Inodilator — Calcium Sensitiser
Pregnancy: Avoid — insufficient safety data
Levosimendan (ICU — Calcium Sensitiser)
Brand names: Simdax
Adult dose
Dose: Loading: 6–12 mcg/kg over 10 min (optional — omit if hypotensive); Maintenance: 0.05–0.2 mcg/kg/min for 24 hours
Route: IV infusion
Frequency: Single 24-hour infusion
Max: 0.2 mcg/kg/min
Unique mechanism: sensitises troponin C to calcium → inotropy WITHOUT increasing intracellular Ca²⁺ or myocardial oxygen demand. Also opens K-ATP channels → vasodilation (reduces preload and afterload). Effects persist 7–9 days due to active metabolite (OR-1896).
Paediatric dose
Dose: 0.1–0.2 mcg/min/kg
Route: IV infusion
Frequency: Continuous (24 hours)
Max: 0.2 mcg/kg/min
Seek specialist opinion — limited paediatric data. Used in paediatric cardiac centres for refractory low cardiac output syndrome.
Dose adjustments
Renal
Avoid in severe renal impairment (eGFR <30) — active metabolite accumulates.
Hepatic
Avoid in severe hepatic impairment — prolonged effect due to metabolite accumulation.
Paediatric weight-based calculator
Seek specialist opinion — limited paediatric data. Used in paediatric cardiac centres for refractory low cardiac output syndrome.
Clinical pearls
- Mechanistically superior to dobutamine in beta-receptor–downregulated states (chronic HF, beta-blocker therapy) — inotropy is receptor-independent
- REVIVE II trial: levosimendan improved dyspnoea but increased hypotension and arrhythmias vs. placebo. SURVIVE trial: no mortality benefit vs. dobutamine in ADHF.
- Prolonged haemodynamic benefit (7–9 days post-infusion) due to active metabolite OR-1896 — single infusion can stabilise patient through procedure or transplant bridge
Contraindications
- Severe hypotension (SBP <85 mmHg) unless loading omitted
- Significant tachycardia
- Severe renal impairment
- Severe hepatic impairment
- History of torsades de pointes
Side effects
- Hypotension (vasodilation — common)
- Tachycardia
- Headache
- Hypokalaemia
- QT prolongation (modest)
Interactions
- Other vasodilators (additive hypotension)
- QT-prolonging drugs (additive)
- Beta-blockers (blunt chronotropic response)
Monitoring
- Continuous BP and HR monitoring during and 24h post-infusion
- Potassium (hypokalaemia)
- ECG
- Cardiac output monitoring
Reference: BNFc; BNF 90; REVIVE II Trial (2006); SURVIVE Trial (JAMA 2007); ESC Acute Heart Failure Guidelines 2021. Verify against your local formulary and the latest BNF before prescribing.
Related
Curated clinical cross-links plus same-class fallbacks.
Calculators