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Dexmedetomidine

Class: Anxiolytics, Sedatives, and Hypnotics; Miscellaneous
- α2-Adrenergic Agonists
VA Class: CN309
Chemical Name: (S)-4-[1-(2,3-Dimethylphenyl)ethyl]-1H-imidazole monohydrochloride
Molecular Formula: C13H16N2•HCl
CAS Number: 145108-58-3
Brands: Precedex

Medically reviewed by Drugs.com. Last updated on Jan 13, 2020.

Introduction

Relatively selective α2-adrenergic agonist with sedative properties.1 2 3 4 5 6 7 8 13

Uses for Dexmedetomidine

Sedation in Critical Care Settings

Sedation of initially intubated and mechanically ventilated patients in an intensive care setting (i.e., ICU).1 800 801

May be used to provide mild to moderate levels of sedation, but not considered suitable for deep sedation.21 23 800 820

FDA-labeled for use only for short-term (<24 hours) sedation;1 however, has been used for prolonged sedation in the intensive care setting.23 801 817 818 819 820 (See Tolerance and Tachyphylaxis under Cautions.)

Produces sedation, anxiolysis, and analgesia without causing significant respiratory depression.24 801 817 818

Appears to be as effective as propofol and benzodiazepines (e.g., midazolam, lorazepam) for sedation in critically ill mechanically ventilated adults; however, because of some modest clinical benefits (e.g., reduced duration of mechanical ventilation, shorter time to extubation, reduced risk of delirium), nonbenzodiazepine sedatives (dexmedetomidine or propofol) are generally preferred to benzodiazepines.800 801 817 818 819 820

When selecting an appropriate sedative agent, consider patient's individual sedation goals in addition to specific drug-related (e.g., pharmacology, pharmacokinetics, adverse effects, availability, costs) and patient-related (e.g., comorbid conditions such as anxiety, seizures, or alcohol or benzodiazepine withdrawal) factors.23 24 800 801

Patients receiving dexmedetomidine are more arousable than those receiving other sedatives, which may be particularly useful for daily awakening trials.21 23 820

Because dexmedetomidine does not have a substantial respiratory depressant effect, infusions of the drug can be continued following extubation, if needed.1 801

Procedural Sedation

Sedation of nonintubated patients prior to and/or during surgical or other procedures.1 16 30 31 823

Comparative efficacy with other sedative agents not established.817 May be preferred in certain patients (e.g., those in whom respiratory compromise with benzodiazepines is a concern); however, consider risks versus benefits.817

Dexmedetomidine Dosage and Administration

General

  • Administer only by individuals experienced in the management of patients in an intensive care or surgical setting.1

  • Individualize dosage and titrate to desired level of sedation.1

  • Monitor patient continuously.1 15

Administration

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer by IV infusion.1

May adsorb to some types of natural rubber; use administration components made with synthetic or coated natural rubber gaskets.1

Commercially available as an injection concentrate that must be diluted prior to IV infusion or as a premixed ready-to-use solution (dexmedetomidine hydrochloride in 0.9% sodium chloride injection).1

Dilution

Must dilute the injection concentrate in 0.9% sodium chloride injection prior to administration.1 To prepare the 4-mcg/mL concentration used for loading and maintenance infusions, one method of dilution is to add 2 mL of the concentrate (100 mcg/mL) to 48 mL of 0.9% sodium chloride injection.1

Rate of Administration

Administer by slow IV infusion via a controlled-infusion device.1

Rapid IV infusion associated with loss of α2-adrenergic selectivity1 and adverse cardiovascular effects.1 2 3 15 (See Actions and also see Cardiovascular Effects under Cautions.)

Dosage

Available as dexmedetomidine hydrochloride; dosage is expressed in terms of dexmedetomidine.1

Adults

Sedation in Critical Care Settings
IV

Initiation of sedation: 1 mcg/kg as a loading infusion over 10 minutes.1 Because of risk of adverse hemodynamic effects, many clinicians do not recommend a loading dose; if a loading dose is used, caution is advised, particularly in patients with bradycardia, heart block, or hemodynamic instability.21 22 25 801 817 Manufacturer states loading dose may not be required in patients converting from an alternative sedative agent.1

Maintenance of sedation: Continuous IV infusion at a rate of 0.2–0.7 mcg/kg per hour recommended.1 Adjust infusion rate to desired level of sedation;1 in most cases, a light rather than deep level of sedation is recommended in critically ill, mechanically ventilated patients.801 Assess depth and quality of sedation using a validated and reliable assessment tool.800 801 Adjust dosage slowly to reduce risk of hypotension and other adverse effects.24 817

