PDR MEMBER LOGIN:
  • PDR Search

    Required field
  • Advertisement
  • CLASSES

    Other Cardiovascular Agents

    DEA CLASS

    Rx

    DESCRIPTION

    Smooth muscle relaxant marketed for relief of cerebral and peripheral ischemia secondary to arterial spasm
    FDA Advisory Committee (1979) concluded insufficient data to support marketed indications and recommended market withdrawal; papaverine remains available despite the FDA Advisory recommendation
    Off-label uses include cardiac procedures or to treat erectile dysfunction (ED)

    HOW SUPPLIED

    Papaverine Hydrochloride Intramuscular Inj Sol: 1mL, 30mg
    Papaverine Hydrochloride Intravenous Inj Sol: 1mL, 30mg

    DOSAGE & INDICATIONS

    For the treatment of ischemic conditions associated with arterial vasospasm (arterial thromboembolism).
    For the treatment of cerebral and peripheral ischemia associated with arterial spasm.
    Oral dosage (extended release capsules)
    Adults

    Initially, 150 mg PO every 12 hours. Dosage may be increased to 150 mg PO every 8 hours, or 300 mg PO every 12 hours.

    For the treatment of non-occlusive mesenteric ischemia.
    Intra-arterial dosage
    Adults

    30 to 60 mg/hour as an intra-arterial infusion for 24 hours followed by angiographic evaluation. Infusion may be restarted for additional 24-hour periods followed by repeat angiograms until resolution of vasoconstriction and clinical signs and symptoms. Infusions have been maintained for as long as 5 days.

    For the evaluation of coronary flow reserve.
    Intracoronary dosage
    Adults

    8 to 12 mg of 1 mg/mL dilution intracoronary, administered over 10 seconds.

    For the prevention of ischemic spinal cord injury following surgery involving aortic cross-clamping.
    Intrathecal dosage (preservative-free injection only)
    Adults

    Inject 30 mg of 1% preservative-free papaverine solution intrathecally over 5 minutes.

    For the treatment of erectile dysfunction (ED)†.
    Intracavernous dosage
    Adult males

    Papaverine is used alone, or in combination with phentolamine, or with phentolamine plus alprostadil (prostaglandin E1 or PGE1). Individual dosages are determined by a series of trial injections under physician supervision. The injections should be given no more than 3 times per week, with a minimum of 24 hours between doses. The maximum amount of papaverine is 60 mg per dose when given in combination therapy. Triple drug therapy with papaverine, phentolamine, and alprostadil is most effective, with response rates of up to 92%. Studied dose ranges are as follows: monotherapy, 20 to 80 mg papaverine per injection; 2-drug regimen, 0.25 to 1.5 mg phentolamine plus 7.5 to 45 mg papaverine per injection; 3-drug regimen, 0.2 to 0.4 mg phentolamine plus 8 to 16 mg papaverine plus 10 to 20 mcg alprostadil per injection. Second-line treatment options for ED include intracavernous injections; such therapy is the most effective nonsurgical treatment for ED, with predictable and sustained response. However, it is invasive and carries notable side effects, including priapism and penile fibrosis. Careful dose selection, proper patient education, and continued monitoring by a prescribing physician is warranted for successful non-oral treatment of ED. Follow-up visits for ED patients, regardless of therapy, are necessary to determine whether therapy continues to be effective and whether cardiovascular health has significantly changed.

    For the treatment of arrhythmias due to myocardial ischemia (acute myocardial infarction† or angina†).
    For the treatment of cardiac extrasystoles associated with myocardial ischemia.
    Intravenous or Intramuscular dosage
    Adults

    30 mg IV or IM every 10 minutes, injected slowly over 1 to 2 minutes, for a total of 2 doses.

    Intravenous or Intramuscular dosage
    Adults

    30 to 120 mg IV or IM every 3 hours as indicated. Papaverine IV must be injected slowly over 1 to 2 minutes.

    For intravascular catheter occlusion prophylaxis† (prolongation of peripheral arterial catheter patency†).
    Intra-Arterial dosage
    Neonates, Infants, Children, and Adolescents

    30 mg of papaverine added to 250 mL of arterial catheter infusion solution (0.9% or 0.45% Sodium Chloride Injection with heparin 1 unit/mL) infused continuously at a rate of 1 mL/hour into a peripheral arterial catheter. Generally, avoid use in extremely premature neonates during the immediate period after birth when the risk of developing intracranial hemorrhage is highest.

    †Indicates off-label use

    MAXIMUM DOSAGE

    Adults

    600 mg/day PO for extended-release capsules.

    Geriatric

    600 mg/day PO for extended-release capsules.

