Dexmedetomidine - Drug Information - UpToDate

13/6/2020 Dexmedetomidine: Drug information - UpToDate
Official reprint from UpToDate®

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Dexmedetomidine: Drug information
Copyright 1978-2020 Lexicomp, Inc. All rights reserved.
(For additional information see "Dexmedetomidine: Patient drug information" and see "Dexmedetomidine: Pediatric
drug information")
For abbreviations and symbols that may be used in Lexicomp (show table)
Brand Names: US
Precedex
Brand Names: Canada

Precedex
Pharmacologic Category
Alpha2-Adrenergic Agonist; Sedative
Dosing: Adult
Note: Errors have occurred due to misinterpretation of dosing information. Maintenance dose
expressed as mcg/kg/hour. Individualized and titrated to desired clinical effect. At recommended
doses, dexmedetomidine does not provide adequate and reliable amnesia (when necessary);
therefore, use of additional agents with amnestic properties (eg, benzodiazepines) may be
necessary (Ebert 2000).
ICU sedation: IV: Initial: Loading infusion (optional; see "Note" below) of 1 mcg/kg over 10
minutes, followed by a maintenance infusion (see "Note" below) of 0.2 to 0.7 mcg/kg/hour;
adjust rate to desired level of sedation; titration no more frequently than every 30 minutes
may reduce the incidence of hypotension (Gerlach 2009)
Note: Loading infusion: The loading dose may be omitted for this indication if patient is
either being converted from another sedative and patient is adequately sedated or there
are concerns for hemodynamic compromise. Maintenance infusion: Dosing ranges
between 0.2 to 1.5 mcg/kg/hour have been reported during randomized controlled
clinical trials (Pandharipande 2007; Riker 2009). Although infusion rates as high as 2.5
mcg/kg/hour have been used, it is thought that doses >1.5 mcg/kg/hour do not add to
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clinical efficacy (Venn 2003). Manufacturer recommends duration of infusion should not
exceed 24 hours; however, randomized clinical trials have demonstrated efficacy and
safety comparable to lorazepam and midazolam with longer-term infusions of up to ~5
days (Pandharipande 2007; Riker 2009).
Procedural sedation: IV: Initial: Loading infusion of 1 mcg/kg (or 0.5 mcg/kg for less invasive
procedures [eg, ophthalmic]) over 10 minutes, followed by a maintenance infusion of 0.6
mcg/kg/hour, titrate to desired effect; usual range: 0.2 to 1 mcg/kg/hour
Fiberoptic intubation (awake): IV: Initial: Loading infusion of 1 mcg/kg over 10 minutes,
followed by a maintenance infusion of 0.7 mcg/kg/hour until endotracheal tube is
secured (Bergese 2010).
Craniotomy (awake) (off-label use): IV: Initial: Loading infusion of 0.5 to 1 mcg/kg over 10 to
20 minutes, followed by a maintenance infusion of 0.5 mcg/kg/hour, titrate to desired effect
(Bekker 2001; Bekker, 2008; Piccioni 2008; Shen 2013); usual range: 0.1 to 0.7 mcg/kg/hour
(Piccioni 2008)
Dosing: Renal Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling; however,
pharmacokinetics were not significantly different in patients with severe renal impairment (CrCl
<30 mL/minute).
Dosing: Hepatic Impairment: Adult

There are no specific dosage adjustments provided in the manufacturer’s labeling; however,
consider a dose reduction. Clearance is reduced in varying degrees based on the level of
impairment.
Dosing: Pediatric
(For additional information see "Dexmedetomidine: Pediatric drug information")

