Precedex

Alpha-2 Adrenergic Receptor Agonist Sedatives

Oral Administration Oral Solid Formulations

Sublingual film (Igalmi):
Only administer under supervision of a health care provider; the patient's vitals and mental status alertness should be assessed after administration to avoid falls and syncope.
For sublingual or buccal administration only.
Keep the film in the foil package until ready to administer. The medication should be given immediately after the pouch is opened and dose prepared.
Open the sealed pouch by tearing at the notch and across the pouch.
If administering a partial dose, remove the film from the pouch with clean, dry hands. Cut the film in half between the dots on the film with clean, dry scissors. Discard unused half in waste container and place the patient's dose back in the pouch. If administering the full dose, skip this step.
Give the pouch to the patient and instruct them to remove the film with clean, dry hands.
For sublingual administration, instruct the patient to place the film under the tongue, close to the base of the tongue on either the left or right side. Instruct patient to avoid food or drink for at least 15 minutes after sublingual administration.
For buccal administration, instruct the patient to place the film on the inside of the lower lip and to avoid food or drink for at least 1 hour after buccal administration.
Instruct the patient to close their mouth and allow the film to dissolve. Instruct the patient not to chew or swallow the film.
After administration, the patient should remain seated or lying down. Ensure that patient is alert and not experiencing orthostatic or symptomatic hypotension prior to resuming ambulation. During clinical studies, maximum reductions in heart rate and blood pressure usually occurred 2 hours after a dose.
If agitation persists after the initial dose, an additional 2 doses may be administered at least 2 hours apart. For partial doses, prepare as stated above. Vital signs, including orthostatic measurements, should be assessed before administration of any additional doses.
Due to the risk of hypotension, additional doses are not recommended for patients with systolic blood pressure less than 90 mmHg, diastolic blood pressure less than 60 mmHg, heart rate less than 60 beats per minute, or a postural change in systolic blood pressure of 20 mmHg or more or a change in diastolic blood pressure of 10 mmHg or more.
The patient should not perform activities requiring mental alertness, such as operating a motor vehicle or operating hazardous machinery, for at least 8 hours after taking the film.

Injectable Administration

Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit. Dexmedetomidine solution is clear and colorless.

Intravenous Administration

Only experienced clinicians, skilled in the management of patients in the intensive care or operating room setting, should administer or supervise the use of dexmedetomidine.
Dexmedetomidine has the potential to adhere to some types of natural rubber; it is advisable to use administration components made with synthetic or coated natural rubber gaskets.
Dexmedetomidine is compatible with 0.9% Sodium Chloride Injection, 5% Dextrose Injection, Lactated Ringer's Injection, 20% mannitol, 0.3% potassium chloride solution, and 100 mg/mL magnesium sulfate solution.
 
Dilution
Dilute the 200 mcg/2 mL (100 mcg/mL) vial with 48 mL of 0.9% Sodium Chloride Injection to provide a final concentration of 4 mcg/mL.[29112]
Dexmedetomidine diluted to a final concentration of 8, 12, and 20 mcg/mL with 0.9% Sodium Chloride Injection is stable for up to 48 hours, despite a slight decrease in solution pH seen with increasing concentrations. NOTE: This is stability data; administration data regarding these concentrations are not available.
ASHP Recommended Standard Concentrations for Adult Continuous Infusions: 4 mcg/mL.[64020]
ASHP Recommended Standard Concentrations for Pediatric Continuous Infusions: 4 mcg/mL.
Shake gently to mix well.
Storage: Prior to use, diluted dexmedetomidine admixed from a multi-dose vial may be stored for up to 4 hours at room temperature or up to 24 hours at 2 to 8 degrees C. Dexmedetomidine 4 mcg/mL in 0.9% Sodium Chloride Injection is stable for at least 48 hours at room temperature (20 to 25 degrees C) and at least 14 days refrigerated (5 degrees C) when stored in polypropylene syringes. Concentrated solutions (8, 12, and 20 mcg/mL) stored in PVC bags at 23 +/- 2 degrees C are stable for 48 hours.
 
Continuous IV Infusion
Administer using a controlled infusion device.
Loading dose: Infuse over 10 minutes. Serious adverse events have occurred after rapid administration; do not administer via IV push.
Do not coadminister dexmedetomidine through the same IV catheter with blood, serum, or plasma because physical compatibility has not been established.
Carefully monitor blood pressure and heart rate.[29112]

Other Administration Route(s)

Intranasal Administration
NOTE: Dexmedetomidine is not FDA-approved for intranasal administration.
Dexmedetomidine injection (100 mcg/mL) has been administered intranasally in pediatric patients requiring both procedural and preanesthesia sedation.
Small studies have administered doses as undiluted or diluted drug in small volumes of normal saline (total volumes ranged from 0.4 to 1.5 mL/dose).
Using a small syringe, drip the solution into both nostrils with the child in a recumbent position 30 to 60 minutes before optimal sedation is required. Alternatively, dexmedetomidine may be administered via a nasal atomizer, which may improve bioavailability.

Severe

bradycardia / Rapid / 3.0-62.0
acute respiratory distress syndrome (ARDS) / Early / 2.5-9.0
atrial fibrillation / Early / 4.0-4.0
renal failure (unspecified) / Delayed / 2.0-2.5
oliguria / Early / 2.0-2.0
pleural effusion / Delayed / 2.0-2.0
ventricular tachycardia / Early / 0-1.0
pulmonary edema / Early / 1.0-1.0
myocardial infarction / Delayed / Incidence not known
arrhythmia exacerbation / Early / Incidence not known
AV block / Early / Incidence not known
cardiac arrest / Early / Incidence not known
hyperkalemia / Delayed / Incidence not known
bronchospasm / Rapid / Incidence not known
apnea / Delayed / Incidence not known
visual impairment / Early / Incidence not known

Moderate

respiratory depression / Rapid / 37.0-67.0
hypotension / Rapid / 5.0-56.0
hypertension / Early / 8.0-38.0
sinus tachycardia / Rapid / 1.0-25.0
constipation / Delayed / 6.0-14.0
hypokalemia / Delayed / 9.0-9.0
hypoxia / Early / 2.0-8.0
hyperglycemia / Delayed / 2.0-7.0
orthostatic hypotension / Delayed / 3.0-5.0
hypoglycemia / Early / 5.0-5.0
withdrawal / Early / 0-5.0
bleeding / Early / 2.0-3.0
hypovolemia / Early / 3.0-3.0
anemia / Delayed / 2.0-3.0
hyperthermia / Delayed / 2.0-2.0
edema / Delayed / 2.0-2.0
metabolic acidosis / Delayed / 1.0-2.0
peripheral edema / Delayed / 0-1.0
hypocalcemia / Delayed / 1.0-1.0
hypomagnesemia / Delayed / 1.0-1.0
wheezing / Rapid / 0-1.0
QT prolongation / Rapid / Incidence not known
palpitations / Early / Incidence not known
supraventricular tachycardia (SVT) / Early / Incidence not known
dysarthria / Delayed / Incidence not known
hyperbilirubinemia / Delayed / Incidence not known
hypernatremia / Delayed / Incidence not known
elevated hepatic enzymes / Delayed / Incidence not known
hypoventilation / Rapid / Incidence not known
dyspnea / Early / Incidence not known
photopsia / Delayed / Incidence not known
adrenocortical insufficiency / Delayed / Incidence not known
tolerance / Delayed / Incidence not known
physiological dependence / Delayed / Incidence not known

Mild

drowsiness / Early / 22.0-23.0
nausea / Early / 2.0-11.0
xerostomia / Early / 3.0-7.0
fever / Early / 4.0-7.0
hypoesthesia / Delayed / 6.0-7.0
paresthesias / Delayed / 6.0-7.0
vomiting / Early / 3.0-4.0
dyspepsia / Early / 0-2.0
gastroesophageal reflux / Delayed / 0-2.0
abdominal pain / Early / 0-2.0
polydipsia / Early / 2.0-2.0
chills / Rapid / 2.0-2.0
diarrhea / Early / Incidence not known
polyuria / Early / Incidence not known
rash / Early / Incidence not known
pruritus / Rapid / Incidence not known
hyperhidrosis / Delayed / Incidence not known
urticaria / Rapid / Incidence not known