    Adolescents

    Safety and efficacy have not been established. Maximum dosage information is not available.

    Children

    Safety and efficacy have not been established. Maximum dosage information is not available.

    Infants

    Safety and efficacy have not been established. Maximum dosage information is not available.

    Neonates

    Safety and efficacy have not been established. Maximum dosage information is not available.

    DOSING CONSIDERATIONS

    Hepatic Impairment

    Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.

    Renal Impairment

    Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are necessary.
     
    Intermittent hemodialysis
    No dosage adjustment is needed.

    ADMINISTRATION

    Oral Administration

    Papaverine may be administered without regard to meals.

    Oral Solid Formulations

    Papaverine capsules should be swallowed whole; do not chew, open, break, or crush.

    Injectable Administration

    Papaverine may be administered via the intramuscular, intravenous, intra-arterial†, intracoronary†, intracavernous†, or intrathecal† routes.
    Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever the solution and container permit.

    Intravenous Administration

    No dilution necessary.
    Inject papaverine IV into a peripheral vein over 1 to 2 minutes. Blood pressure should be monitored frequently.

    Intramuscular Administration

    No dilution necessary.
    Inject papaverine deeply into a large muscle. Aspirate prior to injection to avoid injection into a blood vessel.

    Intrathecal Administration

    NOTE: intrathecal injections require preservative-free product.
    NOTE: Intrathecal administration of papaverine requires specialized techniques. Only clinicians familiar with this method of administration and with management of potential complications should administer papaverine intrathecally.
    Dilute papaverine powder with the appropriate amount of 10% dextrose in water to make a 1% solution. This solution must be filtered using a 0.22 micron filter to produce a preservative-free solution for intrathecal injection.

    Other Injectable Administration

    Intracoronary administration†
    NOTE: Intracoronary administration of papaverine requires specialized techniques. Only clinicians familiar with this method of administration and with management of potential complications should administer papaverine via this route.
    Dilute to a concentration of 1mg/ml in NS.
    Inject 8—12 mg over 10 seconds.
     
    Intracavernous administration†
    NOTE: Papaverine is not approved by the FDA for intercavernous administration.
    This administration method should only be prescribed by specially trained physicians. Patients should be trained and observed for appropriate self-administration technique prior to prescribing.
    No dilution necessary.
    After the appropriate papaverine dose has been drawn into the syringe, the head of the penis is held between the thumb and forefinger. The penis is stretched lengthwise along the thigh while sitting upright or slightly reclined. Position the needle of the syringe so that the drug will be injected as described by your prescriber. Follow the directions given to you by your prescriber. After injection, the syringe should be withdrawn. Apply pressure to the injection site with an alcohol swab for 5 minutes (or until bleeding stops). The injection site and side of the penis should be rotated to minimize local adverse effects related to repeated local injections.
     
    Intra-arterial (superior mesenteric artery) infusion†
    NOTE: Intra-arterial administration of papaverine requires specialized techniques. Only clinicians familiar with this method of administration and with management of potential complications should administer papaverine intra-arterially.
    Dilute to a concentration of 1mg/ml in NS.
    Infuse into the superior mesenteric artery using a controlled infusion device.
     
    Intra-arterial (cerebral vasculature) infusion†
    NOTE: Intra-arterial administration of papaverine requires specialized techniques. Only clinicians familiar with this method of administration and with management of potential complications should administer papaverine intra-arterially.
    Dilute to a concentration of 3mg/ml in NS.
    Infuse into the selected cerebral artery via a superselective catheter over 15—60 minutes using a controlled infusion device. Arterial and intracranial pressures should be continuously monitored.

    STORAGE

    Generic:
    - Discard unused portion. Do not store for later use.
    - Protect from light
    - Store between 68 to 77 degrees F, excursions permitted 59 to 86 degrees F
    - Store in carton until time of use

    CONTRAINDICATIONS / PRECAUTIONS

    General Information

    Although the manufacturer indicates that papaverine should be administered with caution to patients with glaucoma, review of the literature suggests that cautious use is not warranted.

    AV block

    Papaverine is contraindicated in the presence of complete atrioventricular block (AV block). When conduction is depressed, the drug may produce transient ectopic rhythms of ventricular origin, either premature beats or paroxysmal tachycardia.

    Parkinson's disease

    Patients with Parkinson's disease who are taking levodopa should avoid the use of papaverine. Loss of control of Parkinson's disease may result when papaverine is used in these patients. The mechanism of the interaction is unclear, but may be related to the blockage of dopamine receptors in the striatum by papaverine.

    Driving or operating machinery

    Papaverine may cause excessive drowsiness in some individuals. Instruct patients to use caution while driving or operating machinery.

