Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Inhalation, as isethionate:
Nebupent: 300 mg (1 ea)
Generic: 300 mg (1 ea)
Pharmacology
Mechanism of Action
Interferes with microbial RNA/DNA, phospholipids and protein synthesis, through inhibition of oxidative phosphorylation and/or interference with incorporation of nucleotides and nucleic acids into RNA and DNA
Pharmacokinetics/Pharmacodynamics
Absorption
Inhalation: Limited systemic absorption with chronic therapy, potential accumulation and systemic effects unknown
Distribution
Binds to tissues and plasma protein; high concentrations are found in the liver, kidney, adrenals, spleen, lungs, and pancreas; poor penetration into CNS; following oral inhalation, high concentrations are found in bronchoalveolar fluid
Half-Life Elimination
IV: 5 to 8 hours; IM: 7 to 11 hours; may be prolonged with severe renal impairment
Use: Labeled Indications
Prevention of Pneumocystis jirovecii pneumonia (PCP) in high-risk, HIV-infected patients either with a history of PCP or with a CD4+ count ≤200/mm3
Contraindications
Hypersensitivity to pentamidine isethionate or any component of the formulation
Dosage and Administration
Dosing: Adult
Pneumocystis jirovecii pneumonia (PCP), prevention: Primary or secondary prophylaxis (alternative to preferred therapy): Inhalation: 300 mg once every 4 weeks via Respirgard II nebulizer (HHS [OI adult 2015])
Dosing: Geriatric
Refer to adult dosing.
Dosing: Pediatric
Pneumocystis jirovecii (PCP); prophylaxis (primary and secondary): Limited data available: Note: For patients intolerant to sulfamethoxazole and trimethoprim.
Children <5 years who are HSCT recipients: Inhalation: 9 mg/kg (maximum dose: 300 mg/dose) once monthly (every 4 weeks) via Respirgard II nebulizer ([CDC/IDSA [Tomblyn 2009])
Children ≥5 years and Adolescents; independent of HIV status: Inhalation: 300 mg once monthly (every 4 weeks) via Respirgard II nebulizer (DHHS [adult and pediatric] 2013; Red Book [AAP] 2015; CDC/IDSA [Tomblyn 2009])
Reconstitution
Reconstitute with 6 mL SWFI. Do not use sodium chloride for initial reconstitution (sodium chloride will cause precipitation). Do not mix with other nebulizer solutions.
Administration
Inhalation: Deliver via Respirgard II nebulizer until nebulizer is emptied (30-45 minutes). Administer at a flow rate of 5 to 7 L/minute from a 40 to 50 pound-per-square inch (PSI) oxygen or air source. A 40-50 PSI air compressor can be used alternatively, with a set flow rate at 5 to 7 L/minute or a set pressure of 22 to 25 PSI. Air compressors <20 PSI should not be used. Use appropriate precautions to minimize exposure to healthcare personnel; refer to individual institutional policy.
Storage
Store intact vials at 20°C to 25°C (68°F to 77°F); protect from light.
The manufacturer recommends the use of freshly prepared solutions for inhalation; however, may be stored for up to 48 hours in the vial at room temperature if protected from light.
Drug Interactions
BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Avoid combination
BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Monitor therapy
Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Avoid combination
Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Consider therapy modification
Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Vaccination with live attenuated typhoid vaccine (Ty21a) should be avoided in patients being treated with systemic antibacterial agents. Use of this vaccine should be postponed until at least 3 days after cessation of antibacterial agents. Consider therapy modification
Adverse Reactions
>5%:
Central nervous system: Fatigue (66%), dizziness (45%)
Gastrointestinal: Decreased appetite (50%)
Infection: Infection (15%)
Respiratory: Cough (1% to 63%), dyspnea (48%), wheezing (32%), bronchospasm (≤15%)
Miscellaneous: Fever (51%)
1% to 5%:
Cardiovascular: Chest pain
Central nervous system: Headache
Dermatologic: Night sweats
Gastrointestinal: Diarrhea, dysgeusia, nausea, oral candidiasis
Hematologic & oncologic: Anemia
Infection: Herpes virus infection, herpes zoster, influenza
Respiratory: Pharyngitis (≤5%), bronchitis, sinusitis, upper respiratory tract infection
Miscellaneous: Night sweats
<1%, postmarketing, and/or case reports: Abscess (oral), abdominal cramps, andominal pain, acute pancreatitis, acute rhinitis, ageusia, amnesia, anaphylaxis, anxiety, arthralgia, asthma, bacterial pneumonia, blepharitis, blurred vision, body odor, bronchitis, cerebrovascular accident, chest congestion, chest tightness, colitis, confusion, conjunctivitis, constipation, contact lens intolerance, cyanosis, cytomegalovirus disease (including colitis and retinitis), cytopenia, depression, dermatitis, desquamation, diabetes mellitus, disuption of body temperature regulation, drowsiness, dry hair, dyspepsia, dyspnea, emotional lability, encephalitis (viral), eosinophilia, eosinophilic pneumonitis, erythema, esophageal candidiasis, esophagitis, eye pain, facial edema, flank pain, gag reflex, gastritis, gastric ulcer, gingivitis, gout, hallucination, hematochezia, hemianopia, hemoptysis, hepatic insufficiency, hepatitis, hepatomegaly, herpes virus infection (pharyngeal), hiatal hernia, histoplasmosis, hyperglycemia, hyperkalemia, hypersensitivity reaction, hypertension, hyperventilation, hypocalcemia, hypoesthesia, hypoglycemia, hypotension, hypothermia, hypoxia, increased blood urea nitrogen, increased bronchial secretions, increased serum creatinine, infection (mycoplasma), insomnia, interstitial pneumonitis, Kaposi's sarcoma, laryngitis, laryngospasm, lethargy, lower extremity edema, melena, meningitis (cryptococcal infection), myalgia, nasal congestion, nephritis, nervousness, neuralgia, neuropathy, neutropenia, oral herpes, oral mucosa ulcer, otitis, palpitations, pancreatitis, pancytopenia, paranoia, paresthesia, peripheral neuropathy, pleurisy, pneumothorax, pruritus, pulmonary disease, rales, renal failure, renal insufficiency, renal pain, rhinitis, seizure, sepsis (central venous line-related), serious infection (extrapulmonary pneumocystosis), SIADH, sialorrhea, skin rash, splenomegaly, Stevens-Johnson syndrome, ST segment changes on ECG, syncope, tachycardia, tachypnea, thrombocytopenia, tonsillitis, torsades de pointes, tremor, tuberculosis, unsteady gait, urinary incontinence, urticaria, vasodilation, vasculitis, ventricular tachycardia, vertigo, vomiting, xeroderma, xerostomia
Warnings/Precautions
Disease-related concerns:
- Asthma: Use inhalation formulation with caution in patients with asthma. May induce bronchospasm or cough, especially in patients with a smoking or asthma history (an inhaled bronchodilator prior to pentamidine may ameliorate symptoms).
- Pancreatitis: Use with caution in patients with a history of pancreatic disease or elevated amylase/lipase levels; acute pancreatitis (with fatality) has been reported. Discontinue inhalational pentamidine if signs/symptoms of acute pancreatitis occur.
- PCP: Acute PCP may develop despite aerosolized pentamidine prophylaxis. Although rare, extrapulmonary PCP disease may occur and has been associated with aerosolized pentamidine. Use appropriate precautions to minimize exposure to healthcare personnel; refer to individual institutional policy.
Other warnings/precautions:
- Adverse effects: Injection: According to the manufacturer, extent and consequence of pentamidine accumulation following chronic inhalation therapy are not known. Patients receiving pentamidine inhalation should be closely monitored for the development of serious adverse reactions that have occurred in patients receiving parenteral pentamidine, including hypotension, hypoglycemia, hyperglycemia, hypocalcemia, anemia, thrombocytopenia, leukopenia, hepatic or renal dysfunction, ventricular tachycardia (eg, torsade de pointes), pancreatitis, Stevens-Johnson syndrome, hyperkalemia and abnormal ST segment of ECG.
Monitoring Parameters
Liver function tests, renal function tests, blood glucose, serum potassium and calcium, CBC and platelets
Pregnancy
Pregnancy Risk Factor
C
Pregnancy Considerations
It is not known if clinically significant concentrations reach the fetus when administered via the aerosolized route. Information related to fetal outcomes following maternal use of pentamidine is limited. If administered via the aerosolized route, maternal serum concentrations are lower, minimizing the exposure to the fetus (Gates 1993; Nanda 1992; Sperling 1992). Concern regarding occupational exposure and theoretical risk to pregnant health care workers has been discussed in the literature. Pregnant health care workers should avoid aerosolized exposure if possible (Conover 1988; Ito 1994; Smaldone 1991).
Aerosolized pentamidine may be used as an alternative agent for the prophylaxis of Pneumocystis jirovecii pneumonia in pregnant females with HIV infection who either cannot tolerate the preferred therapy or who wish to avoid it during the first trimester of pregnancy (HHS [OI; adult] 2017).
Patient Education
What is this drug used for?
- It is used to prevent Pneumocystis jirovecii pneumonia.
Frequently reported side effects of this drug
- Cough
- Lack of appetite
Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:
- Infection
- Liver problems like dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or yellow skin
- Kidney problems like unable to pass urine, blood in the urine, change in amount of urine passed, or weight gain
- Low blood sugar like dizziness, headache, fatigue, feeling weak, shaking, fast heartbeat, confusion, increased hunger, or sweating
- High blood sugar like confusion, fatigue, increased thirst, increased hunger, passing a lot of urine, flushing, fast breathing, or breath that smells like fruit
- Stevens-Johnson syndrome/toxic epidermal necrolysis like red, swollen, blistered, or peeling skin (with or without fever); red or irritated eyes; or sores in mouth, throat, nose, or eyes
- Low calcium like muscle cramps or spasms, numbness and tingling, or seizures
- Pancreatitis like severe abdominal pain, severe back pain, severe nausea, or vomiting
- High potassium like abnormal heartbeat, confusion, dizziness, passing out, weakness, shortness of breath, or numbness or tingling feeling
- Abnormal heartbeat
- Severe dizziness
- Passing out
- Bruising
- Bleeding
- Severe loss of strength and energy
- Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.
Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.
Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.
