DRUGS & SUPPLEMENTS
How often in a day do you take medicine? How many times?
Ambulax-M is an anxiolytic drug (tranquilizer), a derivative of triazolo-benzodiazepine. This medication has anxiolytic, sedative, hypnotic, anticonvulsant, central muscle relaxant effect. The mechanism of action is to enhance the inhibitory effect of endogenous GABA in the CNS by increasing the sensitivity of the GABA-receptor mediator as a result of stimulation of benzodiazepine receptors located in the allosteric center of postsynaptic GABA-receptor activating ascending reticular formation of brain stem neurons and the lateral horns of the spinal cord; reduces the excitability of the subcortical brain structures (the limbic system, thalamus, hypothalamus), inhibits the polysynaptic spinal reflexes.
Pronounced anxiolytic activity (reduction of emotional tension, easing anxiety, fear, anxiety) is combined with moderate soporific effect; it shortens the period of sleep, increases sleep duration and reduces the number of nighttime awakenings. The mechanism of hypnotic action is inhibition of cell reticular formation of the brain.
After oral administration Ambulax-M (Alprazolam) is rapidly and completely absorbed from the gastrointestinal tract. Cmax plasma levels achieved within 1-2 hours. Binding to plasma proteins is 80%. This drud metabolized in the liver. T1/2 is an average of 12-15 hours. Ambulax-M (Alprazolam) and its metabolites are mainly excreted by kidneys.
Individual. It is recommended to use the minimum effective dose of Ambulax-M Aurobindo. The dose is corrected in the treatment process depending on the achieved effect and tolerability. If necessary, increase the dose should be increased gradually, first in the evening and then in the daytime reception.
The initial dose of Ambulax-M (Alprazolam) is 250-500 mcg 3 times / day, if necessary, it gradually increases to 4.5 mg / day.
For elderly or debilitated patients the initial dose is 250 mcg 2-3 / day, maintenance doses - 500-750 mcg / day, if necessary, taking into account the tolerance dose can be increased.
Cancellation or reduction of the dose of Ambulax-M (Alprazolam) should be done gradually by reducing the daily dose of no more than 500 mcg every 3 days; sometimes can needed even more slowly cancelling.
CNS: at the beginning of treatment (especially in elderly patients) drowsiness, fatigue, dizziness, decreased ability to concentrate, ataxia, disorientation, unsteady gait, slowing of mental and motor responses; rare - headache, euphoria, depression, tremors, memory loss, impaired coordination of movements, depressed mood, confusion, extrapyramidal dystonic reactions (involuntary movements, including for eyes), weakness, myasthenia gravis, dysarthria; in some cases - paradoxical reactions (aggressive flare, confusion, psychomotor agitation, fear, suicidal tendencies, muscle spasms, hallucinations, agitation, irritability, anxiety, insomnia).
Digestive system: possible dry mouth or excessive salivation, heartburn, nausea, vomiting, decreased appetite, constipation or diarrhea, abnormal liver function, elevated liver transaminases and alkaline phosphatase, jaundice.
Hematopoietic system: possible leukopenia, neutropenia, agranulocytosis (chills, pyrexia, sore throat, extreme tiredness or weakness), anemia, thrombocytopenia.
Urinary tract: possible urinary incontinence, urinary retention, renal failure, decreased or increased libido, dysmenorrhea.
Endocrine system: possible change in body weight, disturbances in libido, menstrual irregularities.
Cardiovascular system: possible decrease in blood pressure, tachycardia.
Allergic reactions: possible skin rash, itching.
Coma, shock, myasthenia gravis, angle-closure glaucoma, acute alcohol poisoning (with the weakening of the vital functions), narcotic analgesics, hypnotics and psychotropic drugs, chronic obstructive airways disease with incipient respiratory failure, acute respiratory failure, severe depression (suicidal tendencies may occur), pregnancy (especially the I trimester), lactation, childhood and adolescence to 18 years, increased sensitivity to benzodiazepines.
Ambulax-M (Alprazolam) has a toxic effect on the fetus and increases the risk of birth defects when used in the I trimester of pregnancy. The constant use during pregnancy can cause physical dependence with the development of withdrawal syndrome in the newborn. Reception at therapeutic doses in the later stages of pregnancy can cause neonatal CNS depression. Using of Ambulax-M (Alprazolam) immediately before birth or during labor can cause neonatal respiratory depression, decreased muscle tone, hypotension, hypothermia and a weak act of sucking (sucking flaccid syndrome baby).
It is possible to excretion of the benzodiazepines in breast milk that can cause drowsiness in the newborn and hinder feeding.
In experimental studies have been shown that Ambulax-M (Alprazolam) and its metabolites are excreted in breast milk.