Note: Errors have occurred due to misinterpretation of dosing information. Maintenance dose
expressed as mcg/kg/hour. Individualize and titrate to desired clinical effect. At recommended
doses, dexmedetomidine does not provide adequate and reliable amnesia (when necessary);
therefore, use of additional agents with amnestic properties (eg, benzodiazepines) may be
necessary (Ebert 2000).
ICU sedation: Infants, Children, and Adolescents: Limited data available:
Loading dose (Optional): IV: 0.5 to 1 mcg/kg/dose over 10 minutes (Chrysostomou 2009;
Walker 2006); use of loading dose is dependent upon concomitant sedation agents and
patient's current and desired level of sedation.
Maintenance dose: Continuous IV infusion: Initial: 0.2 to 0.5 mcg/kg/hour; adjust dose to
desired level of sedation. Dosing based on multiple retrospective studies, case reports,
and a few prospective studies. Most reported increasing by 0.1 to 0.3 mcg/kg/hour as
needed. Reported maintenance dose variable, usual reported range was 0.4 to 0.7
mcg/kg/hour (Bejian 2009; Carroll 2008; Chrysostomou 2006; Chrysostomou 2009; Czaja
2009; Hosokawa 2010; Tobias 2004; Walker 2006; Whalen 2014). In general, infants may
require higher maintenance infusion rates than either neonates or older children
(Chrysostomou 2006; Chrysostomou 2009; Tobias 2004). Maximum reported doses
varied; most utilized doses <1 mcg/kg/hour; however, doses as high as 2.5 mcg/kg/hour
in intubated patients have been described (Carroll 2008). Although the manufacturer
recommends duration of infusion should not exceed 24 hours, most studies reported use
beyond this time period; most patients received infusion for ≤72 hours; however, one
patient received dexmedetomidine for 103 days (Whalen 2014). Prolonged infusions
should not be abruptly discontinued and are generally tapered over several days to
prevent withdrawal symptoms.
Sedation/anesthesia, noninvasive procedures: Limited data available:
Loading dose: Infants, Children, and Adolescents: IV: 0.5 to 2 mcg/kg/dose over 10
minutes; may be repeated if sedation is not adequate (Ahmed 2014; Berkenbosch 2005;
Koroglu 2006; Mason 2013; Siddappa 2011).
Maintenance dose: Infants, Children, and Adolescents: Continuous IV infusion: 0.5 to 1

mcg/kg/hour (Ahmed 2014; Berkenbosch 2005; Koroglu 2006; Mason 2013; Siddappa
2011). Dosing based on multiple retrospective and prospective studies in over 800
pediatric patients receiving dexmedetomidine (± other sedatives) for noninvasive
procedures (eg, EEG, MRI, PET scan). In the largest, a retrospective study, 669 patients
(age: 0.1 to 22.5 years) undergoing nuclear medicine imaging received dexmedetomidine
for sedation. A bolus of 2 mcg/kg was administered over 10 minutes; this dose could be
repeated up to 2 additional times if the predefined sedation score was not achieved; in
addition, patients also received a maintenance infusion of 1 mcg/kg/hour. The mean time
to achieve adequate sedation for all patients was 8.6 ± 4.6 minutes (range: 1 to 40
minutes). Hypotension, hypertension, and bradycardia occurred in 58.7%, 2.1% and
4.3% of patients, respectively; no patient required pharmacologic treatment. Hypotension
and bradycardia were noted to be age related; risk of hypotension increased by 25% with
each 5 year age increment increase and bradycardia occurred more often in children 3 to
12 years than any other age group. The authors concluded that the drug was well
tolerated (Mason 2013).
Sedation, nonpainful or minimally painful diagnostic procedures: Limited data available;

reported dosing regimens variable and ideal dose not established:
Infants ≥6 months and Children (very limited data in children >10 years): Intranasal:
Usual dose: 2 to 3 mcg/kg as a single dose 30 to 60 minutes prior to procedure, reported
dose range: 1 to 4 mcg/kg; dosing based on multiple studies evaluating intranasal
dexmedetomidine administered prior to procedures (eg, CT, MRI, transesophageal
echocardiography, ophthalmic exams, audio brainstem response exams) (Cao 2017;
Ghai 2017; Gyanesh 2014; Ibrahim 2014; Li 2014; Li 2020; Reynolds 2016; Sulton 2020;
Yuen 2019).
Sedation, pre-anesthetic: Limited data available: Children and Adolescents (very limited
data available in patients >9 years): Intranasal: 1 to 2 mcg/kg as a single dose 30 to 60
minutes prior to induction of anesthesia. Higher-end doses (2 mcg/kg) are recommended for
older children (≥ 5 years) and adolescents (Talon 2009; Yuen 2012). Dosing based on
multiple prospective studies (Akin 2012; Cimen 2013; Talon 2009; Wang 2014; Yuen 2012).
Dosing: Renal Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling; however,
pharmacokinetics were not significantly different in adult patients with severe renal impairment
(CrCl <30 mL/minute).
Dosing: Hepatic Impairment: Pediatric

