJPOT
VQPO SF- MFBTF JOUP UIF DJSDVMBUJPO JODMVEF SFHVMBUJPO PG
NZPDBSEJBM DPOUSBDUJMJUZ, IFBSU SBUF, WBTDVMBS BOE
CSPODIJBM TNPPUI NVTDMF UPOF, HMBOEVMBS TFDSFUJPOT,
BOE NFUBCPMJD QSP- DFTTFT TVDI BT HMZDPHFOPMZTJT BOE
MJQPMZTJT. *U JT B QPUFOU BDUJWBUPS PG a-BESFOFSHJD
SFDFQUPST BOE BMTP BDUJWBUFT [31 BOE [32 SFDFQUPST. 0SBM
BENJOJTUSBUJPO JT OPU FffFDUJWF BT FQJOFQISJOF JT SBQJEMZ
NFUBCPMJ[FE JO UIF HBTUSPJOUFTUJ- OBM NVDPTB BOE MJWFS.
ThFSFGPSF, FQJOFQISJOF JT BENJOJT- UFSFE
TVCDVUBOFPVTMZ, JOUSBWFOPVTMZ, PS JOUSBNVTDVMBSMZ.
"CTPSQUJPO BftFS TVCDVUBOFPVT JOKFDUJPO JT TMPX CFDBVTF
PG MPDBM FQJOFQISJOFoJOEVDFE WBTPDPOTUSJDUJPO. &QJOFQI-
SJOF JT QPPSMZ MJQJE TPMVCMF, QSFWFOUJOH JUT SFBEZ FOUSBODF
JOUP UIF DFOUSBM OFSWPVT TZTUFN ($/4) BOE BDDPVOUJOH
GPS UIF MBDL PG DFSFCSBM FffFDUT.

Clinical Uses
$MJOJDBM VTFT PG FQJOFQISJOF JODMVEF USFBUNFOU PG
MJGF- UISFBUFOJOH BMMFSHJD SFBDUJPOT/BOBQIZMBYJT,
USFBUNFOU PG TFWFSF BTUINB BOE CSPODIPTQBTN,
BENJOJTUSBUJPO EVS- JOH DBSEJPQVMNPOBSZ SFTVTDJUBUJPO
1
BT B W JUBM UIFSBQFVUJD ESVH, BENJOJTUSBUJPO EVSJOH
QFSJPET PG IFNPEZOBNJD JO- TUBCJMJUZ UP QSPNPUF
NZPDBSEJBM DPOUSBDUJMJUZ BOE JODSFBTF WBTDVMBS SFTJTUBODF,
BOE DPOUJOVPVT JOGVTJPO GPS DPOUJOV- PVT TVQQPSU PG
NZPDBSEJBM DPOUSBDUJMJUZ BOE WBTDVMBS SF- TJTUBODF.
&QJOFQISJOF JT VTFE UP QSPNPUF JOPUSPQZ EVSJOH XFBOJOH
GSPN DBSEJPQVMNPOBSZ CZQBTT. *U JT BMTP VTFE BT B
WBTPDPOTUSJDUPS UP JODSFBTF PYZHFO EFMJWFSZ BOE JODSFBTF
2,3
DBSEJBD PVUQVU JO TFQTJT. -BTUMZ, FQJOFQISJOF JT BEEFE UP

QSPMPOHJOH UIF EVSBUJPO PG BDUJPO PG UIF BOFTUIFUJD
GPS SFHJPOBM BOE MPDBM BOFTUIFTJB. &QJOFQISJOF JT VTFE JO
MPDBM BOE GJ ME CMPDLT UP QSPNPUF B CMPPEMFTT TVSHJDBM GJ
ME.
Cardiovascular Effects
ThF DBSEJPWBTDVMBS effFDUT PG FQJOFQISJOF SFTVMU
GSPN TUJNVMBUJPO PG a- BOE [3-BESFOFSHJD SFDFQUPST
4
(TFF 5BCMF 18-1). 4UJNVMBUJPO PG a1 SFDFQUPST MFBET UP
BSUFSJPMBS WB- TPDPOTUSJDUJPO BOE QVMNPOBSZ BSUFSZ
WBTPDPOTUSJDUJPO. a1 3FDFQUPST BSF QSFEPNJOBOUMZ
MPDBUFE JO DVUBOFPVT, TQMBODIOJD, BOE SFOBM WBTDVMBS
CFET. 4UJNVMBUJPO PG a2 SF- DFQUPST BMTP MFBET UP
WBTPDPOTUSJDUJPO. [32 3FDFQUPS TUJNV- MBUJPO MFBET UP
WBTPEJMBUJPO, QSFEPNJOBOUMZ JO UIF TLFMFUBM NVTDMFT. ThF
SFMBUJWF CBMBODF PG a1 BOE [32 SFDFQUPST JO UIF
WBTDVMBUVSF PG BO PSHBO EFUFSNJOFT FQJOFQISJOF'T
PWFSBMM FffFDU PO CMPPE flPX UP UIF PSHBO. ThF OFU FffFDU
PG UIFTF DIBOHFT JO QFSJQIFSBM WBTDVMBS UPOF JT
QSFGFSFOUJBM EJTUSJ- CVUJPO PG DBSEJBD PVUQVU UP TLFMFUBM
NVTDMFT BOE JODSFBTFE TZTUFNJD WBTDVMBS SFTJTUBODF.
3FOBM CMPPE GM X JT TVCTUBO- UJBMMZ EFDSFBTFE CZ
FQJOFQISJOF, FWFO JO UIF BCTFODF PG DIBOHFT JO
TZTUFNJD CMPPE QSFTTVSF. &QJOFQISJOF JT FTUJ- NBUFE UP
CF 2 UP 10 UJNFT NPSF QPUFOU UIBO OPSFQJOFQI- SJOF BT B
SFOBM WBTPDPOTUSJDUPS. *O HFOFSBM, [32 SFDFQUPST BSF NPSF
TFOTJUJWF UP MPXFS FQJOFQISJOF EPTFT XIJMF FffFDUT PO a1
SFDFQUPST QSFEPNJOBUF BU IJHIFS EPTFT. "U IJHI EPTFT,
UIF QSFEPNJOBOU a BDUJWJUZ BOE SFTVMUBOU
WBTPDPOTUSJDUJPO MFBET UP JODSFBTFE BftFSMPBE, XIJDI NBZ
JNQFEF JODSFBTFT JO DBSEJBD PVUQVU. *OJUJBM UBDIZDBSEJB
NBZ CF GPMMPXFE CZ IFBSU SBUF EFDSFBTFT EVF UP
CBSPSFDFQUPS SFflFYFT. 7FOPVT SFUVSO JT BMTP FOIBODFE CZ
WFOPDPOTUSJDUJPO GSPN UIF IJHI EFOTJUZ PG a SFDFQUPST
JO UIF WFOPVT WBTDVMBUVSF TZTUFN.
#MPPE QSFTTVSF JT JODSFBTFE CZ BO JODSFBTF JO DBSEJBD
JOEFY BT XFMM BT BO JODSFBTF JO TZTUFNJD WBTDVMBS
SFTJTUBODF.
&QJOFQISJOF TUJNVMBUFT [31 SFDFQUPST DBVTJOH BO
JO- DSFBTF JO IFBSU SBUF, NZPDBSEJBM DPOUSBDUJMJUZ, BOE
DBSEJBD PVUQVU. ThFSF NBZ CF B N JME EFDSFBTF JO
EJBTUPMJD CMPPE QSFTTVSF, SeflFDUJOH WBTPEJMBUJPO JO
TLFMFUBM NVTDMF WBTDV- MBUVSF EVF UP TUJNVMBUJPO PG [32
SFDFQUPST. ThF OFU FffFDU PG UIFTF TZTUFNJD CMPPE
QSFTTVSF DIBOHFT JT BO JODSFBTF JO QVMTF QSFTTVSF BOE B
NJME DIBOHF JO NFBO BSUFSJBM QSFTTVSF.
449
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5BCMF 18-1 at
or
Classification and Comparative Pharmacology of Sympathomimetics y
S
ys
t
$FOUSBM 4JOHMF e
3FDFQUPST 4UJNVMBUFE $BSEJBD &ffFDUT
1FSJQIFSBM 3FOBM .FBO /FSWPVT *OUSBWFOPVT $POUJOVPVT
.FDIBOJTN $BSEJBD )FBSU 7BTDVMBS #MPPE "SUFSJBM "JSXBZ 4ZTUFN %PTF (70-LH *OGVTJPO %PTF
a [31 [32 PG "DUJPO 0VUQVU 3BUF %ZTSIZUINJBT 3FTJTUBODF 'MPX 1SFTTVSF 3FTJTUBODF 4UJNVMBUJPO "EVMU) (70-LH "EVMU)
/BUVSBM
DBUFDIPMBNJOFT
&QJOFQISJOF + ++ ++ %JSFDU ++ ++ ++ + + :FT 2o8 µH 1o20 µH/NJO
+
/PSFQJOFQISJOF ++ ++ + %JSFDU + +++ ++ /$ /P /PU VTFE 4o16 µH/NJO
+ +
%PQBNJOF ++ ++ + %JSFDU ++ + + + +++ + /$ /P /PU 6TFE 2o20 µH/LH/NJO
+
4ZOUIFUJD
DBUFDIPMBNJOFT
*TPQSPUFSFOPM 0 ++ ++ %JSFDU ++ ++ ++ + :FT 1o4 µH 1o5 µH/NJO
+ + + + +
%PCVUBNJOF 0 ++ + %JSFDU ++ + + /$ ++ + /$ /PU VTFE 2o10 µH/LH/NJO
+ +
4ZOUIFUJD
OPODBUFDIPMBNJOFT
&QIFESJOF ++ + + %JSFDU BOE ++ ++ ++ + ++ :FT 10o25 µH /PU VTFE
JOEJSFDU
1IFOZMFQISJOF ++ 0 + %JSFDU /$ +++ ++ /$ /P 50o100 µH 20o50 µH/NJO
+ +
0, OPOF; +, NJOJNBM JODSFBTF; ++, NPEFSBUF JODSFBTF; +++, NBSLFE JODSFBTF; , NJOJNBM EFDSFBTF; , NPEFSBUF EFDSFBTF; , NBSLFE EFDSFBTF; /$, OP DIBOHF.
 Chapter 18 s Sympathomimetic Drugs 1

FQJ- OFQISJOF, BT JO QBUJFOUT XJUI QIFPDISPNPDZUPNB,

SFTVMU JO

'*(63& 18-1 Sympathomimetics are derived from [3-

phenylethylamine, with a catecholamine being any com-
pound that has hydroxyl groups on the 3 and 4 carbon
positions of the benzene ring. The naturally occurring cate-
cholamines are epinephrine, norepinephrine, and dopamine.
Isoproterenol and dobutamine are synthetic catecholamines.

&QJOFQISJOF JODSFBTFT IFBSU SBUF CZ BDDFMFSBUJOH

UIF SBUF PG TQPOUBOFPVT QIBTF 4 E FQPMBSJ[BUJPO, XIJDI
BMTP JODSFBTFT UIF MJLFMJIPPE PG DBSEJBD EZTSIZUINJBT.
&QJ- OFQISJOF JODSFBTFT DPOEVDUJPO WFMPDJUZ BOE
EFDSFBTFT UIF SFGSBDUPSZ QFSJPE JO UIF BUSJPWFOUSJDVMBS
OPEF, CVOEMF PG
)JT, 1VSLJOKF fiCFST, BOE WFOUSJDVMBS NVTDMF. *U BMTP NBZ
JODSFBTF BVUPNBUJDJUZ PG MBUFOU QBDFNBLFST.
5BDIZDBSEJB, QSFNBUVSF WFOUSJDVMBS DPOUSBDUJPO,
WFOUSJDVMBS UBDIZDBS- EJB, BOE WFOUSJDVMBr fiCSJMMBUJPO BMM
NBZ PDDVS.
*ODSFBTFE DBSEJBD PVUQVU SeflFDUT FQJOFQISJOF-
JOEVDFE JODSFBTFT JO IFBSU SBUF, NZPDBSEJBM DPOUSBDUJMJUZ,
BOE WFOPVT SFUVSO. 3FQFBUFE EPTFT PG FQJOFQISJOF
QSPEVDF TJNJMBS DBSEJPWBTDVMBS FffFDUT JO DPOUSBTU UP UIF
UBDIZQIZMBYJT UIBU BDDPNQBOJFT BENJOJTUSBUJPO PG
TZOUIFUJD OPODBUFDIPM- BNJOFT UIBU DBVTF UIF SFMFBTF PG
OPSFQJOFQISJOF, TVDI BT FQIFESJOF. .ZPDBSEJBM PYZHFO
DPOTVNQUJPO JT JODSFBTFE XJUI FOIBODFE MFGU
WFOUSJDVMBS QSFMPBE, JODSFBTFE DPO- USBDUJMJUZ, JODSFBTFE
BftFSMPBE, BOE UBDIZDBSEJB. %JBTUPMJD GVODUJPO JT
JNQSPWFE CZ JODSFBTJOH UIF SBUF PG NZPDBSEJBM SFMBYBUJPO,
BOE FBSMZ MFGU FOUSJDVMBr fiMMJOH JT FOIBODFE.
&QJOFQISJOF TUJNVMBUFT SFOBM [3 SFDFQUPST, SFTVMUJOH JO
JODSFBTFE TFDSFUJPO PG SFOJO. *O VTVBM UIFSBQFVUJD EPTFT,
FQJOFQISJOF IBT OP TJHOifiDBOU WBTPDPOTUSJDUJWF effFDU PO
DFSFCSBM BSUFSJPMFT. $PSPOBSZ CMPPE flPX JT FOIBODFE CZ
5
FQJOFQISJOF, FWFO BU EPTFT UIBU EP OPU BMUFS
TZTUFNJD CMPPE QSFTTVSF.
$ISPOJD JODSFBTFT JO UIF QMBTNB DPODFOUSBUJPOT PG
2 Part III s Circulatory System
B EFDSFBTF PG QMBTNB WPMVNF CFDBVTF PG B MPTT PG
QSPUFJO- GSFF flVJE JOUP UIF FYUSBDFMMVMBS TQBDF."SUFSJBM
XBMM EBNBHF BOE MPDBM BSFBT PG NZPDBSEJBM OFDSPTJT
NBZ BMTP BDDPN- QBOZ DISPOJD DJSDVMBUJOH FYDFTTFT
PG FQJOFQISJOF. $PO- WFOUJPOBM EPTFT PG FQJOFQISJOF,
IPXFWFS, EP OPU QSPEVDF UIFTF FffFDUT.
ThF IFNPEZOBNJD effFDUT PG FQJOFQISJOF BSF
BUUFOV- BUFE BOE DBO CF CMPDLFE CZ QSJPS
BENJOJTUSBUJPO PG a- PS [3-BESFOFSHJD SFDFQUPS
4
BOUBHPOJTUT. 4VQSBUIFSBQFVUJD EPTFT PG FQJOFQISJOF
NBZ MFBE UP BDVUF IFBSU GBJMVSF, QVMNPOBSZ FEFNB,
BSSIZUINJBT, IZQFSUFOTJPO, BOE NZPDBSEJBM JTDIFNJB.
Airway Smooth Muscle
4NPPUI NVTDMFT PG UIF CSPODIJ BSF SFMBYFE CZ
FQJOFQI- SJOF-JOEVDFE BDUJWBUJPO PG [32 SFDFQUPST. #Z
JODSFBTJOH JOUSBDFMMVMBS DPODFOUSBUJPOT PG DZDMJD
BEFOPTJOF NPOP- QIPTQIBUF (D".1), [32 TUJNVMBUJPO
EFDSFBTFT SFMFBTF PG WBTPBDUJWF NFEJBUPST BTTPDJBUFE
XJUI TZNQUPNT PG CSPO- DIJBM BTUINB. ThF
CSPODIPEJMBUJOH effFDUT PG FQJOFQISJOF BSF OPU TFFO JO
UIF QSFTFODF PG [3-BESFOFSHJD CMPDLBEF.
*O UIF QSFTFODF PG [3-BESFOFSHJD CMPDLBEF,
FQJOFQISJOF JOTUFBE JOEVDFT CSPODIPDPOTUSJDUJPO GSPN
TUJNVMBUJPO PG CSPODIJBM a SFDFQUPST.
Metabolic Effects
&QJOFQISJOF IBT UIF NPTU TJHOifiDBOU effFDU PO
6
NFUBCP- MJTN PG BMM UIF DBUFDIPMBNJOFT. [31 3FDFQUPS
TUJNVMBUJPO EVF UP FQJOFQISJOF JODSFBTFT MJWFS
HMZDPHFOPMZTJT BOE BEJ- QPTF UJTTVF MJQPMZTJT, XIFSFBT
a1 SFDFQUPS TUJNVMBUJPO JO- IJCJUT SFMFBTF PG JOTVMJO.
-JWFS HMZDPHFOPMZTJT SFTVMUT GSPN FQJOFQISJOF-JOEVDFE
BDUJWBUJPO PG IFQBUJD QIPTQIPSZMBTF FO[ZNF. -JQPMZTJT JT
EVF UP FQJOFQISJOF-JOEVDFE BDUJWBUJPO PG USJHMZDFSJEF
MJQBTF, XIJDI BDDFMFSBUFT UIF CSFBLEPXO PG USJHMZDFSJEFT
UP GPSN GSFF GBUUZ BDJET BOE HMZDFSPM. *OGVTJPOT PG
FQJOFQISJOF VTVBMMZ JODSFBTF QMBTNB DPODFOUSBUJPOT PG
HMVDPTF, DIPMFTUFSPM, QIPTQIPMJQJET, BOE MPX-EFOTJUZ
MJQP- QSPUFJOT. 3FMFBTF PG FOEPHFOPVT FQJOFQISJOF BOE
UIF SF- TVMUJOH HMZDPHFOPMZTJT BOE JOIJCJUJPO PG JOTVMJO
TFDSFUJPO JT UIF NPTU MJLFMZ FYQMBOBUJPO GPS
QFSJPQFSBUJWF IZQFS- HMZDFNJB. *O BEEJUJPO, FQJOFQISJOF
DBO JOIJCJU QFSJQIFSBM HMVDPTF VQUBLF, XIJDI JT BMTP EVF
JO QBSU UP JOIJCJUJPO PG JO- TVMJO TFDSFUJPO. *ODSFBTFE
QMBTNB DPODFOUSBUJPOT PG MBDUBUF QSFTVNBCMZ SeflFDU
FQJOFQISJOF-JOEVDFE HMZDPHFOPMZTJT JO TLFMFUBM
NVTDMFT. 4PNF TUVEJFT EFNPOTUSBUF UIBU FQJ-
OFQISJOF-JOEVDFE IZQFSMBDUFNJB JT QSJNBSJMZ B U
SBOTJFOU QIFOPNFOPO BTTPDJBUFE XJUI JOIJCJUJPO PG
QZSVWBUF EF- IZESPHFOBTF BOE IBT OP SFMBUJPOTIJQ XJUI
DFMMVMBS IZQPYJB BOE UJTTVF QFSGVTJPO PS BTTPDJBUFE
7
NFUBCPMJD BDJEPTJT.
&MFDUSPMZUFT
4FMFDUJWF [32-BESFOFSHJD BHPOJTU effFDUT PG FQJOFQISJOF
BSF TQFDVMBUFE UP SFflFDU BDUJWBUJPO PG UIF
TPEJVNoQPUBTTJVN QVNQ JO TLFMFUBM NVTDMFT, MFBEJOH UP
8
B U SBOTGFS PG QPUBT- TJVN JPOT JOUP DFMMT ('JH.18-2). ThF
PCTFSWBUJPO UIBU TFSVN QPUBTTJVN NFBTVSFNFOUT JO
CMPPE TBNQMFT PCUBJOFE JNNFEJBUFMZ CFGPSF JOEVDUJPO
PG BOFTUIFTJB BSF MPXFS UIBO

'*(63& 18-2 Selective [32-adrenergic agonist effects of
epinephrine are responsible for stimulating the movement
of potassium ions (K +) into cells, with a resulting decrease
in the serum potassium concentration. (From Brown MJ,
Brown DC, Murphy MB. Hypokalemia from beta2-receptor
stimulation by circulating epinephrine. N Engl J Med. 1983;
309[23]:1414–1419, with permission.)
NFBTVSFNFOUT 1 UP 3 EBZT QSFPQFSBUJWFMZ JT QSFTVNFE UP
SFflFDU TUSFTT-JOEVDFE SFMFBTF PG FQJOFQISJOF ('JH. 18-3).
9 &QJOFQISJOF, OPSFQJOFQISJOF, BOE JTPQSPUFSFOPM QSPEVDF
ThF BCJMJUZ PG B OPOTFMFDUJWF [31 BOE [32 BOUBHPOJTU (QSP-
QSBOPMPM) CVU OPU B DBSEJPTFMFDUJWF [31 BOUBHPOJTU
(BUFOPMPM) UP QSFWFOU iQSFPQFSBUJWF IZQPLBMFNJBw JT
DPOTJTUFOU GPS B
'*(63& 18-3 Individual and mean (+ SD) plasma potas-
sium (K ) concentrations determined 1 to 3 days preopera-
tively and immediately before the induction (preinduction)
of anesthesia. (From Kharasch ED, Bowdle TA.
Hypokalemia before induction of anesthesia and prevention
by beta 2 ad- renoceptor antagonism. Anesth Analg.
1991;72[2]:216–220, with permission.)
[32-BESFOFSHJD BHPOJTU FffFDU BT UIF FYQMBOBUJPO GPS QPUBT-
9
TJVN USBOTGFS ('JH. 18-4). *O NBLJOH UIFSBQFVUJD
EFDJTJPOT CBTFE PO B QSFJOEVDUJPO TFSVN QPUBTTJVN
NFBTVSFNFOU, FTQFDJBMMZ JO QBUJFOUT XJUIPVU B SFBTPO UP
FYQFSJFODF IZ- QPLBMFNJB, POF TIPVME DPOTJEFS UIF
QPTTJCMF SPMF PG QSF- PQFSBUJWF BOYJFUZ BOE UIF SFMFBTF PG
FQJOFQISJOF.
&QJOFQISJOF-JOEVDFE IZQPLBMFNJB NBZ
DPOUSJCVUF UP DBSEJBD EZTSIZUINJBT, XIJDI PDDBTJPOBMMZ
BDDPNQBOZ TUJNVMBUJPO PG UIF TZNQBUIFUJD OFSWPVT
TZTUFN. $PO- WFSTFMZ, FQJOFQISJOF NBZ TUJNVMBUF UIF
SFMFBTF PG QP- UBTTJVN GSPN UIF MJWFS, UFOEJOH UP PffTFU
UIF EFDSFBTF JO FYUSBDFMMVMBS DPODFOUSBUJPO PG UIJT JPO
QSPEVDFE CZ FO- USBODF JOUP TLFMFUBM NVTDMFT.
Ocular Effects
&QJOFQISJOF DBVTFT DPOUSBDUJPO PG UIF SBEJBM NVTDMFT PG
UIF JSJT, QSPEVDJOH NZESJBTJT. $POUSBDUJPO PG UIF PSCJUBM
NVTDMFT QSPEVDFT BO BQQFBSBODF PG FYPQIUIBMNPT.
"ESFOFSHJD SFDFQUPST SFTQPOTJCMF GPS UIFTF PDVMBS
FffFDUT BSF MJLFMZ a SFDFQUPST BT OPSFQJOFQISJOF JT MFTT
QPUFOU UIBO FQJOFQISJOF BOE JTPQSPUFSFOPM IBT
QSBDUJDBMMZ OP PDVMBS FffFDUT.
Gastrointestinal and Genitourinary
Effects
SFMBYBUJPO PG HBTUSPJOUFTUJOBM TNPPUI NVTDMF.
"DUJWBUJPO PG [3-BESFOFSHJD SFDFQUPST SFMBYFT UIF
EFUSVTPS NVTDMF PG UIF CMBEEFS, XIFSFBT BDUJWBUJPO PG a-
BESFOFSHJD SFDFQUPST DPOUSBDUT UIF USJHPOF BOE TQIJODUFS
NVTDMFT.
'*(63& 18-4 Propranolol, but not atenolol, was effective in
blunting the difference between preoperative and preinduc-
tion serum potassium (K+) concentrations compared with
patients (controls) not receiving a [3 antagonist. Data are
mean
+ SD. The asterisk denotes a significant difference (P
<.02) between controls and patients treated with propranolol.
(From Kharasch ED, BowdleTA. Hypokalemia before
induction of an- esthesia and prevention by beta 2
adrenoceptor antagonism. Anesth Analg. 1991;72[2]:216–220,
with permission.)
 )FQBUPTQMBODIOJD WBTPDPOTUSJDUJPO PDDVST BT XFMM BT OFZT, BOE TLJO WBTDVMBS CFET. 1FSJQIFSBM WBTPDPOTUSJDUJPO
JNQBJSFE SFOBM CMPPE flPX BT DBSEJBD PVUQVU JT EJWFSUFE NBZ EFDSFBTF UJTTVF CMPPE flPX UP UIF FYUFOU UIBU
10
UP UIF EJMBUFE TLFMFUBM NVTDMF WBTDVMBUVSF. ThJT NFUBCPMJD
SFTVMUT JO EFDSFBTFE IFQBUPTQMBODIOJD PYZHFO FYDIBOHF
BOE MBDUBUF DMFBSBODF. ThF JNQBJSNFOU PG TQMBODIOJD
DJSDVMBUJPO UIBU PDDVST JT HSFBUFS UIBO UIBU BTTPDJBUFE
11,12
XJUI OPSFQJOFQISJOF PS EPQBNJOF. *U NBZ CF
EFQFOEFOU PO UIF TFWFSJUZ PG UIF TIPDL TUBUF BOE UIF EPTF
PG FQJOFQISJOF VTFE.

