Dexmedetomidine with transition to oral clonidine for stabilization of refractory agitation: A case report
Kelvin Lou, Brian Chun-Mond Li, Shikha Minhas, Shalini NayarAbstract
Background
Refractory delirium and agitation in advanced cancer are challenging to manage, particularly when patients have longer prognoses and goals that extend beyond end-of-life sedation. Dexmedetomidine, a highly selective α2-adrenergic agonist, has shown promise for managing refractory symptoms in palliative care. Dexmedetomidine may control agitation while preserving arousability, but prolonged intravenous use limits feasibility.
Objectives
To describe the use of dexmedetomidine as a stabilizing bridge rather than terminal sedation and transition to oral clonidine to facilitate discharge home in a patient with advanced cancer and a longer prognosis.
Methods
A 45-year-old man with metastatic medullary thyroid carcinoma was admitted to the palliative care unit with severe opioid-refractory pain complicated by delirium and agitation, preventing initiation of palliative radiation. A dexmedetomidine infusion was titrated to 0.6 µg/kg/hr. To facilitate discharge home, we implemented a gradual cross-taper to oral clonidine (0.1 mg three times a day titrated to 0.5 mg four times a day) over 1 week while tapering dexmedetomidine by 0.1–0.2 µg/kg/hr decrements.
Results
The dexmedetomidine infusion rapidly achieved symptom control while preserving wakefulness and enabled diagnostic reassessment and completion of radiation therapy. The patient tolerated the transition to oral clonidine without recurrence of agitation or hemodynamic instability, was successfully discharged home, and remained clinically stable 5 months later.
Significance of Results
Dexmedetomidine may function as a stabilizing bridge rather than terminal sedation in selected palliative care patients with longer prognoses. Transition to oral clonidine can facilitate discontinuation of intravenous therapy and support outpatient symptom management. Prospective studies are needed to establish standardized transition protocols and identify optimal candidates for this strategy.