There are no specific dosage adjustments provided in the manufacturer's labeling; however,
clearance is reduced in varying degrees based on the level of hepatic impairment; adult data
suggests a dosage adjustment.
Dosing: Geriatric
ICU sedation: IV: Refer to adult dosing. Consider dosage reduction. No specific guidelines
available. Dose selections should be cautious, at the low end of dosage range; titration should
be slower, allowing adequate time to evaluate response.
Procedural sedation: IV: Refer to adult dosing: Initial: Loading infusion of 0.5 mcg/kg over 10
minutes; Maintenance infusion: Dosage reduction should be considered.
Dosage Forms: US
Excipient information presented when available (limited, particularly for generics); consult specific
product labeling.
Solution, Intravenous:
Generic: 400 mcg/4 mL (4 mL); 1000 mcg/10 mL (10 mL)
Solution, Intravenous [preservative free]:
Precedex: 400 mcg/100 mL (100 mL); 200 mcg/2 mL (2 mL) [additive free, latex free]
Precedex: 200 mcg/50 mL (50 mL) [latex free]
Precedex: 80 mcg/20 mL (20 mL)
Generic: 80 mcg/20 mL (20 mL); 200 mcg/50 mL (50 mL); 400 mcg/100 mL (100 mL);
200 mcg/2 mL (2 mL); Dexmedetomidine 200 mcg/50 mL in Dextrose 5% (50 mL);
Dexmedetomidine 400 mcg/100 mL in Dextrose 5% (100 mL)
Generic Equivalent Available: US

Yes
Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific
product labeling.
Solution, Intravenous:
Precedex: 4 mcg/mL (20 mL, 50 mL, 100 mL); 200 mcg/2 mL (2 mL)
Generic: 100 mcg/mL (2 mL); 200 mcg/2 mL (2 mL)
Administration: Adult
Administer using a controlled infusion device. Advisable to use administration components made
with synthetic or coated natural rubber gaskets. If loading dose used, administer over 10 minutes;
may extend to 20 minutes to further reduce vasoconstrictive effects. Titration no more frequently
than every 30 minutes may reduce the incidence of hypotension when used for ICU sedation
(Gerlach 2009).
Administration: Pediatric
Parenteral: IV: Administer using a controlled infusion device. Infuse loading dose over 10
minutes; may extend up to 20 minutes in neonatal patients or when needed to further reduce
vasoconstrictive effects; rapid infusions are associated with severe side effects.
Dexmedetomidine may adhere to natural rubber; use administration components made with
synthetic or coated natural rubber gaskets.
Intranasal: Administer undiluted (100 mcg/ml) or dilute in a small volume of NS (eg, to a total
volume 1 or 1.5 mL). Divide dose and give half in each nostril by slowly dripping from a
needleless syringe onto the nasal mucosa while in a recumbent position (Akin 2012; Cimen
2013; Ghai 2017; Gyanesh 2014; Wang 2014). Some recommend using a nasal atomizer
such as the MAD Nasal Drug delivery device (Cao 2017; Talon 2009).
Usual Infusion Concentrations: Adult

IV infusion: 200 mcg in 50 mL (concentration: 4 mcg/mL) of NS
Usual Infusion Concentrations: Pediatric

IV infusion: 4 mcg/mL
Use: Labeled Indications
Intensive care unit sedation: Sedation of initially-intubated and mechanically-ventilated

patients during treatment in an intensive care setting
Procedural sedation: Procedural sedation prior to and/or during awake fiberoptic intubation;
sedation prior to and/or during surgical or other procedures of nonintubated patients
Use: Off-Label: Adult
Sedation during awake craniotomy
Medication Safety Issues

Sound-alike/look-alike issues:
DexMEDEtomidine may be confused with dexAMETHasone.
Precedex may be confused with Peridex.
High alert medication:
The Institute for Safe Medication Practices (ISMP) includes this medication among its list
of drug classes which have a heightened risk of causing significant patient harm when
used in error.
Administration issues:
Errors have occurred due to misinterpretation of dosing information; use caution.