IGALMI, Precedex

Rx

Relatively selective alpha2-adrenergic agonist sedative
IV form used for procedural and intensive care sedation; sublingual formulation used for acute agitation due to bipolar I or II disorder or schizophrenia in adults
Produces arousable sedation, limited effects on respiratory drive, and reduced analgesic/anesthetic requirements; hypotension and bradycardia are dose-related

For sedation induction and sedation maintenance of mechanically ventilated intensive care patients. Intravenous dosage Adults

1 mcg/kg IV, followed by 0.2 to 0.7 mcg/kg/hour continuous IV infusion, initially. Titrate until target level of sedation is attained. Loading doses are often bypassed due to their association with bradycardia and hypotension. [54780] Max: 1.5 mcg/kg/hour.[57161] Nonbenzodiazepine sedatives are recommended over benzodiazepines in non-cardiac surgery, mechanically ventilated patients. [65297]

Children† and Adolescents†

0.5 to 1 mcg/kg IV, followed by 0.1 to 0.5 mcg/kg/hour continuous IV infusion, initially. Titrate by 0.1 to 0.2 mcg/kg/hour every 20 to 30 minutes until target level of sedation is attained.[54696] [54780] Loading doses are often bypassed due to their association with bradycardia and hypotension. [54780] Usual maintenance dose: 0.3 to 0.7 mcg/kg/hour. Max: 2.5 mcg/kg/hour.[54696] [54750] [54781] [54783]

Infants†

0.5 to 1 mcg/kg IV, followed by 0.1 to 0.5 mcg/kg/hour continuous IV infusion, initially. Titrate by 0.1 to 0.2 mcg/kg/hour every 20 to 30 minutes until target level of sedation is attained.[54696] [54780] Loading doses are often bypassed due to their association with bradycardia and hypotension. [54780] Usual maintenance dose: 0.3 to 0.7 mcg/kg/hour. Max: 2.5 mcg/kg/hour.[54696] [54750] [54781] [54783] Infants may require higher infusion rates than older patients; in a retrospective case series of 38 patients, the average infusion rate was 0.4 mcg/kg/hour in infants and 0.29 mcg/kg/hour in children and adolescents.

Term Neonates†

0.05 to 0.5 mcg/kg/dose IV loading dose, followed by 0.05 to 0.6 mcg/kg/hour continuous IV infusion, initially. Adjust dose as needed to achieve target level of sedation. Loading doses are often bypassed due to their association with bradycardia and hypotension. [54780] Infusion rates comparable to those used in older populations have been reported in neonates (mean infusion rate: 0.4 mcg/kg/hour); however, decreased clearance and prolonged half-life may warrant relatively lower doses.[54786] [54787] Max: 2.5 mcg/kg/hour.[61945]

Premature Neonates†

Limited data available. 0.05 to 0.5 mcg/kg/dose IV loading dose, followed by 0.05 to 0.3 mcg/kg/hour continuous IV infusion, initially. Adjust dose by 0.1 mcg/kg/hour gradually to achieve target level of sedation.[54788] [56439] Loading doses are often bypassed due to their association with bradycardia and hypotension. [54780] Mean infusion rate was 0.6 mcg/kg/hour (range: 0.3 to 1.2 mcg/kg/hour) and mean duration of infusion was 12 days in a retrospective case-control study (n = 24; mean gestational age: 25 weeks).[54788] Decreased clearance and prolonged half-life may warrant relatively lower doses compared to older populations.[56439] Wean by 0.1 mcg/kg/hour every 12 to 24 hours, as tolerated, upon discontinuation.[54788]

For procedural sedation of non-intubated patients prior to and/or during surgical and other procedures. For procedural sedation prior to and/or during surgical or other invasive procedures. Continuous Intravenous Infusion dosage Adults

1 mcg/kg IV loading dose over 10 minutes, followed by 0.6 mcg/kg/hour continuous IV infusion initially. Titrate until desired level of sedation is attained. Dose range: 0.2 to 1 mcg/kg/hour. For less invasive procedures (e.g., ophthalmic surgery), a loading dose of 0.5 mcg/kg IV may be suitable. For awake fiberoptic intubation, a maintenance infusion of 0.7 mcg/kg/hour is recommended until the endotracheal tube is secured.[29112]

Geriatric Adults

0.5 mcg/kg IV loading dose over 10 minutes, followed by 0.6 mcg/kg/hour continuous IV infusion initially. Titrate until desired level of sedation is attained. Dose range: 0.2 to 1 mcg/kg/hour. For awake fiberoptic intubation, a maintenance infusion of 0.7 mcg/kg/hour is recommended until the endotracheal tube is secured.[29112]

For procedural sedation prior to and/or during non-invasive procedures. Continuous Intravenous Infusion dosage Adults

1 mcg/kg IV loading dose over 10 minutes, followed by 0.6 mcg/kg/hour continuous IV infusion initially. Titrate until desired level of sedation is attained. Dose range: 0.2 to 1 mcg/kg/hour.[29112]

Geriatric Adults

0.5 mcg/kg IV loading dose over 10 minutes, followed by 0.6 mcg/kg/hour continuous IV infusion initially. Titrate until desired level of sedation is attained. Dose range: 0.2 to 1 mcg/kg/hour.[29112]

Children and Adolescents 2 to 17 years

2 mcg/kg IV loading dose over 10 minutes, followed by 1.5 mcg/kg/hour continuous IV infusion initially. Titrate until desired level of sedation is attained. Dose range: 0.5 to 2 mcg/kg/hour. Some studies have used repeat boluses if sedation was inadequate prior to beginning the infusion.

Infants and Children 1 month to 1 year

1.5 mcg/kg IV loading dose over 10 minutes, followed by 1.5 mcg/kg/hour continuous IV infusion initially. Titrate until desired level of sedation is attained. Dose range: 0.5 to 2 mcg/kg/hour. Some studies have used repeat boluses if sedation was inadequate prior to beginning the infusion.

Intranasal dosage† Infants, Children, and Adolescents 6 months to 17 years

1 to 4 mcg/kg (Max: 200 mcg) intranasally (divided and given in both nostrils) as a single dose 30 to 60 minutes before the nonpainful procedure.

Infants 1 to 5 months

2 to 3 mcg/kg intranasally (divided and given in both nostrils) as a single dose 30 minutes before the nonpainful procedure.

For the treatment of acute agitation associated with schizophrenia or bipolar I or II disorder in adults. Sublingual or Buccal dosage Adults

120 mcg (for mild or moderate agitation) or 180 mcg (for severe agitation) via sublingual or buccal administration. If agitation persists after the initial dose, two additional doses of 60 mcg/dose (for mild or moderate symptoms) or 90 mcg/dose (for severe symptoms) may be administered at least 2 hours apart. Remind patient not to eat or drink for 15 minutes after sublingual administration or 1 hour after buccal administration. Max total daily dose: 240 mcg/day for mild to moderate agitation and 360 mcg/day for severe agitation.

Geriatric Adults

120 mcg via sublingual or buccal administration. If agitation persists after the initial dose, two additional doses of 60 mcg per dose may be administered at least 2 hours apart. Remind patient not to eat or drink for 15 minutes after sublingual administration or 1 hour after buccal administration. Max total daily dose: 240 mcg/day.

For preanesthesia sedation†. Intranasal dosage Children†

1 to 2 mcg/kg intranasally (divided and given into both nostrils) as a single dose 30 to 60 minutes before anesthesia induction.

For the treatment of alcohol withdrawal†. Intravenous dosage Adults

0.2 to 1.4 mcg/kg/hour continuous IV infusion. Titrate dose to achieve target clinical score.

†Indicates off-label use

Hepatic Impairment

IV dexmedetomidine: Consider initial dosage reduction in patients with hepatic impairment and titrate to effect.
 