    Intracorporeal administration

    Papaverine injection is contraindicated for the treatment of impotence by intracorporeal administration. The intracorporeal injection of papaverine has been reported to cause persistent priapism requiring medical and surgical intervention.

    QT prolongation

    Intracoronary papaverine may cause torsade de pointes in a small number of patients. Caution should be exercised when administering intracoronary papaverine to patients with preexisting QT prolongation.

    Labor, pregnancy

    Papaverine is classified in FDA pregnancy risk category C. Following single subcutaneous doses of papaverine in rats, no teratogenic effects were reported. Safe use during pregnancy in humans has not been established. It is not known whether papaverine can affect reproduction capacity. According to the manufacturer, papaverine should only be given to a pregnant woman when clearly needed and when the potential benefits outweigh the potential hazards to the fetus. In addition, because papverine relaxes smooth muscle tone; use caution when considering administration to a woman in labor.

    Breast-feeding

    It is not known whether papaverine is excreted in human milk. According to the manufacturer, papaverine should be used with caution in women who are breast-feeding. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.

    Geriatric

    Clinical trials of extended-release papaverine capsules did not include enough geriatric patients to identify a difference in drug response as compared to younger patients. Subsequent clinical experience has not identified any differences. Nevertheless, due to an increased frequency of comorbidities and decreased hepatic and renal function, dosing in the elderly should start at the low end of the dosing range.

    Priapism

    Although papaverine is used off-label for the treatment of erectile dysfunction, the manufacturer notes that papaverine is not indicated for the treatment of impotence by intracorporeal injection. The intracorporeal injection of papaverine hydrochloride has been reported to have resulted in persistent priapism requiring medical and surgical intervention. Priapism, if not treated promptly, can result in irreversible damage to the erectile tissue. Patients who have an erection lasting greater than 4 hours, whether painful or not, should seek emergency medical attention.

    ADVERSE REACTIONS

    Severe

    cirrhosis / Delayed / 0-1.0
    seizures / Delayed / 0-1.0
    ventricular tachycardia / Early / 0-1.0
    torsade de pointes / Rapid / 0-1.0
    increased intracranial pressure / Early / Incidence not known

    Moderate

    hepatitis / Delayed / 0-1.0
    thrombocytopenia / Delayed / 0-1.0
    QT prolongation / Rapid / 0-1.0
    constipation / Delayed / Incidence not known
    hypertension / Early / Incidence not known
    sinus tachycardia / Rapid / Incidence not known
    orthostatic hypotension / Delayed / Incidence not known
    penile pain / Rapid / Incidence not known
    penile fibrosis / Delayed / Incidence not known
    priapism / Early / Incidence not known

    Mild

    abdominal pain / Early / Incidence not known
    vertigo / Early / Incidence not known
    diarrhea / Early / Incidence not known
    nausea / Early / Incidence not known
    rash / Early / Incidence not known
    headache / Early / Incidence not known
    flushing / Rapid / Incidence not known
    malaise / Early / Incidence not known
    drowsiness / Early / Incidence not known
    anorexia / Delayed / Incidence not known
    diaphoresis / Early / Incidence not known
    injection site reaction / Rapid / Incidence not known