Coagulation
$PBHVMBUJPO JT BDDFMFSBUFE CZ FQJOFQISJOF. "
IZQFSDP- BHVMBCMF TUBUF QSFTFOU EVSJOH UIF JOUSBPQFSBUJWF
BOE QPTU- PQFSBUJWF QFSJPE NBZ SFflFDU TUSFTT-
BTTPDJBUFE SFMFBTF PG FQJOFQISJOF. &QJOFQISJOF
JODSFBTFT UIF UPUBM MFVLPDZUF DPVOU CVU DBVTFT
FPTJOPQFOJB. *U JT B Q PUFOU JOEVDFS PG QMBUFMFU
BHHSFHBUJPO BOE JODSFBTFT GBDUPS 7 BDUJWJUZ.

Norepinephrine
/PSFQJOFQISJOF JT UIF FOEPHFOPVT OFVSPUSBOTNJUUFS TZO-
UIFTJ[FE BOE TUPSFE JO QPTUHBOHMJPOJD TZNQBUIFUJD OFSWF
FOEJOHT BOE SFMFBTFE XJUI TZNQBUIFUJD OFSWF
TUJNVMB- UJPO. *U JT UIF JNNFEJBUF QSFDVSTPS PG
FQJOFQISJOF. /PS- FQJOFQISJOF TUJNVMBUFT [31- BOE a1-
BESFOFSHJD SFDFQUPST.
*U JT BQQSPYJNBUFMZ FRVBM JO QPUFODZ UP FQJOFQISJOF GPS
TUJNVMBUJPO PG [31 SFDFQUPST CVU, VOMJLF FQJOFQISJOF, IBT
NJOJNBM effFDU BU [32 SFDFQUPST (TFF 5BCMF 18-1). ThSPVHI
JUT BDUJPO PO [31 SFDFQUPST, OPSFQJOFQISJOF JODSFBTFT IFBSU
SBUF, DPOEVDUJPO, BOE DPOUSBDUJMJUZ. /PSFQJOFQISJOF JT
B QPUFOU a1 BHPOJTU QSPEVDJOH JOUFOTF BSUFSJBM BOE
WFOPVT WBTPDPOTUSJDUJPO JO BMM WBTDVMBS CFET FYDFQU GPS
13
UIF DPS- POBSZ BSUFSJFT. /PSFQJOFQISJOF DBVTFT HSFBUFS
JODSFBTF JO TZTUFNJD WBTDVMBS SFTJTUBODF BOE EJBTUPMJD
CMPPE QSFT- TVSF, NFBO BSUFSJBM QSFTTVSF, BOE TZTUPMJD
CMPPE QSFTTVSF UIBO FQJOFQISJOF. 7FOPVT
WBTPDPOTUSJDUJPO EFDSFBTFT WFOPVT DBQBDJUBODF, UIFSFCZ
JODSFBTJOH WFOPVT SFUVSO UP BVHNFOU TUSPLF WPMVNF
BOE DBSEJBD PVUQVU. )FBSU SBUF DIBOHFT NBZ CF
NJOJNBM BT CBSPSFDFQUPS SFflFYFT USJH- HFSFE CZ
BSUFSJBM WBTPDPOTUSJDUJPO BSF DPVOUFSBDUFE CZ [31-
NFEJBUFE JODSFBTFT JO IFBSU SBUF. ThJT JT JO DPOUSBTU UP
FQJOFQISJOF, XIJDI IBT B NPSF TJHOJGJ BOU DISPOPUSPQJD
effFDU. /PSFQJOFQISJOF JODSFBTFT NFBO BSUFSJBM
QSFTTVSF QSJNBSJMZ CZ WBTPDPOTUSJDUJPO BOE UP MFTTFS
EFHSFF CZ JODSFBTJOH TUSPLF WPMVNF BOE DBSEJBD PVUQVU.
"U IJHIFS EPTFT, WBTPDPOTUSJDUJPO QSFEPNJOBUFT UP BO
FWFO HSFBUFS FYUFOU. /PSFQJOFQISJOF BOE FQJOFQISJOF
JODSFBTF UPUBM QFSJQIFSBM WBTDVMBS SFTJTUBODF NPSF UIBO
EPCVUBNJOF (EFTDSJCFE JO UIF GPMMPXJOH UFYUT). 6OMJLF
FQJOFQISJOF, OPSFQJOFQISJOF IBT NJOJNBM NFUBCPMJD
effFDUT. )ZQFS- HMZDFNJB JT VOMJLFMZ UP PDDVS BT B SFTVMU
PG OPSFQJOFQI- SJOF BENJOJTUSBUJPO.
*OUSBWFOPVT BENJOJTUSBUJPO PG OPSFQJOFQISJOF SFTVMUT
JO JOUFOTF WBTPDPOTUSJDUJPO JO TLFMFUBM NVTDMF, MJWFS, LJE-
BDJEPTJT PDDVST. $ISPOJD JOGVTJPO PG OPSFQJOFQISJOF
PS JODSFBTFE DJSDVMBUJOH DPODFOUSBUJPOT PG UIJT
DBUFDIPM- BNJOF, BT NBZ CF BTTPDJBUFE XJUI
QIFPDISPNPDZUPNB, NBZ DBVTF QSFDBQJMMBSZ
WBTPDPOTUSJDUJPO BOE MPTT PG QSP- UFJO-GSFF flVJE JOUP
UIF FYUSBDFMMVMBS TQBDF. -JLF FQJOFQI-
13
SJOF, OPSFQJOFQISJOF EJMBUFT DPSPOBSZ BSUFSJFT.
" DPOUJOVPVT JOGVTJPO PG OPSFQJOFQISJOF, 2 UP 16
µH QFS NJOVUF, NBZ CF VTFE UP USFBU SFGSBDUPSZ
IZQPUFOTJPO. 1MBDFNFOU PG OPSFQJOFQISJOF JO B 5%
HMVDPTF TPMVUJPO QSPWJEFT TVffiDJFOU BDJEJUZ UP QSFWFOU
PYJEBUJPO PG UIF DBU- FDIPMBNJOF. &YUSBWBTBUJPO EVSJOH
JOGVTJPO DBO QSPEVDF TFWFSF MPDBM WBTPDPOTUSJDUJPO BOE
QPTTJCMF OFDSPTJT; IFODF, BENJOJTUSBUJPO TIPVME CF WJB
DFOUSBM WFOPVT BDDFTT. /PS- FQJOFQISJOF
BENJOJTUSBUJPO TIPVME CF BDDPNQBOJFE CZ JOWBTJWF
IFNPEZOBNJD NPOJUPSJOH. ThF QSJNBSZ NFUIPE PG
FMJNJOBUJPO JT CZ SFVQUBLF JOUP UIF BESFOFSHJD
OFSWF FOEJOHT XIFSF JU JT TUPSFE GPS TVCTFRVFOU SFMFBTF
XJUI POMZ TNBMM BNPVOUT CFJOH NFUBCPMJ[FE.
Clinical Uses
ThF QSJNBSZ VTF PG OPSFQJOFQISJOF JT BT B QPUFOU
WBTP- DPOTUSJDUPS UP JODSFBTF UPUBM QFSJQIFSBM
WBTDVMBS SFTJT- UBODF BOE NFBO BSUFSJBM QSFTTVSF. *U JT
a fiSTU-MJOF BHFOU JO UIF USFBUNFOU PG SFGSBDUPSZ
2,3,14
IZQPUFOTJPO EVSJOH TFWFSF TFQTJT. /PSFQJOFQISJOF-
JOEVDFE WBTPDPOTUSJDUJPO BOE SFEJTUSJCVUJPO PG flPX
NBZ JODSFBTF TQMBODIOJD CMPPE flPX BOE VSJOF PVUQVU
JO TFWFSFMZ IZQPUFOTJWF TFQUJD QBUJFOUT.
/PSFQJOFQISJOF JT BMTP VTFE GPS QBUJFOUT XJUI MPX
TZT- UFNJD WBTDVMBS SFTJTUBODF BftFS DBSEJPQVMNPOBSZ
CZQBTT.
*O QBUJFOUT XJUI DPSPOBSZ BSUFSZ EJTFBTF, OPSFQJOFQISJOF
DBO CF VTFE UP NBJOUBJO QFSGVTJPO QSFTTVSF, BMUIPVHI JU
TIPVME CF CBMBODFE XJUI UIF SFTVMUBOU JODSFBTFE BftFSMPBE
BTTPDJBUFE XJUI IJHI EPTFT.
Side Effects
/PSFQJOFQISJOF TIPVME CF VTFE DBVUJPVTMZ JO QBUJFOUT
XJUI SJHIU WFOUSJDVMBS GBJMVSF. /PSFQJOFQISJOF JODSFBTFT
WFOPVT SFUVSO UP UIF IFBSU BOE BMTP SBJTFT QVMNPOBSZ
BSUFSZ QSFT- TVSFT WJB TUJNVMBUJPO PG QVMNPOBSZ WBTDVMBS
a1-BESFOFS- HJD SFDFQUPST. #PUI PG UIFTF NBZ CF
QPPSMZ UPMFSBUFE CZ QBUJFOUT XJUI SJHIU IFBSU GBJMVSF.
ThF VTF PG OPSFQJOFQISJOF BT BO JOPUSPQJD BHFOU
JT MJNJUFE CZ JUT BDUJPO BT B QPUFOU WBTPDPOTUSJDUPS. ThF
JO- DSFBTFE QFSJQIFSBM SFTJTUBODF BOE BftFSMPBE NBZ
EFDSFBTF DBSEJBD PVUQVU BOE JODSFBTF UIF XPSL PG UIF MFGU
WFOUSJDMF.
*UT VTF JT BMTP MJNJUFE CZ UIF QPUFOUJBM GPS
UBDIZDBSEJB, BMUIPVHI JUT BSSIZUINPHFOJD QPUFOUJBM JT MFTT
UIBO UIBU PG FQJOFQISJOF.
0OF PG UIF NBKPS DPODFSOT XJUI OPSFQJOFQISJOF VTF
JT PSHBO JTDIFNJB. &YDFTTJWF WBTPDPOTUSJDUJPO BOE EF-
DSFBTFE QFSGVTJPO PG SFOBM, TQMBODIOJD, BOE QFSJQIFSBM
WBTDVMBS CFET NBZ MFBE UP FOE-PSHBO IZQPQFSGVTJPO BOE
JTDIFNJB. 3FOBM BSUFSJPMBS WBTPDPOTUSJDUJPO NBZ MFBE
UP PMJHVSJB BOE SFOBM GBJMVSF. )PXFWFS, XIFO MBSHF EPTFT
PG OPSFQJOFQISJOF BDDPNQBOJFE CZ BEFRVBUF flVJE
WPMVNF SFTVTDJUBUJPO BSF VTFE XJUI DBVUJPO UP USFBU
QSPGPVOE
IZQPUFOTJPO, QFSGVTJPO QSFTTVSF BOE SFOBM CMPPE GM X 5I T BGPSFNFOUJPOFE EPTF-EFQFOEFOU NPEFM PG EPQB-
NBZ BDUVBMMZ JODSFBTF. NJOF'T effFDUT JT UPP TJNQMJTUJD, FWFO JO IFBMUIZ JOEJWJEV-

Dopamine
%PQBNJOF JT BO FOEPHFOPVT DBUFDIPMBNJOF UIBU JT
UIF JNNFEJBUF QSFDVSTPS PG OPSFQJOFQISJOF. %PQBNJOF
SFHV- MBUFT DBSEJBD, WBTDVMBS, BOE FOEPDSJOF GVODUJPO BOE
JT BO JNQPSUBOU OFVSPUSBOTNJUUFS JO UIF DFOUSBM BOE
QFSJQI- FSBM OFSWPVT TZTUFNT. ThF QIBSNBDPMPHZ PG
EPQBNJOF JT DPNQMFY BT UIJT DBUFDIPMBNJOF
diffFSFOUJBMMZ TUJNVMBUFT B WBSJFUZ PG EPQBNJOFSHJD BT
XFMM BT BESFOFSHJD SFDFQ- UPST. *U JT B S FMBUJWFMZ
OPOTQFDJfiD BHPOJTU BU CPUI EPQB- NJOF1 (%1) BOE
EPQBNJOF2 (%2) SFDFQUPST BOE UIF a- BOE [3-BESFOFSHJD
SFDFQUPST. %1 SFDFQUPST BSF MPDBUFE QPTUTZO- BQUJDBMMZ.
8IFO BDUJWBUFE %1 SFDFQUPST FMJDJU WBTPEJMBUJPO JO SFOBM,
NFTFOUFSJD, DPSPOBSZ, BOE DFSFCSBM WBTDVMBS CFET BOE
JOIJCJUJPO PG TPEJVNoQPUBTTJVN BEFOPTJOF USJQIPT-
15
QIBUBTF (/B+o,+ "51BTF). "DUJWBUJPO PG UIFTF
SFDFQUPST JT NFEJBUFE CZ BEFOZMBUF DZDMBTF TUJNVMBUJPO.
%2 SFDFQUPST BSF QSJODJQBMMZ QSFTZOBQUJD BOE JOIJCJU
BEFOZMBUF DZDMBTF BDUJWJUZ BOE SFMFBTF PG OPSFQJOFQISJOF
JO BVUPOPNJD OFS- WPVT TZTUFN HBOHMJB BOE BESFOFSHJD
OFSWFT (JO SFOBM BOE NFTFOUFSJD WFTTFMT) MFBEJOH UP
16,17
WBTPEJMBUJPO. %2 SFDFQ- UPST BSF BMTP QSFTFOU JO UIF
QJUVJUBSZ HMBOE, FNFUJD DFOUFS PG UIF NFEVMMB, BOE LJEOFZ.
/BVTFB BOE WPNJUJOH QSPEVDFE CZ EPQBNJOF QSPCBCMZ
SFflFDU TUJNVMBUJPO PG %2 SFDFQUPST.
%PQBNJOF SFDFQUPST NBZ BMTP CF BTTPDJBUFE XJUI UIF
OFV- SBM NFDIBOJTN GPS iSFXBSEw UIBU JT BTTPDJBUFE XJUI
DPDBJOF BOE BMDPIPM EFQFOEFODF.
5SBEJUJPOBMMZ, UIF QIBSNBDPLJOFUJDT PG
EPQBNJOF IBT CFFO BUUSJCVUFE UP EPTF-EFQFOEFOU
16
FffFDUT PO WBSZ- JOH SFDFQUPST. "U MPX JOUSBWFOPVT
(*7) JOGVTJPO SBUFT (0.5 UP 3 µH/LH/NJOVUF), EPQBNJOF
QSJNBSJMZ TUJNVMBUFT
%1 BOE %2 SFDFQUPST MFBEJOH UP WBTPEJMBUJPO,
EFDSFBTFE BSUFSJBM CMPPE QSFTTVSF, BOE JODSFBTFE SFOBM
BOE TQMBODI- OJD WBTDVMBS CMPPE GM X. %JVSFTJT BOE
OBUSJVSFTJT BMTP PDDVS. ThF EFDSFBTF JO EJBTUPMJD CMPPE
QSFTTVSF NJHIU MFBE UP B SFflFY JODSFBTF JO IFBSU SBUF. "U
IJHIFS JOGVTJPO SBUFT (3 UP 10 µH/LH/NJOVUF),
EPQBNJOF QSJNBSJMZ TUJNVMBUFT [31-BESFOFSHJD SFDFQUPST
JO UIF IFBSU BT XFMM BT a SFDFQ- UPST JO UIF QFSJQIFSBM
WBTDVMBUVSF. *U BMTP JOEVDFT OPSFQJ- OFQISJOF SFMFBTF
GSPN WBTDVMBS TZNQBUIFUJD OFVSPOT. ThF BDUJWBUJPO PG [3
SFDFQUPST MFBET UP JODSFBTFE DBSEJBD PVUQVU CZ JODSFBTJOH
DISPOPUSPQZ BOE DPOUSBDUJMJUZ BMPOH XJUI WBTPEJMBUJPO
BOE BftFSMPBE SFEVDUJPO. "T UIF JOGVTJPO SBUF JT JODSFBTFE
FWFO GVSUIFS (>10 µH/LH/NJOVUF), EPQBNJOF
QSFEPNJOBOUMZ TUJNVMBUFT a1 SFDFQUPST, BDUJOH TJNJMBSMZ
UP B QVSF a BHPOJTU. ThF QSFEPNJOBOU TUJNVMBUJPO PG
WBTDVMBS TNPPUI NVTDMF a1 SFDFQUPST BU UIFTF IJHIFS
EPTFT MFBE UP BSUFSJBM BOE WFOPVT WBTPDPOTUSJDUJPO,
JODSFBTFE TZTUFNJD WBTDVMBS SFTJTUBODF, BOE JODSFBTFE
CMPPE QSFTTVSF BUUFOV- BUJOH GVSUIFS JODSFBTFT JO DBSEJBD
PVUQVU. 3eflFY CSBEZDBS- EJB NBZ BMTP PDDVS BU UIJT QPJOU.
BMT. ThFSF BSF B XJEF SBOHF PG DMJOJDBM SFTQPOTFT
EFQFOEJOH PO JOEJWJEVBM WBSJBCJMJUZ JO
QIBSNBDPLJOFUJDT BT XFMM BT PUIFS WBSJBCMFT. 'PS
FYBNQMF, EFTQJUF JEFOUJDBM *7 JOGVTJPO SBUFT, UIFSF NBZ
CF B 10- U P 75-GPME WBSJBCJMJUZ JO QMBTNB EPQBNJOF
DPODFOUSBUJPOT QSPEVDFE FWFO JO IFBMUIZ JOEJ- WJEVBMT
18
XJUI OPSNBM ESVH NFUBCPMJTN. ThF FUJPMPHZ PG UIF
XJEF QIBSNBDPLJOFUJD WBSJBCJMJUZ BOE WBSJBUJPO JO JO-
EJWJEVBM SFTQPOTFT JT MJLFMZ NVMUJGBDUPSJBM, SeflFDUJOH
diffFS- FODFT JO ESVH EJTUSJCVUJPO, FMJNJOBUJPO, BOE
FOEPHFOPVT MFWFMT, BNPOH PUIFS GBDUPST. 4VDI
EJffFSFODFT NBZ CF FWFO NPSF QSPGPVOE JO DSJUJDBMMZ JMM
QBUJFOUT. )FODF, UIF FffFDUT PG EPQBNJOF DBOOPU CF
19
QSFEJDUFE CBTFE PO UIF EPTF, BOE UIF ESVH NVTU CF
UJUSBUFE UP FffFDU.
%PQBNJOF JODSFBTFT DBSEJBD PVUQVU CZ TUJNVMBUJPO
PG [31 SFDFQUPST, JODSFBTJOH TUSPLF WPMVNF. ThJT
JODSFBTF JO DBSEJBD PVUQVU JT VTVBMMZ BDDPNQBOJFE CZ
POMZ NPEFTU JO- DSFBTFT JO IFBSU SBUF, TZTUFNJD CMPPE
QSFTTVSF, BOE TZTUFNJD WBTDVMBS SFTJTUBODF. " QPSUJPO PG
UIF FffFDU PG EPQBNJOF JT BMTP EVF UP TUJNVMBUJPO PG
FOEPHFOPVT OPSFQJOFQISJOF SF- MFBTF, XIJDI NBZ
QSFEJTQPTF UP UIF EFWFMPQNFOU PG DBSEJBD EZTSIZUINJBT.
/FWFSUIFMFTT, EPQBNJOF JT MFTT EZTSIZUI- NPHFOJD
UIBO FQJOFQISJOF. ThF SFMFBTF PG OPSFQJOFQISJOF DBVTFE
CZ EPQBNJOF NBZ CF BO VOSFMJBCMF NFDIBOJTN GPS
JODSFBTJOH DBSEJBD PVUQVU XIFO DBUFDIPMBNJOF TUPSFT
BSF EFQMFUFE, BT PDDVST XJUI QBUJFOUT JO DISPOJD DBSEJBD
GBJMVSF.
%PQBNJOF JODSFBTFT NZPDBSEJBM PYZHFO DPOTVNQUJPO.
%PQBNJOF DBVTFT CPUI SFMBYBUJPO BOE DPOUSBDUJPO
PG WBT- DVMBS TNPPUI NVTDMF XJUI UIF QSFEPNJOBOU
FffFDU WBSZJOH CZ WBTDVMBS CFE, QSFEPNJOBOU SFDFQUPS
UZQF, BOE EPTF BENJO- JTUFSFE. %PQBNJOF'T effFDU PO
QVMNPOBSZ WBTDVMBS SFTJTUBODF IBT OPU CFFO XFMM TUVEJFE
JO IVNBOT, UIPVHI UIFSF BSF TPNF SFQPSUT JU NBZ
EFDSFBTF QVMNPOBSZ WBTDVMBS SFTJTUBODF JO QB- UJFOUT XJUI
DISPOJD PCTUSVDUJWF QVMNPOBSZ EJTFBTF.
3BQJE NFUBCPMJTN PG EPQBNJOF XJUI BO
FMJNJOBUJPO IBMG-MJGF PG 1 UP 2 NJOVUFT NBOEBUFT JUT VTF BT
B DPOUJOVPVT JOGVTJPO (1 UP 20 µH/LH/NJOVUF) UP
NBJOUBJO UIFSBQFVUJD QMBTNB DPODFOUSBUJPOT. %PQBNJOF
TIPVME CF EJTTPMWFE JO 5% HMVDPTF JO XBUFS GPS *7
BENJOJTUSBUJPO UP BWPJE UIF JOBD- UJWBUJPO UIBU NBZ PDDVS
JO BMLBMJOF TPMVUJPOT. &YUSBWBTBUJPO PG EPQBNJOF, MJLF
OPSFQJOFQISJOF, QSPEVDFT JOUFOTF MPDBM WBTPDPOTUSJDUJPO,
XIJDI NBZ CF USFBUFE XJUI MPDBM JOfiMUSB- UJPO PG
20
QIFOUPMBNJOF. %PQBNJOF JT OPU FffFDUJWF PSBMMZ BOE
EPFT OPU DSPTT UIF CMPPEoCSBJO CBSSJFS JO TVffiDJFOU
BNPVOUT UP DBVTF $/4 F ffFDUT. ThF JNNFEJBUF
QSFDVS- TPS PG EPQBNJOF, --EPQB, JT BCTPSCFE GSPN UIF
HBTUSPJO- UFTUJOBM USBDU BOE SFBEJMZ DSPTTFT UIF
CMPPEoCSBJO CBSSJFS.
%PQBNJOF JT QBSUJBMMZ QSPUFJO CPVOE. "QQSPYJNBUFMZ
25% JT DPOWFSUFE UP OPSFQJOFQISJOF. %PQBNJOF
VOEFSHPFT NFUBCPMJTN JO UIF MJWFS XJUI DPOKVHBUJPO UP
TVMGBUFT BOE HMVDVSPOJEFT, QVMNPOBSZ FOEPUIFMJVN CZ
DBUFDIPM-0- NFUIZMUSBOTGFSBTF ($0.5) BOE FYDSFUJPO CZ
UIF LJEOFZT.
Clinical Uses
%PQBNJOF JT VTFE DMJOJDBMMZ UP JODSFBTF DBSEJBD PVUQVU JO
QBUJFOUT XJUI EFDSFBTFE DPOUSBDUJMJUZ, MPX TZTUFNJD CMPPE
QSFTTVSF, BOE MPX VSJOF PVUQVU BT NBZ CF QSFTFOU
BftFS
 21
DBSEJPQVMNPOBSZ CZQBTT PS XJUI DISPOJD IFBSU GBJMVSF. NFE- VMMBSZ DPMMFDUJOH EVDUT TUJNVMBUFT QSPTUBHMBOEJO & 2
*U JT VOJRVF BNPOH UIF DBUFDIPMBNJOFT JO CFJOH BCMF UP (1(&2) QSPEVDUJPO. ThJT BOUBHPOJ[FT UIF FffFDUT PG
TJNVMUBOFPVTMZ JODSFBTF NZPDBSEJBM DPOUSBDUJMJUZ, BOUJEJVSFUJD
SFOBM CMPPE flPX, HMPNFSVMBS fiMUSBUJPO SBUF, FYDSFUJPO PG
22
TPEJVN, BOE VSJOF PVUQVU. %PQBNJOF FYFSUT JUT QPTJUJWF
DISPOP- USPQJD, ESPNPUSPQJD, JOPUSPQJD, BOE MVTJUSPQJD
(NZPDBSEJBM SFMBYBOU) FffFDUT WJB [31-BESFOFSHJD SFDFQUPST.
"DUJWBUJPO PG BSUFSJBM BOE WFOPVT a1 SFDFQUPST JODSFBTFT
TZTUFNJD WBT- DVMBS SFTJTUBODF, QSFMPBE, BOE MFft
23
WFOUSJDVMBS BftFSMPBE.
)PXFWFS, BT EPQBNJOF JODSFBTFT QVMNPOBSZ WBTDVMBS
SFTJTUBODF BT XFMM, JU NBZ OPU CF UIF QSFGFSSFE JOPUSPQJD
BHFOUT JO QBUJFOUT XJUI QVMNPOBSZ IZQFSUFOTJPO PS SJHIU
WFOUSJDVMBS EZTGVODUJPO.
ThF EJWFSHFOU QIBSNBDPMPHJD effFDUT PG EPQBNJOF
BOE EPCVUBNJOF NBLF UIFJS VTF JO DPNCJOBUJPO
QPUFO- UJBMMZ VTFGVM. 'PS FYBNQMF, JOGVTJPOT PG
EPQBNJOF BOE EPCVUBNJOF JO DPNCJOBUJPO IBWF CFFO
OPUFE UP QSPEVDF B HSFBUFS JNQSPWFNFOU JO DBSEJBD
PVUQVU, BU MPXFS EPTFT, UIBO DBO CF BDIJFWFE CZ FJUIFS
ESVH BMPOF. #PUI BSF JOP- USPQJD CVU FBDI ESVH EJMBUFT
diffFSFOU WBTDVMBS CFET TVDI UIBU UIF TVNNBUJPO PG
BftFSMPBE SFEVDUJPO CZ CPUI ESVHT NBZ QSPEVDF B H
SFBUFS JNQSPWFNFOU JO DBSEJBD PVUQVU UIBO DPVME CF
BDIJFWFE CZ FJUIFS ESVH BMPOF. %PQBNJOF NBZ EJTUSJCVUF
UIF DBSEJBD PVUQVU UP UIF SFOBM BOE NFT- FOUFSJD
WBTDVMBS CFET, XIFSFBT EPCVUBNJOF NBZ QSPWJEF
BEEJUJPOBM BftFSMPBE SFEVDUJPO CZ EJMBUJOH TLJO BOE TLFM-
FUBM NVTDMF WBTDVMBS CFET. ThF PCKFDUJWF PG DPNCJOBUJPO
UIFSBQZ JT UP JODSFBTF DPSPOBSZ QFSGVTJPO BOE DBSEJBD
PVU- QVU XIJMF EFDSFBTJOH BftFSMPBE, TJNJMBS UP BO
JOUSBBPSUJD CBMMPPO QVNQ.

