Clonidine

Dosage:

Opioid Withdrawal, Sedation, Adjunct for Pain

Oral: Starting dose 1-2micrograms/kg PO 6-8hourly. Dose may be gradually increased to 5 micrograms/kg 6hourly (Single dose not to exceed 300micrograms).

Slow IV Bolus: Starting dose 0.5-1micrograms/kg IV 6-8hourly. Increase if necessary to max dose of 5microgram/kg 6hourly (Single dose not to exceed 150microgram).

Sedation in PICU

Oral: 2-5micrograms/kg 6-8hourly PO (Single dose not to exceed 300micrograms)

Slow IV Bolus: Starting dose 1-2micrograms/kg IV 6-8hourly. Increase if necessary to max dose of 5micrograms/kg. (Single dose not to exceed 150micrograms).

Note: Intermittent dosing may be sub-optimal in achieving adequate levels of sedation - a continuous infusion should be considered.

Continuous Infusion: Loading dose of 2-3micrograms/kg, followed by continuous infusion of 0-2micrograms/kg/hour. Doses of up to 3micrograms/kg/hour have been used. 

Pre-operative sedation – on the direction of a consultant only:
4micrograms/kg (maximum dose 300micrograms) PO as a single dose.
The onset of action of clonidine is at least 45-60 minutes. Administration of clonidine should be timed accordingly.
Baseline blood pressure and heart rate should be recorded prior to administration and monitored thereafter.

Palliative care: see APPM formulary for dosing in pain/sedation/spasticity in palliative care.

Weaning: Clonidine should be gradually withdrawn – abrupt withdrawal can result in rebound hypertension.  Restlessness, palpitations, tremor, headache and abdominal symptoms have also been reported.
Suggested weaning regimen:
If patient is on clonidine and opioids/benzodiazepines for >2 weeks wean opioids/benzodiazepines first then wean clonidine.
Wean clonidine dose not the frequency. Monitor for rebound hypertension and withdrawal and adjust weaning plan if necessary.

• Clonidine < 1 week:  Stop, no need to wean.
• Clonidine >1 and < 2 weeks: Wean by 50% of dose for 24 hours and then stop.
• Clonidine > 2 weeks and < 1 month: Wean by 20% of original dose over 5 days.
• Clonidine > one month: Wean by 20% of original dose every 48 hours when off opioids. 

Monitoring:

Neonates: must use apnoea and oxygen saturation monitor for first 48hours, especially if used in conjunction with opioids. BP/HR should be monitored where high doses (≥ 2micrograms/kg) are being used.

≥1 month: Always consider the patient's susceptibility to respiratory depression especially if used in conjunction with opioids. Consider apnoea and oxygen saturation monitoring. Monitor BP, HR on initiating treatment, after each dosage increase and where high doses are being used (≥ 3microgram/kg)

Administration:

Oral:

• Clondine Oral Suspension 5microgram/mL (unlicensed)
• Catapres®  Tablets 100microgram may be crushed and dispersed in water, if required
• Clonidine Tablets 25microgram

Intravenous: Catapres® Injection 150microgram/mL

Compatible infusion fluids: Sodium Chloride 0.9% w/v or Glucose 5% w/v 

Method of Administration:

Slow IV bolus over 10 - 15 minutes 

• In areas with access to the CHI Smart-pump drug library (Table 1):

• In areas without access to the CHI Smart-pump drug library (or for the measurement of smaller doses outside of the drug library*): May be diluted to a suitable volume to aid administration. See below for further dilution instructions. 
  * Exceptional circumstances only. Drug library must always be used where possible.

To accommodate measurement of smaller doses a ten-fold dilution is first recommended:

• Draw up 1mL clonidine (150 micrograms) in a 1mL syringe
• Dilute to a final volume of 10mL with infusion fluid.
• This gives a concentration of 15 microgram/1mL.
• The required dose is then drawn up and further diluted to a volume appropriate to the size of the patient.

Continuous Infusion via the CHI Smart-pump Standard Concentration Infusion (SCI) drug library (Table 2).

Preferably administer via a central venous access device to avoid potential venous irritation as the preparation has a low pH.

Interactions:

Clonidine may potentiate the action of other CNS depressants such as opioid analgesics. Concomitant administration of opioid analgesics with clonidine also may potentiate the hypotensive effects of clonidine 
When administered with other hypotensive agents, including diuretics, the hypotensive effect of clonidine may be increased.

Adverse Effects:

CNS: Inital sedation, headache diziness. Very rarely nightmares, perceptual disturbances
GIT: Dry mouth initially, nausea, vomiting and rarely constipation
CVS: Orthostatic hypotension (more likely at the start of treatment), bradycardia,
Skin: rash, urticaria may rarely occur.

This list is not exhaustive. For full details see SPC www.hpra.ie 

Preparations:

Catapres® Injection 150microgram/mL
Catapres®  Tablets 100microgram (may be crushed and dispersed in water)
Clonidine Tablets 25microgram
Clondine Oral Suspension 5microgram/mL (unlicensed) 

Clonidine, when used as an adjunct to postoperative analgesic, should be weaned off before discharge from hospital.
Clonidine Oral Suspension is not routinely available from community pharmacies – if a child must be discharged on Clonidine Oral Suspension please contact the hospital Pharmacy department before discharging patient.