Remifentanil

ULTIVA

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Remifentanil ballicule: receptor binding, kinetics and half-life diagram — Mechanism of action: Remifentanil ballicule

Remifentanil ULTIVA mascot mnemonic cartoon — Visual mnemonic: Remifentanil mascot
**“Ultra-Rimmy fountain eel”**

What it isEsterase-cleared mu-opioid agonist; tightly titratable analgesia during anesthesia.

Why this oneRecovery remains rapid after prolonged infusion and does not depend on hepatic or renal clearance.

What limits it⚑ Analgesia ends abruptly, so longer coverage must precede discontinuation; hyperalgesia, respiratory depression, and chest rigidity can occur.

Remifentanil molecular structure (skeletal formula) — Molecular structure: Remifentanil

FDA-approved for

anesthesia (1996)

FDA label

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BOXED WARNING Addiction, abuse, and misuse; life-threatening respiratory depression; profound sedation/respiratory depression/death with concomitant benzodiazepines or other CNS depressants

FDA dosing	Population	Start	Target	Max
Analgesic during induction/maintenance of general anesthesia	Adults	Continuous IV infusion, titrated to effect (see full PI tables)	Titrate to effect	Per PI
Analgesic component of anesthesia	Geriatric >65 y	Decrease starting dose by 50%	Titrate to effect	Per PI
Analgesic component of anesthesia	Pediatric	Weight-based (see PI)	Titrate to effect	Per PI

Renal No specific adjustment; titrate to effect (caution in renal impairment)

Hepatic Undefined

Instructions

IV use only; must be diluted before use
Continuous infusions via infusion device only
IV bolus only during maintenance of general anesthesia
Reduce starting dose by 50% in patients >65 y
Not for epidural or intrathecal use

Available strengths

inj 1, 2, 5 mg

Contraindications

Epidural or intrathecal administration (glycine in formulation)

Cautions

Life-threatening respiratory depression
Hypotension/sedation/death with concomitant benzodiazepines or CNS depressants
Opioid-induced hyperalgesia and allodynia
MAOIs due to risk of serotonin syndrome
Skeletal muscle rigidity
Bradycardia
Hypotension
Biliary tract disease
Seizures

Adverse reactions

Respiratory depression
Bradycardia
Hypotension
Skeletal muscle rigidity

Pregnancy Insufficient human data; prolonged use may cause neonatal opioid withdrawal

Lactation Unknown if excreted in human milk; monitor breastfed infant for sedation/respiratory depression

Cost

Remifentanil (ULTIVA)

Strength		#/mo	CostPlus
1 mg	inj	per unit	not offered
2 mg	inj	per unit	not offered
5 mg	inj	per unit	not offered

NADAC is a voluntary CMS survey of what retail community pharmacies pay for the drugs they stock. Remifentanil is administered under clinical supervision and dispensed outside retail pharmacies, so it rarely appears on surveyed invoices.

⚠ BOXED WARNINGS

Addiction, abuse and misuse
Life-threatening respiratory depression

Classes and tags

Clinical profile

Therapeutic safety burden3 / 4

Overdose danger4 / 4

Weight-gain liability0 / 4

Sedation liability4 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk2 / 4

Defining liabilityRapid respiratory depression and chest-wall rigidity

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Memory aids: interaction avatars

Box: minimal PK interactions

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