Renal-Dose Dopamine
ThF UFSN renal-dose dopamine PS low-dose
dopamine SFGFST UP UIF DPOUJOVPVT JOGVTJPO PG TNBMM
EPTFT (1 U P 3 µH/LH/NJOVUF) PG EPQBNJOF UP QBUJFOUT
UP QSPNPUF SFOBM CMPPE flPX. *O IFBMUIZ JOEJWJEVBMT,
MPX-EPTF EPQB- NJOF JODSFBTFT SFOBM CMPPE flPX BOE
JOEVDFT OBUSJVSFTJT BOE EJVSFTJT. ThFPSFUJDBMMZ,
EPQBNJOF'T SFOBM WBTPEJMBU- JOH FffFDUT NBZ CF VTFGVM
JO QBUJFOUT XJUI JNQBJSFE SFOBM GVODUJPO PS JO QBUJFOUT
BU SJTL PG EFDSFBTFE SFOBM QFSGV- TJPO BT NBZ PDDVS
XJUI EFDSFBTFE DBSEJBD PVUQVU. 4NBMM EPTFT PG
EPQBNJOF JODSFBTF SFOBM CMPPE GM X QSFEPNJ- OBOUMZ
CZ %1 SFDFQUPST JO UIF SFOBM WBTDVMBUVSF BOE QPT- TJCMZ
CZ %2 SFDFQUPST WJB JOIJCJUJPO PG OPSFQJOFQISJOF
SFMFBTF. -BSHFS EPTFT QSFEPNJOBOUMZ JODSFBTF SFOBM CMPPE
flPX CZ [3-BESFOFSHJDoNFEJBUFE JODSFBTFT JO DBSEJBD PVU-
QVU. )JHIFS EPTFT PG EPQBNJOF QSFTVNBCMZ TUJNVMBUF
a SFDFQUPST UP JODSFBTF QFSGVTJPO QSFTTVSF. *O
BEEJUJPO, EPQBNJOF USJHHFST OBUSJVSFTJT BOE EJVSFTJT
UISPVHI EJSFDU FffFDU PO UVCVMBS DFMM GVODUJPO. %PQBNJOF
CJOET UP %1 BOE
%2 SFDFQUPST JO UIF QSPYJNBM UVCVMF, UIJDL BTDFOEJOH MPPQ
PG )FOMF, BOE DPSUJDBM DPMMFDUJOH EVDUT JOIJCJUJOH /B+o,
+
"51BTF BDUJWJUZ, JODSFBTJOH /B+ FYDSFUJPO, JOEVDJOH
24
OB- USJVSFTJT BOE EJVSFTJT. ThF BDUJWBUJPO PG %2 JO JOOFS

IPSNPOF BOE SFTVMUT JO JODSFBTFE GSFF XBUFS
DMFBSBODF. 1(&2 FOIBODFT CMPPE flPX JO UIF JOOFS
NFEVMMB. *OIJCJ- UJPO PG BMEPTUFSPOF BMTP JODSFBTFT
TPEJVN FYDSFUJPO BOE EJVSFTJT. )FODF, EPQBNJOF IBT
EJSFDU BOE JOEJSFDU effFDUT PO UIF SFOBM WBTDVMBUVSF JO
BEEJUJPO UP GVODUJPOJOH BT B EJVSFUJD.
ThF UFSN renal-dose PS low-dose dopamine JT
NJT- MFBEJOH BT EPQBNJOF IBT NBOZ FffFDUT BU TJUFT
PUIFS UIBO UIF LJEOFZT, FWFO BU MPX EPTFT. %PQBNJOF'T
FffFDUT CBTFE PO EPTF BMPOF BSF VOQSFEJDUBCMF. -PX-
EPTF EPQBNJOF BMTP JNQMJFT BO VOQSPWFO CFOefiDJBM
25o27
effFDU PO SFOBM GVOD- UJPO. *O QBUJFOUT SFDFJWJOH
EPQBNJOF CFGPSF B iSFOBM JOTVMU,w UIFSF JT B D MFBS
EJVSFUJD FffFDU CVU OPOF GPS JN- QSPWFE DSFBUJOJOF
26
DMFBSBODF PS EFDSFBTFE OFFE GPS IF- NPEJBMZTJT.
%FTQJUF ESVH-JOEVDFE EJVSFTJT, UIFSF JT OP FWJEFODF
UIBU VSJOF PVUQVU JO UIF QSFTFODF PG MPX DBSEJBD PVUQVU
BOE/PS IZQPWPMFNJB QSPUFDUT SFOBM GVODUJPO. ThF VTF PG
EPQBNJOF BftFS UIF SFOBM JOTVMU IBT PDDVSSFE IBT OPU
CFFO TIPXO UP JNQSPWF HMPNFSVMBS fiMUSBUJPO SBUF.
ThFSF JT FWJEFODF UIBU UIF CFOFfiDJBM FffFDU PG MPX-EPTF
EP- QBNJOF PO SFOBM CMPPE flPX BOE HMPNFSVMBS
fiMUSBUJPO SBUF PCTFSWFE JO IFBMUIZ JOEJWJEVBMT JT EVF UP
ESVH-JOEVDFE JODSFBTFT JO DBSEJBD PVUQVU, BOE UIJT
27o29
CFOFfiU JT MPTU JO FBSMZ SFOBM GBJMVSF. /P SBOEPNJ[FE
DPOUSPMMFE TUVEJFT IBWF EFNPOTUSBUFE B EFDSFBTF JO UIF
JODJEFODF PG BDVUF SFOBM GBJMVSF XIFO EPQBNJOF JT
BENJOJTUFSFE UP QBUJFOUT DPO- TJEFSFE UP CF BU SJTL GPS
EFWFMPQJOH BDVUF SFOBM GBJMVSF JO NVMUJQMF QBUJFOU
30
QPQVMBUJPOT (NBKPS WBTDVMBS TVSHFSZ,
31
DBSEJPQVMNPOBSZ CZQBTT, JOUFOTJWF DBSF, IFBSU GBJMVSF,
32
TFQTJT, USBOTQMBOUBUJPO, QBUJFOUT FYQPTFE UP OFQISPUPYJD
33
ESVHT ) DPOfiSNJOH UIF SFTVMUT PG UXP MBSHF SFUSPTQFDUJWF
25,26 32,33
TUVEJFT BOE UXP NFUB-BOBMZTFT, GJ EJOH UIBU EPQB-
NJOF EPFT OPU QSFWFOU PS SFWFSTF BDVUF SFOBM GBJMVSF PS
JNQSPWF PVUDPNF. "TJEF GSPN POF TUVEZ EFNPOTUSBUJOH
EPQBNJOF TFMFDUJWFMZ JODSFBTFT SFOBM CMPPE flPX JO IFBSU
GBJMVSF QBUJFOUT WJB EJMBUJPO PG CPUI MBSHF
DPOEVDUBODF BOE TNBMM SFTJTUBODF SFOBM CMPPE
34
WFTTFMT, UIFSF FYJTUT OP QSPWFO JNQSPWFNFOU JO SFOBM
QFSGVTJPO, DSFBUJOJOF DMFBSBODF, PS HMPNFSVMBS fiMUSBUJPO
SBUF BOE OP BMUFSB- UJPO JO UIF DPVSTF PG SFOBM GBJMVSF
PS UIF OFFE GPS SFOBM SFQMBDFNFOU UIFSBQZ.
%PQBNJOF MFBET UP BO JODSFBTF JO DPSUJDBM BOE JOOFS
NFEVMMBSZ CMPPE flPX, TIVOUJOH flPX GSPN UIF PVUFS NF-
EVMMB. *U JODSFBTFT TPMVUF EFMJWFSZ UP UIF EJTUBM UVCVMBS
DFMMT JODSFBTJOH NFEVMMBSZ PYZHFO DPOTVNQUJPO. ThF
PVUFS NFEVMMB JT IJHIMZ NFUBCPMJDBMMZ BDUJWF BOE IJHIMZ
TVTDFQ- UJCMF UP JTDIFNJD JOKVSZ BOE BDVUF SFOBM GBJMVSF.
%PQBNJOF DBO JOEVDF SFOBM GBJMVSF JO CPUI OPSNP- BOE
IZQPWPMFNJD QBUJFOUT.
-PX-EPTF EPQBNJOF JT BTTPDJBUFE XJUI NVMUJQMF DPN-
QMJDBUJPOT BGG DUJOH UIF DBSEJPWBTDVMBS, QVMNPOBSZ,
HBTUSP- JOUFTUJOBM, FOEPDSJOF, BOE JNNVOF TZTUFNT. "
NVMUJDFOUFS PCTFSWBUJPOBM TUVEZ EFNPOTUSBUFE UIBU
EPQBNJOF JT BO JOEFQFOEFOU SJTL GBDUPS GPS EFBUI GPS
35
QBUJFOUT XJUI TIPDL EVF UP BOZ DBVTF. *O UIF BCTFODF PG
EBUB DPOfiSNJOH UIF effiDBDZ PG EPQBNJOF JO
QSFWFOUJOH BDVUF SFOBM GBJMVSF,
 25,36
SFOBM-EPTF EPQBNJOF DBOOPU CF SFDPNNFOEFE. *O DISPOJD TUSFTT. 8IFO EPQBNJOF JT VTFE JO UIF DISPOJD
GBDU, OPU POMZ EPFT MPX-EPTF EPQBNJOF OPU DPOGFS QIBTF PG JMMOFTT, JU GVSUIFS TVQQSFTTFT UIF DJSDVMBUJOH
42
BOZ SFOBM QSPUFDUJWF NFDIBOJTN, JU NBZ JO GBDU CF DPODFOUSBUJPOT PG QJUVJUBSZ IPSNPOFT.
27,37
EFUSJNFOUBM.

Cardiovascular Effects
%PQBNJOF JT BTTPDJBUFE NPSF UIBO EPCVUBNJOF PS
FQJ- OFQISJOF XJUI EPTF-SFMBUFE TJOVT UBDIZDBSEJB
23,38
BOE UIF QPUFOUJBM UP DBVTF WFOUSJDVMBS BSSIZUINJBT
BOE NBZ QSFEJTQPTF UP NZPDBSEJBM JTDIFNJB CZ
QSFDJQJUBUJOH UBDIZ- DBSEJB, JODSFBTJOH DPOUSBDUJMJUZ,
JODSFBTJOH BftFSMPBE, BOE QSFDJQJUBUJOH DPSPOBSZ BSUFSZ
WBTPTQBTN. %PQBNJOF JO- DSFBTFT QFSJQIFSBM WBTDVMBS
SFTJTUBODF BOE QVMNPOBSZ BSUFSZ QSFTTVSFT. 6OMJLF
EPCVUBNJOF, EPQBNJOF EPFT OPU JOIJCJU IZQPYJD
QVMNPOBSZ WBTPDPOTUSJDUJPO. /FWFS- UIFMFTT, EPQBNJOF
JT OPU SFDPNNFOEFE GPS VTF JO SJHIU IFBSU GBJMVSF.

Gastrointestinal Effects
(BTUSPJOUFTUJOBM NVDPTBM JTDIFNJB BOE TVCTFRVFOU USBOT-
MPDBUJPO PG CBDUFSJB BOE CBDUFSJBM UPYJOT QMBZ BO
JNQPSUBOU SPMF JO UIF EFWFMPQNFOU PG NVMUJQMF PSHBO
EZTGVODUJPO TZOESPNF. %PQBNJOF'T FffFDU PO
TQMBODIOJD CMPPE GM X BOE HBTUSJD JOUSBNVDPTBM Q) JT
DPOUSPWFSTJBM BOE JODPO- TJTUFOU. ThFSF JT OP FWJEFODF
UIBU MPX-EPTF EPQBNJOF IBT CFOFfiDJBM FffFDUT PO
TQMBODIOJD GVODUJPO PS SFEVDFT UIF QSPHSFTTJPO UP
NVMUJPSHBO GBJMVSF JO TFQTJT. %PQB- NJOF NBZ JODSFBTF
flPX UP UIF NVTDVMBS MBZFS PG UIF HVU XJUI EFDSFBTFE
flPX UP UIF NVDPTBM MBZFS XJUI EFUSJNFO- UBM FffFDUT BOE
QPTTJCMZ HVU JTDIFNJB. *O TFQUJD QBUJFOUT, EPQBNJOF
CVU OPU OPSFQJOFQISJOF, BT BENJOJTUFSFE UP NBJOUBJO
BO BDDFQUBCMF NFBO BSUFSJBM QSFTTVSF, SFTVMUFE JO BO
VODPNQFOTBUFE JODSFBTF JO TQMBODIOJD PYZHFO SFRVJSF-
NFOUT. "MUIPVHI EPQBNJOF JOGVTJPO JO TFQUJD QBUJFOUT
MFE UP JODSFBTFE IFQBUPTQMBODIOJD QFSGVTJPO,
IFQBUPTQMBODI- OJD PYZHFO VQUBLF XBT SFEVDFE
TVHHFTUJOH BO JNQBJSNFOU PG IFQBUPTQMBODIOJD
40
NFUBCPMJTN. .PTU PG UIFTF TUVEJFT IBWF MPPLFE BU UIF
FffFDUT PG MPX-EPTF EPQBNJOF SBUIFS UIBO EPTFT VTFE UP
USFBU IZQPUFOTJPO.
%2 SFDFQUPST BSF BMTP MPDBUFE JO UIF FOUFSJD
OFSWPVT TZTUFN. %PQBNJOF BHPOJTUT JOUFSGFSF XJUI
HBTUSPJOUFTUJOBM NPUJMJUZ. -PX-EPTF EPQBNJOF IBT CFFO
EFNPOTUSBUFE UP TMPX HBTUSJD NPUJMJUZ JO NFDIBOJDBMMZ
41
WFOUJMBUFE JOUFOTJWF DBSF QBUJFOUT.