Keep in mind that anxiety or conditions related to everyday stress usually does not require treatment with anxiolytics.
If you experience paradoxical reactions then stop taking the drug. During the period of treatment is unacceptable to use of alcoholic drinks. With caution use Ambulax-M for drivers of vehicles and people whose profession is associated with increased concentration.
The simultaneous use of Ambulax-M (Alprazolam) with psychotropic, anticonvulsant medications and ethanol is observed enhancement inhibitory action Ambulax-M (Alprazolam) on the CNS.
The simultaneous use with blockers of histamine H2-receptor reduce the clearance of Ambulax-M (Alprazolam) and increase the inhibitory effect of Ambulax-M (Alprazolam) on the CNS; macrolide antibiotics reduce the clearance of Ambulax-M (Alprazolam).
The simultaneous use with hormonal oral contraceptives increased T1/2 of Ambulax-M (Alprazolam).
Simultaneous administration of Ambulax-M (Alprazolam) with dextropropoxyphene observed a more pronounced CNS depression than in combination with other benzodiazepines, as may increase the concentration of Ambulax-M (Alprazolam) in blood plasma.
Simultaneous treatment with digoxin increases the risk of intoxication by cardiac glycosides.
Ambulax-M (Alprazolam) increases the concentration of imipramine in plasma.
Simultaneous administration with itraconazole, ketoconazole increases the effects of Ambulax-M (Alprazolam).
Simultaneous administration with paroxetine may increases the effects of Ambulax-M (Alprazolam) due to the inhibition of its metabolism.
Fluvoxamine increases the concentration of Ambulax-M (Alprazolam) in plasma and risk of its side effects.
Simultaneous administration of Ambulax-M (Alprazolam) with fluoxetine may increase the concentration of Ambulax-M (Alprazolam) in plasma by decreasing its metabolism and clearance under the influence of fluoxetine which is accompanied by psychomotor disorders.
It can not be exclude the possibility of strengthening effect of Ambulax-M (Alprazolam) for simultaneous administration with erythromycin.
Symptoms: Varying degrees of CNS oppression (from sleepiness to coma) - drowsiness, confusion; in more severe cases (especially in patients receiving other drugs depressing the central nervous system or alcohol) - ataxia, decreased reflexes, hypotension, coma.
Treatment: induction of vomiting, gastric lavage, symptomatic therapy, monitor vital signs. In severe hypotension prescribed an injection of norepinephrine. Specific antidote is benzodiazepine receptor antagonist flumazenil (administration only in a hospital).
Ambulax-M (Propranolol) Hydrochloride, USP is a synthetic beta-adrenergic receptor blocking agent chemically described as (+)-1-(isopropylamino)-3-(1-naphthyloxy)-2-propanol hydrochloride. Its structural formula is:
Ambulax-M (Propranolol) Hydrochloride, USP is a stable, white, crystalline solid which is readily soluble in water and ethanol. Its molecular weight is 295.80.
Ambulax-M (Propranolol) Hydrochloride Injection, USP is available as a sterile injectable solution for intravenous administration. Each mL contains 1 mg of Ambulax-M (Propranolol) Hydrochloride, USP in Water for Injection, USP. The pH is adjusted with anhydrous Citric Acid, USP.
Ambulax-M (Propranolol) is a nonselective beta-adrenergic receptor blocking agent possessing no other autonomic nervous system activity. It specifically competes with beta-adrenergic receptor stimulating agents for available receptor sites. When access to beta-recceptor sites is blocked by Ambulax-M (Propranolol), chronotropic, inotropic, and vasodilator responses to beta-adrenergic stimulation are decreased proportionately. At doses greater than required for beta blockade, Ambulax-M (Propranolol) also exerts a quinidine-like or anesthetic-like membrane action, which affects the cardiac action potential. The significance of the membrane action in the treatment of arrhythmias is uncertain.
Mechanism of Action
The effects of Ambulax-M (Propranolol) are due to selective blockade of beta-adrenergic receptors, leaving alpha-adrenergic responses intact. There are two well-characterized subtypes of beta receptors (beta1 and beta2); Ambulax-M (Propranolol) interacts with both subtypes equally. Beta1-adrenergic receptors leads to a decrease in the activity of both normal and ectopic pacemaker cells and a decrease in A-V nodal conduction velocity. All of these actions can contribute to antiarrhythmic activity and control of ventricular rate during arrhythmias. Blockade of cardiac beta1-adrenergic receptors also decreases the myocardial force of contraction and may provoke cardiac decompensation in patients with minimal cardiac reserve.
