The use of flumazenil has been associated with the occurrence of seizures. These are most frequent in patients who have been on benzodiazepines for long-term sedation or in overdose cases where patients are showing signs of serious cyclic antidepressant overdose. Practitioners should individualize the dosage of flumazenil and be prepared to manage seizures.
Benzodiazepine reversal:
IV: Note: Minimal information available; dosing is extrapolated from experiences in pediatric patients 1-17 years; Initial dose: 0.01 mg/kg given over 15 seconds; may repeat 0.01 mg/kg after 45 seconds, and then every minute to a maximum total cumulative dose of 0.05 mg/kg
Continuous IV infusion (as an alternative to repeat bolus doses): 0.005-0.01 mg/kg/hour; dose based on a case report of premature neonate (GA: 32 weeks) exposed to high doses of diazepam intrapartum (Dixon, 1998)
Myoclonus, benzodiazepine-induced: IV: 0.0078 mg/kg as a single dose was effective in one full-term neonate who was receiving continuous infusion midazolam (Zaw, 2001)
Benzodiazepine reversal when used in conscious sedation or general anesthesia: Infants, Children, and Adolescents: IV: Initial dose: 0.01 mg/kg (maximum dose: 0.2 mg) given over 15 seconds; may repeat 0.01 mg/kg (maximum dose: 0.2 mg) after 45 seconds, and then every minute to a maximum total cumulative dose of 0.05 mg/kg or 1 mg, whichever is lower; usual total dose: 0.08 to 1 mg (mean: 0.65 mg)
Suspected benzodiazepine overdose: Limited data available: Infants, Children, and Adolescents: Initial dose: 0.01 mg/kg (maximum dose: 0.2 mg) with repeat doses of 0.01 mg/kg (maximum dose: 0.2 mg) given every minute to a maximum total cumulative dose of 1 mg; as an alternative to repeat bolus doses, follow up continuous infusions of 0.005-0.01 mg/kg/hour have been used (Clark 1995; Richard 1991; Roald 1989; Sugarman 1994)
There are no dosage adjustments provided in the manufacturer’s labeling; adult pharmacokinetic data suggests drug not significantly affected by renal failure (CrCl <10 mL/minute) or hemodialysis.
Initial reversal dose: Use normal dose; repeat doses should be decreased in size or frequency
(For additional information see "Flumazenil: Drug information")
Benzodiazepine reversal when used in conscious sedation or general anesthesia:
IV: Initial: 0.2 mg over 15 seconds; if the desired level of consciousness is not obtained after 1 minute, 0.2 mg may be repeated at 1-minute intervals up to 4 times; usual cumulative dosage range: 0.6 to 1 mg; maximum cumulative dose: 1 mg.
Resedation: IV: In the event of resedation, repeat 0.2 to 1 mg doses (administered at 0.2 mg/minute) may be given at 20-minute intervals as needed; maximum cumulative resedation dose: 3 mg in 1 hour.
Benzodiazepine overdose, treatment:
IV: Initial: 0.2 mg over 30 seconds; if the desired level of consciousness is not obtained 30 seconds after the dose, 0.3 mg can be given over 30 seconds; if the desired level of consciousness is still not obtained 0.5 mg can be given over 30 seconds and repeated at 1-minute intervals; usual cumulative dosage range: 1 to 3 mg; usual cumulative maximum dose: 3 mg.
Note: Patients with a partial response to a cumulative dose of 3 mg may rarely require additional titration up to a total dose of 5 mg (although doses >3 mg do not reliably produce additional effects). If a patient has not responded 5 minutes after a cumulative dose of 5 mg, the major cause of sedation is not likely due to benzodiazepines or may be due to exposure to additional CNS depressants (eg, opioids).
Resedation: IV: In the event of resedation, repeat 0.5 to 1 mg doses (administered at 0.5 mg/minute) may be given at 20-minute intervals if needed; maximum cumulative resedation dose: 3 mg in 1 hour.
Note: After intoxication with high doses of benzodiazepines, the duration of a single dose of flumazenil is not expected to exceed 1 hour; if desired, the period of wakefulness may be prolonged with repeated low IV doses of flumazenil, or by an infusion of 0.1 to 1 mg/hour (off label) (Weinbroum 1996).
Nonbenzodiazepine hypnotic overdose, treatment (off-label use): Limited data available (Cienki 2005; Höjer 2002; Lheureux 1990; Patat 1994); dose based on use in benzodiazepine overdose.
IV: Initial: 0.2 mg over 30 seconds; if the desired level of consciousness is not obtained 30 seconds after the dose, 0.3 mg can be given over 30 seconds; if the desired level of consciousness is still not obtained 0.5 mg can be given over 30 seconds and repeated at 1-minute intervals; usual cumulative dosage range: 1 to 3 mg; usual maximum cumulative dose: 3 mg.