Endocrine and Immunologic

Effects
%PQBNJOF EJTSVQUT NFUBCPMJD BOE JNNVOPMPHJD GVODUJPOT
UISPVHI JUT FffFDUT PO IPSNPOFT BOE MZNQIPDZUF
GVODUJPO. ThF BOUFSJPS QJUVJUBSZ QMBZT B DSVDJBM SPMF JO
NFUBCPMJD BOE JNNVOPMPHJD IPNFPTUBTJT. ThF JOJUJBM
TUSFTT SFTQPOTF TUJNVMBUFT QJUVJUBSZ IPSNPOF SFMFBTF,
XIFSFBT UIF DISPOJD QIBTF JT BTTPDJBUFE XJUI TVQQSFTTJPO
PG UIF IZQPUIBMBNJD- QJUVJUBSZ BYJT. *O UIF BDVUF QIBTF PG
BO JMMOFTT, EPQBNJOF JOEVDFT UIF QBUUFSO PG
IZQPQJUVJUBSJTN TFFO JO QSPMPOHFE DSJUJDBM JMMOFTT BOE
 %PQBNJOF EFQSFTTFT UIF JNNVOF TUBUVT CZ
SFEVDJOH TFSVN QSPMBDUJO MFWFMT. 1SPMBDUJO JT BO
JNNVOPSFHVMB- UPSZ IPSNPOF BffFDUJOH 5 BOE #
MZNQIPDZUFT. %PQBNJOF JOIJCJUT MZNQIPDZUF
QSPMJGFSBUJPO, JNNVOPHMPCVMJO TZOUIFTJT, BOE
DZUPLJOF QSPEVDUJPO BOE QSPNPUFT MZN- QIPDZUF
BQPQUPTJT. %PQBNJOF BMTP EFDSFBTFT UIF TFDSF- UJPO
PG HSPXUI IPSNPOF, XIJDI IBT BOBCPMJD, MJQPMZUJD,
BOE JNNVOF-TUJNVMBUJOH QSPQFSUJFT. (SPXUI
IPSNPOF EFfiDJFODZ DBO DPOUSJCVUF UP JNQBJSFE
BOBCPMJTN BOE B OFHBUJWF OJUSPHFO CBMBODF.
%PQBNJOF'T JOIJCJUJPO PG UIZ- SPUSPQJO-SFMFBTJOH
IPSNPOF MFBET UP iFVUIZSPJE TJDL TZO- ESPNF.w *U BMTP
EFDSFBTFT EFIZESPFQJBOESPTUFSPOF TVMGBUF BOE NBZ
BffFDU MVUFJOJ[JOH IPSNPOF SFMFBTF. %PQBNJOF'T PWFSBMM
FffFDU JT UP TVQQSFTT UIF TFDSFUJPO BOE GVODUJPO PG
BOUFSJPS QJUVJUBSZ IPSNPOFT, BHHSBWBUJOH DBUBCPMJTN
BOE DFMMVMBS JNNVOF GVODUJPO BOE JOEVDJOH DFOUSBM
42
IZQP- UIZSPJEJTN.
Respiratory Effects
ThF JOGVTJPO PG MPX-EPTF EPQBNJOF JO IFBMUIZ
TVCKFDUT BT XFMM BT IFBSU GBJMVSF QBUJFOUT JOUFSGFSFT XJUI
UIF WFOUJ- MBUPSZ SFTQPOTF UP BSUFSJBM IZQPYFNJB BOE
IZQFSDBQOJB, SeflFDUJOH UIF SPMF PG EPQBNJOF BT BO
43
JOIJCJUPSZ OFVSP- USBOTNJUUFS BU UIF DBSPUJE CPEJFT.
ThF SFTVMU JT EFQSFTTJPO PG WFOUJMBUJPO JO QBUJFOUT XIP
BSF CFJOH USFBUFE XJUI EP- QBNJOF UP JODSFBTF
44
NZPDBSEJBM DPOUSBDUJMJUZ. %PQBNJOF BMTP EFDSFBTFT
BSUFSJBM PYZHFO TBUVSBUJPO CZ JNQBJSJOH SFHJPOBM
45
WFOUJMBUJPO/QFSGVTJPO NBUDIJOH JO UIF MVOHT.
%PTF-EFQFOEFOU SFEVDUJPOT JO BSUFSJBM 1P2 XJUI JODSFBT-
JOH SBUFT PG EPQBNJOF JO DSJUJDBMMZ JMM QBUJFOUT BftFS NBKPS
46
TVSHFSZ IBWF CFFO EFNPOTUSBUFE. "SUFSJBM CMPPE HBTFT
IBWF CFFO PCTFSWFE UP EFUFSJPSBUF EVSJOH JOGVTJPO PG
EPQBNJOF.
0OF TUVEZ EFNPOTUSBUFE MPX-EPTF EPQBNJOF EJE OPU
JOflVFODF WFOUJMBUJPO TQFDJfiDBMMZ JO QBUJFOUT XJUI DISPOJD
PCTUSVDUJWF QVMNPOBSZ EJTFBTF FJUIFS CSFBUIJOH
TQPOUB- OFPVTMZ PS CFJOH XFBOFE GSPN NFDIBOJDBM
WFOUJMBUJPO.
47
%PQBNJOF NBZ FWFO EFDSFBTF QVMNPOBSZ WBTDVMBS
SF- TJTUBODF JO QBUJFOUT XJUI DISPOJD PCTUSVDUJWF
QVMNPOBSZ EJTFBTF. 0UIFS QPUFOUJBM CFOefiDJBM effFDUT BSF
JNQSPWFE SF- TQJSBUPSZ NVTDMF DPOUSBDUJPO, JODSFBTFE
MVOH FEFNB DMFBS- BODF, BOE JOIJCJUJPO PG
47,48
CSPODIPDPOTUSJDUJPO. )PXFWFS, TVDI SFQPSUT BSF
BOFDEPUBM PS OPU UFTUFE JO DMJOJDBM TUVEJFT.
Intraocular Pressure
$POUJOVPVT JOGVTJPOT PG EPQBNJOF UP DSJUJDBMMZ JMM
QB- UJFOUT BSF BTTPDJBUFE XJUI JODSFBTFT JO JOUSBPDVMBS
49
QSFT- TVSF. ThJT NBZ DSFBUF B SJTL JO QBUJFOUT XJUI
QSFFYJTUJOH HMBVDPNB FTQFDJBMMZ JG UIFZ BSF TFEBUFE BOE
NFDIBOJDBMMZ WFOUJMBUFE.
Synthetic Catecholamines
ThF UXP DMJOJDBMMZ VTFGVM TZOUIFUJD DBUFDIPMBNJOFT BSF
JTP- QSPUFSFOPM BOE EPCVUBNJOF (TFF 5BCMF 18-1 BOE 'JH.
18-1).
Isoproterenol
*TPQSPUFSFOPM JT UIF NPTU QPUFOU BDUJWBUPS PG BMM UIF TZN-
QBUIPNJNFUJDT XJUI [31 BOE [32 SFDFQUPS BDUJWJUZ. *U JT UXP
UP UISFF UJNFT NPSF QPUFOU UIBO FQJOFQISJOF BOE BU MFBTU
100 UJNFT NPSF BDUJWF UIBO OPSFQJOFQISJOF. *O
DMJOJDBM EPTFT, JTPQSPUFSFOPM JT EFWPJE PG a BHPOJTU FffFDUT
BOE EPFT OPU DBVTF UIF WBTPDPOTUSJDUJPO BTTPDJBUFE XJUI
UIF OBUV- SBMMZ PDDVSSJOH DBUFDIPMBNJOFT.
ThF DBSEJPWBTDVMBS effFDUT PG JTPQSPUFSFOPM SeflFDU BD-
UJWBUJPO PG [31 SFDFQUPST JO UIF IFBSU BOE [32 SFDFQUPST JO
TLFMFUBM NVTDMF BOE UP B MFTTFS FYUFOU SFOBM BOE TQMBODI-
OJD WBTDVMBS CFET. *O BO BEVMU, DPOUJOVPVT JOGVTJPO PG
JTP- QSPUFSFOPM, 1 UP 5 µH QFS NJOVUF, HSFBUMZ JODSFBTFT
IFBSU SBUF, NZPDBSEJBM DPOUSBDUJMJUZ, BOE DBSEJBD
BVUPNBUJDJUZ, XIFSFBT WBTPEJMBUJPO JO TLFMFUBM NVTDMFT
EFDSFBTFT TZT- UFNJD WBTDVMBS SFTJTUBODF. "MUIPVHI
DBSEJBD PVUQVU NBZ JODSFBTF UIFSFCZ JODSFBTJOH
TZTUPMJD CMPPE QSFTTVSF, UIF NFBO BSUFSJBM QSFTTVSF NBZ
EFDSFBTF EVF UP EFDSFBTFT JO TZTUFNJD WBTDVMBS SFTJTUBODF
BOE BTTPDJBUFE EFDSFBTFT JO EJBTUPMJD CMPPE QSFTTVSF.
*ODSFBTFT JO DBSEJBD PVUQVU NBZ CF BUUFOVBUFE CZ
JNQBJSFE MFGU WFOUSJDVMBS fiMMJOH EVF UP UBDIZDBSEJB BT
XFMM BT EFDSFBTFE QSFMPBE GSPN WFOPVT WBTPEJMBUJPO.
ThFSF JT QSFGFSFOUJBM WBTPEJMBUJPO JO OPOFT- TFOUJBM BSFBT
TVDI BT TLFMFUBM NVTDMF. %FDSFBTFE EJBTUPMJD CMPPE
QSFTTVSF, JODSFBTFE IFBSU SBUF, BOE DBSEJBD EZT-
SIZUINJBT NBZ MFBE UP B EFDSFBTF JO DPSPOBSZ CMPPE flPX
BU UIF TBNF UJNF UIBU NZPDBSEJBM PYZHFO SFRVJSFNFOUT
BSF JODSFBTFE CZ UBDIZDBSEJB BOE JODSFBTFE NZPDBSEJBM
50
DPO- USBDUJMJUZ. $PNQFOTBUPSZ CBSPSFDFQUPS-NFEJBUFE
SFflFY TMPXJOH PG UIF IFBSU SBUF EPFT OPU PDDVS EVSJOH
JOGVTJPO PG JTPQSPUFSFOPM CFDBVTF NFBO BSUFSJBM QSFTTVSF
JT OPU JO- DSFBTFE. ThJT DPNCJOBUJPO PG FWFOUT NBZ CF
EFMFUFSJPVT JO QBUJFOUT XJUI DPSPOBSZ BSUFSZ EJTFBTF.
$PNQBSFE UP EPCVUBNJOF, GPS B DPNQBSBCMF JODSFBTF
JO DBSEJBD PVUQVU, JTPQSPUFSFOPM JT BTTPDJBUFE XJUI MBSHFS
EFDSFBTFT JO UPUBM QFSJQIFSBM WBTDVMBS SFTJTUBODF BOE
CMPPE QSFTTVSF. *U JT BMTP BTTPDJBUFE XJUI NPSF
UBDIZDBSEJB CPUI GSPN EJSFDU [3 FffFDUT BT XFMM BT B SFflFY
JODSFBTF JO IFBSU SBUF XJUI EFDSFBTFE WBTDVMBS UPOF.
.FUBCPMJTN PG JTPQSPUFSFOPM JO UIF MJWFS CZ
$0.5 JT SBQJE, OFDFTTJUBUJOH B DPOUJOVPVT JOGVTJPO UP
NBJOUBJO UIFSBQFVUJD QMBTNB DPODFOUSBUJPOT. 6QUBLF PG
JTPQSPUFS- FOPM JOUP QPTUHBOHMJPOJD TZNQBUIFUJD OFSWF
FOEJOHT JT NJOJNBM.
Clinical Uses
" DPOUJOVPVT JOGVTJPO PG JTPQSPUFSFOPM, 1 UP 5 µH
QFS NJOVUF, JT FffFDUJWF JO JODSFBTJOH UIF IFBSU SBUF JO
BEVMUT JO UIF QSFTFODF PG IFBSU CMPDL. *TPQSPUFSFOPM JT
VTFE UP QSPWJEF TVTUBJOFE JODSFBTFT JO IFBSU SBUF CFGPSF
JOTFSUJPO PG B U FNQPSBSZ PS QFSNBOFOU DBSEJBD
QBDFNBLFS JO UIF USFBUNFOU PG CSBEZEZTSIZUINJBT.
*TPQSPUFSFOPM'T BCJMJUZ UP EFDSFBTF QVMNPOBSZ WBTDVMBS
SFTJTUBODF NBZ CF VTF- GVM JO UIF NBOBHFNFOU PG
QVMNPOBSZ IZQFSUFOTJPO BOE SJHIU WFOUSJDVMBS
51
EZTGVODUJPO. ThF VTF PG JTPQSPUFSFOPM BT BO JOPUSPQJD
ESVH IBT EFDSFBTFE XJUI UIF BWBJMBCJMJUZ
PG JOPUSPQJD BHFOUT TVDI BT EPCVUBNJOF BOE QIPTQIPEJ-
FTUFSBTF JOIJCJUPST. -JLFXJTF, UIF VTF PG JTPQSPUFSFOPM BT B
CSPODIPEJMBUPS IBT CFFO TVQQMBOUFE CZ UIF BWBJMBCJMJUZ PG
TQFDJfiD [32 BHPOJTUT.
Adverse Effects
7BTPEJMBUJPO BOE EFDSFBTFE CMPPE QSFTTVSF NBZ MJNJU
UIF VTF PG JTPQSPUFSFOPM. *O BEEJUJPO, JU DBO MFBE UP
UBDIZBS- SIZUINJBT. ThF DPNCJOBUJPO PG EFDSFBTFE
EJBTUPMJD CMPPE QSFTTVSF BOE JODSFBTFE IFBSU SBUF BOE
EZTSIZUINJBT NBZ MFBE UP NZPDBSEJBM JTDIFNJB.
Dobutamine
%PCVUBNJOF JT B TZOUIFUJD DBUFDIPMBNJOF EFSJWFE
GSPN JTPQSPUFSFOPM DPOTJTUJOH PG B 50:50 SBDFNJD NJYUVSF
52
PG UXP TUFSFPJTPNFST. 5I ( ) FOBOUJPNFS JT B Q
PUFOU a1- BESFOFSHJD BHPOJTU BT XFMM BT B XFBL [31- BOE
[32-BESFOFSHJD BHPOJTU. ThF (+) FOBOUJPNFS JT B
DPNQFUJUJWF BOUBHPOJTU BU UIF a1 SFDFQUPS TJUF BT XFMM BT B
53
QPUFOU [31- BOE [32-BESFOFSHJD BHPOJTU. %PCVUBNJOF IBT
QPUFOU [31-BESFOFSHJD effFDUT XJUI XFBLFS [32-BESFOFSHJD
BDUJWJUZ. *UT FffFDU PO a SFDFQ- UPST JODSFBTFT BU IJHIFS
EPTFT. %PCVUBNJOF'T DBSEJPWBTDV- MBS FffFDUT BSF B SFTVMU
PG UIF DPNCJOBUJPO PG BDUJWJUZ PG JUT UXP
TUFSFPJTPNFST.
53o56
%PCVUBNJOF BDUT QSJNBSJMZ BT B Q PTJUJWF JOPUSPQJD
BHFOU. %PCVUBNJOF MFBET UP BO JODSFBTF JO
JOUSBDFMMVMBS D".1, JODSFBTJOH DBMDJVN SFMFBTF GSPN
UIF TBSDPQMBT- NJD SFUJDVMVN UP JODSFBTF DPOUSBDUJMJUZ.
$BSEJBD PVUQVU JT JODSFBTFE QSJNBSJMZ CZ BO JODSFBTF JO
TUSPLF WPMVNF. $PO- USBDUJMJUZ JT JODSFBTFE GSPN JUT BDUJPO
PO NZPDBSEJBM [31 BOE a1 SFDFQUPST BOE, UP B MFTTFS FYUFOU,
CZ EFDSFBTFE BftFSMPBE GSPN JUT FffFDU PO WBTDVMBS
TNPPUI NVTDMF [32 SFDFQUPST.
%PCVUBNJOF IBT XFBL FffFDUT PO WBTDVMBS UPOF
DBVTJOH QFSJQIFSBM WBTPEJMBUJPO. "U IJHIFS EPTFT, UIF ( )
JTPNFS TUJNVMBUFT a1 SFDFQUPST, MJNJUJOH GVSUIFS
WBTPEJMBUJPO.
#MPPE QSFTTVSF VTVBMMZ JT OPU TJHOJfiDBOUMZ BffFDUFE
BT a1-NFEJBUFE WBTPDPOTUSJDUJPO CZ UIF ( )
FOBOUJPNFS JT DPVOUFSFE CZ a1 BOUBHPOJTN CZ UIF (+)
FOBOUJPNFS BOE CZ JUT [32 BDUJWJUZ, BMUIPVHI UIF MBUUFS NBZ
53o56
CF VONBTLFE CZ [3 CMPDLBEF UIFSBQZ. *O BEEJUJPO,
UIFSF NBZ CF NJOJ- NBM FffFDUT PO UIF NFBO BSUFSJBM
QSFTTVSF BT UIF JODSFBTFE DBSEJBD PVUQVU PffTFUT UIF
EFDSFBTF JO QFSJQIFSBM WBTDVMBS SFTJTUBODF. #FDBVTF
EPCVUBNJOF EPFT OPU QPTTFTT DMJOJ- DBMMZ JNQPSUBOU
WBTPDPOTUSJDUPS BDUJWJUZ, JU NBZ CF JOFffFD- UJWF JO
QBUJFOUT XIP SFRVJSF JODSFBTFE TZTUFNJD WBTDVMBS
SFTJTUBODF SBUIFS UIBO BVHNFOUBUJPO PG DBSEJBD PVUQVU
UP JODSFBTF TZTUFNJD CMPPE QSFTTVSF.
%PCVUBNJOF BffFDUT IFBSU SBUF UISPVHI JUT BDUJPO
PO [31-BESFOFSHJD SFDFQUPST. %PCVUBNJOF TUJNVMBUFT
TJOPBUSJBM OPEF BVUPNBUJDJUZ BT XFMM BT BUSJPWFOUSJDVMBS
38
OPEBM BOE WFOUSJDVMBS DPOEVDUJPO. ThF DISPOPUSPQJD
FffFDUT PG EP- CVUBNJOF QFS VOJU HBJO JO DBSEJBD PVUQVU
BSF MFTT UIBO UIBU PG EPQBNJOF BOE JTPQSPUFSFOPM CVU JODSFBTF JO DBMDJVN UIBU GBDJMJUBUFT JODSFBTFE
52,57,58
NBZ CF HSFBUFS UIBO UIBU PG FQJOFQISJOF. ThF DPOUSBDUJMJUZ BMTP GBDJMJUBUFT JODSFBTFE
BSSIZUINJBT. "U MPX EPTFT, JODSFBTFT JO IFBSU SBUF NBZ
CF NJOJNBM. )PXFWFS, IJHI EPTFT PG EPCVUBNJOF (>10
µH/LH/ NJOVUF *7) NBZ QSFEJTQPTF UIF QBUJFOU UP
UBDIZDBSEJB BOE DBSEJBD EZTSIZUINJBT.
%PCVUBNJOF JODSFBTFT NZPDBSEJBM PYZHFO DPOTVNQ-
UJPO CZ JODSFBTJOH UBDIZDBSEJB BOE NZPDBSEJBM DPOUSBDUJM-
JUZ. $POWFSTFMZ, EPCVUBNJOF-JOEVDFE JODSFBTFT JO
DBSEJBD PVUQVU NBZ JOEJSFDUMZ MFBE UP B EFDSFBTF JO IFBSU
SBUF JO IFBSU GBJMVSF QBUJFOUT BT TZNQBUIFUJD OFSWPVT
TZTUFN UPOF JT SFEVDFE. 4JNJMBSMZ, TZTUFNJD WBTDVMBS
SFTJTUBODF NBZ EFDSFBTF CZ SFflFY XJUIESBXBM PG
TZNQBUIFUJD UPOF JO BEEJ- UJPO UP EPCVUBNJOF'T [32
BHPOJTU FffFDU. .ZPDBSEJBM PYZHFO DPOTVNQUJPO NBZ
BMTP CF SFEVDFE XJUI JNQSPWFE DPO- USBDUJMJUZ,
EFDSFBTFE Meft WFOUSJDVMBS FOE EJBTUPMJD QSFTTVSF (-7&%1),
BOE EFDSFBTFE XBMM UFOTJPO.
%PCVUBNJOF DBVTFT NPEFTU SFEVDUJPOT JO QVMNPOBSZ
BSUFSJBM QSFTTVSF BOE WBTDVMBS SFTJTUBODF UISPVHI JUT
FffFDUT PO [32 SFDFQUPST. *O QBUJFOUT XJUI JODSFBTFE
QVMNPOBSZ BSUFSZ QSFTTVSF BftFS NJUSBM WBMWF
SFQMBDFNFOU, BO JOGVTJPO PG EPCVUBNJOF (VQ UP 10
µH/LH/NJOVUF) JODSFBTFT DBSEJBD PVUQVU BOE EFDSFBTFT
TZTUFNJD BOE QVMNPOBSZ WBTDVMBS SFTJTUBODF.
59
%PCVUBNJOF JOIJCJUT IZQPYJD QVMNPOBSZ
WBTPDPOTUSJDUJPO. 1VMNPOBSZ WBTPEJMBUJPO NBZ XPSTFO
WFOUJMBUJPO/QFSGVTJPO NJTNBUDIJOH BOE NBZ CF
BTTPDJBUFE XJUI JODSFBTFE JOUSBQVMNPOBSZ TIVOt flPX.
59
6OMJLF EPQBNJOF, EPCVUBNJOF EPFT OPU BDU JOEJ-
SFDUMZ CZ TUJNVMBUJOH UIF SFMFBTF PG FOEPHFOPVT
52
OPSFQJ- OFQISJOF. %PCVUBNJOF EPFT OPU BDUJWBUF
EPQBNJOFSHJD SFDFQUPST UP JODSFBTF SFOBM CMPPE flPX.
3FOBM CMPPE flPX, IPXFWFS, NBZ JNQSPWF BT B S
60
FTVMU PG ESVH-JOEVDFE JODSFBTFT JO DBSEJBD PVUQVU.
%PCVUBNJOF CVU OPU EPQB- NJOF JT B DPSPOBSZ BSUFSZ
WBTPEJMBUPS. 3FEJTUSJCVUJPO PG DBSEJBD PVUQVU JO UIF
QSFTFODF PG EPCVUBNJOF NBZ DPO- USJCVUF UP JODSFBTFE
DVUBOFPVT IFBU MPTT NBOJGFTUJOH BT BO BEEJUJPOBM EFDSFBTF
JO CPEZ UFNQFSBUVSF.
61
VU 3BQJE NFUBCPMJTN PG EPCVUBNJOF (IBMG-MJGF PG 2 NJO-
FT) OFDFTTJUBUFT JUT BENJOJTUSBUJPO BT B D POUJOVPVT
JOGVTJPO PG 2 UP 10 µH/LH/NJOVUF UP NBJOUBJO UIFSBQFVUJD
QMBTNB DPODFOUSBUJPOT. 5BDIZQIZMBYJT NBZ PDDVS BT JU
BDUT PO [3-BESFOFSHJD SFDFQUPST. -JLF EPQBNJOF,
EPCVUBNJOF
TIPVME CF EJTTPMWFE JO 5% H MVDPTF JO XBUFS GPS JOGVTJPO
UP BWPJE JOBDUJWBUJPO PG UIF DBUFDIPMBNJOF UIBU NBZ
PDDVS JO BO BMLBMJOF TPMVUJPO. %PCVUBNJOF VOEFSHPFT
CJPUSBOT- GPSNBUJPO JO UIF MJWFS UP JOBDUJWF HMVDVSPOJEF
DPOKVHBUFT BOE 3-0-NFUIZMEPCVUBNJOF, NPTU PG XIJDI JT
62
FYDSFUFE JO UIF VSJOF.
Clinical Uses
%PCVUBNJOF QSPEVDFT QPUFOU [3-BESFOFSHJD BHPOJTU FG-
GFDUT BU EPTFT MFTT UIBO 5 µH/LH/NJOVUF *7 J
ODSFBTJOH NZPDBSEJBM DPOUSBDUJMJUZ ([31 BOE a1 SFDFQUPST)
BOE DBVT- JOH B NPEFTU EFHSFF PG QFSJQIFSBM WBTPEJMBUJPO
([32 SFDFQ- UPST). ThF MFWPSPUBUPSZ JTPNFS PG EPCVUBNJOF
XJUI EPTF-EFQFOEFOU FffFDUT. %PCVUBNJOF JT VTFE UP
JNQSPWF DBSEJBD PVUQVU JO QBUJFOUT XJUI DPOHFTUJWF IFBSU
60,63
GBJMVSF. %PCVUBNJOF JT BMTP VTFGVM GPS XFBOJOH GSPN
58
DBSEJPQVMNPOBSZ CZQBTT. *U NBZ CF PG VTF JO
QBUJFOUT XJUI QVMNPOBSZ IZQFSUFOTJPO, BMUIPVHI JUT
FffFDU PO UIF QVMNPOBSZ WBTDVMBUVSF JT MFTT UIBO UIBU PG
UIF QIPTQIP- EJFTUFSBTF JOIJCJUPST. $PNCJOBUJPOT PG
ESVHT NBZ CF VTFGVM UP JODSFBTF UIF TQFDUSVN PG
BDUJWJUZ BOE JNQSPWF UIF EJTUSJCVUJPO PG DBSEJBD PVUQVU.
'PS FYBNQMF, WBTPEJ- MBUPST NBZ CF DPNCJOFE XJUI
EPCVUBNJOF PS EPQBNJOF UP EFDSFBTF BftFSMPBE,
PQUJNJ[JOH DBSEJBD PVUQVU JO UIF QSFTFODF PG
JODSFBTFE TZTUFNJD WBTDVMBS SFTJTUBODF. .PTU TUVEJFT
EFNPOTUSBUF NJOJNBM IFNPEZOBNJD diffFSFODF
21
CFUXFFO EPQBNJOF BOE EPCVUBNJOF VTF. %PCVUBNJOF
EPFT OPU IBWF TJHOJGJ BOU WFOPDPOTUSJDUPS BDUJWJUZ
DPN- QBSFE UP EPQBNJOF, TP JODSFBTF JO WFOUSJDVMBS
fiMMJOH QSFT- TVSFT NBZ CF TFFO BU MPX EPTFT.
8IFO VTFE JO UIF DPOUFYU PG JTDIFNJB BT PQQPTFE UP
IFBSU GBJMVSF, UIF SFEVDUJPO JO fiMMJOH QSFTTVSFT BOE
PYZHFO SFRVJSFNFOUT GSPN UIF JODSFBTFE DPOUSBDUJMJUZ JT
OPU Pff- TFU CZ UIF JODSFBTFE UBDIZDBSEJB. .ZPDBSEJBM
PYZHFO DPO- TVNQUJPO JT JODSFBTFE CZ UIF JODSFBTJOH
UBDIZDBSEJB BOE DPOUSBDUJMJUZ, XIFSFBT DPSPOBSZ CMPPE
62
flPX JT EFDSFBTFE CZ WBTPEJMBUJPO. ThFTF QSPQFSUJFT
NBLF EPCVUBNJOF VTFGVM GPS QIBSNBDPMPHJD TUSFTT UFTUJOH
UP EFUFDU QPUFOUJBM BSFBT PG NZPDBSEJBM JTDIFNJB.
Adverse Effects
ThF VTF PG EPCVUBNJOF NBZ CF MJNJUFE CZ UIF
PDDVS- SFODF PG UBDIZBSSIZUINJBT, BMUIPVHI JU JT MFTT
MJLFMZ UIBO EPQBNJOF PS JTPQSPUFSFOPM. 4JOVT
UBDIZDBSEJB PDDVST NPTU DPNNPOMZ, BMUIPVHI
38
WFOUSJDVMBS BSSIZUINJBT NBZ BMTP PDDVS.
5BDIZBSSIZUINJBT PDDVS NPSF GSFRVFOUMZ BU IJHIFS
EPTBHFT PS JO QBUJFOUT XJUI VOEFSMZJOH BSSIZUINJBT
PS IFBSU GBJMVSF. "MTP, QSPMPOHFE DPOUJOVPVT JOGVTJPO
PG
EPCVUBNJOF BTTPDJBUFE XJUI FPTJOPQIJMJD NZPDBSEJUJT BOE
QFSJQIFSBM FPTJOPQIJMJB IBWF CFFO SFQPSUFE.
Synthetic
Noncatecholamines
TUJNVMBUFT a1 SFDFQUPST BU IJHIFS EPTFT (>5
µH/LH/NJOVUF) MJN- JUJOH GVSUIFS WBTPEJMBUJPO.
*OEJWJEVBM WBSJBUJPOT FYJTU
5I DPNNPOMZ VTFE OPODBUFDIPMBNJOF
TZNQBUIPNJ- NFUJD ESVHT BSF FQIFESJOF BOE
QIFOZMFQISJOF ('JH. 18-5). ThFTF XJMM CF GBNJMJBS UP
FWFSZ SFBEFS.
'*(63& 18-5 Synthetic noncatecholamine sympathomi-
metics.
Ephedrine XJUI FQJOFQISJOF, UIF POTFU PG BDUJPO PG FQIFESJOF JT
&QIFESJOF JT BO JOEJSFDU-BDUJOH TZOUIFUJD TMPX, CFDPNJOH DPNQMFUF POMZ 1 I PVS PS NPSF
TZNQBUIPNJ- NFUJD UIBU TUJNVMBUFT a- BOE [3-BESFOFSHJD BftFS BENJOJTUSBUJPO. " EFDPOHFTUBOU FffFDU
SFDFQUPST. ThF QIBSNBDPMPHJD FffFDUT PG FQIFESJOF BSF BDDPNQBOZJOH PSBM BENJOJTUSBUJPO PG FQIFESJOF QSPEVDFT
QBSUMZ EVF UP EJ- SFDU TUJNVMBUJPO PG BESFOFSHJD TZNQUPNBUJD SFMJFG GSPN BDVUF DPSZ[B. &QIFESJOF, 0.5
64
SFDFQUPST (EJSFDU-BDUJOH) BOE QBSUMZ EVF UP NH/LH JOUSBNVTDVMBSMZ, IBT BO BOUJFNFUJD FffFDU TJNJMBS
TUJNVMBUJPO PG SFMFBTF PG FOEPHFOPVT OPSFQJOFQISJOF UP UIBU PG ESPQFSJEPM CVU XJUI MFTT TFEBUJPO XIFO
(JOEJSFDU-BDUJOH). &QIFESJOF JT SFTJTUBOU UP NFUBCPMJTN BENJOJTUFSFE UP QBUJFOUT VOEFS- HPJOH PVUQBUJFOU
70
CZ NPOPBNJOF PYJEBTF (."0) JO UIF HBT- USPJOUFTUJOBM MBQBSPTDPQZ VTJOH HFOFSBM BOFTUIFTJB.
USBDU, UIVT QFSNJUUJOH VODIBOHFE ESVH UP CF BCTPSCFE
JOUP UIF DJSDVMBUJPO BftFS PSBM BENJOJTUSBUJPO. Cardiovascular Effects
*OUSBNVTDVMBS JOKFDUJPO PG FQIFESJOF JT DMJOJDBMMZ BDDFQU- ThF DBSEJPWBTDVMBS effFDUT PG FQIFESJOF SFTFNCMF
BCMF CFDBVTF ESVH-JOEVDFE MPDBM WBTPDPOTUSJDUJPO JT JOTVG- UIPTF PG FQJOFQISJOF, CVU JUT TZTUFNJD CMPPE
fiDJFOU UP EFMBZ TZTUFNJD BCTPSQUJPO PS MFBE UP UJTTVF QSFTTVSFoFMFWBUJOH SFTQPOTF JT MFTT JOUFOTF BOE MBTUT
JOKVSZ. 6Q UP 40% PG B TJOHMF EPTF PG FQIFESJOF JT BQQSPYJNBUFMZ 10 UJNFT MPOHFS. *OUSBWFOPVT FQIFESJOF
FYDSFUFE VODIBOHFE JO VSJOF. 4PNF FQIFESJOF JT SFTVMUT JO JODSFBTFT JO TZT- UPMJD BOE EJBTUPMJD CMPPE
EFBNJOBUFE CZ QSFTTVSF, IFBSU SBUF, BOE DBSEJBD PVUQVU. 3FOBM BOE
."0 JO UIF MJWFS, BOE IFQBUJD DPOKVHBUJPO BMTP PDDVST. TQMBODIOJD CMPPE flPXT BSF EFDSFBTFE, XIFSFBT DPSPOBSZ
ThF TMPX JOBDUJWBUJPO BOE FYDSFUJPO PG FQIFESJOF BSF SF- BOE TLFMFUBM NVTDMF CMPPE flPXT BSF JODSFBTFE.
TQPOTJCMF GPS UIF QSPMPOHFE EVSBUJPO PG BDUJPO PG 4ZTUFNJD WBTDVMBS SFTJTUBODF NBZ CF BMUFSFE NJOJNBMMZ
UIJT TZNQBUIPNJNFUJD. CFDBVTF WBTPDPOTUSJDUJPO JO TPNF WBTDVMBS CFET JT PffTFU
&QIFESJOF, VOMJLF FQJOFQISJOF, EPFT OPU CZ WBTPEJMBUJPO ([32 TUJNVMBUJPO) JO PUIFS BSFBT. ThFTF
QSPEVDF NBSLFE IZQFSHMZDFNJB. .ZESJBTJT DBSEJPWBTDVMBS FffFDUT BSF EVF, JO QBSU, UP a SFDFQUPSo
BDDPNQBOJFT UIF BE- NJOJTUSBUJPO PG FQIFESJOF, BOE NFEJBUFE QFSJQIFSBM BSUFSJBM BOE WFOPVT WBTPDPOTUSJDUJPO.
$/4 T UJNVMBUJPO EPFT PDDVS, BMUIPVHI MFTT UIBO UIBU ThF QSJODJQBM NFDIBOJTN, IPXFWFS, GPS DBSEJPWBTDVMBS
QSPEVDFE CZ BNQIFUBNJOF. FG- GFDUT QSPEVDFE CZ FQIFESJOF JT JODSFBTFE NZPDBSEJBM
DPO- USBDUJMJUZ EVF UP BDUJWBUJPO PG [31 SFDFQUPST. *O UIF
Clinical Uses QSFTFODF PG QSFFYJTUJOH [3-BESFOFSHJD CMPDLBEF, UIF
&QIFESJOF, 5 U P 10 N H *7 B ENJOJTUFSFE UP BEVMUT, JT DBSEJPWBTDVMBS FffFDUT PG FQIFESJOF NBZ SFTFNCMF
B DPNNPOMZ TFMFDUFE TZNQBUIPNJNFUJD UP JODSFBTF SFTQPOTFT NPSF UZQJDBM PG a-BESFOFSHJD SFDFQUPS
TZT- UFNJD CMPPE QSFTTVSF JO UIF QSFTFODF PG TZNQBUIFUJD TUJNVMBUJPO.
OFS- WPVT TZTUFN CMPDLBEF QSPEVDFE CZ SFHJPOBM " TFDPOE EPTF PG FQIFESJOF QSPEVDFT B M FTT
BOFTUIFTJB PS IZQPUFOTJPO EVF UP JOIBMFE PS JOKFDUFE JOUFOTF TZTUFNJD CMPPE QSFTTVSF SFTQPOTF UIBO UIF fiSTU
BOFTUIFUJDT. *O BO BOJNBM NPEFM, FQIFESJOF NPSF EPTF. ThJT QIFOPNFOPO, LOPXO BT UBDIZQIZMBYJT, PDDVST
TQFDJfiDBMMZ DPSSFDUFE UIF OPODBSEJBD DJSDVMBUPSZ XJUI NBOZ TZNQBUIPNJNFUJDT. 5BDIZQIZMBYJT UP
DIBOHFT QSPEVDFE CZ TQJOBM FQIFESJOF BQQFBST
65
BOFTUIFTJB UIBO EJE B TFMFDUJWF a PS [3 BHPOJTU ESVH. UP USFBU CSPODIJBM BTUINB CFDBVTF PG JUT CSPODIPEJMBUJOH
6OUJM SFDFOUMZ, FQIFESJOF XBT DPOTJEFSFE UIF QSFGFSSFE FffFDUT CZ BDUJWBUJPO PG [32-BESFOFSHJD SFDFQUPST. $PNQBSFE
TZNQB- UIPNJNFUJD GPS BENJOJTUSBUJPO UP QBSUVSJFOUT
FYQFSJFOD- JOH EFDSFBTFE TZTUFNJD CMPPE QSFTTVSF
PXJOH UP TQJOBM PS FQJEVSBM BOFTUIFTJB. 4VQQPSU GPS UIJT
QSBDUJDF XBT UIF PCTFSWBUJPO JO QSFHOBOU FXFT UIBU
VUFSJOF CMPPE flPX XBT OPU HSFBUMZ BMUFSFE XIFO
FQIFESJOF XBT BENJOJTUFSFE UP SFTUPSF NBUFSOBM CMPPE
QSFTTVSF UP OPSNBM BftFS QSPEVD- UJPO PG TZNQBUIFUJD
66,67
OFSWPVT TZTUFN CMPDLBEF. 3FDFOU SFWJFXT PG USJBMT PG
FQIFESJOF WFSTVT QIFOZMFQISJOF IBWF DPODMVEFE UIBU
TZTUFNJD CMPPE QSFTTVSF DPOUSPM JT TJNJMBS XJUI CPUI
ESVHT CVU QIFOZMFQISJOF JT BTTPDJBUFE XJUI B IJHIFS
68
VNCJMJDBM BSUFSZ Q) BU EFMJWFSZ UIBO FQIFESJOF.
"ENJOJTUSBUJPO PG QIFOZMFQISJOF CZ JOGVTJPO
EVSJOH DFTBSFBO TFDUJPO UP NBJOUBJO NBUFSOBM TZTUPMJD
CMPPE QSFTTVSF BU CBTFMJOF JT BTTPDJBUFE XJUI B MPXFS
69
JODJEFODF PG GFUBM BDJEPTJT UIBO JT FQIFESJOF. #BTFE PO
UIFTF EBUB, JU TFFNT UIBU a BHPOJTUT TVDI BT
QIFOZMFQISJOF NBZ CF QSFGFSBCMF UP FQIFESJOF GPS
USFBUNFOU PG NBUFSOBM IZQP- UFOTJPO.
&QIFESJOF DBO CF VTFE BT DISPOJD PSBM NFEJDBUJPO
 64
UP JOWPMWF a SFDFQUPS JOIJCJUJPO.
Phenylephrine
1IFOZMFQISJOF, 3-IZESPYZQIFOZMFUIZMBNJOF, JT B
TZOUIFUJD OPODBUFDIPMBNJOF. 1IFOZMFQISJOF diffFST
GSPN FQJOFQI- SJOF POMZ JO MBDLJOH B 4-IZESPYZM
HSPVQ PO UIF CFO[FOF SJOH. $MJOJDBMMZ, QIFOZMFQISJOF
NJNJDT UIF effFDUT PG OPS- FQJOFQISJOF CVU JT MFTT
QPUFOU BOE MPOHFS MBTUJOH. 1IFOZM- FQISJOF QSJODJQBMMZ
TUJNVMBUFT a1-BESFOFSHJD SFDFQUPST CZ B EJSFDU FffFDU,
XJUI POMZ B TNBMM QBSU PG UIF QIBSNBDPMPHJD SFTQPOTF
CFJOH EVF UP JUT BCJMJUZ UP FWPLF UIF SFMFBTF PG
71
OPSFQJOFQISJOF (JOEJSFDU-BDUJOH). 1IFOZMFQISJOF FYFSUT
NJOJNBM FffFDUT PO [3-BESFOFSHJD SFDFQUPST. ThF EPTF
PG QIFOZMFQISJOF OFDFTTBSZ UP TUJNVMBUF a1 SFDFQUPST JT
GBS MFTT UIBO UIF EPTF UIBU TUJNVMBUFT a2 SFDFQUPST.
1IFOZMFQI- SJOF QSJNBSJMZ DBVTFT WFOPDPOTUSJDUJPO
SBUIFS UIBO BSUF- SJBM DPOTUSJDUJPO. $/4 TUJNVMBUJPO JT
NJOJNBM.
Clinical Uses
1IFOZMFQISJOF, 50 UP 200 µH *7 CPMVT, JT PftFO BENJOJT-
UFSFE UP BEVMUT UP USFBU TZTUFNJD CMPPE QSFTTVSF EFDSFBTFT
UIBU BDDPNQBOZ TZNQBUIFUJD OFSWPVT TZTUFN CMPDLBEF
QSPEVDFE CZ B S FHJPOBM BOFTUIFUJD BOE QFSJQIFSBM QPUBTTJVN DPODFOUSBUJPO. ThJT FffFDU PG a-BESFOFSHJD
WBTPEJMBUJPO GPMMPXJOH BENJOJTUSBUJPO PG JOKFDUFE PS TUJNVMBUJPO PO NPWFNFOU PG QPUBTTJVN JPOT BDSPTT DFMM
72
JO- IBMFE BOFTUIFUJDT. 1IFOZMFQISJOF JT CFMJFWFE UP CF NFNCSBOFT JT PQQPTJUF UP UIBU QSPEVDFE CZ [32 SFDFQUPS
8
QBS- UJDVMBSMZ VTFGVM JO QBUJFOUT XJUI DPSPOBSZ BSUFSZ TUJNVMBUJPO (TFF 'JH. 18-2).
EJTFBTF BOE JO QBUJFOUT XJUI BPSUJD TUFOPTJT CFDBVTF JU
JODSFBTFT DPSPOBSZ QFSGVTJPO QSFTTVSF XJUIPVU
DISPOPUSPQJD TJEF FG- GFDUT, VOMJLF NPTU PUIFS
TZNQBUIPNJNFUJDT.
1IFOZMFQISJOF IBT CFFO VTFE BT B DPOUJOVPVT
JOGVTJPO (20 UP 100 µH QFS NJOVUF) JO BEVMUT UP
NBJOUBJO OPSNBM CMPPE QSFTTVSF EVSJOH TVSHFSZ. ThF
SeflFY WBHBM effFDUT QSPEVDFE CZ QIFOZMFQISJOF DBO CF
VTFE UP TMPX IFBSU SBUF JO UIF QSFTFODF PG
IFNPEZOBNJDBMMZ TJHOJGJ BOU TVQSBWFO- USJDVMBS
UBDIZEZTSIZUINJBT.
1IFOZMFQISJOF TuffiDJFOU UP JODSFBTF TZTUFNJD
CMPPE QSFTTVSF JO DPNCJOBUJPO XJUI JOIBMFE OJUSJD PYJEF
SFTVMUT JO B H SFBUFS JNQSPWFNFOU JO BSUFSJBM
73
PYZHFOBUJPO UIBO XJUI FJUIFS ESVH BMPOF.
5PQJDBMMZ BQQMJFE, QIFOZMFQISJOF JT B XJEFMZ BWBJMBCMF
OBTBM EFDPOHFTUBOU, VTVBMMZ XJUI UIF CSBOE OBNF
/FP- 4ZOFQISJOF. ThF OBTBM TQSBZ JT B 1% T PMVUJPO,
UIF TBNF DPODFOUSBUJPO BT UIF VOEJMVUFE QIFOZMFQISJOF
BNQVMF JO UIF PQFSBUJOH SPPN. *OUFOTF OBTBM
WBTPDPOTUSJDUJPO QSF- DMVEFT SBQJE BCTPSQUJPO JO
BXBLF TVCKFDUT CVU NVTU CF VTFE WFSZ DBVUJPVTMZ JG
74
BQQMJFE UP UIF TVSHJDBl fiFME.