Maintenance dose expressed as mcg/kg/hour.
Adverse Reactions
Frequency dependent upon dose, duration, and indication.
>10%:
Cardiovascular: Hypotension (24% to 56%), bradycardia (5% to 42%), systolic

hypertension (28%), tachycardia (25%), hypertension (diastolic; 12%), hypertension
(11%)
Central nervous system: Agitation (5% to 14%)
Gastrointestinal: Constipation (6% to 14%), nausea (3% to 11%)
Respiratory: Respiratory depression (37%; placebo 32%)
1% to 10%:
Cardiovascular: Atrial fibrillation (2% to 9%), peripheral edema (3% to 7%), hypovolemia
(3%), edema (2%)
Central nervous system: Anxiety (5% to 9%)
Endocrine & metabolic: Hypokalemia (9%), hyperglycemia (7%), hypoglycemia (5%),

increased thirst (2%), hypocalcemia (1%), hypomagnesemia (1%)
Gastrointestinal: Xerostomia (3% to 4%)
Genitourinary: Oliguria (2%)
Hematologic & oncologic: Anemia (3%)
Renal: Acute renal failure (2% to 3%), decreased urine output (1%)
Respiratory: Respiratory failure (2% to 10%), adult respiratory distress syndrome (1% to
9%), pleural effusion (2%), wheezing (≤1%)
Miscellaneous: Fever (5% to 7%), withdrawal syndrome (ICU sedation; 3% to 5%)
Postmarketing and/or case reports: Abdominal pain, acidosis, apnea, atrioventricular block,
bronchospasm, cardiac arrhythmia, cardiac disease, chills, confusion, convulsions, decreased
visual acuity, delirium, diaphoresis, diarrhea, dizziness, drug tolerance (use >24 hours),
dyspnea, extrasystoles, hallucination, headache, heart block, hemorrhage, hepatic
insufficiency, hyperbilirubinemia, hypercapnia, hyperkalemia, hypernatremia, hyperpyrexia,
hypoventilation, hypoxia, illusion, increased blood urea nitrogen, increased gamma-glutamyl
transferase, increased serum alkaline phosphatase, increased serum ALT, increased serum
AST, inversion T-wave on ECG, myocardial infarction, neuralgia, neuritis, pain, photopsia,
polyuria, prolonged QT interval on ECG, pulmonary congestion, respiratory acidosis, rigors,
seizure, sinoatrial arrest, speech disturbance, supraventricular tachycardia, tachyphylaxis
(use >24 hours), variable blood pressure, ventricular arrhythmia, ventricular tachycardia,
visual disturbance, vomiting
Contraindications
There are no contraindications listed in the US manufacturer's labeling.
Canadian labeling: Hypersensitivity to dexmedetomidine or any component of the formulation.
Warnings/Precautions
Concerns related to adverse effects:

• Cardiovascular effects: Episodes of bradycardia, hypotension, and sinus arrest have

been associated with rapid IV administration (eg, bolus administration) or when given to
patients with high vagal tone. When used for ICU sedation, use of a loading dose is
optional; for the maintenance infusion, titration no more frequently than every 30 minutes
may reduce the incidence of hypotension (Gerlach 2009). If medical intervention is
required, treatment may include stopping or decreasing the infusion, increasing the rate
of IV fluid administration, use of pressor agents, and elevation of the lower extremities. At
low concentrations, mean arterial pressure (MAP) may be reduced without changes in
other hemodynamic parameters (eg, pulmonary artery occlusion pressure [PAOP]);
however, at higher concentrations (>1.9 ng/mL), MAP, CVP, PAOP, PVR, and SVR
increase (Ebert 2000).
• Transient hypertension: Has been primarily observed during loading dose administration
and is associated with the initial peripheral vasoconstrictive effects of dexmedetomidine.
Treatment is generally unnecessary; however, reduction of infusion rate may be required.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with heart block, bradycardia,
severe ventricular dysfunction, hypovolemia, or chronic hypertension. In a scientific
statement from the American Heart Association, dexmedetomidine has been determined
to be an agent that may exacerbate underlying myocardial dysfunction (magnitude:
moderate) (AHA [Page 2016]).
• Diabetes: Use with caution in patients with diabetes mellitus; cardiovascular adverse
events (eg, bradycardia, hypotension) may be more pronounced.
• Hepatic impairment: Use with caution in patients with hepatic impairment; dosage
reductions recommended.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or

