Precedex (dexmedetomidine HCl in 0.9 % sodium chloride)

Dosage of dexmedetomidine hydrochloride is expressed in terms of dexmedetomidine. Dosage of the drug for IV infusion should be individualized and titrated to the desired level of sedation.

Dexmedetomidine hydrochloride for buccal or sublingual administration is available as strips containing 120 or 180 mcg of dexmedetomidine; the 120 or 180 mcg strips may be cut in half to obtain doses of 60 or 90 mcg, respectively.

Dosage reductions may be needed in patients concomitantly receiving other anesthetics, sedatives, hypnotics, or opiates.

Administer by IV infusion or by sublingual or buccal administration depending on the dosage form.

No dosing information is available for this tab.

No dosing information is available for this tab.

There is no enhanced messaging for this drug.

There are no contraindication interactions for this drug.

Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

Agents That Cause Bradycardia/Camizestrant

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Camizestrant may cause symptomatic bradycardia. Additional agents that cause bradycardia further increase the risk for symptomatic bradycardia.(1)

CLINICAL EFFECTS: Bradycardia may be associated with an increase in the QTc interval, increasing the risk for torsade de pointes.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The manufacturer of camizestrant recommends avoiding concurrent use of camizestrant and other agents known to cause bradycardia.(1) If combination therapy is unavoidable, monitor heart rate and blood pressure regularly. Monitor heart rate more frequently during the first 30 days of treatment with camizestrant in patient with bradycardia (heart rate less than 60 beats per minute (bpm)) and those on concomitant medications known to lower heart rate.(1) If bradycardia occurs, symptomatic or Grade 2 or above, withhold camizestrant until symptoms resolve. Obtain an ECG to evaluate the etiology of the symptomatic bradycardia. If a contributing concomitant medication is identified, modify the dosage or discontinue the medication as appropriate until bradycardia symptoms resolve and then resume camizestrant. Consider reassessing the heart rate after restarting camizestrant. Permanently discontinue camizestrant for persistent bradycardia.(1) The manufacturer of camizestrant recommends performing an ECG prior to initiating camizestrant, then every week for the first 2 weeks of treatment, and periodically during treatment as clinically indicated.(1)

DISCUSSION: In a clinical trial, bradycardia occurred in 8% of patients on camizestrant. The mean heart rate decrease from baseline was approximately 13 beats per minute with camizestrant, with the maximum decrease observed on Day 15. The median time to onset of adverse reaction was 17 days (range 13 to 283 days) after starting camizestrant. Bradycardia led to dose interruption of camizestrant in 3.9% of patients.(1) Agents that may cause bradycardia and linked to this monograph include: beta-blockers, non-dihydropyridine calcium channel blockers, clonidine, digoxin, and moxonidine.

Agents That Cause Bradycardia/Crizotinib

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Crizotinib may cause symptomatic bradycardia. Additional agents that cause bradycardia further increase the risk for symptomatic bradycardia.(1)

CLINICAL EFFECTS: Bradycardia may be associated with an increase in the QTc interval, increasing the risk for torsade de pointes.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The manufacturer of crizotinib recommends avoiding concurrent use of crizotinib and other agents known to cause bradycardia to the extent possible. If combination therapy is required, monitor heart rate and blood pressure regularly. If bradycardia occurs, withhold crizotinib until heart rate recovers to 60 bpm or above, or patient is asymptomatic. Re-evaluate the use of the concomitant medication. If the concomitant medication is discontinued or its dose is reduced, resume crizotinib at the previous dose upon patient's recovery. If the concomitant medication is not discontinued or dose adjusted, resume crizotinib at a reduced dose upon patient's recovery. If life-threatening bradycardia occurs, discontinue or reduce the dose of the concomitant medication. Upon the patient's recovery, lower the dose of crizotinib to 250 mg daily. Monitor blood pressure and heart rate frequently.(1)

DISCUSSION: Across clinical trials, bradycardia occurred in 13 % of patients on crizotinib, and grade 3 syncope occurred in 2.4 % of patients on crizotinib compared with 0.6 % on chemotherapy.(1) Agents that may cause bradycardia and linked to this monograph include: beta-blockers, non-dihydropyridine calcium channel blockers, clonidine, digoxin, and moxonidine.(1)

Agents That Cause Bradycardia/Etrasimod

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Initiation of etrasimod has caused transient decreases in heart rate and atrioventricular conduction delays after the first dose. The first dose has also been associated with heart block. Additional agents that cause bradycardia further increase the risk for symptomatic bradycardia.(1)