Cardiovascular Effects
3BQJE *7 JOKFDUJPO PG QIFOZMFQISJOF UP QBUJFOUT XJUI DPS-
POBSZ BSUFSZ EJTFBTF QSPEVDFT EPTF-EFQFOEFOU QFSJQIFSBM
WBTPDPOTUSJDUJPO BOE JODSFBTFT JO TZTUFNJD CMPPE
QSFT- TVSF, XIJDI BSF BDDPNQBOJFE CZ EFDSFBTFT JO
75
DBSEJBD PVU- QVU ('JH. 18-6). %FDSFBTFT JO DBSEJBD
PVUQVU NBZ SFflFDU JODSFBTFE BftFSMPBE CVU NPSF MJLFMZ
BSF EVF UP CBSPSFDFQ- UPS-NFEJBUFE SFflFY CSBEZDBSEJB JO
SFTQPOTF UP ESVH-JO- EVDFE JODSFBTFT JO EJBTUPMJD CMPPE
QSFTTVSF. *U JT QPTTJCMF UIBU EFDSFBTFT JO DBSEJBD PVUQVU
DPVME MJNJU UIF BTTPDJBUFE JODSFBTFT JO TZTUFNJD CMPPE
QSFTTVSF. 3BQJE BENJOJTUSB- UJPO PG QIFOZMFQISJOF, 1
µH/LH *7, UP BOFTUIFUJ[FE QBUJFOUT XJUI DPSPOBSZ BSUFSZ
EJTFBTF DBVTFT B U SBOTJFOU JNQBJS- NFOU PG MFGU
76
WFOUSJDVMBS HMPCBM GVODUJPO. 0SBM DMPOJEJOF
QSFNFEJDBUJPO BVHNFOUT UIF QSFTTPS SFTQPOTF UP QIFOZM-
FQISJOF, QSFTVNBCMZ EVF UP DMPOJEJOF-JOEVDFE QPUFOUJB-
77
UJPO PG a1-NFEJBUFE WBTPDPOTUSJDUJPO. 3FOBM,
TQMBODIOJD, BOE DVUBOFPVT CMPPE flPXT BSF EFDSFBTFE
CVU DPSPOBSZ CMPPE flPX JT JODSFBTFE. 1VMNPOBSZ BSUFSZ
QSFTTVSF JT JO- DSFBTFE CZ QIFOZMFQISJOF.

Metabolic Effects
4UJNVMBUJPO PG a SFDFQUPST CZ B DPOUJOVPVT JOGVTJPO
PG QIFOZMFQISJOF EVSJOH BDVUF QPUBTTJVN MPBEJOH
JOUFS- GFSFT XJUI UIF NPWFNFOU PG QPUBTTJVN JPOT
78
BDSPTT DFMM NFNCSBOFT JOUP DFMMT ('JH. 18-7).
"ENJOJTUSBUJPO PG QIFOZMFQISJOF JO UIF BCTFODF PG BO
BDVUF QPUBTTJVN MPBE EPFT OPU DIBOHF UIF QMBTNB
'*(63& 18-6 Hemodynamic response to rapid
intravenous injection of phenylephrine in a single patient.
Mean arte- rial pressure (MAP) and systemic vascular
resistance (SVR) increase and cardiac output (CO)
decreases in response to phenylephrine, with peak effects
occurring 42 seconds after drug administration. (From
Schwinn DA, Reves JG. Time course and hemodynamic
effects of alpha-1-adrenergic bolus administration in
anesthetized patients with myocardial dis- ease. Anesth
Analg. 1989;68[5]:571–578, with permission.)

Treatment of Overdose
4ZTUFNJD NBOJGFTUBUJPOT PG TZNQBUIFUJD OFSWPVT
TZTUFN BDUJWBUJPO (TZTUFNJD IZQFSUFOTJPO, UBDIZDBSEJB,
CBSPSF- DFQUPS-NFEJBUFE CSBEZDBSEJB) NBZ BDDPNQBOZ
WBTDVMBS BCTPSQUJPO PG a BHPOJTUT (QIFOZMFQISJOF,
FQJOFQISJOF) XIFO VTFE BT UPQJDBM PS JOKFDUFE
74
WBTPDPOTUSJDUPST JO UIF TVSHJDBM GJ ME. 1IFOUPMBNJOF, BO
a1-BESFOFSHJD SFDFQUPS BOUBHPOJTU, JT BO BQQSPQSJBUF
79
QIBSNBDPMPHJD DIPJDF GPS QIFOZMFQISJOF UPYJDJUZ. [32
SFDFQUPS CMPDLBEF JODSFBTFT QFSJQIFSBM WBTDVMBS
SFTJTUBODF. "EEJUJPOBMMZ, QIFOZM- FQISJOF PWFSEPTF
QSFGFSFOUJBMMZ EJTUSJCVUFT CMPPE UP UIF QVMNPOBSZ
WBTDVMBS CFET. ThF OBUVSBM QSPUFDUJPO PG UIF
QVMNPOBSZ WBTDVMBS PWFSMPBE JT UP NBJOUBJO DBSEJBD PVU-
QVU. 4JODF [31 SFDFQUPS CMPDLBEFT SFEVDFT DBSEJBD PVUQVU,
USFBUNFOU PG QIFOZMFQISJOF-JOEVDFE IZQFSUFOTJWF
DSJTJT
'*(63& 18-7 Plasma potassium (K+) concentrations during the infusion of potassium chloride (KCl) increase more in
patients also receiving phenylephrine. (From Williams ME, Rosa RM, Silva P, et al. Impairment of extrarenal potassium
disposal by alpha-adrenergic stimulation. N Engl J Med. 1984;311[3]:145–149, with permission.)

XJUI [3-BESFOFSHJD CMPDLJOH ESVHT JT DPOUSBJOEJDBUFE. Clinical Uses

$BTF SFQPSUT EPDVNFOU UIBU [3-BESFOFSHJD CMPDLBEF
QSFTBHFT QVMNPOBSZ FEFNB BOE JSSFWFSTJCMF
74
DBSEJPWBTDVMBS DPMMBQTF JO UIFTF DBTFT.
)PXFWFS, TZTUFNJD IZQFSUFOTJPO JOEVDFE CZ
JOUSBWF-
OPVTMZ BENJOJTUFSFE a BHPOJTUT NBZ OPU SFRVJSF USFBUNFOU.
ThF EVSBUJPO PG BDUJPO PG *7 QIFOZMFQISJOF BOE
FQJOFQI-
SJOF JT CSJFG BOE IZQFSUFOTJPO NBZ SFTPMWF
TQPOUBOFPVTMZ XJUIPVU QIBSNBDPMPHJD JOUFSWFOUJPOT.
4FWFSF IZQFSUFOTJPO NBZ SFRVJSF QIBSNBDPMPHJD
JOUFSWFOUJPOT CVU USFBUNFOU NVTU OPU EFDSFBTF UIF
BCJMJUZ PG UIF TUSFTTFE NZPDBSEJVN UP JODSFBTF
DPOUSBDUJMJUZ BOE IFBSU SBUF. *O UIJT DJSDVNTUBODF,
WBTPEJMBUJOH ESVHT TVDI BT OJUSPQSVTTJEF PS OJUSPHMZDFSJO
NBZ CF IFMQGVM, BMPOH XJUI QIFOUPMBNJOF BT OPUFE FBSMJFS.
[32-"ESFOFSHJD BHPOJTUT BSF UIF QSFGFSSFE USFBUNFOU
GPS BDVUF FQJTPEFT PG BTUINB BOE UIF QSFWFOUJPO PG
80
FYFSDJTF-JOEVDFE BTUINB. $VSSFOUMZ VTFE [3 2-BESFOFSHJD
BHPOJTUT NBZ CF EJWJEFE JOUP UIPTF XJUI BO JOUFSNFEJBUF
U BSF MPOH-
EVSBUJPO PG BDUJPO (3 UP
80 6 IPVST) BOE UIPTF
BDUJOH (>12 IPVST). "NPOH UIF
JOUFS UIB BUF-BDUJOH
NFEJ
ESVHT, UIFSF JT MJUUMF SFBTPO UP DIPPTF POF PWFS UIF PUIFS.
[32-"ESFOFSHJD BHPOJTUT BSF BMTP VTFE SFHVMBSMZ JO QBUJFOUT
XJUI DISPOJD PCTUSVDUJWF QVMNPOBSZ EJTFBTF, SFTVMUJOH JO
JNQSPWFE BJS flPX BOE FYFSDJTF UPMFSBODF. ThF MPOH-
BDUJOH [32-BESFOFSHJD BHPOJTU TBMNFUFSPM JT IJHIMZ
MJQPQIJMJD BOE IBT B I JHI BffiOJUZ GPS UIF [32 SFDFQUPS,
SFTVMUJOH JO QSP- MPOHFE BDUJWBUJPO BU UIJT TJUF. *O
BEEJUJPO UP UIF USFBUNFOU