Note: Patients with a partial response to a cumulative dose of 3 mg may rarely require additional titration up to a total dose of 5 mg (although doses >3 mg do not reliably produce additional effects). If a patient has not responded 5 minutes after a cumulative dose of 5 mg, the major cause of sedation is not likely due to a nonbenzodiazepine hypnotic or may be due to exposure to additional CNS depressants (eg, opioids).
Resedation: IV: In the event of resedation, repeat 0.5 to 1 mg doses (administered at 0.5 mg/minute) may be given at 20-minute intervals if needed; maximum cumulative resedation dose: 3 mg in 1 hour.
Note: Due to the short duration of sedation of nonbenzodiazepine hypnotics, a continuous infusion is probably unnecessary in patients intoxicated with these agents (Gunja 2013).
No dosage adjustment provided in manufacturer's labeling; however, pharmacokinetics are not significantly affected by renal failure (CrCl <10 mL/minute) or hemodialysis.
Initial reversal: No dosage adjustment necessary. Repeat doses: Reduce dose or frequency.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous:
Generic: 0.5 mg/5 mL (5 mL); 1 mg/10 mL (10 mL)
Yes
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous:
Generic: 0.1 mg/mL (5 mL)
Parenteral: For IV use only; administer by rapid IV injection over 15-30 seconds via a freely running IV infusion into larger vein (to decrease chance of pain, phlebitis). Children: Do not exceed 0.2 mg/minute. In adults for repeat doses, the following is suggested: Do not exceed 0.2 mg/minute for reversal of general anesthesia and do not exceed 0.5 mg/minute for reversal of benzodiazepine overdose.
IV: Administer in freely-running IV into large vein.
Management of benzodiazepine overdose: Administer over 30 seconds.
Reversal of benzodiazepine when used in conscious sedation: Administer over 15 seconds.
Store at 20°C to 25°C (68°F to 77°F). Once drawn up in the syringe or mixed with D5W, LR, or NS, use within 24 hours. Discard any unused solution after 24 hours.
Pharmacy supply of emergency antidotes: Guidelines suggest that at least 6 to 12 mg of flumazenil be stocked. Suggested amount is stated to be a sufficient quantity to treat 1 patient weighing 100 kg for an initial 8- to 24-hour period (Dart 2018); actual amount to be stocked should take into account site-specific and population-specific needs.
Benzodiazepine antagonist; reverses sedative effects of benzodiazepines used in general anesthesia or conscious sedation; management of benzodiazepine overdose; not indicated for ethanol, barbiturate, general anesthetic or opioid overdose
Flumazenil may be confused with influenza virus vaccine
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%: Gastrointestinal: Vomiting (11%)
1% to 10%:
Cardiovascular: Palpitation (3% to 9%), flushing (1% to 3%), thrombophlebitis (1% to 3%), vasodilation (1% to 3%)
Central nervous system: Ataxia (10%), dizziness (10%), vertigo (10%), agitation (3% to 9%), anxiety (3% to 9%), insomnia (3% to 9%), nervousness (3% to 9%), depersonalization (1% to 3%), depression (1% to 3%), dysphoria (1% to 3%), emotional lability (1% to 3%; including crying), euphoria (1% to 3%), fatigue (1% to 3%), headache (1% to 3%), hypoesthesia (1% to 3%), malaise (1% to 3%), paranoia (1% to 3%), paresthesia (1% to 3%)
Dermatologic: Dermatological disease (skin abnormality: 1% to 3%), diaphoresis (1% to 3%), skin rash (1% to 3%)
Endocrine & metabolic: Hot flash (1% to 3%)
Gastrointestinal: Xerostomia (3% to 9%), nausea (1% to 3%)
Local: Pain at injection site (3% to 9%), injection site reaction (1% to 3%)
Neuromuscular & skeletal: Weakness (1% to 3%), tremor
Ophthalmic: Blurred vision (3% to 9%), lacrimation (1% to 3%), visual disturbance (1% to 3%)
Respiratory: Dyspnea (3% to 9%), hyperventilation (3% to 9%)
<1%, postmarketing, and/or case reports: Atrial tachycardia (paroxysmal), auditory disturbance, bradycardia, cardiac arrhythmia, chest pain, confusion, decreased blood pressure, delirium, drowsiness, fear, hiccups, hyperacusis, hypertension, increased blood pressure, lack of concentration, panic attack, reversible hearing loss, rigors, seizure (including generalized), sensation of cold, shivering, stupor, tachycardia, tinnitus, tongue edema, ventricular tachycardia, voice disorder, withdrawal syndrome
Hypersensitivity to flumazenil, benzodiazepines, or any component of the formulation; patients given benzodiazepines for control of potentially life-threatening conditions (eg, control of intracranial pressure or status epilepticus); patients who may have ingested or are showing signs of cyclic-antidepressant overdosage.
Concerns related to adverse effects:
• Amnesia: Does not consistently reverse amnesia; patient may not recall verbal instructions after procedure.