CLINICAL EFFECTS: The heart rate lowering effect of etrasimod is transient and is usually seen with the first dose. Bradycardia may be associated with an increase in the QTc interval, increasing the risk for torsade de pointes.(1)

PREDISPOSING FACTORS: Pre-existing cardiovascular disease (e.g. heart failure, ischemic heart disease, history of myocardial infarction, stroke, history of torsades de pointes, or heart block), severe untreated sleep apnea, a prolonged QTc interval prior to etrasimod initiation, or factors associated with QTc prolongation (e.g. hypokalemia, hypomagnesemia, bradycardia, female gender, or advanced age) may increase risk for cardiovascular toxicity due to etrasimod.(2) Concurrent use of more than one drug known to cause QT prolongation or higher systemic concentrations of either QT prolonging drug are additional risk factors for torsades de pointes. Factors which may increase systemic drug concentrations include rapid infusion of an intravenous dose or impaired metabolism or elimination of the drug (e.g. coadministration with an agent which inhibits its metabolism or elimination, genetic impairment in drug metabolism or elimination, and/or renal/hepatic dysfunction).(2)

PATIENT MANAGEMENT: The prescribing information for etrasimod treatment states that advice from a cardiologist should be sought before initiating etrasimod treatment in patients currently taking additional agents that cause bradycardia or in patients with preexisting heart and cerebrovascular conditions, with resting heart rate of less than 50 bpm, history of symptomatic bradycardia, recurrent cardiogenic syncope, severe untreated sleep apnea, or history of Mobitz type 1 second-degree AV block (unless has functioning pacemaker).(1) Monitor blood pressure during treatment.(1)

DISCUSSION: Initiation of etrasimod treatment has been associated with transient atrioventricular (AV) conduction delays. The AV conduction delays manifested as first or second degree AV block (prolonged PR interval on ECG), which occurred in 0.7% of etrasimod treated patients in UC-1 and in 0.8% of patients in UC-2 and UC-3 compared to 0% for placebo in all studies.(1)

Agents That Cause Bradycardia/Fexinidazole

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Fexinidazole has been shown to prolong the QTc interval. Concurrent use with agents that cause bradycardia may increase the risk of QTc prolongation.(1)

CLINICAL EFFECTS: Bradycardia may be associated with an increase in the QTc interval, increasing the risk for torsade de pointes.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The manufacturer of fexinidazole recommends avoiding concurrent use of fexinidazole and other agents known to cause bradycardia.(1) Avoid use of fexinidazole in patients who have a baseline QTcF interval greater than 470 msec, a history of torsade de pointes, congenital long QT syndrome, cardiac arrhythmias, uncompensated heart failure, or family history of sudden death, or uncorrected hypokalemia.(1) If patients are, or need to be, treated with drugs known to induce bradycardia or prolong the QTc interval do not initiate therapy with fexinidazole until such drugs are eliminated from the body (allow a washout period of 5 half-lives for such other drugs). Do not start such drugs until fexinidazole therapy is eliminated (allow a washout period of 7 days).(1)

DISCUSSION: Bradycardia increases the risk of QTc interval prolongation and torsade de pointes.(1) In clinical studies, fexinidazole was associated with a concentration-dependent QTcF prolongation. At recommended therapeutic doses, the mean (upper 90% confidence interval) increase in QTcF is predicted to be 19.0 msec (23.3 msec). The observed increase in QTcF appears to be associated with the M2 (sulfone) metabolite of fexinidazole.(1) Agents that may cause bradycardia and linked to this monograph include: beta-blockers, clonidine, digoxin and moxonidine.(1)

Agents That Cause Bradycardia/Ponesimod

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Initiation of ponesimod has caused transient decreases in heart rate and atrioventricular conduction delays after the first dose. Decreases in heart rate start within the first hour and maximal decrease in heart rate was seen at approximately 2-4 hours. The first dose has also been associated with heart block. Additional agents that cause bradycardia further increase the risk for symptomatic bradycardia.(1)

CLINICAL EFFECTS: The heart rate lowering effect of ponesimod is transient and is usually seen with the first dose. Bradycardia may be associated with an increase in the QTc interval, increasing the risk for torsade de pointes.(1)

PREDISPOSING FACTORS: Pre-existing cardiovascular disease (e.g. heart failure, ischemic heart disease, history of myocardial infarction, stroke, history of torsades de pointes, or heart block), severe untreated sleep apnea, a prolonged QTc interval prior to siponimod initiation, or factors associated with QTc prolongation (e.g. hypokalemia, hypomagnesemia, bradycardia, female gender, or advanced age) may increase risk for cardiovascular toxicity due to siponimod.(2) Concurrent use of more than one drug known to cause QT prolongation or higher systemic concentrations of either QT prolonging drug are additional risk factors for torsades de pointes. Factors which may increase systemic drug concentrations include rapid infusion of an intravenous dose or impaired metabolism or elimination of the drug (e.g. coadministration with an agent which inhibits its metabolism or elimination, genetic impairment in drug metabolism or elimination, and/or renal/hepatic dysfunction).(2)

PATIENT MANAGEMENT: The prescribing information states ponesimod treatment should generally not be initiated in patients who are on concurrent therapy with additional agents that cause bradycardia. If treatment with ponesimod is considered, advice from a cardiologist should be sought regarding switching to non-heart rate lowering drugs or monitoring during treatment initiation. Treatment initiation recommendations include: - Obtain an ECG in all patients to determine whether preexisting conduction abnormalities are present. - In all patients, a dose titration is recommended for initiation of ponesimod treatment to help reduce cardiac effects. - In patients with sinus bradycardia (HR less than 55 bpm), first- or second-degree [Mobitz type I] AV block, or a history of myocardial infarction or heart failure with onset > 6 months prior to initiation, ECG testing and first dose monitoring is recommended. - Since significant bradycardia may be poorly tolerated in patients with history of cardiac arrest, cerebrovascular disease, uncontrolled hypertension, or severe untreated sleep apnea, ponesimod is not recommended in these patients. If treatment is considered, advice from a cardiologist should be sought prior to initiation of treatment in order to determine the most appropriate monitoring strategy. - Use of ponesimod in patients with a history of recurrent syncope or symptomatic bradycardia should be based on an overall benefit-risk assessment. If treatment is considered, advice from a cardiologist should be sought prior to initiation of treatment in order to determine the most appropriate monitoring. - If a titration dose is missed or if 4 or more consecutive daily doses are missed during maintenance treatment, reinitiate Day 1 of the dose titration and follow titration monitoring recommendations.(1)

DISCUSSION: Initiation of ponesimod treatment has been associated with transient atrioventricular (AV) conduction delays that follow a similar temporal pattern as the observed decrease in heart rate during dose titration. The AV conduction delays manifested in most of the cases as first-degree AV block (prolonged PR interval on ECG), which occurred in 3.4% of ponesimod treated patients and in 1.2% of patients receiving teriflunomide in Study 1. Second-degree or third-degree AV blocks have not been reported in patients in clinical trials. The conduction abnormalities typically were transient, asymptomatic, resolved within 24 hours, and did not require discontinuation of ponesimod treatment.(1)

Agents That Cause Bradycardia/Siponimod

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Initiation of siponimod has caused transient decreases in heart rate and atrioventricular conduction delays after the first dose. Decreases in heart rate start within the first hour and maximal decrease in heart rate was seen at approximately 3-4 hours. The first dose has also been associated with heart block. Additional agents that cause bradycardia further increase the risk for symptomatic bradycardia.(1)

CLINICAL EFFECTS: The heart rate lowering effect of siponimod is transient and is usually seen with the first dose. Bradycardia may be associated with an increase in the QTc interval, increasing the risk for torsade de pointes.(1)

PREDISPOSING FACTORS: Pre-existing cardiovascular disease (e.g. heart failure, ischemic heart disease, history of myocardial infarction, stroke, history of torsades de pointes, or heart block), severe untreated sleep apnea, a prolonged QTc interval prior to siponimod initiation, or factors associated with QTc prolongation (e.g. hypokalemia, hypomagnesemia, bradycardia, female gender, or advanced age) may increase risk for cardiovascular toxicity due to siponimod.(2) Concurrent use of more than one drug known to cause QT prolongation or higher systemic concentrations of either QT prolonging drug are additional risk factors for torsades de pointes. Factors which may increase systemic drug concentrations include rapid infusion of an intravenous dose or impaired metabolism or elimination of the drug (e.g. coadministration with an agent which inhibits its metabolism or elimination, genetic impairment in drug metabolism or elimination, and/or renal/hepatic dysfunction).(2)

PATIENT MANAGEMENT: The prescribing information states siponimod treatment should generally not be initiated in patients who are concurrent therapy with additional agents that cause bradycardia. If treatment with siponimod is considered, advice from a cardiologist should be sought regarding switching to non-heart rate lowering drugs or recommendations for monitoring for treatment initiation. Treatment initiation recommendations include: - Obtain an ECG in all patients to determine whether preexisting conduction abnormalities are present. - In all patients, a dose titration is recommended for initiation of siponimod treatment to help reduce cardiac effects. - In patients with sinus bradycardia (HR less than 55 bpm), first- or second-degree [Mobitz type I] AV block, or a history of myocardial infarction or heart failure with onset > 6 months prior to initiation, ECG testing and first dose monitoring is recommended. - Since significant bradycardia may be poorly tolerated in patients with history of cardiac arrest, cerebrovascular disease, uncontrolled hypertension, or severe untreated sleep apnea, siponimod is not recommended in these patients. If treatment is considered, advice from a cardiologist should be sought prior to initiation of treatment in order to determine the most appropriate monitoring strategy. - Use of siponimod in patients with a history of recurrent syncope or symptomatic bradycardia should be based on an overall benefit-risk assessment. If treatment is considered, advice from a cardiologist should be sought prior to initiation of treatment in order to determine the most appropriate monitoring. - If a titration dose is missed or if 4 or more consecutive daily doses are missed during maintenance treatment, reinitiate Day 1 of the dose titration and follow titration monitoring recommendations.(1)

DISCUSSION: Initiation of siponimod treatment has been associated with transient atrioventricular (AV) conduction delays that follow a similar temporal pattern as the observed decrease in heart rate during dose titration. The AV conduction delays manifested in most of the cases as first-degree AV block (prolonged PR interval on ECG), which occurred in 5.1% of siponimod treated patients and in 1.9 % of patients receiving placebo in Study 1. Second-degree AV blocks, usually Mobitz type I (Wenckebach), have been observed at the time of treatment initiation with siponimod in less than 1.7% of patients in clinical trials. The conduction abnormalities typically were transient, asymptomatic, resolved within 24 hours, rarely required treatment with atropine, and did not require discontinuation of siponimod treatment.(1)

Alpha-2 Agonists/Tizanidine

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Tizanidine is an alpha-2 agonist. Concurrent use with other alpha-2 agonists may result in additive effects on blood pressure.(1)

CLINICAL EFFECTS: Concurrent use of alpha-2 agonists and tizanidine may result in hypotension.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The manufacturer of tizanidine states concurrent use with other alpha-2 agonists is not recommended.(1) Patients receiving concurrent therapy should be monitored for hypotension. The risk of hypotension may be decreased by careful titration of tizanidine dosages and monitoring for hypotension prior to dose advancement. Counsel patients about the risk of orthostatic hypotension.(1)

DISCUSSION: Severe hypotension has been reported following the addition of tizanidine to existing lisinopril therapy.(2-4) Alpha-2 agonists linked include: clonidine, dexmedetomidine, guanabenz, guanadrel, guanethidine, guanfacine, methyldopa, and moxonidine.

Moderate Interaction: Assess the risk to the patient and take action as needed.

Anesthesia Agents/Glp-1 Receptor Agonists

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: GLP-1 receptor agonists can cause delayed gastric emptying.(1,2)

CLINICAL EFFECTS: Gastric contents may remain in the stomach after preoperative fasting, which could increase the risk of regurgitation and aspiration.(1,2)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The American Society of Anesthesiologists (ASA) recommends the following for patients receiving elective procedures: - For patients on daily dosing, consider holding GLP-1 agonists on the day of the procedure. For patients on weekly dosing, consider holding GLP-1 agonists a week prior to the procedure. - Consult an endocrinologist for patients taking GLP-1 agonists for diabetes management if the GLP-1 agonist is held longer than the dosing schedule to avoid hyperglycemia. - For patients requiring urgent or emergent procedures, proceed and treat the patient as 'full stomach.'(3)

DISCUSSION: In one case report, a 31-year-old patient taking semaglutide followed preoperative fasting guidelines but food residue was discovered upon endoscopy, leading to cancellation of the surgical procedure.(4) In a case report, a semaglutide-treated patient experienced regurgitation upon induction of general anesthesia despite a 20 hour preoperative fasting period. The patient received semaglutide two days before the scheduled procedure.(5) A case report of a 42-year-old patient after fasting for 18 hours showed substantial gastric content upon endoscopy. The patient experienced intraoperative pulmonary aspiration of gastric contents which were suctioned from the trachea and bronchi using bronchoscopy.(6)

*None.

There are no contraindication contraindications for this drug.

• Bradycardia
• Disease of liver
• Hypotension
• Hypovolemia
• Severe chronic heart failure
• Severe heart block

There are no moderate contraindications for this drug.

The most common adverse effects occurring in >2% of adults receiving IV dexmedetomidine include hypotension, bradycardia, and dry mouth.

The most common adverse effects occurring in >5% of pediatric patients 1 month to <17 years of age receiving IV dexmedetomidine include bradypnea, bradycardia, hypertension, and hypotension.

