Drug General Information (ID: DDIEXZLOK5)
Drug Name			Ropivacaine		Drug Info		Bupivacaine (liposome)		Drug Info
Drug Type		Small molecule				Small molecule
Therapeutic Class		Anesthetics				Anesthetics
Structure

Mechanism of Ropivacaine-Bupivacaine (liposome) Interaction (Severity Level: Major)
Additive hypotensive effects Click to Show/Hide Mechanism Graph
Drug Name		Ropivacaine				Bupivacaine (liposome)
Mechanism 1		Antihypertensive agent				Antihypertensive agent
Key Mechanism Factor 1
		Factor Name		Hypotensive effects
		Factor Description		Hypotension is a blood pressure reading below the prescribed limit (90/60 mmHg). Symptoms of hypotension may include: blurred or faded vision , dizziness or light-headedness, fainting , fatigue , difficulty concentrating, nausea.
Mechanism Description		Additive hypotensive effects by the combination of Ropivacaine and Bupivacaine (liposome)
Mechanism 2		Hypotensive effects				Antihypertensive agent
Key Mechanism Factor 2
		Factor Name		Hypotensive effects
		Factor Description		Hypotension is a blood pressure reading below the prescribed limit (90/60 mmHg). Symptoms of hypotension may include: blurred or faded vision , dizziness or light-headedness, fainting , fatigue , difficulty concentrating, nausea.
Mechanism Description		Additive hypotensive effects by the combination of Ropivacaine and Bupivacaine (liposome)
Mechanism 3		Antihypertensive agent				Hypotensive effects
Key Mechanism Factor 3
		Factor Name		Hypotensive effects
		Factor Description		Hypotension is a blood pressure reading below the prescribed limit (90/60 mmHg). Symptoms of hypotension may include: blurred or faded vision , dizziness or light-headedness, fainting , fatigue , difficulty concentrating, nausea.
Mechanism Description		Additive hypotensive effects by the combination of Ropivacaine and Bupivacaine (liposome)
Mechanism 4		Hypotensive effects				Hypotensive effects
Key Mechanism Factor 4
		Factor Name		Hypotensive effects
		Factor Description		Hypotension is a blood pressure reading below the prescribed limit (90/60 mmHg). Symptoms of hypotension may include: blurred or faded vision , dizziness or light-headedness, fainting , fatigue , difficulty concentrating, nausea.
Mechanism Description		Additive hypotensive effects by the combination of Ropivacaine and Bupivacaine (liposome)
Increased risk of methemoglobinemia Click to Show/Hide Mechanism Graph
Drug Name		Ropivacaine				Bupivacaine (liposome)
Mechanism 5		Methemoglobinemia				Methemoglobinemia
Key Mechanism Factor 5
		Factor Name		Methemoglobinemia
		Factor Description		Methemoglobinemia is a condition in which higher than normal levels of methemoglobin are found in the blood. Methemoglobinemia is a potentially life-threatening condition in which the oxygen-carrying capacity of circulating hemoglobin is reduced due to the conversion of some or all of the four iron species from the reduced ferrous (Fe2+) state to the oxidized iron (Fe3+) state.
Mechanism Description		Increased risk of methemoglobinemia by the combination of Ropivacaine and Bupivacaine (liposome)

Recommended Action
Management		Bupivacaine liposome suspension should not be admixed with other, non-bupivacaine based local anesthetics. It may be admixed with bupivacaine hydrochloride as long as the ratio of the milligram dose of bupivacaine HCl to bupivacaine liposome does not exceed 1:2. Additional use of local anesthetics should generally be avoided within 96 hours following administration of bupivacaine liposome suspension. Because the toxic effects of these medications are additive, caution and close observation for development of methemoglobinemia as well as central nervous system and cardiovascular adverse reactions are advised during concomitant use. Early warning signs of central nervous system toxicity may include restlessness, anxiety, incoherent speech, dizziness, lightheadedness, numbness and tingling of the mouth and lips, metallic taste, tinnitus, blurred vision, tremors, twitching, depression, and drowsiness. Cardiovascular toxicity include atrioventricular block, ventricular arrhythmias, cardiac arrest, and decreased cardiac output and arterial blood pressure due to depressed cardiac conductivity, excitability, and myocardial contractility. Patients should have cardiovascular and respiratory vital signs and state of consciousness constantly monitored while under treatment.

References
1	Product Information. Exparel (bupivacaine liposome). Pacira Pharmaceuticals Inc, San Diego, CA.
2	Kharitonov V "A review of the compatibility of liposome bupivacaine with other drug products and commonly used implant materials." Postgrad Med 126 (2014): 129-38. [PMID: 24393760]