Selective (32-
Adrenergic Agonists
4FMFDUJWF [32-BESFOFSHJD BHPOJTUT SFMBY CSPODIJPMF BOE
VUFS- JOF TNPPUI NVTDMF CVU JO DPOUSBTU UP JTPQSPUFSFOPM
HFOFS- BMMZ MBDL TUJNVMBUJOH ([31) FffFDUT PO UIF IFBSU.
/FWFSUIFMFTT, IJHI DPODFOUSBUJPOT PG UIFTF ESVHT BSF
MJLFMZ UP DBVTF TUJN- VMBUJPO PG [31 SFDFQUPST. ThF
DIFNJDBM TUSVDUVSF PG TFMFD- UJWF [32-BESFOFSHJD BHPOJTUT
(QMBDFNFOU PG IZESPYZM HSPVQT PO UIF CFO[FOF SJOH BU
TJUFT EJffFSFOU UIBO UIF DBUFDIPM- BNJOFT) SFOEFST UIFN
SFTJTUBOU UP NFUIZMBUJPO CZ $0.5, UIVT DPOUSJCVUJOH UP
UIFJS TVTUBJOFE EVSBUJPO PG BDUJPO. ThF DPNNPOMZ
VTFE [32-BESFOFSHJD BHPOJTUT BSF BMCVUFSPM,
NFUBQSPUFSFOPM, BOE UFSCVUBMJOF ('JH. 18-8) (5BCMF 18-2).
'*(63& 18-8 Selective [32-adrenergic agonists.
 5BCMF 18-2
Comparative Pharmacology of Selective [32-Adrenergic Agonist Bronchodilators
1FBL &ffFDU %VSBUJPO PG
[32 4FMFDUJWJUZ (NJO) "DUJPO (I)
"MCVUFSPM )JHI 30o60
.FUBQSPUFSFOPM .PEFSBUF 30o60
5FSCVUBMJOF )JHI 60
.%*, NFUFSFE-EPTF JOIBMFS.
PG CSPODIPTQBTN, [32-BESFOFSHJD BHPOJTUT NBZ BMTP CF
BENJOJTUFSFE BT DPOUJOVPVT JOGVTJPOT UP TUPQ QSFNBUVSF
VUFSJOF DPOUSBDUJPOT (UPDPMZUJDT).
Route of Administration
[32-"ESFOFSHJD CSPODIPEJMBUPST DBO CF BENJOJTUFSFE
PSBMMZ, CZ JOIBMBUJPO, TVCDVUBOFPVTMZ, PS WJB *7
JOKFDUJPO. ThF JOIBMFE SPVUF JT QSFGFSSFE CFDBVTF UIF TJEF
FffFDUT BSF GFXFS GPS BOZ HJWFO EFHSFF PG CSPODIPEJMBUJPO.
*OIBMBUJPO JT BT FffFDUJWF BT QBSFOUFSBM BENJOJTUSBUJPO
GPS USFBUJOH BDVUF, TFWFSF BUUBDLT PG BTUINB JO NPTU
QBUJFOUT, BMUIPVHI TPNF XIP IBWF TFWFSF CSPODIJBM
PCTUSVDUJPO NBZ CFOFfiU JOJUJBMMZ GSPN QBSFOUFSBM UIFSBQZ.
*OIBMFE [32-BESFOFSHJD BHPOJTUT DBO CF
BENJOJTUFSFE BT BO BFSPTPM GSPN B K FU PS VMUSBTPOJD
OFCVMJ[FS, PS UIFZ DBO CF BENJOJTUFSFE GSPN B NFUFSFE-
EPTF JOIBMFS FJUIFS BT B QSPQFMMBOU-HFOFSBUFE BFSPTPM PS
BT B CSFBUI-QSPQFMMFE ESZ QPXEFS. 8JUI PQUJNBM
JOIBMBUJPO UFDIOJRVF (EJT- DIBSHF UIF JOIBMFS XIJMF
UBLJOH B TMPX EFFQ CSFBUI PWFS 5 UP 6 T FDPOET, BOE UIFO
IPME UIF CSFBUI BU GVMM JOTQJSB- UJPO GPS 10 T FDPOET),
BQQSPYJNBUFMZ 12% P G UIF ESVH JT EFMJWFSFE GSPN UIF
NFUFSFE-EPTF JOIBMFS UP UIF MVOHT; UIF SFNBJOEFS JT
80
EFQPTJUFE JO UIF NPVUI, QIBSZOY, BOE MBS- ZOY. ThF
QSFTFODF PG BO FOEPUSBDIFBM UVCF EFDSFBTFT CZ
BQQSPYJNBUFMZ 50% UP 70% UIF BNPVOU PG ESVH EFMJWFSFE
81
CZ B NFUFSFE-EPTF JOIBMFS UIBU SFBDIFT UIF USBDIFB. "D-
UVBUJPO PG UIF NFUFSFE-EPTF JOIBMFS EVSJOH B N
FDIBOJ- DBMMZ EFMJWFSFE JOTQJSBUJPO JODSFBTFT UIF BNPVOU
PG ESVH UIBU QBTTFT CFZPOE UIF EJTUBM FOE PG UIF USBDIFBM
UVCF. *O HFOFSBM, UIF EPTF SFRVJSFE JO B OFCVMJ[FS JT 6 UP
10 UJNFT UIBU VTFE JO B NFUFSFE-EPTF JOIBMFS UP QSPEVDF
UIF TBNF EFHSFF PG CSPODIPEJMBUJPO.
Side Effects
ThF XJEFTQSFBE EJTUSJCVUJPO PG [32-BESFOFSHJD
SFDFQUPST NBLFT JU MJLFMZ UIBU VOEFTJSFE SFTQPOTFT NBZ
SFTVMU XIFO [32-BESFOFSHJD BHPOJTUT VOEFSHP TZTUFNJD
BCTPSQUJPO. ThF BCJMJUZ UP NJOJNJ[F UIFTF TZTUFNJD TJEF
FffFDUT CZ EFDSFBT- JOH QMBTNB ESVH DPODFOUSBUJPOT JT BO
BEWBOUBHF PG BENJO- JTUFSJOH [32-BESFOFSHJD
CSPODIPEJMBUPST CZ JOIBMBUJPO.
$PODFOUSBUJPO .FUIPE PG
(µH QFS Quff) "ENJOJTUSBUJPO
4 90 .%*, PSBM
3o4 200 0SBM, TVCDVUBOFPVT
4 200 .%*, PSBM, TVCDVUBOFPVT
ThF QSJODJQBM TJEF FffFDU JO BXBLF TVCKFDUT PG
[32- BESFOFSHJD BHPOJTUT USFBUNFOU JT USFNPS, XIJDI JT
DBVTFE CZ EJSFDU TUJNVMBUJPO PG [32 SFDFQUPST JO TLFMFUBM
NVTDMFT.
*ODSFBTFE IFBSU SBUF JT MFTT DPNNPO XJUI UIF
TFMFDUJWF [32-BESFOFSHJD BHPOJTUT, CVU FWFO TUJNVMBUJPO PG
[32 SFDFQ- UPST NBZ SFTVMU JO WBTPEJMBUJPO BOE SFflFY
UBDIZDBSEJB. "T UIFSF BSF [32-BESFOFSHJD SFDFQUPST JO UIF
IFBSU, EJSFDU TUJN- VMBUJPO PG UIF IFBSU SFTVMUT GSPN UIF
VTF PG TFMFDUJWF [32- BESFOFSHJD BHPOJTUT. *O QBUJFOUT XJUI
BDVUF, TFWFSF BTUINB, [32-BESFOFSHJD BHPOJTUT NBZ DBVTF
B U SBOTJFOU EFDSFBTF JO BSUFSJBM PYZHFOBUJPO QSFTVNFE
UP SFflFDU SFMBYBUJPO PG DPNQFOTBUPSZ WBTPDPOTUSJDUJPO JO
BSFBT PG EFDSFBTFE WFO- UJMBUJPO. ThJT JT OPU B TFSJPVT
QSPCMFN JG TVQQMFNFOUBM PYZ- HFO JT BENJOJTUFSFE.
*ODSFBTFE NPSUBMJUZ JO QBUJFOUT XJUI TFWFSF BTUINB
USFBUFE XJUI [32-BESFOFSHJD BHPOJTUT JT NPTU MJLFMZ B
SFflFDUJPO PG UIF TFWFSJUZ PG UIF BTUINB SBUIFS UIBO B UPYJD
82,83
FffFDU PG UIF ESVH UIFSBQZ.
"DVUF NFUBCPMJD SFTQPOTFT UP [32-BESFOFSHJD BHPOJTUT
JODMVEF IZQFSHMZDFNJB, IZQPLBMFNJB, BOE IZQPNBHOF-
TFNJB. #FDBVTF UIFTF SFTQPOTFT EJNJOJTI XJUI
DISPOJD BENJOJTUSBUJPO, TVDI DIBOHFT BSF OPU
JNQPSUBOU JO QB- UJFOUT SFDFJWJOH MPOH-UFSN UIFSBQZ.
-BDUJD BDJEPTJT NBZ PDDVS JO BTTPDJBUJPO XJUI [32
BHPOJTU UIFSBQZ, QFSIBQT SeflFDUJOH FYDFTT
HMZDPHFOPMZTJT BOE MJQPMZTJT GSPN [32 SFDFQUPS
84
BDUJWBUJPO.
Albuterol
"MCVUFSPM, LOPXO BT TBMCVUBNPM PVUTJEF UIF 6OJUFE
4UBUFT, JT UIF QSFGFSSFE TFMFDUJWF [32-BESFOFSHJD BHPOJTU
GPS UIF USFBUNFOU PG BDVUF CSPODIPTQBTN EVF UP BTUINB.
"ENJO- JTUSBUJPO JT NPTU PftFO CZ NFUFSFE-EPTF JOIBMFS,
QSPEVDJOH BCPVU 100 µH QFS QVGG UIF VTVBM EPTF JT UXP
QVffT EFMJW- FSFE EVSJOH EFFQ JOIBMBUJPOT 1 U P 5
N JOVUFT BQBSU. ThJT EPTF NBZ CF SFQFBUFE FWFSZ 4 UP 6
IPVST, OPU UP FYDFFE 16 UP 20 QVffT EBJMZ. "MUFSOBUJWFMZ,
2.5 UP 5 NH PG BMCVUFSPM
(0.5 UP 1 N- PG 0.5% TPMVUJPO JO 5 N- PG OPSNBM TBMJOF)
NBZ CF BENJOJTUFSFE CZ OFCVMJ[BUJPO FWFSZ 15 NJOVUFT
GPS UISFF UP GPVS EPTFT, GPMMPXFE CZ USFBUNFOUT IPVSMZ
EVS- JOH UIF JOJUJBM IPVST PG UIFSBQZ. ThF EVSBUJPO PG
BDUJPO PG BO JOIBMFE EPTF JT BCPVU 4 I PVST, CVU IPVST. ThF FffFDUT PG
TJHOJfiDBOU SF- MJFG PG TZNQUPNT NBZ QFSTJTU VQ UP 8
 VODPNNPO CFDBVTF PG UIF BWBJMBCJMJUZ
BMCVUFSPM BOE WPMBUJMF BOFTUIFUJDT PO CSPODIPNPUPS UPOF
85
BSF BEEJUJWF.
$POUJOVPVT OFCVMJ[BUJPO PG BMCVUFSPM VTJOH B M
BSHF SFTFSWPJS TZTUFN UP EFMJWFS VQ UP 15 N H QFS
IPVS GPS 2 IPVST NBZ CF BQQSPQSJBUF BOE OFDFTTBSZ JO
UIF QSFTFODF PG MJGF-UISFBUFOJOH BTUINB. 5BDIZDBSEJB BOE
IZQPLBMFNJB NBZ BDDPNQBOZ UIFTF MBSHF EPTFT PG
BMCVUFSPM. /FWFSUIF- MFTT, MBSHFS EPTFT BOE NPSF
GSFRVFOU EPTJOH JOUFSWBMT GPS JOIBMFE [3-BESFOFSHJD
BHPOJTU UIFSBQZ BSF OFFEFE JO BDVUF TFWFSF BTUINB EVF
UP EFDSFBTFE EFQPTJUJPO BU UIF TJUF PG BDUJPO (MPX UJEBM
WPMVNFT BOE OBSSPXFE BJSXBZT), BMUFSB- UJPO JO UIF
EPTF-SFTQPOTF DVSWF, BOE BMUFSFE EVSBUJPO PG BDUJWJUZ.
*OIBMFE BMCVUFSPM (GPVS QVffT) CMVOUT BJSXBZ SFTQPOTFT
86
UP USBDIFBM JOUVCBUJPO JO BTUINBUJD QBUJFOUT.

Metaproterenol
.FUBQSPUFSFOPM JT B TFMFDUJWF [32-BESFOFSHJD BHPOJTU VTFE
UP USFBU BTUINB. "ENJOJTUFSFE CZ NFUFSFE-EPTF
JOIBMFS, UIF EBJMZ EPTBHF TIPVME OPU FYDFFE 16 QVffT, XJUI
FBDI NFUFSFE- BFSPTPM BDUVBUJPO EFMJWFSJOH
BQQSPYJNBUFMZ 650 µH. 0SBM BENJOJTUSBUJPO JT GPMMPXFE
CZ FYDSFUJPO BT DPOKVHBUFT PG HMVDVSPOJD BDJE.

Terbutaline
5FSCVUBMJOF JT B QSFEPNJOBOUMZ [32-BESFOFSHJD BHPOJTU
UIBU NBZ CF BENJOJTUFSFE PSBMMZ, TVCDVUBOFPVTMZ, PS CZ
JOIB- MBUJPO UP USFBU BTUINB. ThF TVCDVUBOFPVT
BENJOJTUSBUJPO PG UFSCVUBMJOF (0.25 NH) QSPEVDFT
SFTQPOTFT UIBU SFTFN- CMF UIPTF PG FQJOFQISJOF, CVU
UIF EVSBUJPO PG BDUJPO JT MPOHFS. ThF TVCDVUBOFPVT
EPTF PG UFSCVUBMJOF GPS DIJMESFO JT 0.01 NH/LH.
"ENJOJTUFSFE CZ NFUFSFE-EPTF JOIBMFS, UIF EBJMZ EPTF
TIPVME OPU FYDFFE 16 UP 20 QVffT, XJUI FBDI NF- UFSFE-
EPTF BDUVBUJPO EFMJWFSJOH BCPVU 200 µH.

Cardiac Glycosides
Digitalis JT UIF UFSN VTFE GPS DBSEJBD HMZDPTJEFT UIBU
PDDVS OBUVSBMMZ JO NBOZ QMBOUT, JODMVEJOH UIF
GPYHMPWF QMBOU.
%JHPYJO, EJHJUPYJO, BOE PVBCBJO BSF FYBNQMFT PG
DMJOJ- DBMMZ VTFGVM DBSEJBD HMZDPTJEFT ('JH. 18-9). 0G UIFTF,
POMZ EJHPYJO SFNBJOT DPNNPOMZ VTFE.

Digoxin
%JHPYJO JT VTFE NPTU PftFO EVSJOH UIF QFSJPQFSBUJWF
QFSJPE GPS UIF NBOBHFNFOU PG TVQSBWFOUSJDVMBS
UBDIZEZTSIZUI- NJBT (QBSPYZTNBM BUSJBM UBDIZDBSEJB,
BUSJBM fiCSJMMBUJPO, BUSJBM flVUUFS) BTTPDJBUFE XJUI B SBQJE
WFOUSJDVMBS SFTQPOTF SBUF CBTFE PO UIF BCJMJUZ PG UIFTF
ESVHT UP TMPX DPOEVDUJPO PG DBSEJBD JNQVMTFT UISPVHI
UIF BUSJPWFOUSJDVMBS OPEF. ThF VTF PG EJHPYJO UP USFBU
BDVUF EFDSFBTFT JO MFGU WFOUSJDV- MBS DPOUSBDUJMJUZ JT
 TVCBPSUJD TUFOPTJT CFDBVTF

'*(63& 18-9 Cardiac glycosides.

PG NPSF QPUFOU BOE MFTT UPYJD ESVHT. 'PS FYBNQMF,

QBUJFOUT USFBUFE XJUI EJHPYJO IBWF B EFDSFBTFE SJTL PG
EFBUI GSPN IFBSU GBJMVSF CVU BO JODSFBTFE JODJEFODF PG
TVEEFO EFBUI, QSFTVNBCMZ EVF UP DBSEJBD
EZTSIZUINJBT (TJNJMBS UP JO- DSFBTFE SJTL PG TVEEFO
87,88
EFBUI EFTDSJCFE GPS PUIFS QPTJUJWF JOPUSPQJD ESVHT).
#BTFE PO UIJT PCTFSWBUJPO, EJHPYJO NBZ CF TFMFDUFE
POMZ GPS USFBUNFOU PG TZNQUPNT UIBU QFS- TJTU BftFS
BENJOJTUSBUJPO PG ESVHT (BOHJPUFOTJO-DPOWFSUJOH
FO[ZNF JOIJCJUPST, [3-BESFOFSHJD BOUBHPOJTUT) UIBU EP
87
EF- DSFBTF PWFSBMM NPSUBMJUZ. /FWFSUIFMFTT, EJHPYJO
DPOUJOVFT UP IBWF BO JNQPSUBOU UIFSBQFVUJD SPMF JO UIF
USFBUNFOU PG DISPOJD DPOHFTUJWF IFBSU GBJMVSF. %JHPYJO
NBZ OPU CF PG CFOFfiU JO IJHI-PVUQVU DBSEJBD GBJMVSF,
TVDI BT UIBU DBVTFE CZ IZQFSUIZSPJEJTN PS UIJBNJOF
EFGJ JFODZ.
*OUSBWFOPVT BENJOJTUSBUJPO PG QSPQSBOPMPM PS
FT- NPMPM DPNCJOFE XJUI EJHPYJO NBZ QSPWJEF NPSF
SBQJE DPOUSPM PG TVQSBWFOUSJDVMBS UBDIZEZTSIZUINJBT
BOE NJO- JNJ[F UIF MJLFMJIPPE PG UPYJDJUZ CZ
QFSNJUUJOH EFDSFBTFT JO UIF EPTF PG CPUI DMBTTFT PG
ESVHT. %JSFDU DVSSFOU DBS- EJPWFSTJPO JO UIF QSFTFODF
PG EJHPYJO NBZ CF IB[BSEPVT CFDBVTF PG JODSFBTFE SJTL
PG EFWFMPQJOH DBSEJBD EZTSIZUI- NJBT, JODMVEJOH
WFOUSJDVMBS fiCSJMMBUJPO. *O BQQSPYJNBUFMZ 30% PG
QBUJFOUT XJUI 8PMGG- BSLJOTPO-8IJUF TZOESPNF,
EJHJUBMJT EFDSFBTFT SFGSBDUPSJOFTT JO UIF BDDFTTPSZ
DPOEVD- UJPO QBUIXBZ UP UIF QPJOU UIBU SBQJE BUSJBM
JNQVMTFT DBO DBVTF WFOUSJDVMBS fiCSJMMBUJPO. %JHPYJO
NBZ CF IBSNGVM JO QBUJFOUT XJUI IZQFSUSPQIJD
JODSFBTFE NZPDBSEJBM DPOUSBDUJMJUZ JOUFOTifiFT UIF adults, with implica- tions for dosage. Ther Drug Monit.
SFTJT- UBODF UP WFOUSJDVMBS FKFDUJPO. 2014;36(3):387–393.

Pharmacokinetics
89,90
ThF CJPBWBJMBCJMJUZ PG PSBM EJHPYJO JT 60% U P 80%.
*O TPNF QBUJFOUT, UIF EJHPYJO MFWFMT NBZ CF SFEVDFE
CZ VQ UP 40% E VF UP EJHFTUJPO CZ DPMPOJD CBDUFSJB (TFF
QSPEVDU NPOPHSBQI). 1FBL QMBTNB DPODFOUSBUJPOT BSF
PCTFSWFE 1 UP 3 IPVST GPMMPXJOH PSBM BENJOJTUSBUJPO.
'PMMPXJOH *7 BE- NJOJTUSBUJPO, UIF CJPBWBJMBCJMJUZ JT
100%, BOE QFBL QMBTNB DPODFOUSBUJPOT BSF PCTFSWFE
JNNFEJBUFMZ GPMMPXJOH BENJO- JTUSBUJPO BT FYQFDUFE GPS
BMM ESVHT. %JHPYJO JT FMJNJOBUFE BMNPTU FOUJSFMZ CZ SFOBM
FYDSFUJPO, XJUI B IBMG-MJGF PG 1 UP 2 EBZT. ThF IBMG-MJGF JT
JOWFSTFMZ QSPQPSUJPOBM UP HMPNFSVMBS fiMUSBUJPO SBUF BOE
UIVT JODSFBTFT XJUI BHF PS SFOBM EJTFBTF.
'JHVSF 18-10 T IPXT UIF QMBTNB BOE FffFDU TJUF
UJNF DPVSTF PG 0.5 NH PG EJHPYJO, HJWFO FJUIFS PSBMMZ
('JH. 18- 10") PS JOUSBWFOPVTMZ ('JH. 18-10#), CBTFE PO
91
UIF QIBS- NBDPLJOFUJD NPEFM PG +FMliffF FU BM. ThF UJNF
DPVSTF PG EJHPYJO JT SFflFDUFE JO UIF FffFDU TJUF
DPODFOUSBUJPO, TIPXO JO SFE, SBUIFS UIBO UIF QMBTNB
DPODFOUSBUJPO, TIPXO JO CMVF. ThF FffFDU TJUF JT UIPVHIU
UP JODMVEF UIF NZPDBSEJVN, BMPOH XJUI NPTU PUIFS
UJTTVFT.

'*(63& 18-10 Simulated plasma (blue line) and peripheral

(red line) concentrations of digoxin following a 0.5-mg oral
(A) or intravenous (B) dose. The simulation is based on the
pharmacokinetic model of Jelliffe RW, Milman M,
Schumitzky A, et al. A two-compartment population
pharmacokinetic- pharmacodynamic model of digoxin in
 ThF POTFU UJNF GPS PSBM EJHPYJO JT 0.5 UP 2 IPVST,
XJUI B QFBL FffFDU BCPVU 6 IPVST BftFS JOHFTUJPO. 8JUI
*7 VTF, UIF POTFU UJNF JT 10 UP 30 NJOVUFT, XJUI B QFBL
FffFDU 2 UP 4 IPVST BftFS BENJOJTUSBUJPO. "ftFS
BDIJFWFNFOU PG UIFSB- QFVUJD QMBTNB DPODFOUSBUJPOT
PG EJHPYJO CZ FJUIFS UIF PSBM PS *7 S PVUF, UIF
NBJOUFOBODF PSBM EPTF JT BEKVTUFE BDDPSEJOH UP UIF
JOEJWJEVBM QBUJFOU'T SFTQPOTF, UIF FMFD- USPDBSEJPHSBN
(&$(), BOE UIF QMBTNB DPODFOUSBUJPO PG EJHPYJO.
Mechanism of Action
ThF DPNQMFY NFDIBOJTNT PG UIF QPTJUJWF JOPUSPQJD
FffFDU FWPLFE CZ DBSEJBD HMZDPTJEFT JODMVEFT EJSFDU
FffFDUT PO UIF IFBSU UIBU NPEJGZ JUT FMFDUSJDBM BOE
NFDIBOJDBM BDUJWJUZ BOE JOEJSFDU FffFDUT FWPLFE CZ SFflFY
BMUFSBUJPOT JO BVUPOPNJD OFSWPVT TZTUFN BDUJWJUZ.
$BSEJBD HMZDPTJEFT TFMFDUJWFMZ BOE SFWFSTJCMZ JOIJCJU UIF
/B+o,+ "51BTF JPO USBOTQPSU TZT- UFN (TPEJVN
QVNQ) MPDBUFE JO UIF TBSDPMFNNB (DFMM XBMM) PG DBSEJBD
DFMMT. $BSEJBD HMZDPTJEFT CJOE UP UIF a TVCVOJU PO UIF
FYUSBDFMMVMBS TVSGBDF PG UIF "51BTF FO[ZNF, JOEVD- JOH B
DPOGPSNBUJPOBM DIBOHF UIBU JOUFSGFSFT XJUI PVUXBSE
USBOTQPSU PG TPEJVN JPOT BDSPTT DBSEJBD DFMM
NFNCSBOFT. ThF SFTVMU JT BO JODSFBTF JO JOUFSDFMMVMBS
TPEJVN. " TFD- POE USBOTQPSUFS JT UIF TPEJVNoDBMDJVN
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FYDIBOHF GPS TPEJVN.
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HMZDPTJEFT. ThF SFTVMUJOH JODSFBTF JO DFMMVMBS TPEJVN JPO
DPODFOUSBUJPO JO UVSO CMPDLT UIF TPEJVNoDBMDJVN
FYDIBOHFS BOE JODSFBTFT JOUSBDFMMVMBS DBMDJVN. *ODSFBTFE
JOUSBDFMMVMBS DBMDJVN JT UIF QSJNBSZ NFDIBOJTN PG
JOPUSPQJD BDUJPO GPS EJHJ- UBMJT BOE SFMBUFE DBSEJBD
HMZDPTJEFT. ThF QPTJUJWF JOPUSP- QJD FffFDUT QSPEVDFE CZ
DBSEJBD HMZDPTJEFT PDDVS XJUIPVU DIBOHFT JO IFBSU SBUF
BOE BSF BTTPDJBUFE XJUI EFDSFBTFT JO MFft WFOUSJDVMBS
QSFMPBE, BftFSMPBE, XBMM UFOTJPO, BOE PYZ- HFO
92
DPOTVNQUJPO JO UIF GBJMJOH IFBSU.
ThF QSJODJQBM DBSEJPWBTDVMBS effFDU PG EJHJUBMJT HMZ-
DPTJEFT BENJOJTUFSFE UP QBUJFOUT XJUI DBSEJBD GBJMVSF JT B
EPTF-EFQFOEFOU JODSFBTF JO NZPDBSEJBM DPOUSBDUJMJUZ UIBU
CFDPNFT TJHOJfiDBOU XJUI MFTT UIBO GVMM EJHJUBMJ[JOH EPTFT.
ThF QPTJUJWF JOPUSPQJD FffFDU NBOJGFTUT BT JODSFBTFE
TUSPLF WPMVNF, EFDSFBTFE IFBSU TJ[F, BOE EFDSFBTFE -7&
%1. *O- EFFE, DBSEJBD HMZDPTJEFT DBO EPVCMF TUSPLF
WPMVNF GSPN B GBJMJOH BOE EJMBUFE Meft WFOUSJDMF. ThF
WFOUSJDVMBS GVOD- UJPO DVSWF ('SBOL-4UBSMJOH DVSWF) JT
TIJftFE UP UIF MFft ('JH. 18-11). *NQSPWFE SFOBM
QFSGVTJPO EVF UP BO PWFSBMM JODSFBTF JO DBSEJBD PVUQVU
GBWPST NPCJMJ[BUJPO BOE FYDSF- UJPO PG FEFNB flVJE,
BDDPVOUJOH GPS UIF EJVSFTJT UIBU PftFO BDDPNQBOJFT UIF
BENJOJTUSBUJPO PG DBSEJBD HMZDPTJEFT UP QBUJFOUT JO
DBSEJBD GBJMVSF. &YDFTTJWF TZNQBUIFUJD OFS- WPVT
TZTUFN BDUJWJUZ UIBU PDDVST BT B D PNQFOTBUPSZ SF-
TQPOTF UP DBSEJBD GBJMVSF JT EFDSFBTFE XJUI UIF JNQSPWFE
DJSDVMBUJPO UIBU BDDPNQBOJFT BENJOJTUSBUJPO PG
DBSEJBD HMZDPTJEFT. ThF SFTVMUJOH EFDSFBTF JO TZTUFNJD
WBTDVMBS SF- TJTUBODF GVSUIFS FOIBODFT GPSXBSE MFGU
WFOUSJDVMBS TUSPLF WPMVNF.
 HMZDPTJEFT.

'*(63& 18-11 Cardiac glycosides shift the ventricular

function curve of the failing myocardium to the left. LVFP,
left ventricular filling pressure; SV, stroke volume.