Sublingual film (Igalmi):
Mild to moderate hepatic impairment (Child-Pugh Class A or B): Reduce initial dose to 90 mcg for mild to moderate agitation or 120 mcg for severe agitation. Repeat doses should be limited to 60 mcg regardless of severity of hepatic impairment or agitation.
Severe hepatic impairment (Child-Pugh Class C): Reduce initial dose to 60 mcg for mild to moderate agitation or 90 mcg for severe agitation. Repeat doses should be limited to 60 mcg regardless of severity of hepatic impairment or agitation.

Renal Impairment

Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.

Acebutolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Acetaminophen; Aspirin; Diphenhydramine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Acetaminophen; Caffeine; Dihydrocodeine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Acetaminophen; Caffeine; Pyrilamine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Acetaminophen; Chlorpheniramine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Acetaminophen; Chlorpheniramine; Dextromethorphan: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Acetaminophen; Chlorpheniramine; Dextromethorphan; Pseudoephedrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Acetaminophen; Chlorpheniramine; Phenylephrine : (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Acetaminophen; Codeine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Acetaminophen; Dextromethorphan; Doxylamine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Acetaminophen; Diphenhydramine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Acetaminophen; Hydrocodone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Acetaminophen; Oxycodone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Acetaminophen; Pamabrom; Pyrilamine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Acrivastine; Pseudoephedrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Adagrasib: (Major) Concomitant use of dexmedetomidine and adagrasib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Alfentanil: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Alfuzosin: (Moderate) Concomitant use of dexmedetomidine and alfuzosin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Amiodarone: (Major) Concomitant use of dexmedetomidine and amiodarone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Due to the extremely long half-life of amiodarone, a drug interaction is possible for days to weeks after drug discontinuation.
Amisulpride: (Major) Concomitant use of dexmedetomidine and amisulpride increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Amoxicillin; Clarithromycin; Omeprazole: (Major) Concomitant use of dexmedetomidine and clarithromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Anagrelide: (Major) Concomitant use of dexmedetomidine and anagrelide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Anxiolytics; Sedatives; and Hypnotics: (Moderate) Co-administration of dexmedetomidine with anxiolytics, sedatives, and hypnotics is likely to lead to an enhancement of CNS depression.
Apomorphine: (Moderate) Concomitant use of dexmedetomidine and apomorphine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Aripiprazole: (Moderate) Concomitant use of dexmedetomidine and aripiprazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Arsenic Trioxide: (Major) Concomitant use of dexmedetomidine and arsenic trioxide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Artemether; Lumefantrine: (Major) Concomitant use of dexmedetomidine and artemether increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. (Major) Concomitant use of dexmedetomidine and lumefantrine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Asenapine: (Major) Concomitant use of dexmedetomidine and asenapine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Aspirin, ASA; Carisoprodol; Codeine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Aspirin, ASA; Oxycodone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Atenolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Atenolol; Chlorthalidone: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Atomoxetine: (Minor) QT/QTc prolongation can occur with concomitant use of dexmedetomidine and atomoxetine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Azithromycin: (Major) Concomitant use of dexmedetomidine and azithromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Barbiturates: (Moderate) Co-administration of dexmedetomidine with barbiturates is likely to lead to an enhancement of CNS depression.
Bedaquiline: (Major) Concomitant use of dexmedetomidine and bedaquiline increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Belladonna; Opium: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Benzhydrocodone; Acetaminophen: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Benzodiazepines: (Moderate) Concurrent use of dexmedetomidine and benzodiazepines may result in additive CNS depression. A reduction in dosage of dexmedetomidine or the benzodiazepine may be required.
Beta-blockers (without QT/QTc prolongation): (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Betaxolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Bismuth Subcitrate Potassium; Metronidazole; Tetracycline: (Moderate) Concomitant use of dexmedetomidine and metronidazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Concomitant use of dexmedetomidine and metronidazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Bisoprolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Brimonidine; Timolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Brompheniramine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Brompheniramine; Dextromethorphan; Phenylephrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Brompheniramine; Phenylephrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Brompheniramine; Pseudoephedrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Brompheniramine; Pseudoephedrine; Dextromethorphan: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Buprenorphine: (Moderate) If concurrent use of dexmedetomidine and buprenorphine is necessary, consider a dose reduction of one or both drugs because of the potential for additive pharmacological effects. Hypotension, profound sedation, coma, respiratory depression, or death may occur during co-administration of buprenorphine and other CNS depressants. Monitor patients for sedation or respiratory depression.
Buprenorphine; Naloxone: (Moderate) If concurrent use of dexmedetomidine and buprenorphine is necessary, consider a dose reduction of one or both drugs because of the potential for additive pharmacological effects. Hypotension, profound sedation, coma, respiratory depression, or death may occur during co-administration of buprenorphine and other CNS depressants. Monitor patients for sedation or respiratory depression.
Butalbital; Acetaminophen; Caffeine; Codeine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Butalbital; Aspirin; Caffeine; Codeine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Cabotegravir; Rilpivirine: (Moderate) Concomitant use of dexmedetomidine and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Calcium-channel blockers: (Moderate) Concomitant administration of dexmedetomidine and calcium-channel blockers could lead to additive hypotension and bradycardia; use together with caution. Dexmedetomidine can produce bradycardia or AV block and should be used cautiously in patients who are receiving antihypertensive drugs that may lower the heart rate such as calcium-channel blockers.
Cannabidiol: (Moderate) Monitor for excessive sedation and somnolence during coadministration of cannabidiol and dexmedetomidine. CNS depressants can potentiate the effects of cannabidiol.
Carbinoxamine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Cardiac glycosides: (Moderate) Dexmedetomidine has been associated with hypotension and bradycardia, and should be administered cautiously in combination with cardiac glycosides, such as digoxin, or other negative chronotropic agents.
Carteolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Carvedilol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Celecoxib; Tramadol: (Moderate) Concomitant use of tramadol with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Cenobamate: (Moderate) Although CNS depression is a desired effect of dexmedetomidine, monitor patients also receiving cenobamate closely for additive CNS depression that may prolong recovery after administration of dexmedetomidine.
Ceritinib: (Major) Concomitant use of dexmedetomidine and ceritinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Cetirizine: (Moderate) Concurrent use of cetirizine/levocetirizine with dexmedetomidine should generally be avoided. Coadministration may increase the risk of CNS depressant-related side effects. CNS depression is a desired effect of dexmedetomidine; however, concurrent use with a CNS depressant may prolong recovery. If concurrent use is necessary, monitor patients closely.
Cetirizine; Pseudoephedrine: (Moderate) Concurrent use of cetirizine/levocetirizine with dexmedetomidine should generally be avoided. Coadministration may increase the risk of CNS depressant-related side effects. CNS depression is a desired effect of dexmedetomidine; however, concurrent use with a CNS depressant may prolong recovery. If concurrent use is necessary, monitor patients closely.
Chlophedianol; Dexbrompheniramine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlophedianol; Dexchlorpheniramine; Pseudoephedrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlorcyclizine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chloroquine: (Major) Concomitant use of dexmedetomidine and chloroquine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Chlorpheniramine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlorpheniramine; Codeine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect. (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlorpheniramine; Dextromethorphan: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlorpheniramine; Dextromethorphan; Phenylephrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlorpheniramine; Dextromethorphan; Pseudoephedrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlorpheniramine; Dihydrocodeine; Phenylephrine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect. (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlorpheniramine; Hydrocodone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect. (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlorpheniramine; Ibuprofen; Pseudoephedrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlorpheniramine; Phenylephrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlorpheniramine; Pseudoephedrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Chlorpromazine: (Major) Concomitant use of dexmedetomidine and chlorpromazine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. In addition, consider a dosage reduction for dexmedetomidine or chlorpromazine during concomitant use due to the risk of additive CNS effects.
Ciprofloxacin: (Moderate) Concomitant use of dexmedetomidine and ciprofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Cisapride: (Contraindicated) Avoid concomitant use of dexmedetomidine and cisapride due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Citalopram: (Major) Concomitant use of dexmedetomidine and citalopram increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Clarithromycin: (Major) Concomitant use of dexmedetomidine and clarithromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Clemastine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Clofazimine: (Moderate) Concomitant use of dexmedetomidine and clofazimine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Clozapine: (Moderate) Concomitant use of dexmedetomidine and clozapine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Codeine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Codeine; Guaifenesin: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Codeine; Guaifenesin; Pseudoephedrine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Codeine; Phenylephrine; Promethazine: (Moderate) Concomitant use of dexmedetomidine and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. In addition, consider a dosage reduction for dexmedetomidine or promethazine during concomitant use due to the risk of additive CNS effects. (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Codeine; Promethazine: (Moderate) Concomitant use of dexmedetomidine and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. In addition, consider a dosage reduction for dexmedetomidine or promethazine during concomitant use due to the risk of additive CNS effects. (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
