Episode 102: Dexmedetomidine to clonidine transition

In this episode I’ll discuss how to transition from dexmedetomidine to clonidine.
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Dexmedetomidine is an IV alpha-2A adrenergic agonist. It has sedative effects and is used for the management of pain, agitation, and delirium in critically ill patients.

The use of dexmedetomidine was encouraged in the 2013 Society of Critical Care Medicine practice guidelines as part of a benzodiazepine sparing regimen. While dexmedetomidine is now available generically in the US market, it remains one of the most expensive IV sedatives for use in ICU patients.

At least two studies have evaluated whether enteral clonidine (also an alpha-2A adrenergic agonist) can be used to successfully transition patients off of dexmedetomidine. Clonidine has sedative effects, is inexpensive, and has excellent enteral bioavailability. Patients who are hemodynamically stable and no longer require rapid titration of sedative effect may be ideal candidates to transition from IV dexmedetomidine to enteral clonidine.

In 2015, two separate hospitals published dexmedetomidine to clonidine strategies. Maine Medical Center published a prospective observational pilot study while Partners Healthcare in Utah published a retrospective analysis.

Maine Strategy

The Maine strategy included patients with a favorable response to dexmedetomidine for 12-24 hours, enteral access for medications, and cardiovascular / hemodynamic stability. Elderly patients, patients weighing less than 100 kg or patients on less than 0.7 mcg/kg/hr of dexmedetomidine were given enteral clonidine 0.2 mg q6h. All other patients were given 0.3 mg enteral clonidine q6h. The dexmedetomidine infusion was reduced by 25% within 6 hours of each clonidine dose if the patient did not have any agitation requiring rescue medications. Using this strategy a successful transition occurred in 50% of patients within 24 hours, and 75% within 48 hours of the first clonidine dose.

Utah Strategy

The Utah strategy involved most patients starting at 0.1 mg enteral clonidine, and this was re-dosed or titrated every 6 to 8 hours. Dexemedtomidine was then rapidly titrated off, with 65% of patients discontinuing dexmedetomidine within 8 hours of the first clonidine dose. A greater number of patients who discontinued dexmedetomidine within 8 hours had low infusion rates – less than or equal to 0.4 µg/kg/hr.

Combining the apparent success of these two studies, I’d be inclined to use clonidine 0.1 mg q6h for patients on dexmedetomidine 0.4 mcg/kg/hr or less, clonidine 0.2 mg q6h for patients on 0.5 to 0.7 mcg/kg/hr, and clonidine 0.3 mg q6h for patients on high doses of dexmedetomidine.

Only the Maine study addressed how to taper the patient off clonidine. Clonidine was tapered by increasing the dosing interval every 24– 48 hours; for a clonidine maintenance regimen of 0.3 mg every 6 hours, the dosing interval is increased to 0.3 mg every 8 hours for 1–2 days, then 0.3 mg every 12 hours, then 0.3 mg once daily and then stopped.

I’ve attempted to transition a handful of patients from dexmedetomidine to clonidine, with mixed success. Usually this is being done not to save drug cost, but to transition an otherwise stable patient requiring dexmedetomidine for agitation to a regimen they can continue on a medical floor with lower levels of monitoring. Even in patients receiving high doses of dexmedetomidine, it has been a tough sell to some of my physicians to use 0.3 mg q6h of clonidine.

Despite the tremendous potential to save drug cost, I’d need to see a well designed multi-center trial that examines safety and efficacy outcomes before routinely transitioning patients on dexmedetomidine to enteral clonidine.

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