frequency adjustment, additional monitoring, and/or selection of alternative therapy.
Consult drug interactions database for more detailed information.
Special populations:
• Elderly: Use with caution in the elderly; cardiovascular events (eg, bradycardia,
hypotension) may be more pronounced. Dose reduction may be necessary.
Other warnings/precautions:
• Arousability: Patients may be arousable and alert when stimulated. This alone should
not be considered as lack of efficacy in the absence of other clinical signs/symptoms.
• Experienced personnel: Should be administered only by persons skilled in management

of patients in intensive care setting or operating room. Patients should be continuously
monitored.
• Tolerance and tachyphylaxis: Use of infusions >24 hours has been associated with
tolerance and tachyphylaxis and dose-related increase in adverse reactions.
• Withdrawal: When withdrawn abruptly in patients who have received >24 hours of
therapy, withdrawal symptoms may result (eg, hypertension, tachycardia, nervousness,
nausea, vomiting, agitation, headaches). Use for >24 hours is not recommended by the
manufacturer.
Metabolism/Transport Effects
Substrate of CYP2A6 (minor); Note: Assignment of Major/Minor substrate status based on
clinically relevant drug interaction potential
Drug Interactions
(For additional information: Launch drug interactions program)
Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C:
Monitor therapy
Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of
Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure
lowering medications should be withheld for 24 hours prior to amifostine administration. If
blood pressure lowering therapy cannot be withheld, amifostine should not be administered.
Risk D: Consider therapy modification
Amisulpride (Oral): May enhance the hypotensive effect of Hypotension-Associated Agents.

Risk C: Monitor therapy
Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may
enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Risk
C: Monitor therapy
Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk
C: Monitor therapy
Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C:
Monitor therapy
Beta-Blockers: Alpha2-Agonists may enhance the AV-blocking effect of Beta-Blockers. Sinus

node dysfunction may also be enhanced. Beta-Blockers may enhance the rebound
hypertensive effect of Alpha2-Agonists. This effect can occur when the Alpha2-Agonist is
abruptly withdrawn. Management: Closely monitor heart rate during treatment with a beta
blocker and clonidine. Withdraw beta blockers several days before clonidine withdrawal when
possible, and monitor blood pressure closely. Recommendations for other alpha2-agonists
are unavailable. Exceptions: Levobunolol; Metipranolol. Risk D: Consider therapy
modification
Blood Pressure Lowering Agents: May enhance the hypotensive effect of Hypotension-
Associated Agents. Risk C: Monitor therapy
Bradycardia-Causing Agents: May enhance the bradycardic effect of other Bradycardia-

Causing Agents. Risk C: Monitor therapy
Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering
Agents. Risk C: Monitor therapy
Bromperidol: May diminish the hypotensive effect of Blood Pressure Lowering Agents. Blood
Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Risk X: Avoid
combination
Ceritinib: Bradycardia-Causing Agents may enhance the bradycardic effect of Ceritinib.

Management: If this combination cannot be avoided, monitor patients for evidence of
symptomatic bradycardia, and closely monitor blood pressure and heart rate during therapy.
Exceptions are discussed in separate monographs. Risk D: Consider therapy modification
Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C:
Monitor therapy
DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of
DULoxetine. Risk C: Monitor therapy
Fexinidazole [INT]: Bradycardia-Causing Agents may enhance the arrhythmogenic effect of

Fexinidazole [INT]. Risk X: Avoid combination
Herbs (Hypotensive Properties): May enhance the hypotensive effect of Blood Pressure
Lowering Agents. Risk C: Monitor therapy
Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the

hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy
Ivabradine: Bradycardia-Causing Agents may enhance the bradycardic effect of Ivabradine.