Evidence from clinical studies supports use of infusion rates up to 1.5 mcg/kg per hour.23 24 801 817 818 819 820

Manufacturer states that continuous IV infusion of dexmedetomidine should not exceed 24 hours.1 817 However, the drug has been used for prolonged (>24 hours) sedation in the ICU.817 818 819 820

Procedural Sedation
IV

Initiation of sedation: 1 mcg/kg as a loading infusion over 10 minutes.1 A loading infusion of 0.5 mcg/kg over 10 minutes may be suitable for less invasive procedures (e.g., ophthalmic surgery).1 For awake fiberoptic intubation, a loading infusion of 1 mcg/kg over 10 minutes is recommended.1

Maintenance of sedation: Initiate maintenance infusion at a rate of 0.6 mcg/kg per hour; adjust rate within range of 0.2–1 mcg/kg per hour to achieve desired level of sedation.1 For awake fiberoptic intubation in adults, a maintenance infusion of 0.7 mcg/kg per hour is recommended until endotracheal tube is secured.1

Special Populations

Hepatic Impairment

Consider dosage reduction.1

Renal Impairment

Manufacturer makes no special dosage recommendations.1

Geriatric Patients

For initiation and maintenance of ICU sedation in geriatric patients >65 years of age, consider dosage reduction.1

For procedural sedation in geriatric patients >65 years of age, reduce loading dose to 0.5 mcg/kg over 10 minutes; consider dosage reduction for maintenance of procedural sedation.1

Cautions for Dexmedetomidine

Contraindications

  • None.1

Warnings/Precautions

Administration Precautions

To minimize risk of adverse effects, follow recommendations for administration and monitoring of dexmedetomidine therapy.1 (See General under Dosage and Administration.)

Cardiovascular Effects

Bradycardia and sinus arrest reported in young, healthy adults with high vagal tone; also associated with other methods of administration, including rapid IV administration.1

Hypotension and/or bradycardia reported frequently; although intervention rarely required, some cases resulted in fatality.1 8 9 21 23 818 820 May be more pronounced in geriatric patients or those with hypovolemia, diabetes mellitus, or chronic hypertension.1 If treatment is required, consider slowing or stopping dexmedetomidine infusion, increasing IV fluids, elevating lower extremities, and/or use of vasopressors; consider IV anticholinergic agents (e.g., atropine sulfate, glycopyrrolate) to modify vagal tone.1 More advanced resuscitative measures may be necessary in patients with significant cardiovascular dysfunction.1

Transient hypertension reported with loading dose; treatment generally not required, although reduction in the loading dose infusion rate may be desirable.1

Supraventricular and ventricular tachycardia, atrial fibrillation, extrasystoles, and cardiac arrest reported during postmarketing experience.1 15

Use with caution in patients with (or at risk of) advanced heart block and/or severe ventricular dysfunction, and in patients receiving concomitant drugs that slow cardiac conduction.1 817

Withdrawal Effects

Abrupt withdrawal of dexmedetomidine may result in clonidine-like withdrawal symptoms.1 Withdrawal-related events (e.g., nausea, vomiting, agitation, tachycardia, hypertension) reported following discontinuance of therapy in some patients after prolonged (up to 7 days) infusion for ICU sedation.1 Withdrawal symptoms not reported with short-term (<6 hours) infusions for procedural sedation.1

If tachycardia and/or hypertension occurs after discontinuance of dexmedetomidine, institute supportive therapy.1

Arousability

Some patients observed to be arousable and alert when stimulated; should not be considered as evidence of lack of efficacy in the absence of other signs and symptoms.1

Tolerance and Tachyphylaxis

Use of dexmedetomidine for durations >24 hours associated with tolerance, tachyphylaxis, and dose-related increase in adverse effects.1

Specific Populations

Pregnancy

Category C.1

No adequate and well-controlled studies in pregnant women.1 No evidence of teratogenicity in animal studies; however, fetal toxicity (e.g., postimplantation loss, reduced pup viability, reduced pup weight) observed.1

Use during pregnancy only when potential benefits justify potential risks to fetus.1

Lactation

Distributed into milk in rats; not known whether distributed into human milk.1 Caution if used in nursing women.1

Pediatric Use

Manufacturer states safety and efficacy not established in pediatric patients <18 years of age.1 However, the drug has been used in pediatric patients undergoing sedation in the ICU or other settings to facilitate mechanical ventilation or other procedures (e.g., radiologic imaging).25 26 27 Additional study is needed to evaluate the drug's safety in this population.21 25 26

Geriatric Use

Hypotension and/or bradycardia may be more pronounced.1 Consider dosage reduction.1 (See Geriatric Patients under Dosage and Administration.)