    DRUG INTERACTIONS

    Acetaminophen; Dextromethorphan; Doxylamine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as doxylamine could lead to enhanced sedation.
    Acetaminophen; Diphenhydramine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as diphenhydramine could lead to enhanced sedation.
    Alprazolam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Amobarbital: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Anxiolytics; Sedatives; and Hypnotics: (Moderate) Papaverine is a benzylisoquinoline alkaloid of opium and may have synergistic effects with potent CNS depressants such as anxiolytics, sedatives, and hypnotics, which could lead to enhanced sedation.
    Aspirin, ASA; Butalbital; Caffeine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Aspirin, ASA; Butalbital; Caffeine; Codeine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Atropine; Difenoxin: (Moderate) Concurrent administration of diphenoxylate/difenoxin with papaverine can potentiate the CNS-depressant effects of diphenoxylate/difenoxin. Use caution during coadministration.
    Barbiturates: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Belladonna Alkaloids; Ergotamine; Phenobarbital: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Benzodiazepines: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Buspirone: (Moderate) Concurrent use of papaverine with potent CNS depressants such as buspirone could lead to enhanced sedation.
    Butabarbital: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Butalbital; Acetaminophen: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Butalbital; Acetaminophen; Caffeine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Butalbital; Acetaminophen; Caffeine; Codeine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Carbetapentane; Diphenhydramine; Phenylephrine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as diphenhydramine could lead to enhanced sedation.
    Carbidopa; Levodopa: (Major) The beneficial effects of levodopa in Parkinson's disease have been reported to be reversed by coadministration of papaverine; avoid concurrent use in these patients. Papaverine may block dopamine receptors in the striatum and result in loss of control of Parkinson's disease in patients who are taking levodopa.
    Carbidopa; Levodopa; Entacapone: (Major) The beneficial effects of levodopa in Parkinson's disease have been reported to be reversed by coadministration of papaverine; avoid concurrent use in these patients. Papaverine may block dopamine receptors in the striatum and result in loss of control of Parkinson's disease in patients who are taking levodopa.
    Chlordiazepoxide: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Chlordiazepoxide; Amitriptyline: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Chlordiazepoxide; Clidinium: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Clonazepam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Clorazepate: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Dextromethorphan; Diphenhydramine; Phenylephrine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as diphenhydramine could lead to enhanced sedation.
    Diazepam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Diphenhydramine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as diphenhydramine could lead to enhanced sedation.
    Diphenhydramine; Hydrocodone; Phenylephrine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as diphenhydramine could lead to enhanced sedation.
    Diphenhydramine; Ibuprofen: (Moderate) Concurrent use of papaverine with potent CNS depressants such as diphenhydramine could lead to enhanced sedation.
    Diphenhydramine; Naproxen: (Moderate) Concurrent use of papaverine with potent CNS depressants such as diphenhydramine could lead to enhanced sedation.
    Diphenhydramine; Phenylephrine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as diphenhydramine could lead to enhanced sedation.
    Diphenoxylate; Atropine: (Moderate) Concurrent administration of diphenoxylate/difenoxin with papaverine can potentiate the CNS-depressant effects of diphenoxylate/difenoxin. Use caution during coadministration.
    Doxylamine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as doxylamine could lead to enhanced sedation.
    Doxylamine; Pyridoxine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as doxylamine could lead to enhanced sedation.
    Droperidol: (Moderate) Concurrent use of papaverine with potent CNS depressants such as droperidol could lead to enhanced sedation.
    Estazolam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Flurazepam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    General anesthetics: (Moderate) Papaverine is a benzylisoquinoline alkaloid of opium and may have synergistic effects with potent CNS depressants such as general anesthetics, which could lead to enhanced sedation.
    Hydroxyzine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as hydroxyzine could lead to enhanced sedation.
    Levodopa: (Major) The beneficial effects of levodopa in Parkinson's disease have been reported to be reversed by coadministration of papaverine; avoid concurrent use in these patients. Papaverine may block dopamine receptors in the striatum and result in loss of control of Parkinson's disease in patients who are taking levodopa.
    Lorazepam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Mephobarbital: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Methohexital: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Midazolam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Oxazepam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Pentobarbital: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Phenobarbital: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Phenobarbital; Hyoscyamine; Atropine; Scopolamine: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Primidone: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Quazepam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Remimazolam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Secobarbital: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Temazepam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.
    Thiopental: (Moderate) Concurrent use of papaverine with potent CNS depressants such as barbiturates could lead to enhanced sedation.
    Triazolam: (Moderate) Concurrent use of papaverine with potent CNS depressants such as benzodiazepines could lead to enhanced sedation.

    PREGNANCY AND LACTATION

    Pregnancy

    It is not known whether papaverine is excreted in human milk. According to the manufacturer, papaverine should be used with caution in women who are breast-feeding. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.

    MECHANISM OF ACTION

    Papaverine is a benzylisoquinoline alkaloid of opium. It is structurally different from morphine and codeine, which are phenanthrene alkaloids. Papaverine acts by inhibiting phosphodiesterase in smooth muscle cells, which produces increased tissue levels of cyclic adenosine monophosphate and cyclic guanosine 3,5-monophosphate and subsequent relaxation of vascular smooth muscle. Calcium ion channels in cell membranes may also be blocked by papaverine, resulting in a reduction of release of calcium from the intracellular spaces. Papaverine has a spasmolytic effect on smooth muscle of the large blood vessels, particularly those of the coronary, cerebral, peripheral and pulmonary arteries. This spasmolytic effect is unrelated to muscle innervation, and the muscle cell is still responsive to drugs and other stimuli which cause contraction. Relaxation of smooth muscle is also produced in the bronchial musculature, and in the gastrointestinal, biliary, and urinary tracts. Papaverine also relaxes cardiac muscle by directly depressing conduction and excitability of the myocardium and prolonging the refractory period.

    PHARMACOKINETICS

    Papaverine is administered orally and parenterally.  Papaverine is metabolized in the liver to inactive metabolites, which are excreted in the urine.

    Oral Route

    Following oral administration, papaverine is rapidly absorbed with peak plasma levels occurring within 1—2 hours. Oral bioavailability is approximately 54% and plasma protein binding is 90%.