clonidine

ROUTE	ONSET	PEAK	DURATION
PO	30–60 min	1–3 hr	8–12 hr
Transdermal	2–3 days	unknown	7 days‡
Epidural	unknown	unknown	unknown

Contraindicated in:

Hypersensitivity;
Injection site infection, anticoagulant therapy, or bleeding problems (for epidural only).

Use Cautiously in:

Serious cardiac or cerebrovascular disease;
Renal impairment;
OB: Use during pregnancy only if potential maternal benefit justifies potential fetal risk;
Lactation: Use while breastfeeding only if potential maternal benefit justifies potential risk to infant;
Pedi: Safety and efficacy not established in children 6 yr (ADHD); evaluation for cardiac disease should precede initiation of therapy for ADHD in children;
Geri: Appears on Beers list. risk of CNS effects, orthostatic hypotension, and bradycardia in older adults. Avoid use as first-line treatment of hypertension in older adults.

Adv. Reactions/Side Effects ⬆ ⬇

CV: bradycardia, heart block, hypotension (↑ with epidural), palpitations

Derm: rash, sweating

EENT: dry eyes

GI: dry mouth, constipation, nausea, vomiting

GU: ↓fertility, erectile dysfunction

Metab: weight gain

Neuro: drowsiness, depression, dizziness, hallucinations, nervousness, nightmares, paresthesia

Interactions ⬆ ⬇

Drug-drug:

Additive sedation with CNS depressants, including alcohol, antihistamines, opioid analgesics, and sedative/hypnotics.
Additive hypotension with other antihypertensives and nitrates.
Additive bradycardia with beta blockers, diltiazem, ivabradine, verapamil, or digoxin.
MAO inhibitors, amphetamines, or tricyclic antidepressants may ↓ antihypertensive effect.
Withdrawal phenomenon may be ↑ by discontinuation of beta blockers.
Epidural clonidine prolongs the effects of epidurally administered local anesthetics.
May ↓ effectiveness of levodopa.

Route/Dosage ⬆ ⬇

Do NOT substitute between clonidine products on a mg-per-mg basis.

Hypertension

PO (Adults ): Immediate release: 0.1 mg twice daily; ↑ by 0.1–0.2 mg/day every 2–4 days until BP is controlled; usual maintenance dose is 0.2–0.6 mg/day in 2–3 divided doses (up to 2.4 mg/day). Extended release: 0.17 mg once daily; ↑ by 0.09 mg/day at weekly intervals until BP is controlled; usual maintenance dose is 0.17–0.52 mg/day. Urgent treatment of hypertension (immediate release): 0.2 mg loading dose; then 0.1 mg every hr until BP is controlled or 0.8 mg total has been administered; follow with maintenance dosing;
PO Geriatric Patients ): Immediate release: 0.1 mg at bedtime initially; ↑ as needed.
Transdermal (Adults ): 0.1 mg/24 hr patch applied once every 7 days; ↑ by 0.1 mg every 1–2 wk (usual dose range: 0.1 to 0.3 mg/24-hr patch applied once every 7 days).

Attention-Deficit Hyperactivity Disorder

PO (Children ≥6 yr and >45 kg): Immediate release: 0.1 mg at bedtime; then ↑ every 2–3 days to 0.1 mg twice daily; then 0.1 mg 3 times daily; then 0.1 mg 4 times daily (max dose = 0.4 mg/day).
PO (Children ≥6 yr and 40.6–45 kg): Immediate release: 0.05 mg at bedtime; then ↑ every 2–3 days to 0.05 mg twice daily; then 0.05 mg 3 times daily; then 0.05 mg 4 times daily (max dose = 0.3 mg/day).
PO (Children ≥6 yr and 27–40.5 kg): Immediate release: 0.05 mg at bedtime; then ↑ every 2–3 days to 0.05 mg twice daily; then 0.05 mg 3 times daily; then 0.05 mg 4 times daily (max dose = 0.2 mg/day).
PO (Children ≥6 yr): Extended release (generic): 0.1 mg at bedtime; after 1 wk, ↑ dose to 0.1 mg in am and at bedtime; after 1 wk, ↑ dose to 0.1 mg in am and 0.2 mg at bedtime; after 1 wk, ↑ dose to 0.2 mg in am and at bedtime (max dose = 0.4 mg/day). Extended release (Onyda XR): 0.1 mg at bedtime; titrate dose by 0.1 mg/day at weekly intervals (max dose = 0.4 mg/day).

Cancer Pain

(Adults ): 30 mcg/hr initially; titrated according to need.
(Children ): 0.5 mcg/kg/hr initially; titrated according to need up to 2 mcg/kg/hr.

Opioid Withdrawal

PO (Adults ): Immediate release: 0.3–1.2 mg/day; may ↓ by 50% per day for 3 days; then discontinued or ↓ by 0.1–0.2 mg/day.