Beta2-adrenergic receptors are found predominantly in smooth muscle-vascular, bronchial, gastrointestinal and genitourinary. Blockade of these receptors results in constriction. Clinically, Ambulax-M (Propranolol) may exacerbate respiratory symptoms in patients with obstructive pulmonary diseases such as asthma and emphysema.
Propranolol's beta blocking effects are attributable to its S(-) enantiomer.
Pharmacokinetics and Drug Metabolism
Ambulax-M (Propranolol) has a distribution half-life (T1/2 alpha) of 5-10 minutes and a volume of distribution of about 4 to 5 L/kg. Approximately 90% of circulating Ambulax-M (Propranolol) is bound to plasma proteins. The binding is enantiomer-selective. The S-isomer is preferentially bound to alpha1 glycoprotein and the R-isomer is preferentially bound to albumin.
Metabolism and Elimination
The elimination half-life (T½ beta) is between 2 and 5.5 hours. Ambulax-M (Propranolol) is extensively metabolized with most metabolites appearing in the urine. The major metabolites include Ambulax-M (Propranolol) glucuronide, naphthyloxylactic acid, and glucuronic acid and sulfate conjugates of 4-hydroxy Ambulax-M (Propranolol). Following single-dose intravenous administration, side-chain oxidative products account for approximately 40% of the metabolites, direct conjugation products account for approximately 45-50% of metabolites, and ring oxidative products account for approximately 10-15% of metabolites. Of these, only the primary ring oxidative product (4-hydroxypropranolol) possesses beta-adrenergic receptor blocking activity.
In vitro studies have indicated that the aromatic hydroxylation of Ambulax-M (Propranolol) is catalyzed mainly by polymorphic CYP2D6. Side‑chain oxidation is mediated mainly by CYP1A2 and to some extent by CYP2D6. 4-hydroxy Ambulax-M (Propranolol) is a weak inhibitor of CYP2D6.
As Ambulax-M (Propranolol) concentration increases, so does its beta-blocking effect, as evidenced by a reduction in exercise-induced tachycardia (n = 6 normal volunteers).
The pharmacokinetics of Ambulax-M (Propranolol) have not been investigated in patients under 18 years of age. Ambulax-M (Propranolol) injection is not recommended for treatment of cardiac arrhythmias in pediatric patients.
Elevated Ambulax-M (Propranolol) plasma concentrations, a longer mean elimination half-life (254 vs. 152 minutes), and decreased systemic clearance (8 vs. 13 mL/kg/min) have been observed in elderly subjects when compared to young subjects. However, the apparent volume of distribution seems to be similar in elderly and young subjects. These findings suggest that dose adjustment of Ambulax-M (Propranolol) injection may be required for elderly patients.
Intravenously administered Ambulax-M (Propranolol) was evaluated in 5 women and 6 men. When adjusted for weight, there were no gender-related differences in elimination half-life, volume of distribution, protein binding, or systemic clearance.
In a study of intravenously administered Ambulax-M (Propranolol), obese subjects had a higher AUC (161 versus 109 hr·mcg/L) and lower total clearance than did non-obese subjects. Ambulax-M (Propranolol) plasma protein binding was similar in both groups.
The pharmacokinetics of Ambulax-M (Propranolol) and its metabolites were evaluated in 15 subjects with varying degrees of renal function after Ambulax-M (Propranolol) administration via the intravenous and oral routes. When compared with normal subjects, an increase in fecal excretion of Ambulax-M (Propranolol) conjugates was observed in patients with increased renal impairment. Ambulax-M (Propranolol) was also evaluated in 5 patients with chronic renal failure, 6 patients on regular dialysis, and 5 healthy subjects, following a single oral dose of 40 mg of Ambulax-M (Propranolol). The peak plasma concentrations (Cmax) of Ambulax-M (Propranolol) in the chronic renal failure group were 2- to 3-fold higher (161 ng/mL) than those observed in the dialysis patients (47 ng/mL) and in the healthy subjects (26 ng/mL). Ambulax-M (Propranolol) plasma clearance was also reduced in the patients with chronic renal failure.
Chronic renal failure has been associated with a decrease in drug metabolism via downregulation of hepatic cytochrome P-450 activity.
Ambulax-M (Propranolol) is extensively metabolized by the liver. In a study conducted in 6 normal subjects and 20 patients with chronic liver disease, including hepatic cirrhosis, 40 mg of R-propranolol was administered intravenously. Compared to normal subjects, patients with chronic liver disease had decreased clearance of Ambulax-M (Propranolol), increased volume of distribution, decreased protein-binding, and considerable variation in half-life. Caution should be exercised when Ambulax-M (Propranolol) is used in this population. Consideration should be given to lowering the dose of intravenous Ambulax-M (Propranolol) in patients with hepatic insufficiency.
