Elevated intraocular pressure:
US labeling: Ophthalmic: 0.1%, 0.15%, 0.2% solution: Instill 1 drop in affected eye(s) 3 times/day (approximately every 8 hours).
Canadian labeling: Ophthalmic:
Solution 0.15%: Instill 1 drop in affected eye(s) 3 times/day (approximately every 8 hours).
Solution 0.2%: Instill 1 drop in affected eye(s) 2 times/day (approximately every 12 hours).
Miosis (following laser refractive surgery) (off-label use): Ophthalmic: 0.15%, 0.2% solution: Instill 1 drop in each eye 30 to 60 minutes before scotopic condition (Ref).
Ocular redness (OTC): Ophthalmic (0.025% solution): Instill 1 drop in affected eye(s) every 6 to 8 hours up to 4 times daily.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied); use with caution.
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied); use with caution.
Refer to adult dosing.
(For additional information see "Brimonidine (ophthalmic): Pediatric drug information")
Glaucoma, ocular hypertension: Children ≥2 years and Adolescents: Ophthalmic solution (0.1%, 0.15%, or 0.2%): Ophthalmic: Instill 1 drop into lower conjunctival sac of affected eye(s) 3 times daily (approximately every 8 hours)
Ocular redness: Children ≥5 years: Ophthalmic solution (0.025%): Ophthalmic: Instill 1 drop info affected eye(s) every 6 to 8 hours as needed up to 4 times daily
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Actual frequency of adverse reactions may be formulation dependent; percentages reported with Alphagan P:
>10%:
Central nervous system: Drowsiness (children 25% to 83%; adults 1% to 4%)
Ophthalmic: Allergic conjunctivitis, conjunctival hyperemia, eye pruritus
1% to 10% (unless otherwise noted 1% to 4%):
Cardiovascular: Hypertension (5% to 9%), hypotension
Central nervous system: Dizziness, fatigue, foreign body sensation of eye, headache, impaired consciousness (children), insomnia
Dermatologic: Erythema of eyelid, skin rash
Endocrine & metabolic: Hypercholesterolemia
Gastrointestinal: Xerostomia (5% to 9%), dyspepsia
Hypersensitivity: Local ocular hypersensitivity reaction (5% to 9%), hypersensitivity reaction
Infection: Infection
Neuromuscular & skeletal: Weakness
Ophthalmic: Burning sensation of eyes (5% to 9%), follicular conjunctivitis (5% to 9%), visual disturbance (5% to 9%), blepharitis, blepharoconjunctivitis, blurred vision, cataract, conjunctival edema, conjunctival hemorrhage, conjunctivitis, decreased visual acuity, dry eye syndrome, epiphora, eye discharge, eye irritation, eyelid disease, eyelid edema, eye pain, keratitis, photophobia, stinging of eyes, superficial punctate keratitis, visual field defect, vitreous detachment, vitreous opacity, watery eyes
Respiratory: Bronchitis, cough, dyspnea, flu-like symptoms, pharyngitis, rhinitis, sinus infection, sinusitis
<1%, postmarketing, and/or case reports: Anterior uveitis, apnea (infants), bradycardia, corneal erosion, depression, dermatological reaction (erythema, eyelid pruritus, vasodilation), dry nose, dysgeusia, hordeolum, hypothermia (infants), hypotonia (infants), iritis, miosis, nausea, tachycardia
Hypersensitivity to brimonidine or any component of the formulation; neonates and infants <2 years; concomitant MAO inhibitor therapy
Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Concerns related to adverse effects:
• Bacterial keratitis: Inadvertent contamination of multiple-dose ophthalmic solutions has caused bacterial keratitis.
• 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).
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with severe cardiovascular disease or coronary insufficiency.
• Cerebrovascular insufficiency: Use with caution in patients with cerebral insufficiency.
• Hepatic impairment: Use with caution in patients with hepatic impairment (has not been studied).
• Orthostatic hypotension: Use with caution in patients with orthostatic hypotension.
