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Clonidine - transdermal

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For use in Ward 23b and PICU

Action of medication

Centrally acting antihypertensive. Clonidine stimulates alpha-adrenoreceptors in the brain stem. This action results in reduced sympathetic outflow from the central nervous system and decreases in peripheral resistance, renal vascular resistance, heart rate and blood pressure4.

Indications

  • To provide analgesia and sedation post cardiac surgery.
  • To control hypertension.
  • As an adjunct in weaning patients who are withdrawing from opiates and/or benzodiazepines.

Dose & Prescription

Dose

  • Clonidine can be given orally, intravenously, or by transdermal patch. This guideline only covers transdermal use.
  • Transdermal patches are preferred as they release a controlled amount continuously for a week.
  • Clonidine transdermal patches should only be initiated by PICU medical personal, anaesthetics or by the pain service

Dosing for Clonidine transdermal patches

[Note that there is no published data on transdermal dosing in infants and young children. The doses below are based on current practice which is extrapolated from IV and oral dosing.]

For children under 8 Kg
Clonidine transdermal patches are not to be used outside of the PICU setting for patients less than 8kg. They can be used in PICU at the discretion of the PICU consultant. 
If used for patients < 8 kg the clonidine patch is to be removed at discharge from PICU and is not to be re-charted on the ward drug chart. 
For children greater than 8 Kg
Maximum daily dose is between 15-18 mcg/kg/day 
Patients 8-20 kg use a TTS1 patch
Patients >20kg use a TTS2 patch
Can grade up after 1-2 weeks to the next dose size if required (this will be very unlikely in the ward situation) 

Prescription

  • To be charted on the ward medication chart with a date and time noted when applied in PICU.
  • The ward medical staff will not initiate a clonidine patch in the ward setting.

Administration

  • Apply to dry hairless skin on the upper arm or chest. If replacing apply at a new site
  • Be very careful not to damage the under side membrane during application.
  • Patches are supplied with an optional extra adhesive backing. It is not necessary to apply this unless the patch begins to peel off during the week. However, care must be taken to ensure the active medicated side of the patch is applied, rather than the non-medicated backing adhesive.
  • The patches all last for 7 days and come in 3 different doses - TTS1, TTS2, and TTS3
    • TTS1 releases 100mcg/day clonidine
    • TTS2 releases 200mcg/day clonidine
    • TTS3 releases 300mcg/day clonidine
  • In virtually all cases, patches will already have been applied while the patient is in PICU.
  • Clonidine patches should be discontinued once the child is comfortable with minimal other analgesia (paracetamol +/- NSAIDs). For most children, this is likely to be around day 3-4 postoperatively. Patches should be removed earlier if adverse reactions occur.

Observation & Documentation

  1. Document heart rate and blood pressure at least 4 hourly, or as specified by the prescriber
  2. Document sedation level at least 4 hourly
  3. Observe skin site daily for irritation
  4. Monitor for adverse reactions
  5. Discontinue by removing patch but remember it will take a number of hours for effects to dissipate
  6. Monitor for symptoms of excessive dose
    1. Manifestations of excessive dose are due to generalised sympathetic depression
    2. These include pupillary constriction, lethargy, bradycardia, hypotension, somnolence (coma in severe cases), and respiratory depression (including apnoea).
    3. Paradoxic hypertension caused by stimulation of peripheral alpha1-receptors may occur rarely.

Special considerations

  • Clonidine patches contain aluminium, and should be removed prior to MRI to prevent skin burns, or before defibrillation or cardioversion as the alteration in electrical conductivity may increase the risk of arcing.
  • Handover between staff is important: discussion with medical staff needs to take place at both morning and evening handover and also between nursing staff at each shift change.
  • In the event of excessive sedation, bradycardia, or hypotension remove the patch and notify medical staff.

Contraindications & Precautions

Contraindications

  1. Heart block or severe bradyarrhythmia
  2. Hypotension (use with caution in combination with other antihypertensives)
  3. Overly sedated patient

Precautions

  1. Hypovolaemia - makes hypotension more likely
  2. Bradycardia - can exacerbate this
  3. Renal failure - avoid or reduce dose
  4. Constipation - can exacerbate this

For detailed information about this drug including clinical pharmacology, please see Medsafe data sheet for Clonidine.

Possible adverse effects

  • Excessive sedation
  • Dry mouth/eyes
  • Hypotension
  • Rash / Itch
  • Skin irritation at site of patch

This list is not exhaustive, for detailed information about this drug including side effects,  please see  Medsafe data sheet for ClonidineInformation is also available in the  NZFC.

Drug interactions

  1. The hypotensive effects of other antihypertensive medications (diuretics, vasodilators, beta- receptor blockers, calcium antagonists or ACE-inhibitors) may be potentiated by the addition of clonidine
  2. Concomitant administration of other medications which can slow heart rate (e.g. beta blockers or digoxin) can cause or potentiate bradycardic rhythm disturbances.

For detailed information about this drug including clinical pharmacology, please see  Medsafe data sheet for Clonidine. Information on drug interactions is also available in the  NZFC.

Presentation

  • Transdermal Therapeutic System No. 1 (Patch): 2.5mg/3.5cm², printed with Company symbol and BI 31. 
  • Transdermal Therapeutic System No. 2 (Patch): 5mg/7.0cm², printed with Company symbol and BI 32. 
  • Transdermal Therapeutic System No. 3 (Patch): 7.5mg/10.5cm², printed with Company symbol and BI 33.

References

  1. Brunton LL, Chabner BA, Knollmann BC, editors. Goodman and Gillman's The Pharmacological Basis of Therapeutics. 12th edition. New York: McGraw-Hill; 2010
  2. Kemp A, McDowell JM, editors. Paediatric Pharmacopoeia. 13th edition. Melbourne: Pharmacy Dept Royal Children's Hospital; 2002
  3. Shann, F. Drug doses. 14th edition. Melbourne: Royal Children's Hospital; 2010
  4. Catapress TTS [data sheet online]. Boehringer Ingelheim (N.Z.) Limited [updated 8/10/2010]. Available from URL: http://www.medsafe.govt.nz
  5. 5.Woods, DJ (editor), New Zealand Formulary for Children [Internet]. 2016 [updated 2016 March 1; 2015 Sept 1; cited 2016, March 18]. Available from: www.nzfchildren.org.nz

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Document Control

  • Date last published: 03 October 2016
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Cardiology
  • Author(s): Marion Hamer, Liz Oliphant, D Buckley
  • Editor: Marion Hamer
  • Review frequency: 2 years