Gagnon David J, Riker Richard R, Glisic Elizabeth K, Kelner Andrew, Perrey Hilary M, Fraser Gilles L
Department of Pharmacy, Maine Medical Center, Portland, Maine.
Pharmacotherapy. 2015 Mar;35(3):251-9. doi: 10.1002/phar.1559.
Enteral clonidine represents a potentially less costly alternative to dexmedetomidine for sedation in intensive care unit (ICU) patients. This study describes our practice of transitioning selected adult ICU patients from dexmedetomidine to clonidine with a focus on efficacy, safety, and drug acquisition costs.
We conducted a single-center prospective observational pilot study from January through March 2014. Consecutive patients 18 years and older treated with dexmedetomidine and transitioned to clonidine were followed. The transition was assessed in five phases: dexmedetomidine maintenance, transition, clonidine maintenance, clonidine taper, and post clonidine. Efficacy data included any occurrence of significant pain, excessive agitation or oversedation, delirium, and need for ancillary psychoactive medications. Safety data included any occurrence of bradycardia, hypotension, new second- or third-degree atrioventricular node blockade, and clonidine withdrawal syndrome. Drug acquisition cost avoidances were estimated using average wholesale price.
Twenty patients were evaluated. Fifteen (75%) were successfully transitioned from dexmedetomidine within 48 hours of starting clonidine. The initial and maintenance clonidine regimens were 0.3 mg every 6 hours. Clonidine was the sole α2A -receptor agonist administered for 45 hours while in the ICU and for 54 hours outside the ICU. Fentanyl requirements were lower when clonidine was administered as the sole α2A -receptor agonist as compared to dexmedetomidine alone (387 vs. 891 μg/day, p = 0.03). Otherwise, there were no statistically significant differences in efficacy data during the dexmedetomidine and clonidine maintenance phases. No statistically significant differences in safety data were observed. Clonidine withdrawal syndrome criteria were met in one patient. The potential drug acquisition cost avoidance was $819-$2338 per patient during the 3-month study.
Transitioning from dexmedetomidine to clonidine may be an efficacious, safe, and less costly method of maintaining α2A -receptor agonist therapy in critically ill adults; these results warrant confirmation in expanded studies.
对于重症监护病房（ICU）患者的镇静，肠内可乐定可能是一种成本较低的右美托咪定替代药物。本研究描述了我们将部分成年ICU患者从右美托咪定转换为可乐定的实践，重点关注疗效、安全性和药物购置成本。
我们在2014年1月至3月进行了一项单中心前瞻性观察性试点研究。对连续接受右美托咪定治疗并转换为可乐定的18岁及以上患者进行随访。转换过程分五个阶段进行评估：右美托咪定维持期、转换期、可乐定维持期、可乐定减量期和可乐定停用后。疗效数据包括是否出现严重疼痛、过度躁动或镇静过度、谵妄以及是否需要辅助精神活性药物。安全性数据包括是否出现心动过缓、低血压、新的二度或三度房室传导阻滞以及可乐定戒断综合征。使用平均批发价格估算药物购置成本节约情况。
评估了20例患者。15例（75%）在开始使用可乐定后48小时内成功从右美托咪定转换。初始和维持可乐定方案为每6小时0.3毫克。在ICU期间，可乐定作为唯一的α2A受体激动剂使用45小时，在ICU外使用54小时。与单独使用右美托咪定相比，当可乐定作为唯一的α2A受体激动剂使用时，芬太尼需求量更低（387微克/天对891微克/天，p = 0.03）。否则，在右美托咪定和可乐定维持阶段，疗效数据无统计学显著差异。安全性数据也未观察到统计学显著差异。1例患者符合可乐定戒断综合征标准。在为期3个月的研究中，每位患者潜在的药物购置成本节约为819美元至2338美元。
从右美托咪定转换为可乐定可能是在危重症成年患者中维持α2A受体激动剂治疗的一种有效、安全且成本较低的方法；这些结果有待在扩大研究中得到证实。