• Raynaud phenomenon: Use with caution in patients with Raynaud phenomenon.
• Renal impairment: Use with caution in patients with renal impairment (has not been studied).
• Thromboangiitis obliterans: Use with caution in patients with thromboangiitis obliterans.
Special populations:
• Contact lens wearers: Some formulations may contain benzalkonium chloride which may be adsorbed by soft contact lenses; remove contacts prior to administration and wait 15 minutes before reinserting.
• Pediatric: Systemic absorption has been reported; children are at higher risk of systemic adverse events (Levy, 2004). Use is contraindicated in children <2 years of age.
Other warnings/precautions:
• Self-medication (OTC use): Discontinue use and contact health care provider if eye pain or changes in vision occur; redness or irritation of the eye continues, or condition worsens or persists for >3 days. Do not use if solution changes color or becomes cloudy.
May cause CNS depression, particularly in young children; not recommended for use in infants or children <2 years. The most common adverse effects reported in a study of pediatric glaucoma patients were somnolence and decreased alertness (50% to 83% in children 2 to 6 years of age); these effects resulted in a 16% discontinuation of treatment rate; children >7 years (>20 kg) had a much lower rate of somnolence (25%); apnea, bradycardia, hypotension, hypothermia, hypotonia, and somnolence have been reported in infants receiving brimonidine.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Ophthalmic, as tartrate:
Alphagan P: 0.1% (5 mL, 10 mL, 15 mL); 0.15% (5 mL, 10 mL, 15 mL)
Lumify: 0.025% (2.5 mL, 7.5 mL) [contains benzalkonium chloride]
Generic: 0.1% (5 mL, 10 mL, 15 mL); 0.15% (5 mL, 10 mL, 15 mL); 0.2% (5 mL, 10 mL, 15 mL)
Yes
Solution (Alphagan P Ophthalmic)
0.1% (per mL): $46.64
0.15% (per mL): $49.74
Solution (Brimonidine Tartrate Ophthalmic)
0.1% (per mL): $44.31
0.15% (per mL): $38.33
0.2% (per mL): $0.84 - $6.52
Solution (Lumify Ophthalmic)
0.025% (per mL): $3.77
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Ophthalmic, as tartrate:
Alphagan: 0.2% (5 mL, 10 mL) [contains benzalkonium chloride]
Alphagan P: 0.15% (5 mL, 10 mL)
Generic: 0.15% (5 mL, 10 mL); 0.2% (5 mL, 10 mL)
Ophthalmic: For topical ophthalmic use only. Remove contact lenses prior to administration; wait 15 minutes before reinserting if using products containing benzalkonium chloride. Separate administration of other ophthalmic agents by at least 5 minutes. Do not touch tip of container to any surface, the eyelids, or the surrounding area.
Ophthalmic: Wash hands prior to use. Instill into conjunctival sac avoiding contact of bottle tip with skin or eye. Apply gentle pressure to lacrimal sac during and immediately following instillation (1 minute) or instruct patient to gently close eyelid after administration, to decrease systemic absorption of ophthalmic drops (Ref). Administer other topical ophthalmic medications at least 5 minutes apart; generic formulation contains benzalkonium chloride which may be absorbed by soft contact lenses; wait at least 10 to 15 minutes after administration to insert soft contact lenses.
