dexmedetomidine (Rx)

Brand and Other Names:Precedex
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Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

injectable solution

  • 200mcg/2mL (100mcg/mL) single-dose glass vial
  • Requires further dilution before administering

ready-to-use injectable solution

  • 80mcg/20mL 0.9% NaCl (4mcg/mL)
  • 200mcg/50mL 0.9% NaCl (4mcg/mL)
  • 400mcg/100mL 0.9% NaCl (4mcg/mL)

ICU Sedation

Indicated for sedation of initially intubated and mechanically ventilated patients in ICU setting

Load: 1 mcg/kg IV over 10 minutes; loading dose may not be required for adults converted from other sedative therapy  

Maintenance 0.2-0.7 mcg/kg/hr continuous IV infusion; not to exceed 24 hr

Dexmedetomidine has been continuously infused in mechanically ventilated patients before, during, and after extubation; it is not necessary to discontinue dexmedetomidine before extubation

Procedural Sedation

Indicated for sedation of nonintubated patients before and/or during surgical and other procedures

Load: 1 mcg/kg IV over 10 minutes

Maintenance 0.6 mcg/kg/hr IV titrate to effect (usually 0.2-1 mcg/kg/hr)  

Awake fiberoptic Intubation

  • Load: 1 mcg/kg IV over 10 minutes  
  • Maintenance 0.7 mcg/kg/hr IV until endotracheal tube secured

Dosage Modifications

Dose reduction may be required if coadministered with other concomitant anesthetics, sedatives, hypnotics, or opioids

Consider dose reduction in patients with hepatic impairment or aged ≥65 yr; clearance decreases with increasing severity of hepatic impairment

Renal impairment: No dosage adjustment required

Safety and efficacy not established

ICU Sedation

Indicated for sedation of initially intubated and mechanically ventilated patients in ICU setting; not to exceed 24 hr

Consider dose reduction: Higher incidence of bradycardia and hypotension was observed following administration in patients aged >65 yr

Dexmedetomidine has been continuously infused in mechanically ventilated patients before, during, and after extubation; it is not necessary to discontinue dexmedetomidine before extubation

Procedural sedation

Indicated for sedation of nonintubated patients before and/or during surgical and other procedures

Reduced loading dose recommended: 0.5 mcg/kg IV over 10 minutes  

Maintenance: Consider reduced maintenance infusion

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Interactions

Interaction Checker

and dexmedetomidine

No Results

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    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            >10%

            Hypotension (25-28%)

            Hypertension (12-16%)

            Nausea (9-11%)

            1-10%

            Bradycardia (5-7%)

            Pyrexia (4-5%)

            Atrial fibrillation (4%)

            Dry mouth (3-4%)

            Vomiting (3-4%)

            Hypoxia (2-4%)

            Hypovolemia (3%)

            Atelectasis (3%)

            Tachycardia (2-3%)

            Postprocedural hemorrhage (2-3%)

            Anemia (2-3%)

            Agitation (2%)

            Hyperthermia (2%)

            Pain (2%)

            Hyperglycemia (2%)

            Chills or rigors (2%)

            Hyperglycemia (2%)

            Oliguria (2%)

            Thirst (2%)

            Acidosis (1-2%)

            Pleural effusion (1-2%)

            Pulmonary edema (1%)

            Hypocalcemia (1%)

            Urine output decreased (1%)

            Sinus tachycardia (1%)

            <1%

            Ventricular tachycardia

            Wheezing

            Peripheral edema

            Postmarketing Reports

            Blood and lymphatic system disorders: Anemia

            Cardiac disorders: Arrhythmia, atrial fibrillation, atrioventricular block, bradycardia, cardiac arrest, cardiac disorder, extrasystoles, myocardial infarction, supraventricular tachycardia, tachycardia, ventricular arrhythmia, ventricular tachycardia

            Eye disorders: Photopsia, visual impairment

            Gastrointestinal disorders: Abdominal pain, diarrhea, nausea, vomiting

            General: Chills, hyperpyrexia, pain, pyrexia, thirst

            Investigations: AST/ALT increased, blood alkaline phosphatase increased, blood urea increased, EKG T wave inversion, GGT increased, QT prolonged

            Metabolism and nutrition disorders: Acidosis, hyperkalemia, hypoglycemia, hypovolemia, hypernatremia

            Nervous system disorders: Convulsion, dizziness, headache, neuralgia, neuritis, speech disorder

            Psychiatric disorders: Agitation, confusional state, delirium, hallucination, illusion

            Renal and urinary disorders: Oliguria, polyuria

            Respiratory, thoracic, and mediastinal disorders: Apnea, bronchospasm, dyspnea, hypercapnia, hypoventilation, hypoxia, pulmonary congestion, respiratory acidosis

            Skin and subcutaneous tissue disorders: Hyperhidrosis, pruritus, rash, urticaria

            Surgical and medical procedures: Light anesthesia

            Vascular disorders: Blood pressure fluctuation, hemorrhage, hypertension, hypotension