Renal Impairment

Pharmacokinetics in patients with severe renal impairment (Clcr <30 mL/minute) and healthy individuals are similar.1

Hepatic Impairment

Clearance may be reduced.1 Consider dosage reduction.1 (See Hepatic Impairment under Dosage and Administration.)

Common Adverse Effects

Short-term (<24 hours) infusions for ICU sedation: Hypotension, hypertension, nausea, bradycardia, fever, vomiting, hypovolemia, atelectasis, atrial fibrillation, hypoxia, tachycardia, hemorrhage, anemia, dry mouth.1

Long-term (>24 hours) infusions for ICU sedation: Hypotension, bradycardia, hypertension, tachycardia, hypokalemia, agitation, hyperglycemia, constipation, hypoglycemia, respiratory failure.1

Procedural sedation: Hypotension, respiratory depression, bradycardia, hypertension, tachycardia, nausea, dry mouth.1

Interactions for Dexmedetomidine

Metabolized by CYP isoenzymes, principally CYP2A6.1 However, no evidence of clinically important CYP-mediated drug interactions in vitro.1

Drugs with Negative Chronotropic Effects

Potential pharmacodynamic interaction (additive pharmacodynamic effects).1 Use with caution.1

Protein-bound Drugs

Pharmacokinetic interaction unlikely.1

Specific Drugs

Drug

Interaction

Comments

Anesthetics

Additive pharmacologic effects1 8

May require reduction in dosage of dexmedetomidine or concomitant drug1 8

Digoxin

Negligible change in dexmedetomidine protein binding in vitro; negligible displacement of digoxin from protein binding sites in vitro1

Possible additive hypotensive and bradycardic effects1 25

Caution is advised1

Fentanyl

Negligible change in dexmedetomidine protein binding in vitro1

Ibuprofen

Negligible displacement of ibuprofen from protein binding sites in vitro1

Ketorolac

Negligible change in dexmedetomidine protein binding in vitro1

Lidocaine

Negligible change in dexmedetomidine protein binding in vitro1

Neuromuscular blocking agents

Increased plasma rocuronium concentrations1 12

No clinically important effect on neuromuscular blockade1 12

Opiate agonists

Additive pharmacologic effects1 8

May require reduction in dosage of dexmedetomidine or concomitant drug1 8

Phenytoin

Negligible displacement of phenytoin from protein binding sites in vitro1

Propranolol

Negligible displacement of propranolol from protein binding sites in vitro1

Sedatives/hypnotics

Additive pharmacologic effects1 8

May require reduction in dosage of dexmedetomidine or concomitant drug1 8

Theophylline

Negligible change in dexmedetomidine protein binding in vitro; negligible displacement of theophylline from protein binding sites in vitro1

Vasodilators

Possible additive hypotensive effects1

Use with caution1

Warfarin

Negligible displacement of warfarin from protein binding sites in vitro1

Dexmedetomidine Pharmacokinetics

Distribution

Extent

Rapidly distributed.1 Rapidly crosses blood-brain barrier.25

Crosses the placenta and is distributed into milk in rats.1

Plasma Protein Binding

Approximately 94%.1

Elimination

Metabolism

Undergoes almost complete biotransformation by direct glucuronidation, aliphatic hydroxylation by CYP2A6, and N-methylation.1 15

Elimination Route

Excreted in urine (95%) and feces (4%).1

Half-life

Terminal elimination half-life is approximately 2 hours.2 3 6

Special Populations

Clearance decreases with increasing severity of hepatic impairment.1 In patients with mild, moderate, or severe hepatic impairment, mean clearance values were 74, 64, or 53%, respectively, of those in healthy individuals.1

Pharmacokinetics in patients with severe renal impairment (Clcr <30 mL/minute) not substantially altered.1

Stability

Storage

Parenteral

Injection Concentrate

25°C (may be exposed to 15–30°C).1

Premixed Injection in 0.9% Sodium Chloride Injection

25°C (may be exposed to 15–30°C).1

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Should not be infused through the same IV line with blood or plasma.1