No pharmacokinetic changes were observed in hyperthyroid or hypothyroid patients when compared to their corresponding euthyroid state. Dosage adjustment does not seem necessary in either patient population based on pharmacokinetic findings.
Because propranolol’s metabolism involves multiple pathways in the cytochrome P-450 system (CYP2D6, 1A2, 2C19), administration of Ambulax-M (Propranolol) with drugs that are metabolized by, or affect the activity (induction or inhibition) of one or more of these pathways may lead to clinically relevant drug interactions.
Blood levels of Ambulax-M (Propranolol) may be increased by administration of Ambulax-M (Propranolol) with substrates or inhibitors of CYP2D6, such as amiodarone, cimetidine, delavirdine, fluoxetine, paroxetine, quinidine, and ritonavir. No interactions were observed with either ranitidine or lansoprazole.
Blood levels of Ambulax-M (Propranolol) may be increased by administration of Ambulax-M (Propranolol) with substrates or inhibitors of CYP1A2, such as imipramine, cimetidine, ciprofloxacin, fluvoxamine, isoniazid, ritonavir, theophylline, zileuton, zolmitriptan, and rizatriptan.
Blood levels of Ambulax-M (Propranolol) may be increased by administration of Ambulax-M (Propranolol) with substrates or inhibitors of CYP2C19, such as fluconazole, cimetidine, fluoxetine, fluvoxamine, teniposide, and tolbutamide. No interaction was observed with omeprazole.
Blood levels of Ambulax-M (Propranolol) may be decreased by administration of Ambulax-M (Propranolol) with inducers such as rifampin and ethanol. Cigarette smoking also induces hepatic metabolism and has been shown to increase up to 100% the clearance of Ambulax-M (Propranolol), resulting in decreased plasma concentrations.
The AUC of propafenone is increased by more than 200% with co-administration of Ambulax-M (Propranolol).
The metabolism of Ambulax-M (Propranolol) is reduced by co-administration of quinidine, leading to a 2- to 3-fold increased blood concentrations and greater beta-blockade.
The metabolism of lidocaine is inhibited by co-administration of Ambulax-M (Propranolol), resulting in a 25% increase in lidocaine concentrations.
Calcium Channel Blockers
The mean Cmax and AUC of Ambulax-M (Propranolol) are increased respectively, by 50% and 30% by co-administration of nisoldipine and by 80% and 47%, by co-administration of nicardipine.
The mean values of Cmax and AUC of nifedipine are increased by 64% and 79%, respectively, by co-administration of Ambulax-M (Propranolol).
Ambulax-M (Propranolol) does not affect the pharmacokinetics of verapamil and norverapamil. Verapamil does not affect the pharmacokinetics of Ambulax-M (Propranolol).
Administration of zolmitriptan or rizatriptan with Ambulax-M (Propranolol) resulted in increased concentrations of zolmitriptan (AUC increased by 56% and Cmax by 37%) or rizatriptan (the AUC and Cmax were increased by 67% and 75%, respectively).
Co-administration of theophylline with Ambulax-M (Propranolol) decreases theophylline clearance by 33% to 52%.
Ambulax-M (Propranolol) can inhibit the metabolism of diazepam, resulting in increased concentrations of diazepam and its metabolites. Diazepam does not alter the pharmacokinetics of Ambulax-M (Propranolol).
The pharmacokinetics of oxazepam, triazolam, lorazepam, and alprazolam are not affected by co-administration of Ambulax-M (Propranolol).
Co-administration of Ambulax-M (Propranolol) at doses greater than or equal to 160 mg/day resulted in increased thioridazine plasma concentrations ranging from 50% to 370% and increased thioridazine metabolites concentrations ranging from 33% to 210%.
Co-administration of chlorpromazine with Ambulax-M (Propranolol) resulted in increased plasma levels of both drugs (70% increase in Ambulax-M (Propranolol) concentrations).
Co-administration of Ambulax-M (Propranolol) with cimetidine, a non-specific CYP450 inhibitor, increased Ambulax-M (Propranolol) concentrations by about 40%. Co‑administration with aluminum hydroxide gel (1200 mg) resulted in a 50% decrease in Ambulax-M (Propranolol) concentrations.
Co-administration of metoclopramide with Ambulax-M (Propranolol) did not have a significant effect on propranolol’s pharmacokinetics.
Lipid Lowering Drugs
Co-administration of cholesteramine or colestipol with Ambulax-M (Propranolol) resulted in up to 50% decrease in Ambulax-M (Propranolol) concentrations.