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            Warnings

            Contraindications

            None

            Cautions

            Continuously monitor patients while on therapy; therapy should be administered only by persons skilled in the management of patients in the intensive care or operating room setting

            Bradycardia and sinus arrest have occurred in young healthy volunteers with high vagal tone or with different routes of administration, including rapid IV bolus administration

            Caution with advanced heart block and/or severe ventricular dysfunction; because dexmedetomidine decreases sympathetic nervous system activity, hypotension and/or bradycardia may be expected to be more pronounced in patients with hypovolemia, diabetes mellitus, or chronic hypertension, and in older patients

            Transient hypertension reported primarily during loading dose; consider reduction in loading infusion rate

            Patients can become aroused/alert with stimulation; this alone should not be considered as lack of efficacy

            Prolonged exposure to dexmedetomidine beyond 24 hours may be associated with tolerance and tachyphylaxis and a dose-related increase in adverse events (eg, ARDS, respiratory failure, agitation)

            Use with caution in hepatic impairment; consider dose reduction

            Hypotension and bradycardia may necessitate medical intervention; may be more pronounced in patients with hypovolemia, diabetes mellitus, or chronic hypertension, and in the elderly; use with caution in patients with advanced heart block or severe ventricular dysfunction

            Withdrawal symptoms after discontinuation reported when administered for longer than 6 hr; most common events reported include nausea, vomiting, and agitation

            Tachycardia and hypertension reported, requiring intervention 48 hr following study drug discontinuation; if tachycardia and/or hypertension occurs after discontinuation, supportive therapy is indicated

            Drug interaction overview

            • Caution if coadministered with other vasodilators or negative chronotropic agents owing to additive pharmacodynamic effects
            • Coadministration with anesthetics, sedatives, hypnotics, and opioids is likely to lead to an enhancement of pharmacodynamic effects
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            Pregnancy & Lactation

            Pregnancy

            There are no adequate and well-controlled studies of use in pregnant women

            In an in vitro human placenta study, placental transfer of dexmedetomidine occurred

            Animal studies

            • In pregnant rats, dexmedetomidine placental transfer observed when radiolabeled dexmedetomidine was administered SC
            • Thus, fetal exposure should be expected in humans; use during pregnancy only if potential benefits justify potential fetal risk

            Lactation

            Unknown if excreted in human milk

            Radio-labeled dexmedetomidine administered SC to lactating female rats was excreted in milk

            Because many drugs are excreted in human milk, caution should be exercised when administered to breastfeeding women

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Centrally acting alpha2-adrenoceptor agonist that has sedative and anesthetic properties possibly by activating G-proteins in the brainstem, which results in the inhibition of norepinephrine release

            Pharmacokinetics

            Half-life, elimination: 6 min; 2 hr (terminal)

            Peak plasma: 0.3-1.5 ng/mL

            Protein bound: 94%

            Vd: 118 L

            Metabolism: Liver, including glucuronidation and CYP2A6

            Metabolites: 3-hydroxy, 3-carboxy, 3-hydroxy N-methyl, 3-carboxy N-methyl, and N-methyl O-glucuronide dexmedetomidine

            Total body clearance: 39 L/hr

            Excretion: Urine (95%); feces (4%)

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            Administration

            IV Incompatibilities

            Y-site: amphotericin B, diazepam

            IV Compatibilities

            Solution: D5W, LR, 0.9% NaCl, mannitol 20%, MgSO4 100 mg/mL, KCl 0.3%

            Y-site (partial list): amiodarone, cefepime, cefoperazone, ceftriaxone, chlorpromazine, ciprofloxacin, clindamycin, digoxin, diphenhydramine, dobutamine, dopamine, epinephrine, fluconazole, furosemide, heparin, hydroxyzine, labetalol, lidocaine, linezolid, lorazepam, meperidine, metoclopramide, MgSO4, metronidazole, KCl, nitroglycerin, prochlorperazine, promethazine, NaHCO3, Na-nitroprusside, TMP-SMX, vancomycin, verapamil

            Not specified: atracurium, atropine, etomidate, fentanyl, glycopyrrolate, midazolam, mivacurium, morphine, pancuronium, phenylephrine, succinylcholine, thiopental, vecuronium

            IV Preparation

            200 mcg/2 mL (100 mcg/mL) vial

            • Must be diluted with 0.9% NaCl to achieve required concentration (4 mcg/mL) before
            • Preparation of solutions is the same, whether for the loading dose or maintenance infusion
            • Withdraw 2 mL of 100 mcg/mL dexmedetomidine and add to 48 mL of 0.9% NaCl to a total of 50 mL
            • Shake gently to mix well

            IV Administration

            Use controlled infusion device; use components made with synthetic or coated natural rubber gaskets

            Infuse loading dose over 10 min

            Maintenance dose: Administer by IV continuous infusion at recommended rate; individualized infusion rte and adjust rate to desired clinical response

            Storage

            Controlled room temperature of 25ºC (77ºF); excursions allowed from 15-30ºC (59-86ºF)

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            Formulary

            FormularyPatient Discounts

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.