Lacosamide: Bradycardia-Causing Agents may enhance the AV-blocking effect of

Lacosamide. Risk C: Monitor therapy
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Levodopa-Containing Products: Blood Pressure Lowering Agents may enhance the

hypotensive effect of Levodopa-Containing Products. Risk C: Monitor therapy
Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Midodrine: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C:

Monitor therapy
Mirtazapine: May diminish the antihypertensive effect of Alpha2-Agonists. Management:

Consider avoiding concurrent use. If the combination cannot be avoided, monitor for
decreased effects of alpha2-agonists if mirtazapine is initiated/dose increased, or increased
effects if mirtazapine is discontinued/dose decreased. Risk D: Consider therapy modification
Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk
C: Monitor therapy
Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C:
Monitor therapy
Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C:
Monitor therapy
Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C:
Monitor therapy
Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of
Nitroprusside. Risk C: Monitor therapy
Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Management: Consider temporarily withholding blood pressure lowering medications
beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of
the infusion. Risk D: Consider therapy modification
Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk
C: Monitor therapy
Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of
Pholcodine. Risk C: Monitor therapy
Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure

Lowering Agents. Risk C: Monitor therapy
Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering
Agents. Risk C: Monitor therapy
Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk
C: Monitor therapy
Ruxolitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents.

Management: Ruxolitinib Canadian product labeling recommends avoiding use with
bradycardia-causing agents to the extent possible. Risk C: Monitor therapy
Serotonin/Norepinephrine Reuptake Inhibitors: May diminish the antihypertensive effect of

Alpha2-Agonists. Risk C: Monitor therapy
Siponimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Siponimod.

Management: Avoid coadministration of siponimod with drugs that may cause bradycardia.
Risk D: Consider therapy modification
Solriamfetol: May enhance the hypertensive effect of Hypertension-Associated Agents. Risk

C: Monitor therapy
Terlipressin: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C:

Monitor therapy
Tofacitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C:

Monitor therapy
Tricyclic Antidepressants: May diminish the antihypertensive effect of Alpha2-Agonists.

Management: Consider avoiding this combination. If used, monitor for decreased effects of
the alpha2-agonist. Exercise great caution if discontinuing an alpha2-agonist in a patient
receiving a TCA. Risk D: Consider therapy modification
Pregnancy Risk Factor

C (show table)
Pregnancy Considerations
Dexmedetomidine is expected to cross the placenta. Information related to use during pregnancy
is limited (El-Tahan 2012).
Breast-Feeding Considerations
It is not known if dexmedetomidine is excreted in breast milk. According to the manufacturer, the
decision to continue or discontinue breastfeeding during therapy should take into account the risk
of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the
mother.
Monitoring Parameters
Level of sedation; heart rate, respiration, rhythm, blood pressure; pain control. Note:
Dexmedetomidine causes minimal respiratory depression, inhibits salivation, and is analgesic-
sparing.
Critically-ill mechanically ventilated ICU patients: Assess and adjust sedation according to scoring
system (Richmond Agitation-Sedation Scale [RASS] or Sedation-Agitation Scale [SAS]) (SCCM
[Devlin 2018]).
Mechanism of Action
Selective alpha2-adrenoceptor agonist with anesthetic and sedative properties thought to be due
to activation of G-proteins by alpha2a-adrenoceptors in the brainstem resulting in inhibition of
norepinephrine release; peripheral alpha2b-adrenoceptors are activated at high doses or with rapid
IV administration resulting in vasoconstriction.
Pharmacodynamics and Pharmacokinetics
Onset of action:
IV loading dose: 5 to 10 minutes
Intranasal: 45 to 60 minutes (Yuen 2007), may be faster in pediatric patients when