Parenteral

Solution Compatibility

Compatible1

Dextrose 5%

Ringer’s injection lactated

Sodium chloride 0.9%

Drug Compatibility
Y-Site Injection Compatibility

Compatible1 HID

Alfentanil HCl

Amikacin sulfate

Aminophylline

Amiodarone HCl

Ampicillin sodium

Ampicillin sodium-sulbactam sodium

Atracurium besylate

Atropine sulfate

Azithromycin

Aztreonam

Bumetanide

Butorphanol tartrate

Calcium gluconate

Cefazolin sodium

Cefepime HCl

Cefotaxime sodium

Cefotetan disodium

Cefoxitin sodium

Ceftazidime

Ceftolozane sulfate-tazobactam sodium

Ceftriaxone sodium

Cefuroxime sodium

Chlorpromazine HCl

Ciprofloxacin

Cisatracurium besylate

Clindamycin phosphate

Co-trimoxazole

Dexamethasone sodium phosphate

Digoxin

Diltiazem HCl

Diphenhydramine HCl

Dobutamine HCl

Dolasetron mesylate

Dopamine HCl

Doxycycline hyclate

Droperidol

Enalaprilat

Ephedrine sulfate

Epinephrine HCl

Erythromycin lactobionate

Esmolol HCl

Etomidate

Famotidine

Fenoldopam mesylate

Fentanyl citrate

Fluconazole

Furosemide

Gentamicin sulfate

Glycopyrrolate

Granisetron HCl

Haloperidol lactate

Heparin sodium

Hydrocortisone sodium succinate

Hydromorphone HCl

Hydroxyzine HCl

Isavuconazonium sulfate

Isoproterenol HCl

Ketorolac tromethamine

Labetalol HCl

Levofloxacin

Lidocaine HCl

Linezolid

Lorazepam

Magnesium sulfate

Mannitol 20%

Meperidine HCl

Meropenem-vaborbactam

Methylprednisolone sodium succinate

Metoclopramide HCl

Metronidazole

Midazolam HCl

Milrinone lactate

Morphine sulfate

Nalbuphine HCl

Nitroglycerin

Norepinephrine bitartrate

Ondansetron HCl

Oritavancin diphosphate

Pancuronium bromide

Phenylephrine HCl

Piperacillin sodium-tazobactam sodium

Potassium chloride

Procainamide HCl

Prochlorperazine edisylate

Promethazine HCl

Propofol

Ranitidine HCl

Remifentanil HCl

Rocuronium bromide

Sodium bicarbonate

Sodium nitroprusside

Succinylcholine chloride

Sufentanil citrate

Tedizolid phosphate

Theophylline

Tobramycin sulfate

Vancomycin HCl

Vecuronium bromide

Verapamil HCl

Incompatible

Amphotericin B

Diazepam

Actions

  • Dose-related sedative, anxiolytic, analgesic, and anesthetic-sparing effects;2 3 5 6 8 13 does not appear to reduce dosage requirements of skeletal muscle relaxants.3 12

  • Helps maintain intraoperative hemodynamic stability by blunting sympathetic response to surgery.2 3 5 6 8 13

  • Does not cause respiratory depression in healthy individuals when given by IV infusion in recommended dosages.1

  • Compared with clonidine, dexmedetomidine has a shorter half-life2 3 5 (about 2 versus 8–12 hours)2 3 6 and greater α2-selectivity, with potential for reduced incidence of undesirable α1-adrenergic effects (e.g., hypotension, bradycardia).3

  • Exhibits α2-selectivity when given by slow IV infusion in low to moderate doses (10–300 mcg/kg); selectivity diminishes at 12 high doses (e.g., 1000 mcg/kg) or with rapid IV administration.1

Advice to Patients

  • When dexmedetomidine hydrochloride is used for short-term IV sedation, dosage must be individualized and titrated to the desired clinical effect.1 BP, heart rate, and oxygen concentrations are continuously monitored during the infusion and as clinically appropriate after discontinuance.1

  • Risk of withdrawal reactions and other adverse effects.1 When dexmedetomidine is infused for >6 hours, patients should report any nervousness, agitation, and/or headaches that may occur for up to 48 hours following dexmedetomidine administration to their clinician.1 In addition, patients should report symptoms that may occur within 48 hours following administration (e.g., weakness, confusion, excessive sweating, weight loss, abdominal pain, salt cravings, diarrhea, constipation, dizziness, lightheadedness) to their clinician.1