Availability ⬆ ⬇

(Generic available)

Immediate-release tablets: 0.025 mg; 0.1 mg; 0.2 mg; 0.3 mg
Extended-release tablets: 0.1 mg
Extended-release tablets (Nexiclon XR): 0.17 mg; 0.26 mg
Extended-release oral suspensionorange flavor (Onyda XR): 0.1 mg/mL
Solution for epidural injection (Duraclon): 100 mcg/mL; 500 mcg/mL
Transdermal patch: 0.1 mg/24 hr; 0.2 mg/24 hr; 0.3 mg/24 hr

Assessment ⬆ ⬇

Hypertension: Monitor intake and output ratios and daily weight, and assess for edema daily, especially at beginning of therapy.
Monitor BP and pulse prior to starting, frequently during initial dose adjustment and dose increases, and periodically during therapy. Titrate slowly in patients with cardiac conditions or those taking other sympatholytic drugs. Report significant changes.
Pain: Assess location, character, and intensity of pain prior to therapy, frequently during first few days, and routinely during administration.
- Monitor for fever as potential sign of catheter infection.
Opioid Withdrawal: Monitor patient for signs and symptoms of opioid withdrawal (tachycardia, fever, runny nose, diarrhea, sweating, nausea, vomiting, irritability, stomach cramps, shivering, unusually large pupils, weakness, difficulty sleeping, gooseflesh).
ADHD: Assess attention span, impulse control, and interactions with others.

Lab Test Considerations:

May cause transient ↑ in blood glucose levels.
- May cause ↓ urinary catecholamine and vanillylmandelic acid concentrations; these may ↑ on abrupt withdrawal.
- May cause weakly positive Coombs’ test result.

Implementation ⬆ ⬇

Do not confuse clonidine with clonazepam (Klonopin) or clozapine.
- Do not substitute between clonidine products on a mg-per-mg basis, because of differing pharmacokinetic profiles.
- In the perioperative setting, continue clonidine up to 4 hr prior to surgery and resume as soon as possible thereafter. Do not interrupt transdermal clonidine during surgery. Monitor BP carefully.
PO: Administer last dose of the day at bedtime. May be taken with or without food.
- DNC: Extended-release tablets (Nexiclon XR) are scored and may be split in half; do not crush or chew.
- For extended-release oral suspension, insert bottle adapter into bottle; do not remove this adapter once it has been inserted. Shake suspension gently for 10 sec before administering. Use oral dosing syringe to obtain accurate dose; tip of syringe should be inserted into bottle adapter to obtain dose. Discard any unused suspension that remains in bottle after 60 days of opening the bottle.
Transdermal system should be applied once every 7 days. May be applied to any hairless site; avoid cuts or calluses. Absorption is greater when placed on chest or upper arm and decreased when placed on thigh. Rotate sites weekly. Wash area with soap and water; dry thoroughly before application. Apply firm pressure over patch to ensure contact with skin, especially around edges. Remove old system and discard. System includes a protective adhesive overlay to be applied over medication patch to ensure adhesion, should medication patch loosen.
Dilute 500 mcg/mL with 0.9% NaCl for a concentration of 100 mcg/mL. Do not administer solutions that are discolored or contain a precipitate. Discard unused portion.

Patient/Family Teaching ⬆ ⬇

Instruct patient to take clonidine at the same time each day, even if feeling well. Take missed dose as soon as remembered. If dose of extended-release product is missed, omit dose and take next dose as scheduled. Do not take more than the prescribed daily dose in any 24 hr. If more than 1 oral dose in a row is missed or if transdermal system is late in being changed by ≥3 days, consult health care professional. All routes of clonidine should be gradually discontinued over 2–4 days to prevent rebound hypertension. Advise patients taking oral and transdermal forms to read Patient Information before starting and with each Rx refill in case of changes.
- Advise patient to make sure enough medication is available for weekends, holidays, and vacations. A written prescription may be kept in wallet in case of emergency.
- May cause drowsiness, which usually diminishes with continued use. Advise patient to avoid driving or other activities requiring alertness until response to medication is known.
- Caution patient to avoid sudden changes in position to decrease orthostatic hypotension. Use of alcohol, standing for long periods, exercising, and hot weather may increase orthostatic hypotension.
- If dry mouth occurs, frequent mouth rinses, good oral hygiene, and sugarless gum or candy may decrease effect. If dry mouth continues for >2 wk, consult health care professional.
- Caution patients with contact lenses that clonidine may cause dryness of eyes.
- Caution patient to avoid concurrent use of alcohol, marijuana or other forms of cannabis, and other CNS depressants, including opioids, with this medication.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any other Rx, OTC, or herbal products, especially cough, cold, or allergy remedies.
- Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
- Advise patient to notify health care professional if itching or redness of skin (with transdermal patch), mental depression, swelling of feet and lower legs, paleness or cold feeling in fingertips or toes, or vivid dreams or nightmares occur. May require discontinuation of therapy, especially with depression.
Hypertension: Encourage patient to comply with additional interventions for hypertension (weight reduction, low-sodium diet, discontinuation of smoking, moderation of alcohol consumption, regular exercise, and stress management). Medication helps control but does not cure hypertension.
- Instruct patient and family on proper technique for BP monitoring. Advise them to check BP at least weekly and report significant changes.
Instruct patient on proper application of transdermal system. Do not cut or trim unit. Transdermal system can remain in place during bathing or swimming.
- Advise patient referred for MRI test to discuss patch with referring health care professional and MRI facility to determine if removal of patch is necessary prior to test and for directions for replacing patch.
Pedi: Advise parents to notify school nurse of medication regimen.
Rep: Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Monitor breastfeeding infants exposed to Kapvay through breast milk for symptoms of hypotension and/or bradycardia, such as sedation, lethargy, tachypnea, and poor feeding. May impair female and male fertility. There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to ADHD medications during pregnancy. Register patients by calling the National Pregnancy Registry for ADHD Medications at 1-866961-2388 or visiting https://womensmentalhealth.org/adhd-medications/.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