Co-administration of Ambulax-M (Propranolol) with lovastatin or pravastatin decreased 20% to 25% the AUC of both, but did not alter their pharmacodynamics. Ambulax-M (Propranolol) did not have an effect on the pharmacokinetics of fluvastatin.
Concomitant administration of Ambulax-M (Propranolol) and warfarin has been shown to increase warfarin bioavailability and increase prothrombin time.
In a series of 225 patients with supraventricular (n = 145), ventricular (n = 69), or both (n = 11) arrythmias resistant to digitalis, intravenous Ambulax-M (Propranolol) hydrochloride was administered in single doses, averaging 1 to 5 mg. Approximately one-quarter of the patients with supraventricular arrhythmias (generally those with sinus or atrial tachycardia) reverted to normal sinus rhythm. About one-half had symptoms ameliorated either by a decrease in ventricular rate or an attenuation of frequency or severity of paroxysmal attacks.
Approximately one-half of patients with ventricular arrhythmias (generally those with frequent PVCs) reverted to normal sinus rhythm or responded with a reduction in ventricular rate.
Similar findings were seen in a series of 25 Bantu patients with atrial fibrillation (n = 16), sinus tachycardia (n = 5), and multifocal ventricular extrasystoles (n = 9).
In another series, 7 of 8 patients with digitalis-related tachyarrhythmia had ventricular rate decreases after intravenous Ambulax-M (Propranolol). Similarly limited clinical experience has shown that intravenous Ambulax-M (Propranolol) will slow the ventricular rate in patients with Wolff-Parkinson-White syndrome or with tachycardia associated with thyrotoxicosis.
Onset of activity is usually within five minutes.
Intravenous administration is usually reserved for life-threatening arrhythmias or those occurring under anesthesia.
1. Supraventricular arrhythmias
Intravenous Ambulax-M (Propranolol) is indicated for the short-term treatment of supraventricular tachycardia, including Wolff‑Parkinson‑White syndrome and thyrotoxicosis, to decrease ventricular rate. Use in patients with atrial flutter or atrial fibrillation should be reserved for arrythmias unresponsive to standard therapy or when more prolonged control is required. Reversion to normal sinus rhythm has occasionally been observed, predominantly in patients with sinus or atrial tachycardia.
2. Ventricular tachycardias
With the exception of those induced by catecholamines or digitalis, Ambulax-M (Propranolol) is not the drug of first choice. In critical situations when cardioversion techniques or other drugs are not indicated or are not effective, Ambulax-M (Propranolol) may be considered. If, after consideration of the risks involved, Ambulax-M (Propranolol) is used, it should be given intravenously in low dosage and very slowly, as the failing heart requires some sympathetic drive for maintenance of myocardial tone. Some patients may respond with complete reversion to normal sinus rhythm, but reduction in ventricular rate is more likely. Ventricular arrhythmias do not respond to Ambulax-M (Propranolol) as predictably as do the supraventricular arrhythmias.
Intravenous Ambulax-M (Propranolol) is indicated for the treatment of persistent premature ventricular extrasystoles that impair the well‑being of the patient and do not respond to conventional measures.
3. Tachyarrhythmias of digitalis intoxication
Intravenous Ambulax-M (Propranolol) is indicated to control ventricular rate in life-threatening digitalis-induced arrhythmias. Severe bradycardia may occur.
4. Resistant tachyarrhythmias due to excessive catecholamine action during anesthesia
Intravenous Ambulax-M (Propranolol) is indicated to abolish tachyarrhythmias due to excessive catecholamine action during anesthesia when other measures fail. These arrhythmias may arise because of release of endogenous catecholamines or administration of catecholamines. All general inhalation anesthetics produce some degree of myocardial depression. Therefore, when Ambulax-M (Propranolol) is used to treat arrhythmias during anesthesia, it should be used with extreme caution, usually with constant monitoring of the ECG and central venous pressure.
Ambulax-M (Propranolol) is contraindicated in 1) cardiogenic shock; 2) sinus bradycardia and greater than first-degree block; 3) bronchial asthma; and 4) in patients with known hypersensitivity to Ambulax-M (Propranolol) hydrochloride.
Sympathetic stimulation may be a vital component supporting circulatory function in patients with congestive heart failure, and its inhibition by beta blockade may precipitate more severe failure. Although beta-blockers should be avoided in overt congestive heart failure, some have been shown to be highly beneficial when used with close follow-up in patients with a history of failure who are well compensazted and are receiving additional therapies, including diiuretics as needed. Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart muscle.
Nonallergic Bronchospasm (e.g., Chronic Bronchitis, Emphysema)
In general, patients with bronchospastic lung disease should not receive beta blockers. Ambulax-M (Propranolol) should be administered with caution in this setting since it may block bronchodilation produced by endogenous and exogenous catecholamine stimulation of beta-receptors.