administered via an atomizing device (Talon 2009)
Peak effect:
IV loading dose: 15 to 30 minutes
Intranasal: 90 to 105 minutes (Yuen 2007)
Duration (dose dependent): 60 to 120 minutes
Distribution: Vss:
Preterm Neonates (28 to <36 weeks GA): 2.7 L/kg (range: 2.5 to 5.9 L/kg)
(Chrysostomou 2014)
Term neonates (36 to ≤44 weeks GA): 3.9 L/kg (range: 0.1 to 10.9 L/kg) (Chrysostomou
2014)
Infants and Children <2 years: Median: 3.8 L/kg (range: 1.9 to 4.6 L/kg) (Vilo 2008)
Children 2 to 11 years: Median: 2.2 L/kg (range: 1.3 to 2.8 L/kg) (Vilo 2008)
Adults: ~118 L; rapid
Bioavailability: Intranasal: Variable: Median: 65% (range: 35% to 93%) (Iirola 2011)
Protein binding: ~94%
Metabolism: Hepatic via N-glucuronidation, N-methylation, and CYP2A6
Half-life elimination:
Preterm Neonates (28 to <36 weeks GA): Terminal: 7.6 hours (range: 3 to 9.1 hours)
(Chrysostomou 2014)
Term Neonates (36 to ≤44 weeks GA): Terminal: Median: 3.2 hours (range: 1 to 9.4
hours) (Chrysostomou 2014)
Infants and Children <2 years: Terminal: Median: 2.3 hours (range: 1.5 to 3.3 hours) (Vilo
2008)
Children 2 to 11 years: Terminal: Median: 1.6 hours (range: 1.2 to 2.3 hours) (Vilo 2008)
Adults: Distribution: ~6 minutes; Terminal: ~up to 3 hours (Venn 2002); significantly

prolonged in patients with severe hepatic impairment (Cunningham 1999)
Time to peak, serum: Intranasal: Median: 38 minutes (range: 15 to 60 minutes) (Iirola 2011)
Excretion: Urine (95%); feces (4%)
Clearance:
Note: Clearance following cardiac surgery was reduced by 27% in pediatric patients
aged 1 week to 14 years (Potts 2009)
Preterm Neonates (28 to <36 weeks GA): 0.3 L/hour/kg (0.2 to 0.4 L/hour/kg)
(Chrysostomou 2014)
Term Neonates (36 to ≤44 weeks GA): 0.9 L/hour/kg (0.2 to 1.5 L/hour/kg)
Infants and Children <2 years: Median: 1 L/hour/kg (0.85 to 1.66 L/hour/kg) (Vilo
2008)
Children 2 to 11 years: Median: 1 L/hour/kg (0.56 to 1.35 L/hour/kg) (Vilo 2008)
Adults: ~39 L/hour; Hepatic impairment (Child-Pugh class A, B, or C): Mean

clearance values were 74%, 64%, and 53% respectively, of those observed in
healthy adults
Pharmacodynamics and Pharmacokinetics: Additional Considerations
Hepatic function impairment: Clearance and plasma protein binding are decreased in patients
with hepatic impairment.
Pricing: US
Solution (Dexmedetomidine HCl in NaCl Intravenous)
80 mcg/20 mL (per mL): $1.56
200 mcg/50 mL (per mL): $1.03
400 mcg/100 mL (per mL): $0.96
Solution (Dexmedetomidine HCl Intravenous)
200 mcg/2 mL (per mL): $3.25 - $38.52
400MCG/4ML (per mL): $23.69
1000MCG/10ML (per mL): $23.39
Solution (Dexmedetomidine HCl-Dextrose Intravenous)
200MCG/50ML -5% (per mL): $0.87
400MCG/100ML -5% (per mL): $0.64
Solution (Precedex Intravenous)
80 mcg/20 mL (per mL): $1.58
200 mcg/2 mL (per mL): $25.20
200 mcg/50 mL (per mL): $1.11
400 mcg/100 mL (per mL): $1.01
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as
reference price only. A range is provided when more than one manufacturer's AWP price is
available and uses the low and high price reported by the manufacturers to determine the range.
The pricing data should be used for benchmarking purposes only, and as such should not be used
alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to
be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all
warranties of any kind or nature, whether express or implied, and assumes no liability with respect
to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be
liable for special, indirect, incidental, or consequential damages arising from use of price or price
range data. Pricing data is updated monthly.
Brand Names: International
Alphadex (IN); Cepedex (AT); Demesynt (CR, DO, GT, HN, PA, SV); Demsynt (NI); Detomax IV
(BD); Dexdomitor (AT); Dexdor (AT, BE, DK, ES, HR, HU, IE, LT, LV, MT, NL, PL, RO, TR, UA);
Dexem (IN, LK); Hydex (TH); Meproxidina (CR, DO, GT, HN, NI, PA, SV); Precedex (AE, AR, AU,
BH, BR, CR, CZ, DO, EG, GT, HK, HN, ID, JO, JP, KR, KW, LB, MX, MY, NI, NZ, PA, PE, PH, SA,
SG, SV, TH, TW, UY, VN); Sedadex (AT); Xamdex (IN)
For country abbreviations used in Lexicomp (show table)
Use of UpToDate is subject to the Subscription and License Agreement.
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Dexmedetomidine: Drug information

