Dexmedetomidine
PRECEDEX
Pronunciation: dex-med-e-TOE-mi-deen
“Pre-sedate (for) Death metal toe meeting”
Orange plus signs → alpha-2 agonist
What it isSelective alpha-2 adrenergic agonist sedative for ICU and procedural sedation.
Why this oneProduces arousable, cooperative sedation with relatively little respiratory depression and can continue through extubation.
What limits itBradycardia, hypotension, and occasionally sinus arrest limit dosing; prolonged infusions can produce tolerance and withdrawal.
FDA-approved for
- ICU sedation (1999)
- procedural sedation (2008)
Off-label
- ICU delirium prevention
- alcohol withdrawal adjunct
- procedural sedation in children
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| ICU sedation (initially intubated/mechanically ventilated; infusion ≤24 h) | Adult | Load 1 mcg/kg IV over 10 min (load may be omitted if converting from another sedative) | Maintenance 0.2–0.7 mcg/kg/hr, titrated to sedation level | 0.7 mcg/kg/hr maintenance; infusion ≤24 hr |
| Procedural sedation (non-intubated) | Adult | Load 1 mcg/kg IV over 10 min (0.5 mcg/kg for less invasive procedures, e.g. ophthalmic) | Maintenance initiate 0.6 mcg/kg/hr, titrate to effect | 1 mcg/kg/hr maintenance (range 0.2–1) |
| Awake fiberoptic intubation | Adult | Load 1 mcg/kg IV over 10 min | Maintenance 0.7 mcg/kg/hr until endotracheal tube secured | 0.7 mcg/kg/hr |
| Procedural sedation | >65 yr | Load 0.5 mcg/kg IV over 10 min; consider maintenance reduction | Titrate to effect | Per adult range with reduction considered |
| Sedation for non-invasive procedures | 1 mo to <2 yr | Load 1.5 mcg/kg IV over 10 min | Maintenance initiate 1.5 mcg/kg/hr, titrate 0.5–1.5 mcg/kg/hr | 1.5 mcg/kg/hr maintenance |
| Sedation for non-invasive procedures | 2 to <18 yr | Load 2 mcg/kg IV over 10 min | Maintenance initiate 1.5 mcg/kg/hr, titrate 0.5–1.5 mcg/kg/hr | 1.5 mcg/kg/hr maintenance |
Renal PK unchanged in severe renal impairment (CrCl <30 mL/min); no adjustment stated on label
Hepatic Consider dose reduction (clearance decreases with severity of hepatic impairment)
Loading dose may be omitted when converting from alternate sedative therapy; consider dose reduction >65 yr
Instructions
- Administer only by persons skilled in ICU/OR patient management, with continuous monitoring
- Administer using a controlled infusion device; individualize and titrate to desired clinical effect
- Not indicated for infusions lasting >24 hours
- 200 mcg/50 mL and 400 mcg/100 mL single-dose vials require no further dilution
Available strengths
- inj 4, 100 mcg/mL
- SL film 120, 180 mcg
- film 0.12, 0.18 mg
Cautions
- Clinically significant bradycardia, sinus arrest, and hypotension (some fatal); more pronounced with hypovolemia, diabetes mellitus, chronic hypertension, and in elderly
- Caution in advanced heart block or severe ventricular dysfunction
- Caution with other vasodilators or negative chronotropic agents (additive effects)
- Transient hypertension during loading dose (consider slowing loading infusion)
- Arousability with stimulation is expected and is not lack of efficacy
- Withdrawal (nausea, vomiting, agitation; tachycardia/hypertension) after ICU infusions >24 hr
- Tolerance and tachyphylaxis with use beyond 24 hr, with dose-related increase in adverse reactions
- Diabetes insipidus reported (polyuria, dilute urine, hypernatremia); monitor urine output
- Hyperthermia/pyrexia, possibly resistant to traditional cooling — discontinue if drug-related
Adverse reactions
- Adults (>2%): hypotension, bradycardia, dry mouth
- Adults, also: hypertension, nausea, atrial fibrillation, pyrexia
- Pediatric (>5%): bradypnea, bradycardia, hypertension, hypotension
- Infusions >24 hr: ARDS, respiratory failure, agitation
Pregnancy Decades of IV-use data (exposures after 1st trimester, mostly at cesarean delivery): no identified risk of major birth defects or miscarriage; crosses the placenta; fetal/developmental toxicity in rats at ≥1.8x MRHD.
Lactation Present in human milk (detectable up to ~12 h after stopping; relative infant dose 0.02–0.098%); monitor breastfed infant for irritability.
Cost
| Strength | #/mo | generic $/unit | CostPlus | |
|---|---|---|---|---|
| 4 mcg/mL | inj | per unit | not offered | |
| 100 mcg/mL | inj | per unit | not offered |
Other forms: Dexmedetomidine sublingual (IGALMI)
Generic entry2014
NO BOXED WARNINGS
Principal riskbradycardia and hypotension, including sinus arrest
Classes and tags
Clinical profile
Legacy pregnancy categoryC
Defining liabilitySedation, falls, dependence and additive respiratory depression with opioids or other CNS depressants.
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