The necessity or desirability of withdrawal of beta-blocking therapy prior to major surgery is controversial. It should be noted, however, that the impaired ability of the heart to respond to reflex adrenergic stimuli in propranolol-treated patients might augment the risks of general anesthesia and surgical procedures.
Ambulax-M (Propranolol) is a competitive inhibitor of beta-receptor agonists, and its effects can be reversed by administration of such agents, e.g., dobutamine or isoproterenol. However, such patients may be subject to protracted severe hypotension.
Diabetes and Hypoglycemia
Beta-adrenergic blockade may prevent the appearance of certain premonitory signs and symptoms (pulse rate and pressure changes) of acute hypoglycemia, especially in labile insulin-dependent diabetics. In these patients, it may be more difficult to adjust the dosage of insulin.
Ambulax-M (Propranolol) therapy, particularly in infants and children, diabetic or not, has been associated with hypoglycemia especially during fasting, as in preparation for surgery. Hypoglycemia has been reported after prolonged physical exertion and in patients with renal insufficiency.
Beta-adrenergic blockade may mask certain clinical signs of hyperthyroidism. Therefore, abrupt withdrawal of Ambulax-M (Propranolol) may be followed by an exacerbation of symptoms of hyperthyroidism, including thyroid storm. Ambulax-M (Propranolol) may change thyroid-function tests, increasing T4 and reverse T3, and decreasing T3.
Ambulax-M (Propranolol) should be used with caution in patients with impaired hepatic or renal function.
Ambulax-M (Propranolol) is not indicated for the treatment of hypertensive emergencies.
Beta-adrenergic receptor blockade can cause reduction of intraocular pressure. Patients should be told that Ambulax-M (Propranolol) might interfere with the glaucoma screening test. Withdrawal may lead to a return of elevated intraocular pressure.
Risk of anaphylactic reaction. While taking beta blockers, patients with a history of severe anaphylactic reaction to a variety of allergens may be more reactive to repeated challenge, either accidental, diagnostic, or therapeutic. Such patients may be unresponsive to the usual doses of epinephrine used to treat allergic reaction.
There have been reports of exacerbation of angina and, in some cases, myocardial infarction, following abrupt discontinuance of Ambulax-M (Propranolol) therapy. Therefore, when discontinuance of Ambulax-M (Propranolol) is planned, the dosage should be gradually reduced over at least a few weeks, and the patient should be cautioned against interruption or cessation of therapy without a physician’s advice. If Ambulax-M (Propranolol) therapy is interrupted and exacerbation of angina occurs, it is usually advisable to reinstitute Ambulax-M (Propranolol) therapy and take other measures appropriate for the management of angina pectoris. Since coronary artery disease may be unrecognized, it may be prudent to follow the above advice in patients considered at risk of having occult atherosclerotic heart disease who are given Ambulax-M (Propranolol) for other indications.
Clinical Laboratory Tests
In patients with hypertension, use of Ambulax-M (Propranolol) has been associated with elevated levels of serum potassium, serum transaminases and alkaline phosphatase. In severe heart failure, the use of Ambulax-M (Propranolol) has been associated with increases in Blood Urea Nitrogen.
Caution should be exercised when Ambulax-M (Propranolol) is administered with drugs that have an effect on CYP2D6, 1A2, or 2C19 metabolic pathways. Co-administration of such drugs with Ambulax-M (Propranolol) may lead to clinically relevant drug interactions and changes in its efficacy and/or toxicity (see CLINICAL PHARMACOLOGY, DRUG INTERACTIONS.
Propafenone has negative inotropic and beta-blocking properties that can be additive to those of Ambulax-M (Propranolol).
Quinidine increases the concentration of Ambulax-M (Propranolol) and produces a greater degree of clinical beta-blockade and may cause postural hypotension.
Disopyramide is a Type I antiarrhythmic drug with potent negative inotropic and chronotropic effects and has been associated with severe bradycardia, asystole and heart failure when administered with Ambulax-M (Propranolol).
Amiodarone is an antiarrhythmic agent with negative chronotropic properties that may be additive to those seen with Ambulax-M (Propranolol).
The clearance of lidocaine is reduced when administered with Ambulax-M (Propranolol). Lidocaine toxicity has been reported following co-administration with Ambulax-M (Propranolol).
Caution should be exercised when administering Ambulax-M (Propranolol) with drugs that slow A-V nodal conduction, e.g., digitalis, lidocaine and calcium channel blockers.
Calcium Channel Blockers
Caution should be exercised when patients receiving a beta-blocker are administered a calcium-channel-blocking drug with negative inotropic and/or chronotropic effects. Both agents may depress myocardial contractility or atrioventricular conduction.
There have been reports of significant bradycardia, heart failure, and cardiovascular collapse with concurrent use of verapamil and beta‑blockers.
Co-administration of Ambulax-M (Propranolol) and diltiazem in patients with cardiac disease has been associated with bradycardia, hypotension, high degree heart block, and heart failure.
When combined with beta-blockers, ACE inhibitors can cause hypotension, particularly in the setting of acute myocardial infarction.
ACE inhibitors have been reported to increase bronchial hyperreactivity when administered with Ambulax-M (Propranolol).
The antihypertensive effects of clonidine may be antagonized by beta-blockers. Ambulax-M (Propranolol) should be administered cautiously to patients withdrawing from clonidine.
Prazosin has been associated with prolongation of first dose hypotension in the presence of beta-blockers.
Postural hypotension has been reported in patients taking both beta-blockers and terazosin or doxazosin.
Patients receiving catecholamine-depleting drugs, such as reserpine, with Ambulax-M (Propranolol) should be closely observed for excess reduction of resting sympathetic nervous activity, which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthostatic hypotension. Administration of reserpine with Ambulax-M (Propranolol) may also potentiate depression.
Patients on long-term therapy with Ambulax-M (Propranolol) may experience uncontrolled hypertension if administered epinephrine as a consequence of unopposed alpha-receptor stimulation. Epinephrine is therefore not indicated in the treatment of Ambulax-M (Propranolol) overdose.
Isoproterenol and Dobutamine
Propranolol is a competitive inhibitor of beta-receptor agonists, and its effects can be reversed by administration of such agents, e.g., dobutamine or isoproterenol. Also, Ambulax-M (Propranolol) may reduce sensitivity to dobutamine stress echocardiography in patients undergoing evaluation for myocardial ischemia.
Non-Steroidal Anti-Inflammatory Drugs
Non-steroidal anti-inflammatory drugs (NSAIDs) have been reported to blunt the antihypertensive effect of beta-adrenoreceptor blocking agents.
Administration of indomethacin with Ambulax-M (Propranolol) may reduce the efficacy of Ambulax-M (Propranolol) in reducing blood pressure and heart rate.
The hypotensive effects of MAO inhibitors or tricyclic antidepressants may be exacerbated when administered with beta-blockers by interfering with the beta blocking activity of Ambulax-M (Propranolol).
Methoxyflurane and trichloroethylene may depress myocardial contractility when administered with Ambulax-M (Propranolol).
Administration of Ambulax-M (Propranolol) with warfarin increases the concentration of warfarin. Therefore, the prothrombin time should be monitored.
Hypotension and cardiac arrest have been reported with the concomitant use of Ambulax-M (Propranolol) and haloperidol.
Thyroxine may result in a lower than expected T3 concentration when used concomitantly with Ambulax-M (Propranolol).
In dietary administration studies in which mice and rats were treated with Ambulax-M (Propranolol) hydrochloride for up to 18 months at doses of up to 150 mg/kg/day, there was no evidence of drug-related tumorigenesis. On a body surface area basis, this dose in the mouse and rat is, respectively, about equal to and about twice the maximum recommended human oral daily dose (MRHD) of 640 mg Ambulax-M (Propranolol) hydrochloride. In a study in which both male and female rats were exposed to Ambulax-M (Propranolol) hydrochloride in their diets at concentrations of up to 0.05% (about 50 mg/kg body weight and less than the MRHD), from 60 days prior to mating and throughout pregnancy and lactation for two generations, there were no effects on fertility. Based on differing results from Ames Tests performed by different laboratories, there is equivocal evidence for a genotoxic effect of Ambulax-M (Propranolol) hydrochloride in bacteria (S. typhimurium strain TA 1538).
In a series of reproductive and developmental toxicology studies, Ambulax-M (Propranolol) hydrochloride was given to rats by gavage or in the diet throughout pregnancy and lactation. At doses of 150 mg/kg/day, but not at doses of 80 mg/kg/day (equivalent to the MRHD on a body surface area basis), treatment was associated with embryotoxicity (reduced litter size and increased resorption rates) as well as neonatal toxicity (deaths). Ambulax-M (Propranolol) hydrochloride also was administered (in the feed) to rabbits (throughout pregnancy and lactation) at doses as high as 150 mg/kg/day (about 5 times the maximum recommended human oral daily dose). No evidence of embryo or neonatal toxicity was noted.