Copyright 1978-2020 Lexicomp, Inc. All rights reserved.

Brand Names: Canada

Dosing: Renal Impairment: Adult

Dosing: Hepatic Impairment: Adult

(For additional information see "Dexmedetomidine: Pediatric drug information")

ICU sedation: Infants, Children, and Adolescents: Limited data available:

Sedation/anesthesia, noninvasive procedures: Limited data available:

Maintenance dose: Infants, Children, and Adolescents: Continuous IV infusion: 0.5 to 1

Sedation, nonpainful or minimally painful diagnostic procedures: Limited data available;

Dosing: Renal Impairment: Pediatric

Dosing: Hepatic Impairment: Pediatric

Generic: 400 mcg/4 mL (4 mL); 1000 mcg/10 mL (10 mL)

Solution, Intravenous [preservative free]:

Precedex: 200 mcg/50 mL (50 mL) [latex free]

Precedex: 80 mcg/20 mL (20 mL)

Generic Equivalent Available: US

Dosage Forms: Canada

Generic: 100 mcg/mL (2 mL); 200 mcg/2 mL (2 mL)

Usual Infusion Concentrations: Adult

Usual Infusion Concentrations: Pediatric

Use: Labeled Indications

Intensive care unit sedation: Sedation of initially-intubated and mechanically-ventilated

Use: Off-Label: Adult

Sedation during awake craniotomy

Medication Safety Issues

DexMEDEtomidine may be confused with dexAMETHasone.

Precedex may be confused with Peridex.

High alert medication:

Errors have occurred due to misinterpretation of dosing information; use caution.

Cardiovascular: Hypotension (24% to 56%), bradycardia (5% to 42%), systolic

Central nervous system: Agitation (5% to 14%)

Gastrointestinal: Constipation (6% to 14%), nausea (3% to 11%)

Respiratory: Respiratory depression (37%; placebo 32%)

Central nervous system: Anxiety (5% to 9%)

Endocrine & metabolic: Hypokalemia (9%), hyperglycemia (7%), hypoglycemia (5%),

Gastrointestinal: Xerostomia (3% to 4%)

Genitourinary: Oliguria (2%)

Hematologic & oncologic: Anemia (3%)

Miscellaneous: Fever (5% to 7%), withdrawal syndrome (ICU sedation; 3% to 5%)

There are no contraindications listed in the US manufacturer's labeling.

Canadian labeling: Hypersensitivity to dexmedetomidine or any component of the formulation.

Concerns related to adverse effects:

• Cardiovascular effects: Episodes of bradycardia, hypotension, and sinus arrest have

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or

• Experienced personnel: Should be administered only by persons skilled in management

Amisulpride (Oral): May enhance the hypotensive effect of Hypotension-Associated Agents.

Beta-Blockers: Alpha2-Agonists may enhance the AV-blocking effect of Beta-Blockers. Sinus

Bradycardia-Causing Agents: May enhance the bradycardic effect of other Bradycardia-

Ceritinib: Bradycardia-Causing Agents may enhance the bradycardic effect of Ceritinib.

Fexinidazole [INT]: Bradycardia-Causing Agents may enhance the arrhythmogenic effect of

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the

Ivabradine: Bradycardia-Causing Agents may enhance the bradycardic effect of Ivabradine.

Lacosamide: Bradycardia-Causing Agents may enhance the AV-blocking effect of

Levodopa-Containing Products: Blood Pressure Lowering Agents may enhance the

Midodrine: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: