Source: Medicines & Healthcare Products Regulatory Agency (GB) Revision Year: 2019 Publisher: Aventis Pharma Limited, 410 Thames Valley Park Drive, Reading, Berkshire, RG6 1PTUK Trading as: Sanofi, 410 Thames Valley Park Drive, Reading, Berkshire, RG6 1PTUK
Pharmacotherapeutic group: Cardiac therapy; Phosphodiesterase inhibitor
ATC code: C01CE02
Milrinone is a positive inotrope and vasodilator, with little chronotropic activity. It also improves left ventricular diastolic relaxation. It differs in structure and mode of action from the digitalis glycosides, catecholamines or angiotensin converting enzyme inhibitors. It is a selective inhibitor of peak III phosphodiesterase isoenzyme in cardiac and vascular muscle. It produces slight enhancement of A-V node conduction, but no other significant electro-physiological effects.
In clinical studies Primacor Injection has been shown to produce prompt improvements in the haemodynamic indices of congestive heart failure, including cardiac output, pulmonary capillary wedge pressure and vascular resistance, without clinically significant effect on heart rate or myocardial oxygen consumption. Haemodynamic improvement during intravenous Primacor therapy is accompanied by clinical symptomatic improvement in congestive cardiac failure, as measured by change in New York Heart Association classification.
Literature review identified clinical studies with patients treated for low cardiac output syndrome following cardiac surgery, septic shock or pulmonary hypertension. The usual dosages were a loading dose of 50–75 μg/kg administered over 30–60 minutes followed by an intravenous continuous infusion of 0.25–0.75 μg/kg/min for a period up to 35 hours. In these studies, milrinone demonstrated an increase of cardiac output, a decrease in cardiac filling pressure, a decrease in systemic and pulmonary vascular resistance, with minimal changes in heart rate and in myocardial oxygen consumption.
Studies of a longer use of milrinone are not sufficient to recommend an administration of milrinone during a period of more than 35 hours.
Some studies explored the paediatric use of milrinone in patients with nonhyperdynamic septic shock (Barton et al., 1996; Lindsay et al., 1998); the effect of milrinone on postbypass pulmonary hypertension after tetralogy of Fallot repair (Chu et al., 2000); the combined effect of nitric oxide and milrinone on pulmonary circulation after Fontan-type procedure (Cai et al., 2008).
The results of these studies were inconclusive. Therefore, the use of milrinone in these indications cannot be recommended.
Following intravenous injections of 12.5-125 µg/kg to congestive heart failure patients, Primacor Injection had a volume of distribution of 0.38 L/kg/hr, a mean terminal elimination half-life of 2.3 hours, and a clearance of 0.13 L/kg/hr. Following intravenous infusions of 0.2-0.7 µg/kg/min to congestive heart failure patients, the drug had a volume of distribution of about 0.45 L/kg, a mean terminal elimination half-life of 2.4 hours, and a clearance of 0.14 L/kg/hr. These pharmacokinetic parameters were not dose-dependent, and the area under the plasma concentration versus time curve following injection was significantly dose-dependent.
The primary route of excretion of milrinone in man is via the urine. Elimination in normal subjects via the urine is rapid, with approximately 60% recovered within the first two hours following dosing, and approximately 90% recovered within the first eight hours following dosing. The mean renal clearance of milrinone is approximately 0.3 L/min, indicative of active secretion.
Milrinone is cleared more rapidly in children than in adults, but infants have significantly lower clearance than children, and preterm infants have even lower clearance. As a consequence of this more rapid clearance compared to adults, steady-state plasma concentrations of milrinone were lower in children than in adults. In paediatric population with normal renal function, steady-state milrinone plasma concentrations after 6–12 hours continuous infusion of 0.5-0.75 µg/kg/min were about 100-300 ng/ml.
Following intravenous infusion of 0.5–0.75 µg/kg/min to neonates, infants and children after open heart surgery, milrinone has a volume of distribution ranging from 0.35–0.9 L/kg with no significant difference across age groups. Following intravenous infusion of 0.5 µg/kg/min to very preterm infants to prevent low systemic outflow after birth, milrinone has a volume of distribution of about 0.5 L/kg.
Several pharmacokinetic studies showed that, in paediatric population, clearance increases with increasing age. Infants have significantly lower clearance than children (3.4–3.8 ml/kg/min versus 5.9–6.7 ml/kg/min). In neonates milrinone clearance was about 1.64 ml/kg/min and preterm infants have even lower clearance (0.64 ml/kg/min).
Milrinone has a mean terminal half-life of 2–4 hours in infants and children and a mean terminal elimination half-life of 10 hours in preterm infants.
It was concluded that the optimal dose of milrinone in paediatric patients in order to obtain plasma levels above the threshold of pharmacodynamic efficacy appeared higher than in adults, but that optimal dose in preterms in order to obtain plasma levels above the threshold of pharmacodynamic efficacy appeared lower than in children.
Milrinone is cleared by renal excretion and has a volume of distribution that is restricted to extracellular space which suggests that the fluid overload and hemodynamic changes associated with patent ductus arteriosus may have an effect on distribution and excretion of milrinone (see sections 4.2, 4.4, 4.8, and 5.3).
A preclinical study was performed to clarify the ductus-dilating effects of PDE 3 inhibitors in near-term rat pups and their differential effects in near-term and preterm fetal rats. Postnatal ductus arteriosus dilatation by milrinone was studied with three doses (10 mg/kg, 1 mg/kg and 0.1 mg/kg). The dilating effects of milrinone in the fetal ductus constricted by indomethacin were studied by simultaneous administration of milrinone (10 mg/kg, 1 mg/kg and 0.1 mg/kg) and indomethacin (10 mg/kg) to the mother rat at D21 (near-term) and D19 (preterm). This in vivo study has shown that milrinone induces dose-dependent dilation of the fetal and the postnatal constricted ductus arteriosus. Dilating effects were more potent with injection immediately after birth than at 1 hour after birth. In addition, study showed that the premature ductus arteriosus is more sensitive to milrinone than the mature ductus arteriosus (see sections 4.2, 4.4, 4.8, and 5.2).
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