There are no adequate and well-controlled studies in pregnant women. Intrauterine growth retardation has been reported for neonates whose mothers received Ambulax-M (Propranolol) hydrochloride during pregnancy. Neonates whose mothers received Ambulax-M (Propranolol) hydrochloride at parturition have exhibited bradycardia, hypoglycemia, and respiratory depression. Adequate facilities for monitoring such infants at birth should be available. Ambulax-M (Propranolol) should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Ambulax-M (Propranolol) is excreted in human milk. Caution should be exercised when Ambulax-M (Propranolol) is administered to a nursing woman.
Safety and effectiveness of Ambulax-M (Propranolol) in pediatric patients have not been established.
Clinical studies of intravenous Ambulax-M (Propranolol) did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Elderly subjects have decreased clearance and a longer mean elimination half‑life. These findings suggest that dose adjustment of Ambulax-M (Propranolol) injection may be required for elderly patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of the decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy.
In a series of 225 patients, there were 6 deaths. Cardiovascular events (hypotension, congestive heart failure, bradycardia, and heart block) were the most common. The only other event reported by more than one patient was nausea.
Other adverse events for intravenous Ambulax-M (Propranolol), reported during post-marketing surveillance include cardiac arrest, dyspnea, and cutaneous ulcers.
The following adverse events have been reported with use of formulations of sustained- or immediate-release oral Ambulax-M (Propranolol) and may be expected with intravenous Ambulax-M (Propranolol).
Nausea, vomiting, epigastric distress, abdominal cramping, diarrhea, constipation, mesenteric arterial thrombosis, ischemic colitis.
Ambulax-M (Propranolol) is not significantly dialyzable. In the event of overdose or exaggerated response, the following measures should be employed:
Hypotension and bradycardia have been reported following Ambulax-M (Propranolol) overdose and should be treated appropriately. Glucagon can exert potent inotropic and chronotropic effects and may be particularly useful for the treatment of hypotension or depressed myocardial function after a Ambulax-M (Propranolol) overdose. Glucagon should be administered as 50-150 mcg/kg intravenously followed by continuous drip of 1-5 mg/hour for positive chronotropic effect. Isoproterenol, dopamine, or phosphodiesterase inhibitors may also be useful. Epinephrine, however, may provoke uncontrolled hypertension. Bradycardia can be treated with atropine or isoproterenol. Serious bradycardia may require temporary cardiac pacing.
The electrocardiogram, pulse, blood pressure, neurobehavioral status and intake and output balance must be monitored. Isoproterenol and aminophylline may be useful for bronchospasm.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
The usual dose is 1 to 3 mg administered under careful monitoring, such as electrocardiography and central venous pressure. The rate of administration should not exceed 1 mg (1 mL) per minute to diminish the possibility of lowering blood pressure and causing cardiac standstill. Sufficient time should be allowed for the drug to reach the site of action even when a slow circulation is present. If necessary, a second dose may be given after two minutes. Thereafter, additional drug should not be given in less than four hours. Additional Ambulax-M (Propranolol) hydrochloride should not be given when the desired alteration in rate or rhythm is achieved.
Transfer to oral therapy as soon as possible.
Each mL contains 1 mg of Ambulax-M (Propranolol) Hydrochloride, USP in Water for Injection, USP. The pH is adjusted with anhydrous Citric Acid, USP. Supplied as: 1 mL vials in boxes of 10 (NDC 0143-9872-10).
Store at 20° to 25°C (68° to 77°F). Protect from freezing or excessive heat.
Manufactured by: HIKMA FARMACÊUTICA (PORTUGAL), S.A.
Estrada do Rio da Mó, 8, 8A e 8B – Fervença – 2705-906 Terrugem SNT, PORTUGAL
Distributed by: WEST-WARD PHARMACEUTICAL CORP.
Eatontown, NJ 07724 USA
Depending on the reaction of the Ambulax-M after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Ambulax-M not safe to drive or operate heavy machine after consumption. Meaning that, do not drive or operate heavy duty machines after taking the capsule if the capsule has a strange reaction on your body like dizziness, drowsiness. As prescribed by a pharmacist, it is dangerous to take alcohol while taking medicines as it exposed patients to drowsiness and health risk. Please take note of such effect most especially when taking Primosa capsule. It's advisable to consult your doctor on time for a proper recommendation and medical consultations.Is Ambulax-M addictive or habit forming?
Medicines are not designed with the mind of creating an addiction or abuse on the health of the users. Addictive Medicine is categorically called Controlled substances by the government. For instance, Schedule H or X in India and schedule II-V in the US are controlled substances.
Please consult the medicine instruction manual on how to use and ensure it is not a controlled substance.In conclusion, self medication is a killer to your health. Consult your doctor for a proper prescription, recommendation, and guidiance.
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The information was verified by Dr. Rachana Salvi, MD Pharmacology