Drugs List

Therapeutic Indications

Uses

Depolarising muscle relaxant

Depolarising muscle relaxant with rapid onset and short duration for use in:
i) endotracheal intubation
ii) mechanical ventilation
iii) other surgical and obstetric procedures

Suxamethonium chloride may also be used to reduce the intensity of pharmacologically or electrically induced convulsions.

Administration

Suxamethonium may be given as an intravenous injection, intravenous infusion or intramuscular injection depending on the patient's age and condition.

Contraindications

Familial history of malignant hyperthermia
Inherited abnormal plasma cholinesterase activity
Predisposition to malignant hyperthermia
Severe trauma
Cerebral palsy
Duchenne muscular dystrophy
Hyperkalaemia
Myotonia congenita
Myotonic dystrophy
Severe burn

Precautions and Warnings

Autoimmune disease
Burns
Children under 18 years
Chronic debilitating disease
Hypothermia
Infection
Plasma cholinesterase deficiency
Prolonged immobilisation
Severe generalised tetanus
Severe sepsis
Acute renal failure
Anaemia
Breastfeeding
Cardiac impairment
Chronic renal failure
Collagen disorder
Electrolyte imbalance
Glaucoma
Hepatic impairment
Malignant neoplasm
Malnutrition
Myasthenia gravis
Myasthenic Eaton-Lambert syndrome
Myxoedema
Neuromuscular disorder
Penetrating ocular injury
Pregnancy
Respiratory impairment
Tuberculosis

Patient must be fully anaesthetised before administration
Treatment to be initiated and supervised by a specialist
Do not mix with other injections or infusions prior to administration
Monitor respiratory function
Monitor using peripheral nerve stimulator during prolonged administration
Use only when equipment adequate for cardiac/respiratory monitoring/support
Repeated doses result in tachyphylaxis
Driving or operating machinery not advisable following treatment

Prolonged periods of suxamethonium administration may result in the change of the characteristic phase I (depolarising neuromuscular) block into a phase II (non-depolarising neuromuscular) block. A developing phase II block can not always be fully or permanently reversed by anticholinesterase agents. However, once fully established, the phase II block may be fully reversed with standard doses of neostigmine accompanied with an anticholinergic agent.

Patients with reduced plasma cholinesterase activity may experience prolonged and intensified neuromuscular blockade following administration of suxamethonium. In these patients it may be advisable to administer reduced doses of suxamethonium injection.

Pregnancy and Lactation

Pregnancy

The potential benefits to the mother should be weighed against any possible risk to the foetus before administering suxamethonium chloride.
There have been no studies performed on the effect of suxamethonium on female fertility or pregnancy.

There are no direct effects of suxamethonium on the uterus or other smooth muscle structures and it does not cross the placental barrier, at normal therapeutic levels, in sufficient amounts to affect the respiration of the foetus.

Pregnant and puerperal patients may take longer to recover from the neuromuscular blockade following suxamethonium chloride injection. This is due to a fall in plasma cholinesterase levels during the first trimester of pregnancy ( to about 70 to 80% of pre-pregnancy levels); and a further fall within 2 to 4 days after delivery (to about 60 to 70% pre-pregnancy levels). These levels return to normal over the following 6 weeks.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

The potential benefits to the mother should be weighed against any possible risk to the child before administering suxamethonium chloride.

It is not certain whether suxamethonium chloride or its metabolites are secreted in human milk. It is ionised at physiological pH.

Suxamethonium is rapidly eliminated and poorly absorbed orally. It is not likely to reach the bloodstream of the infant or cause any adverse effect in breastfed infants. Breastfeeding may be resumed once the mother has recovered from neuromuscular block.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Anaphylactic reaction
Apnoea
Arrhythmias
Bradycardia
Bronchospasm
Cardiac arrest
Fasciculation
Flushing
Gastric secretions increased
Hyperkalaemia
Hypersalivation
Hypertension
Hypotension
Increased bowel action
Increased bronchial secretions
Increased intra-gastric pressure
Increased intra-ocular pressure
Malignant hyperthermia
Muscle pain
Myoglobinaemia
Myoglobinuria
Post-operative pain
Rash
Respiratory depression
Rhabdomyolysis
Tachycardia
Trismus

Presentation

Solution for injection containing suxamethonium chloride

Drugs List

Therapeutic Indications

Uses

Depolarising muscle relaxant

Depolarising muscle relaxant with rapid onset and short duration for use in:
i) endotracheal intubation
ii) mechanical ventilation
iii) other surgical and obstetric procedures

Suxamethonium chloride may also be used to reduce the intensity of pharmacologically or electrically induced convulsions.

Dosage

Initial dosage is dependent on route of administration, degree of muscular relaxation required and body weight. Dosage should be adjusted in relation to the patient's individual response. Infants and young children are more resistant to suxamethonium chloride compared with adult.

Adults

Children

Neonates

Patients with Renal Impairment

Administration

Suxamethonium may be given as an intravenous injection, intravenous infusion or intramuscular injection depending on the patient's age and condition.

Contraindications

Familial history of malignant hyperthermia
Inherited abnormal plasma cholinesterase activity
Predisposition to malignant hyperthermia
Severe trauma
Cerebral palsy
Duchenne muscular dystrophy
Hyperkalaemia
Myotonia congenita
Myotonic dystrophy
Severe burn

Precautions and Warnings

Autoimmune disease
Burns
Children under 18 years
Chronic debilitating disease
Hypothermia
Infection
Plasma cholinesterase deficiency
Prolonged immobilisation
Severe generalised tetanus
Severe sepsis
Acute renal failure
Anaemia
Breastfeeding
Cardiac impairment
Chronic renal failure
Collagen disorder
Electrolyte imbalance
Glaucoma
Hepatic impairment
Malignant neoplasm
Malnutrition
Myasthenia gravis
Myasthenic Eaton-Lambert syndrome
Myxoedema
Neuromuscular disorder
Penetrating ocular injury
Pregnancy
Respiratory impairment
Tuberculosis

Patient must be fully anaesthetised before administration
Treatment to be initiated and supervised by a specialist
Do not mix with other injections or infusions prior to administration
Monitor respiratory function
Monitor using peripheral nerve stimulator during prolonged administration
Use only when equipment adequate for cardiac/respiratory monitoring/support
Repeated doses result in tachyphylaxis
Driving or operating machinery not advisable following treatment

Prolonged periods of suxamethonium administration may result in the change of the characteristic phase I (depolarising neuromuscular) block into a phase II (non-depolarising neuromuscular) block. A developing phase II block can not always be fully or permanently reversed by anticholinesterase agents. However, once fully established, the phase II block may be fully reversed with standard doses of neostigmine accompanied with an anticholinergic agent.

Patients with reduced plasma cholinesterase activity may experience prolonged and intensified neuromuscular blockade following administration of suxamethonium. In these patients it may be advisable to administer reduced doses of suxamethonium injection.

Pregnancy and Lactation

Pregnancy

The potential benefits to the mother should be weighed against any possible risk to the foetus before administering suxamethonium chloride.
There have been no studies performed on the effect of suxamethonium on female fertility or pregnancy.

There are no direct effects of suxamethonium on the uterus or other smooth muscle structures and it does not cross the placental barrier, at normal therapeutic levels, in sufficient amounts to affect the respiration of the foetus.

Pregnant and puerperal patients may take longer to recover from the neuromuscular blockade following suxamethonium chloride injection. This is due to a fall in plasma cholinesterase levels during the first trimester of pregnancy ( to about 70 to 80% of pre-pregnancy levels); and a further fall within 2 to 4 days after delivery (to about 60 to 70% pre-pregnancy levels). These levels return to normal over the following 6 weeks.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

The potential benefits to the mother should be weighed against any possible risk to the child before administering suxamethonium chloride.

It is not certain whether suxamethonium chloride or its metabolites are secreted in human milk. It is ionised at physiological pH.

Suxamethonium is rapidly eliminated and poorly absorbed orally. It is not likely to reach the bloodstream of the infant or cause any adverse effect in breastfed infants. Breastfeeding may be resumed once the mother has recovered from neuromuscular block.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Effects on Ability to Drive and Operate Machinery

Suxamethonium will always be used in combination with a general anaesthetic and therefore patients should be warned not to drive or operate machinery until all effects of anaesthesia and/or surgery have ceased.

Side Effects

Anaphylactic reaction
Apnoea
Arrhythmias
Bradycardia
Bronchospasm
Cardiac arrest
Fasciculation
Flushing
Gastric secretions increased
Hyperkalaemia
Hypersalivation
Hypertension
Hypotension
Increased bowel action
Increased bronchial secretions
Increased intra-gastric pressure
Increased intra-ocular pressure
Malignant hyperthermia
Muscle pain
Myoglobinaemia
Myoglobinuria
Post-operative pain
Rash
Respiratory depression
Rhabdomyolysis
Tachycardia
Trismus

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: March 2013

Reference Sources

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.

Summary of Product Characteristics: Anectine Injection. GlaxoSmithKline UK. Revised January 2016.

Summary of Product Characteristics: Suxamethonium Chloride Injection BP 50mg/2ml. Aurum Pharmaceuticals Ltd. Revised July 2007.

Summary of Product Characteristics: Suxamethonium Chloride 50mg/ml Solution for Injection. Mercury Pharma group. Revised August 2012.

NICE Evidence Services Available at: www.nice.org.uk Last accessed: 01 September 2017

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Succinylcholine Last revised: January 4, 2011
Last accessed: March 14, 2013