In this episode, I’ll discuss an article about rebound hypertension from dexmedetomidine.
Lead author: Lauren A. Flieller
Published in the journal Pharmacotherapy August 2019
Because the sedative dexmedetomidine shares receptor targets with the antihypertensive clonidine, a warning was placed into the dexmedetomidine prescribing information to avoid abrupt discontinuation over concerns of rebound hypertension.
While there have been case reports of rebound hypertension with dexmedetomidine discontinuation, this phenomena has not shown up in a frequency high enough to be detected in clinical trials comparing it to other sedatives such as propofol or midazolam.
The authors of this study designed it to identify whether rebound hypertension does occur more frequently after discontinuation of sedation with dexmedetomidine compared to propofol or midazolam.
The study was a retrospective matched cohort of intensive care unit patients receiving continuous infusions of at least 72 hours in duration of dexmedetomidine, propofol, or midazolam. Controls of propofol or midazolam were matched 3:1 to dexmedetomidine patients based on whether or not the patients had a history of hypertension. Exclusion criteria were minimal and justified – patients who received combination therapy or had alcohol withdrawal or status epilepticus were excluded.
Patients were from a single center from 2014 to 2017 and sedation practices were guided by the recommendations of the Society of Critical Care Medicine guidelines on pain, agitation, and delirium. Rebound hypertension was defined as receipt of an antihypertensive medication in response to hypertension or re-initiation of dexmedetomidine infusion due to hypertension within 24 hours of discontinuation.
Overall there were 54 patients who received dexmedetomidine and 162 who received propofol or midazolam. There was no difference in the incidence of rebound hypertension between groups. Dexmedetomidine had an incidence of 16.7% and the propofol/midazolam group had an incidence of 17.9% with a p-value of 0.8. Of the patients in either group who did experience rebound hypertension, approximately three quarters had a history of hypertension.
The authors concluded:
When compared to either propofol or midazolam, dexmedetomidine did not increase the incidence of rebound hypertension upon discontinuation. Hypertension history appears to be associated with an increased risk of rebound hypertension, regardless of which sedative medication is selected. In patients with a history of hypertension, a longer titration of dexmedetomidine may be most appropriate. However, in other patients, less time on sedation may allow for better outcomes as well as lower medication costs.
This study provides at least 3 helpful findings regarding rebound hypertension and ICU sedatives:
1. Despite concerns about the similarity to clonidine, dexmedetomidine does not appear to have a higher risk of rebound hypertension compared with other common ICU sedatives.
2. Pharmacists should be aware of the patient’s prior hypertension history in order to identify patients that might benefit from slower weaning of sedation.
3. Because the duration of dexmedetomidine infusion did not influence the occurrence of rebound hypertension in this study, the degree of exposure to dexmedetomidine does not appear to be useful in predicting rebound hypertension
Members of my Hospital Pharmacy Academy have access to practical and detailed trainings on the use of dexmedetomidine and ICU sedation as well as many other resources to help you in your practice. To sign up for immediate access go to pharmacyjoe.com/academy.
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