Elevated intraocular pressure: Reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension
Ocular redness (OTC only): Relief of redness of the eye due to minor eye irritations
Miosis (following laser refractive surgery)
Brimonidine may be confused with bromocriptine
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Alcohol (Ethyl): CNS Depressants may enhance the CNS depressant effect of Alcohol (Ethyl). Risk C: Monitor therapy
Alizapride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Azelastine (Nasal): May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination
Beta-Blockers: Alpha2-Agonists may enhance the AV-blocking effect of Beta-Blockers. Sinus node dysfunction may also be enhanced. Beta-Blockers may enhance the rebound hypertensive effect of Alpha2-Agonists. This effect can occur when the Alpha2-Agonist is abruptly withdrawn. Management: Closely monitor heart rate during treatment with a beta blocker and clonidine. Withdraw beta blockers several days before clonidine withdrawal when possible, and monitor blood pressure closely. Recommendations for other alpha2-agonists are unavailable. Risk D: Consider therapy modification
Blonanserin: CNS Depressants may enhance the CNS depressant effect of Blonanserin. Management: Use caution if coadministering blonanserin and CNS depressants; dose reduction of the other CNS depressant may be required. Strong CNS depressants should not be coadministered with blonanserin. Risk D: Consider therapy modification
Brexanolone: CNS Depressants may enhance the CNS depressant effect of Brexanolone. Risk C: Monitor therapy
Brimonidine (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Bromopride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Bromperidol: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination
Buprenorphine: CNS Depressants may enhance the CNS depressant effect of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine at lower doses in patients already receiving CNS depressants. Risk D: Consider therapy modification
Cannabinoid-Containing Products: CNS Depressants may enhance the CNS depressant effect of Cannabinoid-Containing Products. Risk C: Monitor therapy
Chlormethiazole: May enhance the CNS depressant effect of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used. Risk D: Consider therapy modification
Chlorphenesin Carbamate: May enhance the adverse/toxic effect of CNS Depressants. Risk C: Monitor therapy
CNS Depressants: May enhance the adverse/toxic effect of other CNS Depressants. Risk C: Monitor therapy
Daridorexant: May enhance the CNS depressant effect of CNS Depressants. Management: Dose reduction of daridorexant and/or any other CNS depressant may be necessary. Use of daridorexant with alcohol is not recommended, and the use of daridorexant with any other drug to treat insomnia is not recommended. Risk D: Consider therapy modification
DexmedeTOMIDine: CNS Depressants may enhance the CNS depressant effect of DexmedeTOMIDine. Management: Monitor for increased CNS depression during coadministration of dexmedetomidine and CNS depressants, and consider dose reductions of either agent to avoid excessive CNS depression. Risk D: Consider therapy modification
Difelikefalin: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Dimethindene (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Doxylamine: CNS Depressants may enhance the CNS depressant effect of Doxylamine. Risk C: Monitor therapy
DroPERidol: May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (eg, opioids, barbiturates) with concomitant use. Risk D: Consider therapy modification
Esketamine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Flunarizine: CNS Depressants may enhance the CNS depressant effect of Flunarizine. Risk X: Avoid combination
Flunitrazepam: CNS Depressants may enhance the CNS depressant effect of Flunitrazepam. Management: Reduce the dose of CNS depressants when combined with flunitrazepam and monitor patients for evidence of CNS depression (eg, sedation, respiratory depression). Use non-CNS depressant alternatives when available. Risk D: Consider therapy modification
HydrOXYzine: May enhance the CNS depressant effect of CNS Depressants. Management: Consider a decrease in the CNS depressant dose, as appropriate, when used together with hydroxyzine. Increase monitoring of signs/symptoms of CNS depression in any patient receiving hydroxyzine together with another CNS depressant. Risk D: Consider therapy modification
Ixabepilone: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Kava Kava: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Kratom: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination
Lemborexant: May enhance the CNS depressant effect of CNS Depressants. Management: Dosage adjustments of lemborexant and of concomitant CNS depressants may be necessary when administered together because of potentially additive CNS depressant effects. Close monitoring for CNS depressant effects is necessary. Risk D: Consider therapy modification
Lisuride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Lofexidine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Magnesium Sulfate: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Methotrimeprazine: CNS Depressants may enhance the CNS depressant effect of Methotrimeprazine. Methotrimeprazine may enhance the CNS depressant effect of CNS Depressants. Management: Reduce the usual dose of CNS depressants by 50% if starting methotrimeprazine until the dose of methotrimeprazine is stable. Monitor patient closely for evidence of CNS depression. Risk D: Consider therapy modification
Metoclopramide: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
MetyroSINE: CNS Depressants may enhance the sedative effect of MetyroSINE. Risk C: Monitor therapy
Mianserin: May diminish the therapeutic effect of Alpha2-Agonists (Ophthalmic). Risk X: Avoid combination
Minocycline (Systemic): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Mirtazapine: May diminish the antihypertensive effect of Alpha2-Agonists. Management: Consider avoiding concurrent use. If the combination cannot be avoided, monitor for decreased effects of alpha2-agonists if mirtazapine is initiated/dose increased, or increased effects if mirtazapine is discontinued/dose decreased. Risk D: Consider therapy modification
Monoamine Oxidase Inhibitors: May enhance the adverse/toxic effect of Brimonidine (Ophthalmic). Monoamine Oxidase Inhibitors may increase the serum concentration of Brimonidine (Ophthalmic). Risk C: Monitor therapy
Nabilone: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination
Olopatadine (Nasal): May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination
Opioid Agonists: CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification
Orphenadrine: CNS Depressants may enhance the CNS depressant effect of Orphenadrine. Risk X: Avoid combination
Oxomemazine: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination
Oxybate Salt Products: CNS Depressants may enhance the CNS depressant effect of Oxybate Salt Products. Management: Consider alternatives to this combination when possible. If combined, dose reduction or discontinuation of one or more CNS depressants (including the oxybate salt product) should be considered. Interrupt oxybate salt treatment during short-term opioid use Risk D: Consider therapy modification
OxyCODONE: CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification
Paraldehyde: CNS Depressants may enhance the CNS depressant effect of Paraldehyde. Risk X: Avoid combination
Perampanel: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Piribedil: CNS Depressants may enhance the CNS depressant effect of Piribedil. Risk C: Monitor therapy
Pramipexole: CNS Depressants may enhance the sedative effect of Pramipexole. Risk C: Monitor therapy
Procarbazine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Ropeginterferon Alfa-2b: CNS Depressants may enhance the adverse/toxic effect of Ropeginterferon Alfa-2b. Specifically, the risk of neuropsychiatric adverse effects may be increased. Management: Avoid coadministration of ropeginterferon alfa-2b and other CNS depressants. If this combination cannot be avoided, monitor patients for neuropsychiatric adverse effects (eg, depression, suicidal ideation, aggression, mania). Risk D: Consider therapy modification
ROPINIRole: CNS Depressants may enhance the sedative effect of ROPINIRole. Risk C: Monitor therapy
Rotigotine: CNS Depressants may enhance the sedative effect of Rotigotine. Risk C: Monitor therapy
Rufinamide: May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced. Risk C: Monitor therapy
Serotonin/Norepinephrine Reuptake Inhibitors: May diminish the therapeutic effect of Alpha2-Agonists. Risk C: Monitor therapy
Suvorexant: CNS Depressants may enhance the CNS depressant effect of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended. Risk D: Consider therapy modification
Thalidomide: CNS Depressants may enhance the CNS depressant effect of Thalidomide. Risk X: Avoid combination
Tricyclic Antidepressants: May diminish the therapeutic effect of Alpha2-Agonists (Ophthalmic). Risk C: Monitor therapy
Trimeprazine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Valerian: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy
Zolpidem: CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. Risk D: Consider therapy modification
Zuranolone: May enhance the CNS depressant effect of CNS Depressants. Management: Consider alternatives to the use of zuranolone with other CNS depressants or alcohol. If combined, consider a zuranolone dose reduction and monitor patients closely for increased CNS depressant effects. Risk D: Consider therapy modification
Teratogenic effects were not observed in animal reproduction studies.
It is not known if brimonidine is excreted in breast milk. Due to the potential for serious adverse reactions in the nursing infant, the manufacturer recommends a decision be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of treatment to the mother.
IOP routinely (first month of therapy may not reflect long-term level of IOP reduction)
A relatively selective alpha-2 adrenergic agonist; causes reduction of aqueous humor formation and increased uveoscleral outflow
Metabolism: Hepatic (extensive)
Half-life elimination: ~3 hours
Time to peak, plasma: 1 to 4 hours
Excretion: Urine (74%)
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