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs as well as any concomitant diseases.1

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1

  • Importance of informing patients of other important precautionary information. (See Cautions.)1

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Dexmedetomidine Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injection concentrate, for IV infusion

100 mcg (of dexmedetomidine) per mL*

Dexmedetomidine Hydrochloride Injection (available in single-dose and multiple-dose vials)

Precedex Injection

Hospira

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Dexmedetomidine Hydrochloride in Sodium Chloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection, for IV infusion

4 mcg (of dexmedetomidine) per mL (80, 200, or 400 mcg) in sodium chloride 0.9%*

Dexmedetomidine Hydrochloride in 0.9% Sodium Chloride Injection

Precedex in 0.9% Sodium Chloride Injection

Hospira

AHFS DI Essentials™. © Copyright 2021, Selected Revisions January 13, 2020. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

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15. Abbott, Abbott Park, IL: Personal communication.

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21. Keating GM. Dexmedetomidine: A Review of Its Use for Sedation in the Intensive Care Setting. Drugs. 2015; 75:1119-30. http://www.ncbi.nlm.nih.gov/pubmed/26063213?dopt=AbstractPlus

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23. MacLaren R, Krisl JC, Cochrane RE et al. A case-based approach to the practical application of dexmedetomidine in critically ill adults. Pharmacotherapy. 2013; 33:165-86. http://www.ncbi.nlm.nih.gov/pubmed/23386596?dopt=AbstractPlus

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25. McMorrow SP, Abramo TJ. Dexmedetomidine sedation: uses in pediatric procedural sedation outside the operating room. Pediatr Emerg Care. 2012; 28:292-6. http://www.ncbi.nlm.nih.gov/pubmed/22391930?dopt=AbstractPlus

26. Grant MJ, Schneider JB, Asaro LA et al. Dexmedetomidine Use in Critically Ill Children With Acute Respiratory Failure. Pediatr Crit Care Med. 2016; 17:1131-1141. http://www.ncbi.nlm.nih.gov/pubmed/27654816?dopt=AbstractPlus

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31. Candiotti KA, Bergese SD, Bokesch PM et al. Monitored anesthesia care with dexmedetomidine: a prospective, randomized, double-blind, multicenter trial. Anesth Analg. 2010; 110:47-56. http://www.ncbi.nlm.nih.gov/pubmed/19713256?dopt=AbstractPlus

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800. Devlin JW, Skrobik Y, Gélinas C et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018; 46:e825-e873. http://www.ncbi.nlm.nih.gov/pubmed/30113379?dopt=AbstractPlus

801. Barr J, Fraser GL, Puntillo K et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41:263-306. http://www.ncbi.nlm.nih.gov/pubmed/23269131?dopt=AbstractPlus

817. Gerlach AT, Murphy CV, Dasta JF. An updated focused review of dexmedetomidine in adults. Ann Pharmacother. 2009; 43:2064-74. http://www.ncbi.nlm.nih.gov/pubmed/19934395?dopt=AbstractPlus

818. Riker RR, Shehabi Y, Bokesch PM et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009; 301:489-99. http://www.ncbi.nlm.nih.gov/pubmed/19188334?dopt=AbstractPlus

819. Pandharipande PP, Pun BT, Herr DL et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007; 298:2644-53. http://www.ncbi.nlm.nih.gov/pubmed/18073360?dopt=AbstractPlus

820. Jakob SM, Ruokonen E, Grounds RM et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012; 307:1151-60. http://www.ncbi.nlm.nih.gov/pubmed/22436955?dopt=AbstractPlus

821. Godwin SA, Caro DA, Wolf SJ et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2005; 45:177-96. http://www.ncbi.nlm.nih.gov/pubmed/15671976?dopt=AbstractPlus

822. Godwin SA, Burton JH, Gerardo CJ et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014; 63:247-58.e18. http://www.ncbi.nlm.nih.gov/pubmed/24438649?dopt=AbstractPlus

823. . Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology. 2018; 128:437-479. http://www.ncbi.nlm.nih.gov/pubmed/29334501?dopt=AbstractPlus

HID. ASHP’s interactive handbook on injectable drugs. Snow EK, ed. Bethesda, MD: American Society of Health-System Pharmacists, Inc; Updated 2018 Dec 13. From HID website. http://www.interactivehandbook.com