$BSEJBD HMZDPTJEFT BMTP JODSFBTF NZPDBSEJBM DPOUSBD-

UJMJUZ JO UIF BCTFODF PG DBSEJBD GBJMVSF. /FWFSUIFMFTT, UIF
SFTVMUJOH UFOEFODZ GPS DBSEJBD PVUQVU UP JODSFBTF NBZ CF
PffTFU CZ EFDSFBTFT JO IFBSU SBUF BOE EJSFDU WBTPDPOTUSJDU-
JOH FffFDUT PG DBSEJBD HMZDPTJEFT PO BSUFSJBM, BOE UP B
MFTTFS FYUFOU, WFOPVT TNPPUI NVTDMF. *OEFFE, DBSEJBD
PVUQVU JT PftFO VODIBOHFE PS FWFO EFDSFBTFE XIFO
DBSEJBD HMZDP- TJEFT BSF BENJOJTUFSFE UP QBUJFOUT XJUI
OPSNBM IFBSUT.
*O BEEJUJPO UP QPTJUJWF JOPUSPQJD FffFDUT, DBSEJBD HMZ-
DPTJEFT FOIBODF QBSBTZNQBUIFUJD OFSWPVT TZTUFN
BDUJWJUZ, MFBEJOH UP EFMBZFE DPOEVDUJPO PG DBSEJBD
JNQVMTFT UISPVHI UIF BUSJPWFOUSJDVMBS OPEF BOE
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ESPNPUSPQJD BOE DISPOPUSPQJD FffFDU EFQFOET PO UIF
QSFFYJTUJOH BDUJWJUZ PG UIF BVUPOPNJD OFSWPVT TZTUFN.
*ODSFBTFE QBSBTZNQBUIFUJD OFSWPVT TZT- UFN BDUJWJUZ
EFDSFBTFT DPOUSBDUJMJUZ JO UIF BUSJB, CVU EJSFDU QPTJUJWF
JOPUSPQJD FffFDUT PG DBSEJBD HMZDPTJEFT NPSF UIBO PffTFU
UIFTF OFSWPVT TZTUFNoJOEVDFE OFHBUJWF JOPUSPQJD
FffFDUT PO UIF WFOUSJDMFT.
ThF FMFDUSPQIZTJPMPHJD FffFDUT PG UIFSBQFVUJD QMBTNB
DPODFOUSBUJPOT PG DBSEJBD HMZDPTJEFT NBOJGFTU PO UIF
&$( BT (B) QSPMPOHFE 1-3 JOUFSWBMT EVF UP EFMBZFE DPO-
EVDUJPO PG DBSEJBD JNQVMTFT UISPVHI UIF BUSJPWFOUSJDVMBS
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WFOUSJDVMBS SFQPMBSJ[BUJPO, (D) 45 TFHNFOU EFQSFTTJPO
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QIBTF 3 EFQPMBSJ[BUJPO PG DBSEJBD BDUJPO QPUFOUJBMT, BOE
(E) EJNJOJTIFE BNQMJUVEF PS JOWFSTJPO PG 5 XBWFT. ThF
1-3 JOUFSWBM JT SBSFMZ QSPMPOHFE UP MPOHFS UIBO 0.25 TFD-
POE, BOE UIF effFDU PO UIF 25D JOUFSWBM JT JOEFQFOEFOU
PG QBSBTZNQBUIFUJD OFSWPVT TZTUFN BDUJWJUZ. $IBOHFT
JO UIF 45 TFHNFOU BOE 5 X BWF EP OPU DPSSFMBUF
XJUI UIFSBQFVUJD QMBTNB DPODFOUSBUJPOT PG DBSEJBD
'VSUIFSNPSF, 45-TFHNFOU BOE 5-XBWF DIBOHFT PO
UIF &$( NBZ TVHHFTU NZPDBSEJBM JTDIFNJB. 8IFO
EJHJUBMJT JT EJTDPOUJOVFE, UIF DIBOHFT PO UIF &$(
EJTBQQFBS JO TFWFSBM XFFLT.
Toxicity
$BSEJBD HMZDPTJEFT IBWF B O BSSPX UIFSBQFVUJD
SBOHF.
*OEFFE, JU JT FTUJNBUFE UIBU BQQSPYJNBUFMZ 20% PG
QBUJFOUT XIP BSF CFJOH USFBUFE XJUI DBSEJBD HMZDPTJEFT
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UIFSBQFVUJD FffFDUT PG DBSEJBD HMZDPTJEFT EFWFMPQ BU
BQQSPYJNBUFMZ 35% P G UIF GBUBM EPTF, BOE DBSEJBD
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PG UIF GBUBM EPTF. ThF POMZ EJffFSFODF CFUXFFO WBSJPVT
DBSEJBD HMZDPTJEFT XIFO UPYJDJUZ EFWFM- PQT JT UIF
EVSBUJPO PG BEWFSTF FffFDUT.
ThJT JODSFBTF JO DBMDJVN SFTQPOTJCMF GPS UIF
JOPUSPQJD FffFDUT PG EJHPYJO BSF MJLFMZ SFTQPOTJCMF GPS UIF
93
BSSIZUINP- HFOJD FffFDUT BT XFMM. ThF JODSFBTFE
DBMDJVN JT TUPSFE JO UIF TBSDPQMBTNJD SFUJDVMVN. *O UIF
TFUUJOH PG NZPDBSEJBM TBSDPQMBTNJD SFUJDVMVN DBMDJVN
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TBSDPQMBTNJD SFUJDVMVN, SFTVMU- JOH JO EFMBZFE
BftFSEFQPMBSJ[BUJPOT. *G TUSPOH FOPVHI, EF- MBZFE
BftFSEFQPMBSJ[BUJPOT NBZ SFTVMU JO NZPDBSEJBM BDUJPO
QPUFOUJBMT BOE BSSIZUINJBT.
ThF NPTU GSFRVFOU DBVTF PG EJHJUBMJT UPYJDJUZ JO
UIF BCTFODF PG SFOBM EZTGVODUJPO JT UIF DPODVSSFOU
BENJOJT- USBUJPO PG EJVSFUJDT UIBU DBVTF QPUBTTJVN
EFQMFUJPO. %VS- JOH BOFTUIFTJB, IZQFSWFOUJMBUJPO PG UIF
QBUJFOU'T MVOHT DBO EFDSFBTF UIF TFSVN QPUBTTJVN
DPODFOUSBUJPO BO BWFSBHF PG 0.5 N& R/- GPS FWFSZ 10
94
N N )H EFDSFBTF JO 1BDP 2.
)ZQPLBMFNJB QSPCBCMZ JODSFBTFT NZPDBSEJBM
CJOEJOH PG DBSEJBD HMZDPTJEFT, SFTVMUJOH JO BO FYDFTT
ESVH FffFDU.
*OEFFE, CJOEJOH PG DBSEJBD HMZDPTJEFT UP UIF /B+o,
+
"51BTF FO[ZNF DPNQMFY JT JOIJCJUFE CZ JODSFBTFT JO
UIF QMBTNB DPODFOUSBUJPO PG QPUBTTJVN. 0UIFS
FMFDUSPMZUF BCOPSNBMJUJFT UIBU DPOUSJCVUF UP EJHJUBMJT
UPYJDJUZ JO- DMVEF IZQFSDBMDFNJB BOE IZQPNBHOFTFNJB.
"O JODSFBTF JO TZNQBUIFUJD OFSWPVT TZTUFN BDUJWJUZ BT
QSPEVDFE CZ BSUFSJBM IZQPYFNJB JODSFBTFT UIF
MJLFMJIPPE PG EJHJUBMJT UPYJDJUZ.
&MEFSMZ QBUJFOUT XJUI EFDSFBTFE SFOBM GVODUJPO BSF
WVM- OFSBCMF UP UIF EFWFMPQNFOU PG EJHJUBMJT UPYJDJUZ JG
VTVBM EPTFT PG EJHPYJO BSF BENJOJTUFSFE. *NQBJSFE SFOBM
GVOD- UJPO BOE FMFDUSPMZUF DIBOHFT (IZQPLBMFNJB,
IZQPNBHOFTF- NJB) UIBU NBZ BDDPNQBOZ
DBSEJPQVMNPOBSZ CZQBTT DPVME QSFEJTQPTF UIF QBUJFOU
UP UIF EFWFMPQNFOU PG EJHJUBMJT UPYJDJUZ.
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FffFDUT PG UIF DBSEJBD EJTFBTF. 'PS UIJT SFBTPO,
EFUFSNJOBUJPO PG UIF QMBTNB EJHPYJO DPODFOUSBUJPO
NBZ CF VTFE UP JOEJDBUF UIF MJLFMZ QSFTFODF PG EJHJUBMJT
UPYJDJUZ. " QMBTNB EJHPYJO DPODFOUSBUJPO PG MFTT UIBO 0.5
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1MBTNB DPODFOUSBUJPOT CFUXFFO
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BOE MFWFMT HSFBUFS UIBO 3 O H/N- BSF JO B UPYJD SBOHF.
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DBSEJBD HMZ- DPTJEFT, BOE UIFJS SBOHF PG UIFSBQFVUJD
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UJPOT PG EJHJUBMJT UPYJDJUZ. ThFTF TZNQUPNT, XIFO QSFTFOU
QSFPQFSBUJWFMZ JO QBUJFOUT SFDFJWJOH DBSEJBD HMZDPTJEFT,
TIPVME BSPVTF TVTQJDJPO PG EJHJUBMJT UPYJDJUZ.
ThFSF BSF OP VOFRVJWPDBM GFBUVSFT PO UIF &$(
95
UIBU DPOfiSN UIF QSFTFODF PG EJHJUBMJT UPYJDJUZ.
/FWFSUIFMFTT, UPYJD QMBTNB DPODFOUSBUJPOT PG EJHJUBMJT
UZQJDBMMZ DBVTF BUSJBM PS WFOUSJDVMBS DBSEJBD
EZTSIZUINJBT (JODSFBTFE BVUPNBUJDJUZ) BOE EFMBZFE
DPOEVDUJPO PG DBSEJBD JNQVMTFT UISPVHI UIF
BUSJPWFOUSJDVMBS OPEF (QSPMPOHFE 1-3 JOUFSWBM PO UIF &$
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"USJBM UBDIZDBSEJB XJUI CMPDL JT UIF NPTU DPNNPO
DBSEJBD EZTSIZUINJB BUUSJCVUFE UP EJHJUBMJT UPYJDJUZ.
"DUJW- JUZ PG UIF TJOPBUSJBM OPEF NBZ BMTP CF EJSFDUMZ
JOIJCJUFE CZ IJHI EPTFT PG DBSEJBD HMZDPTJEFT.
$POEVDUJPO PG DBSEJBD JNQVMTFT UISPVHI TQFDJBMJ[FE
DPOEVDUJOH UJTTVFT PG UIF WFOUSJDMFT JT OPU BMUFSFE, BT
FWJEFODFE CZ UIF GBJMVSF PG FWFO UPYJD QMBTNB
DPODFOUSBUJPOT PG EJHPYJO UP BMUFS UIF EVSB- UJPO PG UIF
234 DPNQMFY PO UIF &$(. 7FOUSJDVMBS fiCSJM- MBUJPO JT
UIF NPTU GSFRVFOU DBVTF PG EFBUI GSPN EJHJUBMJT UPYJDJUZ.
5SFBUNFOU
5SFBUNFOU PG EJHJUBMJT UPYJDJUZ JODMVEFT (B) DPSSFDUJPO
PG QSF- EJTQPTJOH DBVTFT (IZQPLBMFNJB, IZQPNBHOFTFNJB,
BSUFSJBM IZQPYFNJB), (C) B ENJOJTUSBUJPO PG ESVHT
(QIFOZUPJO, MJ- EPDBJOF, BUSPQJOF) UP USFBU DBSEJBD
EZTSIZUINJBT, BOE (D) JOTFSUJPO PG B U FNQPSBSZ
BSUJfiDJBM USBOTWFOPVT DBSEJBD QBDFNBLFS JG DPNQMFUF
IFBSU CMPDL JT QSFTFOU. 4VQQMFNFO- UBM QPUBTTJVN
EFDSFBTFT UIF CJOEJOH PG EJHJUBMJT UP DBSEJBD NVTDMF BOE
EJSFDUMZ BOUBHPOJ[FT UIF DBSEJPUPYJD FffFDUT PG DBSEJBD
HMZDPTJEFT. 4FSVN QPUBTTJVN DPODFOUSBUJPOT TIPVME CF
EFUFSNJOFE CFGPSF USFBUNFOU CFDBVTF TVQQMF- NFOUBM
QPUBTTJVN JO UIF QSFTFODF PG B I JHI QSFFYJTUJOH
QMBTNB MFWFM PG QPUBTTJVN XJMM JOUFOTJGZ BUSJPWFOUSJDVMBS
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FST JO UIF WFOUSJDMFT, MFBEJOH UP DPNQMFUF IFBSU CMPDL. *G
SFOBM GVODUJPO JT OPSNBM BOE BUSJPWFOUSJDVMBS DPOEVDUJPO
CMPDL JT OPU QSFTFOU, JU JT BDDFQUBCMF UP BENJOJTUFS QPUBT-
TJVN, 0.025 UP 0.050 N& R/LH *7, UP USFBU MJGF-
UISFBUFOJOH DBSEJBD EZTSIZUINJBT BTTPDJBUFE XJUI
EJHJUBMJT UPYJDJUZ, PCWJPVTMZ XJUI DPOUJOVPVT &$(
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NJOVUFT) PS MJEPDBJOF (1 UP 2 NH/LH *7) JT FffFDUJWF JO
TVQQSFTTJOH WFOUSJDVMBS DBS- EJBD EZTSIZUINJBT DBVTFE
CZ EJHJUBMJT. 1IFOZUPJO JT BMTP effFDUJWF JO TVQQSFTTJOH
BUSJBM EZTSIZUINJBT. "USPQJOF, 35 UP 70 µH/LH *7, DBO
CF BENJOJTUFSFE UP JODSFBTF IFBSU SBUF CZ PffTFUUJOH
FYDFTTJWF QBSBTZNQBUIFUJD OFSWPVT TZT- UFN BDUJWJUZ
QSPEVDFE CZ UPYJD QMBTNB DPODFOUSBUJPOT PG EJHJUBMJT.
1SPQSBOPMPM JT effFDUJWF JO TVQQSFTTJOH JO-
DSFBTFE BVUPNBUJDJUZ QSPEVDFE CZ EJHJUBMJT UPYJDJUZ,
CVU JUT UFOEFODZ UP JODSFBTF BUSJPWFOUSJDVMBS OPEF
SFGSBDUP- SJOFTT MJNJUT JUT VTFGVMOFTT XIFO DPOEVDUJPO
CMPDLBEF JT QSFTFOU.
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96
CZ BENJOJTUFSJOH EJHPYJO BOUJCPEJFT, EFDSFBTJOH UIF
QMBTNB DPODFOUSBUJPO PG EJHPYJO. ThF EJHPYJOoBOUJCPEZ
DPNQMFY JT FMJNJOBUFE CZ UIF LJEOFZT.
Drug Interactions
2VJOJEJOF QSPEVDFT B EPTF-EFQFOEFOU JODSFBTF JO UIF
QMBTNB DPODFOUSBUJPO PG EJHPYJO UIBU CFDPNFT
BQQBSFOU XJUIJO 24 IPVST BftFS UIF GJ TU EPTF. ThJT effFDU
PG RVJOJEJOF NBZ CF EVF UP EJTQMBDFNFOU PG EJHPYJO GSPN
CJOEJOH TJUFT JO UJTTVFT.
4VDDJOZMDIPMJOF, PS BOZ PUIFS ESVH UIBU DBO BCSVQUMZ
JODSFBTF QBSBTZNQBUIFUJD OFSWPVT TZTUFN BDUJWJUZ, DPVME
UIFPSFUJDBMMZ IBWF BO BEEJUJWF FffFDU XJUI DBSEJBD
HMZDP- TJEFT. $BSEJBD EZTSIZUINJBT BMTP DPVME SFGM DU
TVDDJOZM- DIPMJOF-JOEVDFE DBUFDIPMBNJOF SFMFBTF BOE
SFTVMUJOH DBSEJBD JSSJUBCJMJUZ. %FTQJUF UIFTF UIFPSFUJDBM
DPODFSOT, DMJOJDBM FYQFSJFODF EPFT OPU TVQQPSU UIF
PDDVSSFODF PG BO JODSFBTFE JODJEFODF PG DBSEJBD
EZTSIZUINJBT JO QB- UJFOUT CFJOH USFBUFE XJUI DBSEJBD
97
HMZDPTJEFT BOE SFDFJWJOH TVDDJOZMDIPMJOF.
4ZNQBUIPNJNFUJDT XJUI [3-BESFOFSHJD BHPOJTU
FffFDUT NBZ JODSFBTF UIF MJLFMJIPPE PG DBSEJBD
EZTSIZUINJBT JO UIF QSFTFODF PG DBSEJBD
97
HMZDPTJEFT. *OUSBWFOPVT BENJOJTUSBUJPO PG DBMDJVN
NBZ QSFDJQJUBUF DBSEJBD EZT- SIZUINJBT JO QBUJFOUT
SFDFJWJOH DBSEJBD HMZDPTJEFT. "OZ ESVH UIBU GBDJMJUBUFT
SFOBM MPTT PG QPUBTTJVN JODSFBTFT UIF MJLFMJIPPE PG
IZQPLBMFNJB BOE BTTPDJBUFE EJHJUBMJT UPYJD- JUZ. ThF
TJNVMUBOFPVT BENJOJTUSBUJPO PG BO PSBM BOUBDJE BOE
EJHJUBMJT EFDSFBTFT UIF HBTUSPJOUFTUJOBM BCTPSQUJPO PG
DBSEJBD HMZDPTJEFT. 'FOUBOZM, FnflVSBOF, BOE, UP B MFTTFS
FY- UFOU, JTPflVSBOF QSPUFDU BHBJOTU EJHJUBMJT-FOIBODFE
98
DBSEJBD BVUPNBUJDJUZ.
Selective
Phosphodiesterase
Inhibitors
1IPTQIPEJFTUFSBTF JOIJCJUPST BSF B IFUFSPHFOFPVT HSPVQ
PG OPODBUFDIPMBNJOF OPOHMZDPTJEF DPNQPVOET UIBU FYFSU
B DPNQFUJUJWF JOIJCJUPSZ BDUJPO PO QIPTQIPEJFTUFSBTF
FO[ZNFT. .VMUJQMF UZQFT PG QIPTQIPEJFTUFSBTF
FO[ZNFT FYJTU JO EJffFSFOU UJTTVFT (DBSEJBD NVTDMF,
WBTDVMBS TNPPUI NVTDMF, QMBUFMFUT, MJWFS, BOE MVOHT)
QPTTFTTJOH diffFSFOU DZDMJD OVDMFPUJEF TVCTUSBUF TQFDJGJ
JUZ. 4FMFDUJWF QIPTQIP- EJFTUFSBTF JOIJCJUPST FYFSU
diffFSFOU QIZTJPMPHJD effFDUT EFQFOEJOH PO UIFJS
99
FO[ZNF GSBDUJPO TQFDJfiDJUZ. 4FMFD- UJWF JOIJCJUPST PG
QIPTQIPEJFTUFSBTF GSBDUJPO *** (1 %&
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 GSPN [3 SFDFQUPS CMPDLBEF BOE JO QBUJFOUT XIP IBWF
EPXO-

'*(63& 18-12 Selective inhibitors of phosphodiesterase

subtype III, amrinone and milrinone.

BMTP IBWF BO JOEJSFDU effFDU PO DZDMJD HVBOPTJOF

NPOP- QIPTQIBUFoEFQFOEFOU QSPUFJO LJOBTF JO WBTDVMBS
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TUJNVMBUJPO PG QSPUFJO LJOBTFT UIBU QIPTQIPSZMBUF UIF
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JODMVEF JODSFBTFE DPOUSBDUJMJUZ, JODSFBTFE DBSEJBD PVUQVU,
BOE EF- DSFBTFE -7&%1 JO BEEJUJPO UP JODSFBTFE
WFOPVT DBQBDJ- UBODF, EFDSFBTFE fiMMJOH QSFTTVSFT (DFOUSBM
WFOPVT QSFTTVSF BOE QVMNPOBSZ DBQJMMBSZ XFEHF
QSFTTVSF), BOE EFDSFBTFE WFOPVT SFUVSO UP UIF IFBSU.
.FBO QVMNPOBSZ BSUFSZ QSFT- TVSFT BOE QVMNPOBSZ BOE
TZTUFNJD WBTDVMBS SFTJTUBODF BSF EFDSFBTFE. 4FMFDUJWF 1%&
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100
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DBMDJVN SFNPWBM GSPN UIF TBSDPQMBTN, UIFSFCZ
JNQSPWJOH WFOUSJDVMBS fiMMJOH.
4FMFDUJWF 1%& *** JOIJCJUPST IBWF NJME FffFDUT PO
IFBSU SBUF BOE NFBO BSUFSJBM QSFTTVSF IBWJOH BTTPDJBUJPO
XJUI SBSF BSSIZUINJBT BOE TPNF EFDSFBTF JO NFBO
BSUFSJBM QSFTTVSF. ThFTF JOPEJMBUPST EFDSFBTF QSFMPBE BOE
BftFSMPBE.
)FODF UIFPSFUJDBMMZ, XBMM UFOTJPO BOE NZPDBSEJBM PYZHFO
DPOTVNQUJPO TIPVME EFDSFBTF, JO DPOUSBTU UP
EPCVUBNJOF, XIJDI JODSFBTFT NZPDBSEJBM PYZHFO
DPOTVNQUJPO BT JU JODSFBTFT DPOUSBDUJMJUZ. 8BMM UFOTJPO
EFDSFBTFT XJUI EF- DSFBTJOH WFOUSJDVMBS WPMVNF BOE XJUI
EFDSFBTJOH BftFSMPBE, BOE NZPDBSEJBM PYZHFO
DPOTVNQUJPO EFQFOET QSJNBSJMZ PO IFBSU SBUF,
DPOUSBDUJMJUZ, BOE WFOUSJDVMBS XBMM UFOTJPO.
4FMFDUJWF 1%& *** J OIJCJUPST BDU JOEFQFOEFOUMZ PG
[3- BESFOFSHJD SFDFQUPST BOE XJMM JODSFBTF NZPDBSEJBM
DPO- USBDUJMJUZ JO QBUJFOUT XJUI NZPDBSEJBM EFQSFTTJPO
SFHVMBUJPO PG [3-BESFOFSHJD SFDFQUPST BOE BSF
SFGSBDUPSZ UP DBUFDIPMBNJOF UIFSBQZ. ThF FffFDUT PG
DBUFDIPMBNJOFT, XIJDI BMTP JODSFBTF D".1 D
PODFOUSBUJPOT CVU UISPVHI [3-BESFOFSHJD TUJNVMBUJPO,
BSF QPUFOUJBMMZ FOIBODFE CZ 1%& *** JOIJCJUJPO. ThF
IFNPEZOBNJD SFTQPOTF UP TF- MFDUJWF 1%& JOIJCJUPST
FYDFFET UIBU PG DBSEJBD HMZDPTJEFT BOE JT TZOFSHJTUJD UP
UIF BDUJPOT PG DBUFDIPMBNJOFT. ThFTF ESVHT DBO CF VTFE
JO DPOKVODUJPO XJUI EJHJUBMJT XJUIPVU QSPWPLJOH
EJHJUBMJT UPYJDJUZ. ThF 1%& *** JOIJCJUPST IBWF UIFJS
HSFBUFTU DMJOJDBM VTFGVMOFTT JO QBUJFOUT XIP XPVME
CFOefiU GSPN DPNCJOFE JOPUSPQJD BOE WBTPEJMBUPS
UIFSBQZ.
Amrinone (Inamrinone)
"NSJOPOF JT B CJQZSJEJOF EFSJWBUJWF UIBU BDUT BT B T FMFD-
UJWF 1%& *** J OIJCJUPS BOE QSPEVDFT EPTF-EFQFOEFOU
QPTJUJWF JOPUSPQJD BOE WBTPEJMBUPS effFDUT NBOJGFTUJOH BT
JODSFBTFE DBSEJBD PVUQVU BOE EFDSFBTFE -7&%1.
101
5I OBNF BNSJOPOF XBT DIBOHFE UP JOBNSJOPOF JO UIF
6OJUFE 4UBUFT JO 2000 U P BWPJE DPOGVTJPO XJUI
BNJPEBSPOF, NVDI UP UIF DPOGVTJPO PG UIPTF BDDVTUPNFE
UP UIF OBNF BNSJOPOF.
"NSJOPOF JODSFBTFT DBSEJBD JOEFY, MFft
WFOUSJDVMBS TUSPLF JOEFY, BOE MFft WFOUSJDVMBS FKFDUJPO
GSBDUJPO, EF- DSFBTJOH -7&%1, QVMNPOBSZ DBQJMMBSZ
XFEHF QSFTTVSF, QVMNPOBSZ BSUFSZ QSFTTVSF, SJHIU BUSJBM
QSFTTVSF, BOE TZT- UFNJD WBTDVMBS SFTJTUBODF, XJUI
NJOJNBM FffFDU PO IFBSU SBUF.
102
%FQFOEJOH PO UIF
DBSEJPWBTDVMBS TUBUVT PG UIF QBUJFOU, BNSJOPOF NBZ
JODSFBTF DBSEJBD PVUQVU FJUIFS UISPVHI JUT JOPUSPQJD PS
WBTPEJMBUJOH NFDIBOJTNT.
"NSJOPOF JT TVCKFDU UP NJOJNBM QSPUFJO CJOEJOH BOE
IBT B SB QJE EJTUSJCVUJPO IBMG-MJGF PG 1 U P 2 N JOVUFT.
ThF QSJODJQBM SPVUF PG FYDSFUJPO JT 26% U P 40% V
ODIBOHFE ESVH JO UIF VSJOF XJUI B M BSHF GSBDUJPO
VOEFSHPJOH
/-BDFUZMBUJPO BOE HMVDVSPOJEBUJPO CZ UIF MJWFS. ThF
FMJN- JOBUJPO IBMG-UJNF PG BNSJOPOF JO IFBMUIZ QBUJFOUT
JT BQ- QSPYJNBUFMZ 2.6 UP 4.1 IPVST CVU NBZ JODSFBTF
102
GVSUIFS JO QBUJFOUT XJUI TFWFSF IFBSU GBJMVSF.
"NSJOPOF JT FffFDUJWF XIFO BENJOJTUFSFE PSBMMZ
BT XFMM BT JOUSBWFOPVTMZ. )PXFWFS, PSBM BENJOJTUSBUJPO
JT DPOGPVOEFE CZ VODFSUBJOUJFT JO CJPBWBJMBCJMJUZ BT XFMM
BT JODSFBTFE TJEF FffFDUT XJUI MPOH-UFSN PSBM VTF.
*OUSBWF- OPVT BENJOJTUSBUJPO PG B MPBEJOH EPTF, 0.5 UP
1.5 NH/LH, JODSFBTFT DBSEJBD PVUQVU XJUIJO 5 N JOVUFT,
XJUI EFUFDU- BCMF QPTJUJWF JOPUSPQJD FffFDUT QFSTJTUJOH GPS
BQQSPYJNBUFMZ 2 IPVST. "ftFS UIF JOJUJBM EPTF, B
NBJOUFOBODF JOGVTJPO PG
2 UP 10 µH/LH/NJOVUF QSPEVDFT QPTJUJWF JOPUSPQJD FffFDUT
UIBU BSF NBJOUBJOFE EVSJOH UIF JOGVTJPO
(UBDIZQIZMBYJT EPFT OPU PDDVS) BOE GPS TFWFSBM IPVST BftFS
EJTDPOUJOVBUJPO PG UIF JOGVTJPO. ThF SFDPNNFOEFE
NBYJNVN EBJMZ EPTF JT 10 NH/LH JODMVEJOH UIF JOJUJBM
MPBEJOH EPTF, XIJDI NBZ CF SFQFBUFE 30 NJOVUFT BftFS
UIF fiSTU JOKFDUJPO. #PMVT BE- NJOJTUSBUJPO TIPVME CF
BENJOJTUFSFE TMPXMZ BOE DBSFGVMMZ HJWFO UIF QPUFOUJBM
102
GPS IZQPUFOTJPO. ThF EPTF TIPVME CF EFDSFBTFE JO
QBUJFOUT XJUI TFWFSF SFOBM EZTGVODUJPO.
1BUJFOUT XIP IBWF GBJMFE UP SFTQPOE UP UJNF JT 2.7 IPVST BOE BCPVU 80% PG UIF ESVH JT FYDSFUFE
DBUFDIPMBNJOFT NBZ SFTQPOE UP BNSJOPOF. VODIBOHFE CZ UIF LJEOFZT XJUI B NJOPS QBSU VOEFSHPJOH
HMVDVSPOJEF DPOKVHBUJPO CFGPSF FYDSFUJPO. ThF EPTF
Side Effects TIPVME CF EFDSFBTFE JO QBUJFOUT XJUI TFWFSF SFOBM
)ZQPUFOTJPO GSPN WBTPEJMBUJPO, FTQFDJBMMZ XJUI SBQJE EZTGVODUJPO.
CPMVT BENJOJTUSBUJPO, NBZ PDDVS BOE NBZ CF BUUFOVBUFE
CZ TMPXFS BENJOJTUSBUJPO PS DPODPNJUBOU BENJOJTUSBUJPO
XJUI WBTPQSFTTPST.
%PTF-SFMBUFE UISPNCPDZUPQFOJB NBZ PDDVS
103
QBSUJDV- MBSMZ XJUI DISPOJD PSBM UIFSBQZ. D".1 JO
QMBUFMFUT BDUT BT JOUSBDFMMVMBS NFTTFOHFST JOIJCJUJOH UIF
QMBUFMFU BDUJWBUJPO TFRVFODF BU TFWFSBM TUFQT. 0SBM
BNSJOPOF IBT CFFO BTTPDJ- BUFE XJUI BDDFMFSBUFE QFSJQIFSBM
QMBUFMFU MPTT."MUIPVHI UIF NFDIBOJTN JT VODMFBS, JU JT
UIPVHIU UP CF B OPOoJNNVOF- NFEJBUFE FffFDU PG
104,105
BNSJOPOF PS JUT NFUBCPMJUFT.
1IPTQIPEJFTUFSBTF JOIJCJUPST BSF UIPVHIU UP
QPTTFTT SBSF DMJOJDBMMZ TJHOJGJ BOU EZTSIZUINPHFOJD
QSPQFSUJFT.
*ODSFBTFE NZPDBSEJBM DBMDJVN JT LOPXO UP QSPNPUF UIF
EFWFMPQNFOU PG DBSEJBD BSSIZUINJBT. "NSJOPOF JODSFBTFT
BUSJPWFOUSJDVMBS OPEBM DPOEVDUJPO BOE EFDSFBTFT BUSJBM
38
SFGSBDUPSJOFTT. *U JT EJffiDVMU UP BTTFTT JO IVNBO TUVEJFT
XIFUIFS BSSIZUINJBT BSF ESVH-JOEVDFE PS EVF UP
VOEFSMZ- JOH WFOUSJDVMBS EZTGVODUJPO. "OZ QSPBSSIZUINJD
QPUFOUJBM PG BNSJOPOF BQQFBST UP CF EPTF-SFMBUFE BOE
38
BTTPDJBUFE QSJNBSJMZ XJUI SBQJE *7 B ENJOJTUSBUJPO.
$ISPOJD PSBM BNSJOPOF IBT CFFO BTTPDJBUFE XJUI
HBTUSPJOUFTUJOBM JOUPM- FSBODFT JO BOJNBMT, BT XFMM BT
IFQBUJD EZTGVODUJPO.

Milrinone
.JMSJOPOF JT B CJQZSJEJOF EFSJWBUJWF PG BNSJOPOF
XJUI BMNPTU 30 U JNFT UIF JOPUSPQJD QPUFODZ PG
BNSJOPOF CVU MFTT BEWFSTF TJEF FffFDUT. #FDBVTF PG JUT
SFEVDFE JODJEFODF PG TJEF effFDUT, NJMSJOPOF IBT SFQMBDFE
BNSJOPOF JO DMJOJDBM VTF. $BSEJBD PVUQVU JNQSPWFT CPUI
BT B SFTVMU PG JODSFBTFE JOPUSPQZ BT XFMM BT WBTDVMBS
TNPPUI NVTDMF SFMBYBUJPO PG QFSJQIFSBM BOE
106
QVMNPOBSZ WFTTFM. %PTF-EFQFOEFOU JODSFBTFT JO
DBSEJBD JOEFY PDDVS XJUI NJOJNBM JODSFBTFT JO
NZPDBSEJBM PYZHFO DPOTVNQUJPO. %FDSFBTFT JO -7&%1,
NFBO BSUFSJBM QSFTTVSF, DFOUSBM WFOPVT QSFTTVSF,
QVMNP- OBSZ BSUFSZ PDDMVTJPO QSFTTVSF, QVMNPOBSZ
WBTDVMBS SF- TJTUBODF, BOE TZTUFNJD WBTDVMBS SFTJTUBODF
107
PDDVS BT XFMM BT JNQSPWFNFOUT JO EJBTUPMJD GVODUJPO.
.JMSJOPOF JT BENJOJTUFSFE BT BO *7 CPMVT PG 50 µH/LH
PWFS 10 NJOVUFT GPMMPXFE CZ B DPOUJOVPVT JOGVTJPO PG
0.375 UP 0.75 µH/LH/NJOVUF UP NBJOUBJO QMBTNB
NJMSJOPOF DPO- DFOUSBUJPOT BU PS BCPWF UIFSBQFVUJD
108
MFWFMT. " CPMVT EPTF PG 50 µH/LH XBT GPVOE UP CF BT
FffFDUJWF BT B EPTF PG 75 µH/ LH XJUI GFXFS TJEF FffFDUT
109
BOE NPSF FffFDUJWF UIBO B EPTF PG 25 µH/LH. ThF
NBYJNVN EBJMZ EPTF PG NJMSJOPOF TIPVME OPU FYDFFE 1.3
NH/LH/EBZ. "QQSPYJNBUFMZ 70% PG UIF ESVH JO
DJSDVMBUJPO JT QSPUFJO-CPVOE. ThF FMJNJOBUJPO IBMG-
Clinical Uses
.JMSJOPOF NBZ CF VTFGVM JO UIF NBOBHFNFOU PG
BDVUF Meft WFOUSJDVMBS EZTGVODUJPO TVDI BT BftFS DBSEJBD
TVSHFSZ. 4VDDFTTGVM XFBOJOH PG IJHI-SJTL QBUJFOUT GSPN
DBSEJPQVM- NPOBSZ CZQBTT NBZ CF FOIBODFE CZ
BENJOJTUSBUJPO PG NJMSJOPOF.
107,109o111
.JMSJOPOF NBZ
QPUFOUJBUF UIF FffFDUT PG BESFOFSHJD BHFOUT BT XFMM BT
IFMQ JODSFBTF JOPUSPQZ JO DISPOJD IFBSU GBJMVSF QBUJFOUT
XIP IBWF EPXOSFHVMBUJPO PG [31-BESFOFSHJD SFDFQUPST. *O
QBUJFOUT XJUI DPOHFTUJWF IFBSU GBJMVSF, TZNQUPNBUJD BOE
IFNPEZOBNJD JNQSPWFNFOUT BT XFMM BT JNQSPWFNFOU
JO FYFSDJTF IBWF CFFO SFQPSUFE, BM- UIPVHI NJMSJOPOF
VTF EPFT OPU TMPX UIF OBUVSBM QSPHSFTTJPO PG EJTFBTF.
112
3PVUJOF TIPSU-UFSN NJMSJOPOF USFBUNFOU GPS BDVUF
FYBDFSCBUJPO PG DISPOJD IFBSU GBJMVSF XJUIPVU IZQP-
UFOTJPO GSPN B MPX DBSEJBD PVUQVU TUBUF JT OPU
113
TVQQPSUFE, BMUIPVHI NJMSJOPOF NBZ CF VTFE BT B
CSJEHF UP PSUIPUPQJD IFBSU USBOTQMBOUBUJPO. *U JT
QBSUJDVMBSMZ VTFGVM JO UIF TFUUJOH PG QVMNPOBSZ
IZQFSUFOTJPO. .JMSJOPOF EFDSFBTFT QVMNP- OBSZ BSUFSZ
QSFTTVSFT NPSF FffFDUJWFMZ UIBO PUIFS QPTJUJWF JOPUSPQJD
114,115
BHFOUT, FWFO EPCVUBNJOF. ThF JOPUSPQJD FG- GFDUT PG
NJMSJOPOF BSF SFEVDFE CZ BDJEPTJT, QSFTVNBCMZ SF-
flFDUJOH EFDSFBTFE D".1 GPSNBUJPO JO BDJEPUJD
116
NVTDMF.
#PUI NJMSJOPOF BOE EPCVUBNJOF JNQSPWF
DBSEJBD JOEFY BOE EFDSFBTF DBSEJBD fiMMJOH QSFTTVSFT
BMUIPVHI NJM- SJOPOF NBZ CF NPSF FffFDUJWF GPS UIF
MBUUFS XJUI TJHOJfiDBOU SFEVDUJPOT JO SJHIU BOE MFGU IFBSU
fiMMJOH QSFTTVSFT. .JMSJ- OPOF JT BTTPDJBUFE XJUI NPSF
WBTPEJMBUJPO BOE HSFBUFS EF- DSFBTFT JO TZTUFNJD WBTDVMBS
SFTJTUBODF BOE CMPPE QSFTTVSF UIBO EPCVUBNJOF. 6OMJLF
EPCVUBNJOF, NJMSJOPOF SBSFMZ DBVTFT UBDIZDBSEJB. #PUI
BHFOUT NBZ JODSFBTF NZPDBSEJBM PYZHFO DPOTVNQUJPO
XJUI NJMSJOPOF EPJOH TP UP B MFTTFS FYUFOU. ThF DIPJDF
CFUXFFO EPCVUBNJOF BOE NJMSJOPOF NBZ CF CBTFE PO
IFNPEZOBNJD diffFSFODFT. .JMSJOPOF NBZ CF QSFGFSSFE
JO TJUVBUJPOT XJUI IJHI fiMMJOH QSFTTVSFT, FMFWBUFE
QVMNPOBSZ BSUFSZ QSFTTVSF, OFFE GPS DPOUJOVFE [3
CMPDLBEF, EFDSFBTFE SFTQPOTJWFOFTT UP DBUFDIPMBNJOF
UIFSBQZ, BOE JODSFBTFE SJTL GPS UBDIZBSSIZUINJBT.
%PCVUB- NJOF NBZ CF QSFGFSSFE JO TJUVBUJPOT XJUI
TJHOifiDBOU WBTP- EJMBUJPO PS SFOBM EZTGVODUJPO.
.JMSJOPOF IBT UIF BEEJUJPOBM SPMF PG CFJOH BCMF
117
UP SFWFSTF WBTPTQBTN JO BSUFSJBM HSBftT. .JMSJOPOF JT
BMTP UIPVHIU UP IBWF BOUJJOflBNNBUPSZ FffFDUT, BOE UIVT
QFSJ- PQFSBUJWF BENJOJTUSBUJPO NBZ EJMBUF TQMBODIOJD
WBTDV- MBUVSF BOE BUUFOVBUF TZTUFNJD JOflBNNBUJPO JO
UIF BDVUF QIBTF SFTQPOTF BftFS DBSEJPQVMNPOBSZ
118,119
CZQBTT.
Side Effects
3BQJE BENJOJTUSBUJPO PG NJMSJOPOF NBZ EFDSFBTF
TZTUFNJD WBTDVMBS SFTJTUBODF, EFDSFBTF WFOPVT SFUVSO,
BOE SFTVMU JO IZQPUFOTJPO. ThF IZQPUFOTJPO NBZ CF
BUUFOVBUFE CZ TMPXFS CPMVT BENJOJTUSBUJPO BOE
DPODPNJUBOU BENJOJTUSB- UJPO XJUI WBTPQSFTTPST.
%FTQJUF JUT CFOFGJ JBM IFNPEZOBNJD BDUJPOT,
DISPOJD PSBM UIFSBQZ XJUI NJMSJOPOF NBZ JODSFBTF
NPSCJEJUZ BOE NPSUBMJUZ JO QBUJFOUT XJUI TFWFSF DISPOJD
IFBSU GBJMVSF BOE JT OPU BQQSPWFE CZ UIF 6.4. 'PPE BOE
%SVH "ENJOJTUSBUJPO
 112,120
('%") GPS UIJT JOEJDBUJPO. ThF NFDIBOJTN GPS DPNQMFYFE XJUI DJUSBUF BOE QIPTQIPSVT JPOT, BOE (D)
UIJT SFNBJOT VOLOPXO BMUIPVHI B Q SPBSSIZUINJD GSFFMZ EJffVTJCMF JPOJ[FE DBMDJVN. "T XPVME CF FYQFDUFE,
FffFDU IBT CFFO TVHHFTUFE. 3BQJE BENJOJTUSBUJPO PG UPUBM QMBTNB DBMDJVN EFDSFBTFT XJUI MPX TFSVN BMCVNJO
MBSHF *7 MPBE- JOH EPTFT NBZ BMTP CF BTTPDJBUFE XJUI BOE XJUI IZQPQIPTQIBUFNJB.
109
BSSIZUINJBT. &OIBODFE BUSJPWFOUSJDVMBS OPEBM
DPOEVDUJPO JT JUT NBKPS FMFDUSPQIZTJPMPHJD effFDU.
.JMSJOPOF NBZ BMTP JODSFBTF WFOUSJDVMBS BVUPNBUJDJUZ
38
JO JTDIFNJD NZPDBSEJVN. 7FO- USJDVMBS BOE
TVQSBWFOUSJDVMBS BSSIZUINJBT IBWF CFFO SF- QPSUFE XJUI
111o113
NJMSJOPOF.
#FDBVTF PG JUT IJHIFS QPUFODZ, NJMSJOPOF IBT MFTT PG
BO FffFDU PO QMBUFMFUT UIBO BNSJOPOF. "MUIPVHI CPUI
BHFOUT JOIJCJU JO WJUSP QMBUFMFU BHHSFHBUJPO, TIPSU-UFSN
NJMSJOPOF VTF EJE OPU DBVTF TJHOJfiDBOU DIBOHFT JO
QMBUFMFU OVNCFS PS GVODUJPO BftFS DBSEJPQVMNPOBSZ CZQBTT
CFZPOE UIF VTVBM effFDUT PG DBSEJPQVMNPOBSZ CZQBTT BOE
121
DBSEJBD TVSHFSZ.

Calcium
$BMDJVN JT QSFTFOU JO UIF CPEZ JO HSFBUFS BNPVOUT UIBO
BOZ PUIFS NJOFSBM. $BMDJVN JT JNQPSUBOU GPS (B) O
FVSP- NVTDVMBS USBOTNJTTJPO, (C) T LFMFUBM NVTDMF
DPOUSBDUJPO,
(D) DBSEJBD NVTDMF DPOUSBDUJMJUZ, (E) C MPPE
DPBHVMBUJPO, BOE (F) FYPDZUPTJT OFDFTTBSZ GPS SFMFBTF PG
OFVSPUSBOTNJU- UFST. *O BEEJUJPO, DBMDJVN JT UIF QSJODJQBM
DPNQPOFOU PG CPOF. ThF DZUPQMBTNJD DPODFOUSBUJPO PG
JPOJ[FE DBMDJVN JT NBJOUBJOFE BU MPX MFWFMT CZ FYUSVTJPO
GSPN UIF DFMMT BOE TFRVFTUSBUJPO PG DBMDJVN JPOT XJUIJO
DFMMVMBS PSHBOFMMFT, QBSUJDVMBSMZ NJUPDIPOESJB, BOE JO UIF
TBSDPQMBTNJD SFUJD- VMVN PG TLFMFUBM NVTDMFT. ThF MBSHF
HSBEJFOU GPS DBMDJVN BDSPTT DFMM NFNCSBOFT JT FTTFOUJBM
GPS DBMDJVN'T SPMF JO USBOTNFNCSBOF TJHOBMJOH JO
SFTQPOTF UP WBSJPVT FMFDUSJDBM PS DIFNJDBM TUJNVMJ.
$BMDJVN JT B Q PUFOU JOPUSPQF. *ODSFBTJOH UIF
QMBTNB DPODFOUSBUJPOT PG JPOJ[FE DBMDJVN XJUI
FYPHFOPVT BE- NJOJTUSBUJPO PG DBMDJVN DIMPSJEF PS
DBMDJVN HMVDPOBUF JT DPNNPOMZ VTFE UP USFBU DBSEJBD
EFQSFTTJPO BT NBZ BDDPNQBOZ EFMJWFSZ PG WPMBUJMF
BOFTUIFUJDT, USBOTGVTJPO PG DJUSBUFE CMPPE, BOE
GPMMPXJOH UFSNJOBUJPO PG DBSEJP- QVMNPOBSZ CZQBTT.
$BMDJVN JT OFDFTTBSZ GPS FYDJUBUJPO- DPOUSBDUJPO
DPVQMJOH JO WBTDVMBS TNPPUI NVTDMF BOE NBZ SFTVMU JO B
W BTPDPOTUSJDUJOH FffFDU PO DPSPOBSZ BSUFSJFT UIBU
JNQBJST DPVQMJOH PG DPSPOBSZ CMPPE flPX UP BVHNFOU
122
NZPDBSEJBM PYZHFO EFNBOE.

Calcium Measurement
ThF QMBTNB DPODFOUSBUJPO PG DBMDJVN JT NBJOUBJOFE CF-
UXFFO 4.3 B OE 5.3 N& R/- (8.5 U P 10.5 N H/E-) CZ
FOEP- DSJOF DPOUSPM PG JPO USBOTQPSU JO UIF LJEOFZ,
JOUFTUJOF, BOE CPOF, NFEJBUFE CZ WJUBNJO %, QBSBUIZSPJE
123
IPSNPOF, BOE DBMDJUPOJO. 5PUBM QMBTNB DBMDJVN
DPOTJTUT PG (B) DBMDJVN CPVOE UP BMCVNJO, (C) DBMDJVN
 *U JT UIF JPOJ[FE DBMDJVN, BOE OPU UIF UPUBM QMBTNB
DBM- DJVN, UIBU QSPEVDFT UIF QIZTJPMPHJD FffFDUT PG
DBMDJVN. ThFSFGPSF, IZQPBMCVNJOFNJB BOE
IZQPQIPTQIBUFNJB UZQ- JDBMMZ BSF OPU BTTPDJBUFE XJUI
TJHOT PG IZQPDBMDFNJB. $PO- WFSTFMZ, MBSHF USBOTGVTJPOT
NBZ CF BTTPDJBUFE XJUI BDVUF IZQPDBMDFNJB CFDBVTF
PG UIF CJOEJOH PG JPOJ[FE DBMDJVN UP UIF DJUSBUF
BOUJDPBHVMBOU.
*POJ[FE DBMDJVN UZQJDBMMZ SFQSFTFOUT
BQQSPYJNBUFMZ 45% PG UIF UPUBM QMBTNB DPODFOUSBUJPO.
ThF JPOJ[FE GSBD- UJPO PG DBMDJVN DIBOHFT XJUI Q)
CFDBVTF DBMDJVN BOE IZESPHFO JPOT DPNQFUF GPS UIF
CJOEJOH TJUF PO BMCVNJO. "DJEPTJT JODSFBTFT JPOJ[FE
DBMDJVN, XIFSFBT BMLBMPTJT SFEVDFT JPOJ[FE DBMDJVN.
.PTU MBCPSBUPSJFT OPX EJSFDUMZ NFBTVSF JPOJ[FE
124
DBM- DJVN, UIF NPJFUZ PG DMJOJDBM JOUFSFTU. " OPSNBM
QMBTNB JPOJ[FE DBMDJVN DPODFOUSBUJPO JT 1 UP 1.26 N
124,125
NPM/- (2 UP 2.5 N&R/- PS 4 UP 5 NH/E-).

Calcium Sensitizers
Levosimendan
-FWPTJNFOEBO JT UIF fiSTU ESVH JO B OPWFM DMBTT PG
JOPUSPQFT UIBU JODSFBTFT DPOUSBDUJMJUZ CZ JODSFBTJOH
UIF TFOTJUJWJUZ PG UIF NZPDBSEJVN UP DBMDJVN ('JH. 18-
13). ThF JOPUSP- QJD FOIBODFNFOU JT B SFTVMU PG
CJOEJOH PG MFWPTJNFOEBO UP USPQPOJO $, JODSFBTJOH
126,127
UIF TFOTJUJWJUZ PG USPQPOJO UP DBMDJVN.
-FWPTJNFOEBO BMTP BDUJWBUFT BEFOPTJOF
USJQIPTQIBUFoSFHVMBUFE QPUBTTJVN DIBOOFMT
128 129
(,"51), DBVTJOH WBTPEJMBUJPO BOE NZPDBSEJBM
130
QSPUFDUJPO. "T B SFTVMU, DBSEJBD PVUQVU JT JODSFBTFE
XJUI EFDSFBTFE TZTUFNJD WBTDVMBS SFTJTUBODF BOE
QVMNPOBSZ WBTDVMBS SFTJTUBODF. 0SBM CJPBWBJMBCJMJUZ JT
85%. .FUBCPMJTN JT MBSHFMZ IFQBUJD XJUI SFOBM FYDSFUJPO.
-FWPTJNFOEBO XBT EFWFMPQFE XJUI BO
JOEJDBUJPO GPS UIF USFBUNFOU PG DBSEJPHFOJD TIPDL. "
SFEVDUJPO JO 180-EBZ NPSUBMJUZ IBT OPU CFFO
EFNPOTUSBUFE DPN- QBSFE UP EPCVUBNJOF JO B N
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1989;70(6):1008o1010.
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1993;270(15):1842o1845.
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1991;265(22): 2995o2997.
93. 7FOFUVDDJ -", 5SBffPSE "8, 0'/FJMM 4$, FU BM. ThF
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