• CNS depression: May cause CNS depression, which may impair physical or mental abilities; patients must be cautioned about performing tasks which require mental alertness (eg, operating machinery or driving) for 24 hours after discharge.
• Resedation: Occurs more frequently in patients where a large single dose or cumulative dose of a benzodiazepine has been administered along with a neuromuscular-blocking agent and multiple anesthetic agents.
• Respiratory depression: Should not rely upon to reverse respiratory depression/hypoventilation. Flumazenil is not a substitute for evaluation of oxygenation. Establishing an airway and assisting ventilation, as necessary, is always the initial step in overdose management.
• Seizures: [US Boxed Warning]: Benzodiazepine reversal may result in seizures; seizures may occur more frequently in patients on benzodiazepines for long-term sedation or following tricyclic antidepressant overdose. Dose should be individualized and practitioners should be prepared to manage seizures. Seizures may also develop in patients with concurrent major sedative-hypnotic drug withdrawal, recent therapy with repeated doses of parenteral benzodiazepines, myoclonic jerking or seizure activity prior to flumazenil administration. Use with caution in patients relying on a benzodiazepine for seizure control.
Disease-related concerns:
• Head injury: Use with caution in patients with a head injury; may alter cerebral blood flow or precipitate convulsions in patients receiving benzodiazepines.
• Hepatic impairment: Use with caution in patients with hepatic dysfunction; repeated doses of the drug should be reduced in frequency or amount.
• Panic disorder: Use with caution in patients with a history of panic disorder; may provoke panic attacks.
Special populations:
• Drug/alcohol dependence: Use caution in drug and ethanol-dependent patients; these patients may also be dependent on benzodiazepines.
• Intensive care patients: Should be used with caution in the intensive care unit because of increased risk of unrecognized benzodiazepine dependence in such settings.
Other warnings/precautions:
• Appropriate use: Should not be used to diagnose benzodiazepine-induced sedation. Reverse neuromuscular blockade before considering use. Flumazenil does not antagonize the CNS effects of other GABA agonists (such as ethanol, barbiturates, or general anesthetics); nor does it reverse opioids. Not recommended for treatment of benzodiazepine dependence.
• Overdose use: Use with caution in patients with mixed drug overdoses; toxic effects of other drugs taken may emerge once benzodiazepine effects are reversed.
Pediatric patients (especially 1 to 5 years of age) may experience resedation; these patients may require repeat bolus doses or continuous infusion.
None known.
There are no known significant interactions.
Avoid alcohol for the first 24 hours after administration or as long as the effects of benzodiazepines exist.
Teratogenic effects were not seen in animal reproduction studies. Embryocidal effects were seen at large doses. Use during labor and delivery is not recommended. In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey 2003).
Level of consciousness and resedation, blood pressure, heart rate, respiratory rate, continuous pulse oximetry; monitor for resedation for 1-2 hours after reversal of sedation in patients who receive benzodiazepine sedation
Competitively inhibits the activity at the benzodiazepine receptor site on the GABA/benzodiazepine receptor complex. Flumazenil does not antagonize the CNS effect of drugs affecting GABA-ergic neurons by means other than the benzodiazepine receptor (ethanol, barbiturates, general anesthetics) and does not reverse the effects of opioids
Note: Follows a two compartment open model; Clearance and Vd per kg are similar for children and adults, but children display more variability
Onset of action: 1-2 minutes; 80% response within 3 minutes
Peak effect: 6-10 minutes
Duration: Resedation occurs after ~1 hour (range: 19-50 minutes); duration related to dose given and benzodiazepine plasma concentrations; reversal effects of flumazenil may wear off before effects of benzodiazepine
Distribution: Initial Vd: 0.5 L/kg; Vdss: 0.9-1.1 L/kg
Protein binding: ~50% (~67% of which is bound to albumin)
Metabolism: Hepatic; dependent upon hepatic blood flow
Half-life elimination:
Children: Terminal: 20-75 minutes (mean: 40 minutes)
Adults: Alpha: 4-11 minutes; Terminal: 40-80 minutes
Moderate hepatic dysfunction: 1.3 hours
Severe hepatic impairment: 2.4 hours
Excretion: Feces; urine (<1% as unchanged drug)
Clearance: Dependent upon hepatic blood flow; Adults: 0.8-1 L/hour/kg
Hepatic function impairment: Moderate: Mean total clearance decreased 40% to 60%. Severe: Mean total clearance decreased 75%.
Flumazenil is a weak lipophilic base. In one study of conscious sedation reversal in 107 pediatric patients (1-17 years of age), resedation occurred between 19-50 minutes after the start of flumazenil. Flumazenil has been used to successfully treat paradoxical reactions in children associated with midazolam use (eg, agitation, restlessness, combativeness) (Massanari, 1997).
Solution (Flumazenil Intravenous)
0.5 mg/5 mL (per mL): $1.56 - $1.70
1 mg/10 mL (per mL): $1.56 - $7.49
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