The most common adverse effects occurring in >=5% of adults receiving sublingual/buccal dexmedetomidine include somnolence, oral paresthesia or oral hypoesthesia, dizziness, dry mouth, hypotension, and orthostatic hypotension.

More Frequent

• Hypotension
• Hypoxia

Less Frequent

• Acute renal failure
• Atrial fibrillation
• Bradycardia
• Hyperglycemia
• Hypertension
• Hypokalemia
• Hypomagnesemia
• Pleural effusions
• Pulmonary edema

Rare or Very Rare

• Acidosis
• Acute cognitive impairment
• Acute respiratory distress syndrome
• Agitation
• Anemia
• Apnea
• Atrioventricular block
• Bronchospastic pulmonary disease
• Delirium
• Diabetes insipidus
• Dyspnea
• Extrasystoles
• Hallucinations
• Heart block
• Hemorrhage
• Hyperbilirubinemia
• Hypercapnia
• Hyperkalemia
• Hypernatremia
• Hyperthermia
• Oliguria
• Pulmonary congestion
• Respiratory acidosis
• Respiratory depression
• Seizure disorder
• Sinus arrest
• Supraventricular tachycardia
• Ventricular arrhythmias
• Ventricular tachycardia

More Frequent

• Xerostomia

Less Frequent

• Chills
• Constipation
• Fever
• Hypocalcemia
• Nausea
• Peripheral edema
• Symptoms of anxiety
• Vomiting
• Wheezing

Rare or Very Rare

• Accidental fall
• Acute abdominal pain
• Dizziness
• Dysphasia
• Headache disorder
• Hyperhidrosis
• Neuralgia
• Pain
• Photopsia
• Polydipsia
• Polyuria
• Visual changes

No enhanced messaging available.

The manufacturer states that safety and efficacy of dexmedetomidine for ICU sedation have not been established in pediatric patients. 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). A wide range of dosage regimens has been used. Although there are some data suggesting a possible role of dexmedetomidine for sedation in pediatric patients, additional study is needed to evaluate the drug's safety in this population.

The safety and efficacy of IV dexmedetomidine have been established in pediatric patients 1 month to <18 years of age for sedation during noninvasive procedures. Use in this age group is based on a randomized, double-blind, dose-ranging, safety and efficacy trial in nonintubated pediatric patients 1 month to <17 years of age who required sedation prior to undergoing MRI scans. An increase in frequency of bradypnea, bradycardia, hypertension, and hypotension was observed in pediatric patients treated with dexmedetomidine. The overall safety profile of the drug in pediatric patients was consistent with the known safety profile in adults. The safety and efficacy of dexmedetomidine for sedation during noninvasive procedures have not been established in pediatric patients <1 month of age.

The safety and efficacy of sublingual/buccal dexmedetomidine have not been established in pediatric patients.

Data from randomized controlled trials and case reports have not identified a drug-associated risk of major birth defects and miscarriage associated with use of IV dexmedetomidine during pregnancy; however, the reported exposures occurred after the first trimester. Most of the exposures occurred at the time of caesarean section delivery, and adverse effects on maternal outcomes or infant Apgar scores were not observed. Available data indicate that dexmedetomidine crosses the placenta.

In animal reproduction studies, fetal toxicity (lower fetal viability and reduced live fetuses) occurred with subcutaneous administration of dexmedetomidine to pregnant rats during organogenesis at doses 1.8 times the maximum recommended human dose of 17.8 mcg/kg per day. Developmental toxicity (low pup weights and adult offspring weights, decreased grip strength, increased early implantation loss, and decreased viability of second-generation offspring) occurred when pregnant rats received subcutaneous dexmedetomidine at doses less than the clinical dose from late pregnancy through lactation and weaning.

There are no available data on the use of dexmedetomidine strips for sublingual or buccal administration in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage, or other adverse maternal or fetal effects.

Dexmedetomidine is distributed into human milk following IV infusion. The potential effects of IV or transmucosal dexmedetomidine on the breast-fed infant or on milk production are not known.

Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for dexmedetomidine and any potential adverse effects on the breast-fed infant from the drug or from the underlying condition. Advise nursing women receiving the drug to monitor the breast-fed infant for irritability.

A higher incidence of bradycardia and hypotension has been reported in geriatric patients >65 years of age receiving IV dexmedetomidine. Consider reducing the dosage of IV dexmedetomidine in geriatric patients. A reduced loading dose of IV dexmedetomidine is recommended in geriatric patients receiving the drug for procedural sedation.

Dosage reduction of sublingual/buccal dexmedetomidine is recommended in geriatric patients. Clinical studies did not include sufficient numbers of patients >=65 years of age to determine whether efficacy of transmucosal dexmedetomidine in these patients differs from younger adults.