COMT inhibitors: (Moderate) COMT inhibitors should be given cautiously with other agents that cause CNS depression, including dexmedetomidine, due to the possibility of additive sedation. COMT inhibitors have also been associated with sudden sleep onset during activities of daily living such as driving, which has resulted in accidents in some cases. Prescribers should re-assess patients for drowsiness or sleepiness regularly throughout treatment, especially since events may occur well after the start of treatment. Monitor patients closely for additive effects that may prolong recovery from dexmedetomidine administration.
Crizotinib: (Major) Concomitant use of dexmedetomidine and crizotinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Cyclizine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Cyproheptadine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Dasatinib: (Moderate) Concomitant use of dexmedetomidine and dasatinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Degarelix: (Moderate) Concomitant use of dexmedetomidine and androgen deprivation therapy (i.e., degarelix) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Desflurane: (Major) Concomitant use of dexmedetomidine and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. In addition, consider a dosage reduction for dexmedetomidine or the anesthetic during concomitant use due to the risk of additive CNS effects.
Deutetrabenazine: (Moderate) Concurrent use of deutetrabenazine and drugs that can cause CNS depression, such as dexmedetomidine, may have additive effects and worsen drowsiness or sedation. Advise patients about worsened somnolence and not to drive or perform other tasks requiring mental alertness until they know how deutetrabenazine affects them.
Dexbrompheniramine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Dexbrompheniramine; Pseudoephedrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Dexchlorpheniramine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Dexchlorpheniramine; Dextromethorphan; Pseudoephedrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Dextromethorphan; Diphenhydramine; Phenylephrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Dextromethorphan; Quinidine: (Major) Concomitant use of dexmedetomidine and quinidine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Diazoxide: (Moderate) Concomitant administration of dexmedetomidine and vasodilators could lead to additive hypotension and bradycardia; use together with caution. In clinical trials where vasodilators were co-administered with dexmedetomidine an additive pharmacodynamic effect was not observed. However, both vasodilators and dexmeditomidine may cause symptomatic hypotension. If hypotension occurs, dose reduction of one or both drugs may be needed and supportive measures instituted.
Difelikefalin: (Moderate) Monitor for dizziness, somnolence, mental status changes, and gait disturbances if concomitant use of difelikefalin with CNS depressants is necessary. Concomitant use may increase the risk for these adverse reactions.
Digoxin: (Moderate) Dexmedetomidine has been associated with hypotension and bradycardia, and should be administered cautiously in combination with cardiac glycosides, such as digoxin, or other negative chronotropic agents.
Dimenhydrinate: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Diphenhydramine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Diphenhydramine; Ibuprofen: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Diphenhydramine; Naproxen: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Diphenhydramine; Phenylephrine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Disopyramide: (Major) Concomitant use of dexmedetomidine and disopyramide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Dofetilide: (Major) Concomitant use of dexmedetomidine and dofetilide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Dolasetron: (Moderate) Concomitant use of dexmedetomidine and dolasetron may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Dolutegravir; Rilpivirine: (Moderate) Concomitant use of dexmedetomidine and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Donepezil: (Moderate) Concomitant use of dexmedetomidine and donepezil may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Donepezil; Memantine: (Moderate) Concomitant use of dexmedetomidine and donepezil may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Dorzolamide; Timolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Doxylamine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Doxylamine; Pyridoxine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Dronedarone: (Contraindicated) Avoid concomitant use of dexmedetomidine and dronedarone due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Droperidol: (Moderate) Co-administration of dexmedetomidine with droperidol is likely to lead to an enhancement of CNS depression.
Efavirenz: (Moderate) Concomitant use of dexmedetomidine and efavirenz may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Efavirenz; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Concomitant use of dexmedetomidine and efavirenz may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Concomitant use of dexmedetomidine and efavirenz may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Eliglustat: (Minor) QT/QTc prolongation can occur with concomitant use of dexmedetomidine and eliglustat although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Emtricitabine; Rilpivirine; Tenofovir alafenamide: (Moderate) Concomitant use of dexmedetomidine and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Emtricitabine; Rilpivirine; Tenofovir Disoproxil Fumarate: (Moderate) Concomitant use of dexmedetomidine and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Encorafenib: (Major) Concomitant use of dexmedetomidine and encorafenib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Entrectinib: (Major) Concomitant use of dexmedetomidine and entrectinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Eribulin: (Major) Concomitant use of dexmedetomidine and eribulin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Erythromycin: (Major) Concomitant use of dexmedetomidine and erythromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Escitalopram: (Moderate) Concomitant use of dexmedetomidine and escitalopram may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Esketamine: (Moderate) Closely monitor patients receiving esketamine and dexmedetomidine for sedation and other CNS depressant effects. Instruct patients who receive a dose of esketamine not to drive or engage in other activities requiring alertness until the next day after a restful sleep.
Esmolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Ethanol: (Major) Advise patients to avoid alcohol consumption while taking CNS depressants. Alcohol consumption may result in additive CNS depression.
Etomidate: (Moderate) Consider a dosage reduction for dexmedetomidine or the general anesthetic during concomitant use due to the risk of additive CNS effects.
Fenfluramine: (Moderate) Monitor for excessive sedation and somnolence during coadministration of fenfluramine and dexmedetomidine. Concurrent use may result in additive CNS depression.
Fenoldopam: (Moderate) Concomitant administration of dexmedetomidine and vasodilators could lead to additive hypotension and bradycardia; use together with caution. In clinical trials where vasodilators were co-administered with dexmedetomidine an additive pharmacodynamic effect was not observed. However, both vasodilators and dexmeditomidine may cause symptomatic hypotension. If hypotension occurs, dose reduction of one or both drugs may be needed and supportive measures instituted.
Fentanyl: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Fingolimod: (Moderate) Concomitant use of dexmedetomidine and fingolimod may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Flecainide: (Major) Concomitant use of dexmedetomidine and flecainide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Fluconazole: (Moderate) Concomitant use of dexmedetomidine and fluconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Fluoxetine: (Moderate) Concomitant use of dexmedetomidine and fluoxetine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Fluphenazine: (Moderate) Consider a dosage reduction for dexmedetomidine or the phenothiazine during concomitant use due to the risk of additive CNS effects.
Fluvoxamine: (Minor) QT/QTc prolongation can occur with concomitant use of dexmedetomidine and fluvoxamine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Food: (Major) Advise patients to avoid cannabis use while taking CNS depressants due to the risk for additive CNS depression and potential for other cognitive adverse reactions.
Foscarnet: (Major) Concomitant use of dexmedetomidine and foscarnet increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Fostemsavir: (Moderate) Concomitant use of dexmedetomidine and fostemsavir may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with fostemsavir is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 4 times the recommended daily dose.
Gabapentin: (Moderate) Monitor for excessive sedation, somnolence, and respiratory depression during coadministration of dexmedetomidine and gabapentin. Concurrent use may result in additive CNS and respiratory depression.
Gemifloxacin: (Moderate) Concomitant use of dexmedetomidine and gemifloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Gemtuzumab Ozogamicin: (Moderate) Concomitant use of dexmedetomidine and gemtuzumab ozogamicin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
General anesthetics (selected): (Moderate) Consider a dosage reduction for dexmedetomidine or the general anesthetic during concomitant use due to the risk of additive CNS effects.
Gilteritinib: (Moderate) Concomitant use of dexmedetomidine and gilteritinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Glasdegib: (Major) Concomitant use of dexmedetomidine and glasdegib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Goserelin: (Moderate) Concomitant use of dexmedetomidine and androgen deprivation therapy (i.e., goserelin) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Granisetron: (Moderate) Concomitant use of dexmedetomidine and granisetron may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Guaifenesin; Hydrocodone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Halogenated Anesthetics: (Major) Concomitant use of dexmedetomidine and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. In addition, consider a dosage reduction for dexmedetomidine or the anesthetic during concomitant use due to the risk of additive CNS effects.
Haloperidol: (Moderate) Concomitant use of dexmedetomidine and haloperidol may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The intravenous route may carry a higher risk for haloperidol-induced QT/QTc prolongation than other routes of administration.
Histrelin: (Moderate) Concomitant use of dexmedetomidine and androgen deprivation therapy (i.e., histrelin) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Homatropine; Hydrocodone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Hydralazine: (Moderate) Concomitant administration of dexmedetomidine and vasodilators could lead to additive hypotension and bradycardia; use together with caution. In clinical trials where vasodilators were co-administered with dexmedetomidine an additive pharmacodynamic effect was not observed. However, both vasodilators and dexmeditomidine may cause symptomatic hypotension. If hypotension occurs, dose reduction of one or both drugs may be needed and supportive measures instituted.
Hydralazine; Isosorbide Dinitrate, ISDN: (Moderate) Concomitant administration of dexmedetomidine and vasodilators could lead to additive hypotension and bradycardia; use together with caution. In clinical trials where vasodilators were co-administered with dexmedetomidine an additive pharmacodynamic effect was not observed. However, both vasodilators and dexmeditomidine may cause symptomatic hypotension. If hypotension occurs, dose reduction of one or both drugs may be needed and supportive measures instituted.
Hydrocodone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Hydrocodone; Ibuprofen: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Hydrocodone; Pseudoephedrine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Hydromorphone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Hydroxychloroquine: (Major) Concomitant use of dexmedetomidine and hydroxychloroquine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc

interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Hydroxyzine: (Moderate) Concomitant use of dexmedetomidine and hydroxyzine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. In addition, consider a dosage reduction for dexmedetomidine or hydroxyzine during concomitant use due to the risk of additive CNS effects.
Ibuprofen; Oxycodone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Ibutilide: (Major) Concomitant use of dexmedetomidine and ibutilide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Iloperidone: (Major) Concomitant use of dexmedetomidine and iloperidone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Inotuzumab Ozogamicin: (Major) Concomitant use of dexmedetomidine and inotuzumab ozogamicin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Isoflurane: (Major) Concomitant use of dexmedetomidine and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. In addition, consider a dosage reduction for dexmedetomidine or the anesthetic during concomitant use due to the risk of additive CNS effects.
Itraconazole: (Moderate) Concomitant use of dexmedetomidine and itraconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Ivosidenib: (Major) Concomitant use of dexmedetomidine and ivosidenib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ketamine: (Moderate) Consider a dosage reduction for dexmedetomidine or the general anesthetic during concomitant use due to the risk of additive CNS effects.
Ketoconazole: (Contraindicated) Avoid concomitant use of dexmedetomidine and ketoconazole due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Labetalol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Lansoprazole; Amoxicillin; Clarithromycin: (Major) Concomitant use of dexmedetomidine and clarithromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Lapatinib: (Moderate) Concomitant use of dexmedetomidine and lapatinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Lasmiditan: (Moderate) Although CNS depression is a desired effect of dexmedetomidine, patients also receiving lasmiditan should be closely monitored for additive effects that may prolong recovery after administration of dexmedetomidine.
Lefamulin: (Major) Concomitant use of dexmedetomidine and lefamulin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Lemborexant: (Moderate) Although CNS depression is a desired effect of dexmedetomidine, patients also receiving lemborexant should be closely monitored for additive effects that may prolong recovery after administration of dexmedetomidine.
Lenvatinib: (Major) Concomitant use of dexmedetomidine and lenvatinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Leuprolide: (Moderate) Concomitant use of dexmedetomidine and androgen deprivation therapy (i.e., leuprolide) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Leuprolide; Norethindrone: (Moderate) Concomitant use of dexmedetomidine and androgen deprivation therapy (i.e., leuprolide) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Levobunolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Levocetirizine: (Moderate) Concurrent use of cetirizine/levocetirizine with dexmedetomidine should generally be avoided. Coadministration may increase the risk of CNS depressant-related side effects. CNS depression is a desired effect of dexmedetomidine; however, concurrent use with a CNS depressant may prolong recovery. If concurrent use is necessary, monitor patients closely.
Levofloxacin: (Moderate) Concomitant use of dexmedetomidine and levofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Levoketoconazole: (Contraindicated) Avoid concomitant use of dexmedetomidine and ketoconazole due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Levorphanol: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Lithium: (Moderate) Concomitant use of dexmedetomidine and lithium may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Lofexidine: (Major) Concomitant use of dexmedetomidine and lofexidine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Loperamide: (Moderate) Concomitant use of dexmedetomidine and loperamide may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Loperamide; Simethicone: (Moderate) Concomitant use of dexmedetomidine and loperamide may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Lopinavir; Ritonavir: (Major) Concomitant use of dexmedetomidine and lopinavir; ritonavir increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. (Moderate) Use caution if ritonavir is coadministered with dexmedetomidine due to the potential for decreased dexmedetomidine exposure which may decrease its efficacy. Limited data suggests that dexmedetomidine is metabolized by several enzymes, including CYP2C19. Ritonavir is an inducer of CYP2C19.
Lumateperone: (Moderate) Monitor for excessive sedation and somnolence during coadministration of lumateperone and dexmedetomidine. Concurrent use may result in additive CNS depression. Although CNS depression is a desired effect of dexmedetomidine, monitor patients closely for additive effects that may prolong recovery.
Macimorelin: (Major) Concomitant use of dexmedetomidine and macimorelin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Maprotiline: (Minor) QT/QTc prolongation can occur with concomitant use of dexmedetomidine and maprotiline although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Meclizine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Mefloquine: (Minor) QT/QTc prolongation can occur with concomitant use of dexmedetomidine and mefloquine although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Meperidine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Methadone: (Major) Concomitant use of dexmedetomidine and methadone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. In addition, if concomitant use is necessary, consider a dose reduction of one or both drugs because of the potential for additive pharmacological effects. Hypotension, profound sedation, coma, respiratory depression, or death may occur during coadministration of methadone and other CNS depressants. Prior to concurrent use of methadone in patients taking a CNS depressant, assess the level of tolerance to CNS depression that has developed, the duration of use, and the patient's overall response to treatment. Evaluate the patient's use of alcohol or illicit drugs. Monitor patients for sedation or respiratory depression.
Methocarbamol: (Moderate) Due to the anesthetic effects of dexmedetomidine, concurrent use with other CNS depressants, such as skeletal muscle relaxants, could result in additive sedative effects and possibly prolong recovery from anesthesia.
Metoprolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Metronidazole: (Moderate) Concomitant use of dexmedetomidine and metronidazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Midostaurin: (Major) Concomitant use of dexmedetomidine and midostaurin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Mifepristone: (Major) Concomitant use of dexmedetomidine and mifepristone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Minoxidil: (Moderate) Concomitant administration of dexmedetomidine and vasodilators could lead to additive hypotension and bradycardia; use together with caution. In clinical trials where vasodilators were co-administered with dexmedetomidine an additive pharmacodynamic effect was not observed. However, both vasodilators and dexmeditomidine may cause symptomatic hypotension. If hypotension occurs, dose reduction of one or both drugs may be needed and supportive measures instituted.
Mirtazapine: (Moderate) Concomitant use of dexmedetomidine and mirtazapine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Mobocertinib: (Major) Concomitant use of dexmedetomidine and mobocertinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Morphine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Morphine; Naltrexone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Moxifloxacin: (Major) Concomitant use of dexmedetomidine and moxifloxacin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Nabilone: (Moderate) Monitor for excessive sedation and somnolence during coadministration of nabilone and dexmedetomidine. Concurrent use may result in additive CNS depression. CNS depression is a desired effect of dexmedetomidine; monitor patients closely for additive effects that may prolong recovery.
Nadolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Nebivolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Nebivolol; Valsartan: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Nesiritide, BNP: (Moderate) Concomitant administration of dexmedetomidine and nesiritide could lead to additive hypotension and bradycardia; use together with caution. In clinical trials where other vasodilators were co-administered with dexmedetomidine an additive pharmacodynamic effect was not observed. Nonetheless, both drugs may cause symptomatic hypotension. If hypotension occurs, dose reduction of one or both infusions may be needed and supportive measures instituted.
Nilotinib: (Major) Concomitant use of dexmedetomidine and nilotinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Nirmatrelvir; Ritonavir: (Moderate) Use caution if ritonavir is coadministered with dexmedetomidine due to the potential for decreased dexmedetomidine exposure which may decrease its efficacy. Limited data suggests that dexmedetomidine is metabolized by several enzymes, including CYP2C19. Ritonavir is an inducer of CYP2C19.
Nitroprusside: (Moderate) Concomitant administration of dexmedetomidine and vasodilators could lead to additive hypotension and bradycardia; use together with caution. In clinical trials where vasodilators were co-administered with dexmedetomidine an additive pharmacodynamic effect was not observed. However, both vasodilators and dexmeditomidine may cause symptomatic hypotension. If hypotension occurs, dose reduction of one or both drugs may be needed and supportive measures instituted.
Ofloxacin: (Moderate) Concomitant use of dexmedetomidine and ofloxacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Olanzapine: (Moderate) Concomitant use of dexmedetomidine and olanzapine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Olanzapine; Fluoxetine: (Moderate) Concomitant use of dexmedetomidine and fluoxetine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. (Moderate) Concomitant use of dexmedetomidine and olanzapine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Olanzapine; Samidorphan: (Moderate) Concomitant use of dexmedetomidine and olanzapine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Oliceridine: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Ondansetron: (Major) Concomitant use of dexmedetomidine and ondansetron increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Do not exceed 16 mg of IV ondansetron in a single dose; the degree of QT prolongation associated with ondansetron significantly increases above this dose.
Opioid medications (selected): (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Osilodrostat: (Moderate) Concomitant use of dexmedetomidine and osilodrostat may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Osimertinib: (Major) Concomitant use of dexmedetomidine and osimertinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Oxaliplatin: (Major) Concomitant use of dexmedetomidine and oxaliplatin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Oxycodone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Oxymorphone: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Ozanimod: (Major) Concomitant use of dexmedetomidine and ozanimod increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Ozanimod has a limited effect on the QT/QTc interval at therapeutic doses but may cause bradycardia and atrioventricular conduction delays which may increase the risk for TdP in patients with a prolonged QT/QTc interval.
Pacritinib: (Major) Concomitant use of dexmedetomidine and pacritinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Paliperidone: (Major) Concomitant use of dexmedetomidine and paliperidone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Panobinostat: (Major) Concomitant use of dexmedetomidine and panobinostat increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pasireotide: (Moderate) Concomitant use of dexmedetomidine and pasireotide may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Pazopanib: (Major) Concomitant use of dexmedetomidine and pazopanib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pentamidine: (Major) Concomitant use of dexmedetomidine and systemic pentamidine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Perphenazine: (Moderate) Consider a dosage reduction for dexmedetomidine or perphenazine during concomitant use due to the risk of additive CNS effects. QT/QTc prolongation can also occur with concomitant use, although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Perphenazine; Amitriptyline: (Moderate) Consider a dosage reduction for dexmedetomidine or perphenazine during concomitant use due to the risk of additive CNS effects. QT/QTc prolongation can also occur with concomitant use, although the risk of developing torsade de pointes (TdP) is low. Additional steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, may be considered in patients with additional risk factors for TdP.
Phenothiazines (selected): (Moderate) Consider a dosage reduction for dexmedetomidine or the phenothiazine during concomitant use due to the risk of additive CNS effects.
Pimavanserin: (Major) Concomitant use of dexmedetomidine and pimavanserin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Pimozide: (Contraindicated) Avoid concomitant use of dexmedetomidine and pimozide due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation.
Pindolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Pitolisant: (Major) Concomitant use of dexmedetomidine and pitolisant increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ponesimod: (Major) Concomitant use of dexmedetomidine and ponesimod increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. Ponesimod has a limited effect on the QT/QTc interval at therapeutic doses but may cause bradycardia and atrioventricular conduction delays which may increase the risk for TdP in patients with a prolonged QT/QTc interval.
Posaconazole: (Moderate) Concomitant use of dexmedetomidine and posaconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Pregabalin: (Moderate) Monitor for excessive sedation, somnolence, and respiratory depression during coadministration of dexmedetomidine and pregabalin. Concurrent use may result in additive CNS and respiratory depression.
Primaquine: (Moderate) Concomitant use of dexmedetomidine and primaquine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Procainamide: (Major) Concomitant use of dexmedetomidine and procainamide increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Prochlorperazine: (Moderate) Consider a dosage reduction for dexmedetomidine or the phenothiazine during concomitant use due to the risk of additive CNS effects.
Promethazine: (Moderate) Concomitant use of dexmedetomidine and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. In addition, consider a dosage reduction for dexmedetomidine or promethazine during concomitant use due to the risk of additive CNS effects.
Promethazine; Dextromethorphan: (Moderate) Concomitant use of dexmedetomidine and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. In addition, consider a dosage reduction for dexmedetomidine or promethazine during concomitant use due to the risk of additive CNS effects.
Promethazine; Phenylephrine: (Moderate) Concomitant use of dexmedetomidine and promethazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. In addition, consider a dosage reduction for dexmedetomidine or promethazine during concomitant use due to the risk of additive CNS effects.
Propafenone: (Major) Concomitant use of dexmedetomidine and propafenone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Propofol: (Moderate) Consider a dosage reduction for dexmedetomidine or the general anesthetic during concomitant use due to the risk of additive CNS effects.
Propranolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Propranolol; Hydrochlorothiazide, HCTZ: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Pseudoephedrine; Triprolidine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Pyrilamine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Quetiapine: (Major) Concomitant use of dexmedetomidine and quetiapine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Quinidine: (Major) Concomitant use of dexmedetomidine and quinidine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Quinine: (Major) Concomitant use of dexmedetomidine and quinine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Quizartinib: (Major) Concomitant use of dexmedetomidine and quizartinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ranolazine: (Moderate) Concomitant use of dexmedetomidine and ranolazine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Relugolix: (Moderate) Concomitant use of dexmedetomidine and androgen deprivation therapy (i.e., relugolix) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Relugolix; Estradiol; Norethindrone acetate: (Moderate) Concomitant use of dexmedetomidine and androgen deprivation therapy (i.e., relugolix) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Remifentanil: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Ribociclib: (Major) Concomitant use of dexmedetomidine and ribociclib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Ribociclib; Letrozole: (Major) Concomitant use of dexmedetomidine and ribociclib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Rilpivirine: (Moderate) Concomitant use of dexmedetomidine and rilpivirine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with rilpivirine is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Risperidone: (Moderate) Concomitant use of dexmedetomidine and risperidone may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Ritonavir: (Moderate) Use caution if ritonavir is coadministered with dexmedetomidine due to the potential for decreased dexmedetomidine exposure which may decrease its efficacy. Limited data suggests that dexmedetomidine is metabolized by several enzymes, including CYP2C19. Ritonavir is an inducer of CYP2C19.
Romidepsin: (Moderate) Concomitant use of dexmedetomidine and romidepsin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Saquinavir: (Major) Concomitant use of dexmedetomidine and saquinavir increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Sedating H1-blockers (selected): (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Selpercatinib: (Major) Concomitant use of dexmedetomidine and selpercatinib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Sertraline: (Moderate) Concomitant use of dexmedetomidine and sertraline may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with sertraline is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 2 times the maximum recommended dose.
Sevoflurane: (Major) Concomitant use of dexmedetomidine and halogenated anesthetics increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary. In addition, consider a dosage reduction for dexmedetomidine or the anesthetic during concomitant use due to the risk of additive CNS effects.
Siponimod: (Major) Concomitant use of dexmedetomidine and siponimod increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Skeletal Muscle Relaxants: (Moderate) Due to the anesthetic effects of dexmedetomidine, concurrent use with other CNS depressants, such as skeletal muscle relaxants, could result in additive sedative effects and possibly prolong recovery from anesthesia. Dosage adjustments of either or both medications may be necessary.
Sodium Stibogluconate: (Moderate) Concomitant use of dexmedetomidine and sodium stibogluconate may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Solifenacin: (Moderate) Concomitant use of dexmedetomidine and solifenacin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Sorafenib: (Major) Concomitant use of dexmedetomidine and sorafenib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Sotalol: (Major) Concomitant use of dexmedetomidine and sotalol increases the risk of QT/QTc prolongation, torsade de pointes (TdP), bradycardia, and hypotension. Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Stiripentol: (Moderate) Monitor for excessive sedation and somnolence during coadministration of stiripentol and dexmedetomidine. CNS depressants can potentiate the effects of stiripentol.
Sufentanil: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Sunitinib: (Moderate) Concomitant use of dexmedetomidine and sunitinib may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Tacrolimus: (Moderate) Concomitant use of dexmedetomidine and tacrolimus may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Tamoxifen: (Moderate) Concomitant use of dexmedetomidine and tamoxifen may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Tapentadol: (Moderate) Concomitant use of opioid agonists with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Telavancin: (Moderate) Concomitant use of dexmedetomidine and telavancin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Tetrabenazine: (Major) Concomitant use of dexmedetomidine and tetrabenazine increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Thioridazine: (Contraindicated) Avoid concomitant use of dexmedetomidine and thioridazine due to an increased risk for torsade de pointes (TdP) and QT/QTc prolongation. In addition, concomitant use may also increase risk of additive CNS effects.
Timolol: (Moderate) Monitor blood pressure and heart rate during concomitant use of dexmedetomidine and beta-blockers due to the risk of additive bradycardia and hypotensive effects.
Tizanidine: (Moderate) Due to the anesthetic effects of dexmedetomidine, concurrent use with other CNS depressants, such as skeletal muscle relaxants, could result in additive sedative effects and possibly prolong recovery from anesthesia.
Tolterodine: (Moderate) Concomitant use of dexmedetomidine and tolterodine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The risk for tolterodine-associated QT/QTc prolongation may be increased in poor CYP2D6 metabolizers.
Toremifene: (Major) Concomitant use of dexmedetomidine and toremifene increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Tramadol: (Moderate) Concomitant use of tramadol with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Tramadol; Acetaminophen: (Moderate) Concomitant use of tramadol with dexmedetomidine may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opioid pain medication with dexmedetomidine to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect.
Trazodone: (Major) Concomitant use of dexmedetomidine and trazodone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Treprostinil: (Moderate) Concomitant administration of dexmedetomidine and treprostinil could lead to additive hypotension; use together with caution. Both agents are associated with a risk for hypotension. In clinical trials where other vasodilators were coadministered with dexmedetomidine injection an additive pharmacodynamic effect was not observed. Nonetheless, caution should be used when such agents are administered concomitantly with dexmedetomidine.
Triclabendazole: (Moderate) Concomitant use of dexmedetomidine and triclabendazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Trifluoperazine: (Moderate) Consider a dosage reduction for dexmedetomidine or the phenothiazine during concomitant use due to the risk of additive CNS effects.
Triprolidine: (Moderate) Consider a dosage reduction for dexmedetomidine or the sedating antihistamine during concomitant use due to the risk of additive CNS effects.
Triptorelin: (Moderate) Concomitant use of dexmedetomidine and androgen deprivation therapy (i.e., triptorelin) may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Vandetanib: (Major) Concomitant use of dexmedetomidine and vandetanib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Vardenafil: (Moderate) Concomitant use of dexmedetomidine and vardenafil may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Vasodilators: (Moderate) Concomitant administration of dexmedetomidine and vasodilators could lead to additive hypotension and bradycardia; use together with caution. In clinical trials where vasodilators were co-administered with dexmedetomidine an additive pharmacodynamic effect was not observed. However, both vasodilators and dexmeditomidine may cause symptomatic hypotension. If hypotension occurs, dose reduction of one or both drugs may be needed and supportive measures instituted.
Vemurafenib: (Major) Concomitant use of dexmedetomidine and vemurafenib increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Venlafaxine: (Moderate) Concomitant use of dexmedetomidine and venlafaxine may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Voclosporin: (Moderate) Concomitant use of dexmedetomidine and voclosporin may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP. The degree of QT prolongation associated with voclosporin is not clinically significant when administered within the recommended dosage range; QT prolongation has been described at 3 times the maximum recommended dose.
Vonoprazan; Amoxicillin; Clarithromycin: (Major) Concomitant use of dexmedetomidine and clarithromycin increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.
Voriconazole: (Moderate) Concomitant use of dexmedetomidine and voriconazole may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Vorinostat: (Moderate) Concomitant use of dexmedetomidine and vorinostat may increase the risk of QT/QTc prolongation and torsade de pointes (TdP) in some patients. Consider taking steps to minimize the risk of QT/QTc interval prolongation and TdP, such as avoidance, electrolyte monitoring and repletion, and ECG monitoring, especially in patients with additional risk factors for TdP.
Ziprasidone: (Major) Concomitant use of dexmedetomidine and ziprasidone increases the risk of QT/QTc prolongation and torsade de pointes (TdP). Avoid concomitant use if possible, especially in patients with additional risk factors for TdP. Consider taking steps to minimize the risk for QT/QTc interval prolongation and TdP, such as electrolyte monitoring and repletion and ECG monitoring, if concomitant use is necessary.

Dexmedetomidine/Dexmedetomidine Hydrochloride/Precedex Intravenous Inj Sol: 1mL, 4mcg, 100mcg
IGALMI Buccal Film: 120mcg, 180mg
IGALMI Sublingual Film: 120mcg, 180mg

Adults

1 mcg/kg IV loading dose and 1.5 mcg/kg/hour continuous IV infusion; 180 mcg as initial single dose maximum and do not exceed 360 mcg/day total for sublingual film.

Geriatric

1 mcg/kg IV loading dose and 1.5 mcg/kg/hour continuous IV infusion; 120 mcg as initial single dose maximum and do not exceed 240 mcg/day total for sublingual film.

Adolescents

2 mcg/kg IV loading dose and 1.5 mcg/kg/hour continuous IV infusion are FDA-approved maximums; however, doses up to 2.5 mcg/kg/hour continuous IV infusion have been used off-label. Doses up to 4 mcg/kg/dose intranasally used off-label for procedural sedation.

Children

2 to 12 years: 2 mcg/kg IV loading dose and 1.5 mcg/kg/hour continuous IV infusion are FDA-approved maximums; however, doses up to 2.5 mcg/kg/hour continuous IV infusion have been used off-label. Doses up to 4 mcg/kg/dose intranasally used off-label for procedural sedation.
1 year: 1.5 mcg/kg IV loading dose and 1.5 mcg/kg/hour continuous IV infusion are FDA-approved maximums; however, doses up to 2.5 mcg/kg/hour continuous IV infusion have been used off-label. Doses up to 4 mcg/kg/dose intranasally used off-label for procedural sedation.

Infants

6 to 11 months: 1.5 mcg/kg IV loading dose and 1.5 mcg/kg/hour continuous IV infusion are FDA-approved maximums; however, doses up to 2.5 mcg/kg/hour continuous IV infusion have been used off-label. Doses up to 4 mcg/kg/dose intranasally used off-label for procedural sedation.
1 to 5 months: 1.5 mcg/kg IV loading dose and 1.5 mcg/kg/hour continuous IV infusion are FDA-approved maximums; however, doses up to 2.5 mcg/kg/hour continuous IV infusion have been used off-label. Doses up to 3 mcg/kg/dose intranasally used off-label for procedural sedation.

Neonates

Term Neonates: Safety and efficacy have not been established; however, loading doses up to 0.5 mcg/kg IV and continuous infusions up to 2.5 mcg/kg/hour IV have been used off-label.
Premature Neonates: Safety and efficacy have not been established; however, loading doses up to 0.5 mcg/kg IV and continuous infusions up to 1.2 mcg/kg/hour IV have been used off-label.

Dexmedetomidine is a relatively selective, centrally-acting, alpha2-adrenergic agonist with sedative, analgesic, and sympatholytic properties but without significant ventilatory effects. Selectivity for the alpha2-receptors is observed in animals after slow intravenous (IV) infusion of dosages ranging from 10 to 300 mcg/kg. Both alpha1 and alpha2 activity is observed after slow IV infusion of very high doses (1,000 mcg/kg or more) or with rapid IV administration. Dexmedetomidine is 8 times more specific for alpha2-receptors than clonidine; activity ratios of alpha2:alpha1 activity are 1,620:1 and 220:1 for dexmedetomidine and clonidine, respectively.[29112] [54692]
 
In general, presynaptic activation of alpha2-receptors inhibits the release of norepinephrine and terminates the propagation of pain signals. Postsynaptic activation of alpha2-receptors in the central nervous system (CNS) inhibits sympathetic activity and therefore decreases blood pressure and heart rate. Together, the presynaptic and postsynaptic actions produce sedation, analgesia, and anxiolysis. The analgesic effect of dexmedetomidine is not clearly understood. It is believed that the drug may somehow regulate the transmission of nociceptive signals at both CNS and peripheral sites. In addition, it is known that alpha2-agonism activates G1-protein-gated potassium channels, preventing neuronal firing, and reduces G0-protein-mediated calcium conductance into the cells, inhibiting neurotransmitter release. High densities of alpha2-receptors are found in the locus coeruleus, a predominate noradrenergic center in the brain, which not only modulates alertness but is the site of origin for the descending medullospinal noradrenergic pathway, an important modulator of nociceptive transmission. Dexmedetomidine also directly stimulates alpha2-receptors in the spinal cord, inhibiting nociceptive neuronal firing and the release of substance P.[54692]
 
Alpha2-receptor agonists reduce blood pressure, heart rate, and plasma catecholamine concentrations; hypotension and bradycardia occur in a dose-dependent manner. Rapid injection of dexmedetomidine activates alpha2-receptors in peripheral blood vessels, resulting in transient hypertension and significant reflex bradycardia. Dexmedetomidine does not alter respiratory rate or oxygen saturation at the recommended dosage. The sympathetic effects of dexmedetomidine may attenuate myocardial oxygen requirements and myocardial oxygen consumption, as well as increase endocardial/epicardial blood flow ratios. Other physiologic responses to alpha2-receptor activation outside the CNS include decreased salivation, secretion, and bowel motility in the gastrointestinal tract; contraction of vascular and smooth muscle; inhibition of renin release, increased glomerular filtration, and increased sodium and water secretion in the kidney; decreased intraocular pressure; and decreased release of insulin from the pancreas.[54692] [54696] [54697]

Dexmedetomidine is administered by intravenous infusion or as an orally dissolving film that is administered sublingually or buccally. It is rapidly distributed with a distribution half-life of 6 minutes and a large volume of distribution (118 L in adults at steady-state). Plasma protein binding is 94%. Dexmedetomidine undergoes almost complete biotransformation with minimal unchanged drug excreted in urine and feces. Biotransformation involves direct N-glucuronidation, aliphatic hydroxylation (mediated primarily by CYP2A6), and N-methylation. About 95% of the dose is recovered in the urine (85% within 24 hours) and 4% in the feces. Pharmacokinetic parameters (Vd, half-life, and clearance) are similar between IV continuous infusion dosage ranges of 0.2 to 0.7 mcg/kg/hour for 24 hours or less and 0.2 to 1.4 mcg/kg/hour for more than 24 hours in adults. Terminal elimination half-life of the intravenous injection is approximately 2 hours, and clearance is estimated to be approximately 39 L/hour in adults. The mean terminal elimination half-life of dexmedetomidine is approximately 2.8 hours following sublingual or buccal administration.
 
Affected cytochrome P450 isoenzymes and drug transporters: CYP2A6
Biotransformation of dexmedetomidine involves both direct glucuronidation and cytochrome P450 mediated metabolism. Dexmedetomidine undergoes aliphatic hydroxylation mediated primarily by CYP2A6 with a minor role of CYP1A2, CYP2E1, CYP2D6, and CYP2C19; however, clinically significant cytochrome P450-mediated drug interactions are not expected.

Oral Route

Sublingual/Buccal Route: The mean time for dexmedetomidine film to dissolve in the mouth was 6 to 8 minutes for sublingual and 18 minutes for buccal administration. Plasma levels were measurable 5 to 20 minutes post-dose. The absolute bioavailability was 72% following sublingual and 82% following buccal administration. Mean maximum plasma concentration was reached approximately 2 hours after administration for both routes. Following sublingual administration of 40 mcg (0.33 times the lowest recommended initial dose) with water drinking at 2 hours post dose and 20 mcg dexmedetomidine intravenous infusion for 90 minutes in healthy volunteers, the mean peak plasma concentration (Cmax) of dexmedetomidine was 143 ng/L and 144 ng/L, respectively. The mean area under concentration curve (AUC) of dexmedetomidine was 851 hour x ng/L and 584 hour x ng/L, respectively. Compared to drinking water at 2 hours post sublingual administration, early water intake (as early as 15 minutes post dose) had minimal effects on the rate or extent of absorption of dexmedetomidine. The effect of early water intake (i.e., before 2 hours post-dose) on the absorption of dexmedetomidine has not been evaluated following buccal administration.

Intravenous Route

In general, onset of action occurs within 5 to 10 minutes and persists for 60 to 120 minutes.[64934] Dexmedetomidine exhibits linear kinetics in the dosage range of 0.2 to 0.7 mcg/kg/hour when administered by continuous IV infusion for up to 24 hours.[29112]

Other Route(s)

Intranasal Route
In general, onset of action occurs in 20 to 30 minutes and persists 30 to 45 minutes.[64934] In a pharmacokinetic study of 6 healthy adult males, dexmedetomidine 84 mcg administered via nasal spray (1 dose in each nostril) resulted in a median Cmax of 0.34 ng/mL (range: 0.23 to 0.7 ng/mL) within approximately 40 minutes (range: 15 to 60 minutes). The bioavailability of intranasal dexmedetomidine varied, with a median of 65% (range: 35% to 93%).[54809]

Pregnancy

Use dexmedetomidine during human pregnancy only if the potential benefits justify the potential risk to the fetus.There are no adequate and well-controlled studies of IV dexmedetomidine use in pregnant women. There are no available data on the use of dexmedetomidine sublingual film in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage or other adverse maternal or fetal effects. In an in vitro human placenta study, placental transfer of dexmedetomidine occurred. Available data from published randomized controlled trials and case reports over several decades of IV dexmedetomidine use during pregnancy have not identified a drug-associated risk of major birth defects or miscarriage; however, the reported exposures occurred after the first trimester. Most of the available data are based on use at the time of cesarean-section delivery, and these studies have not identified an adverse effect on maternal outcomes or infant Apgar scores. In animal reproduction studies, fetal toxicity occurred in the presence of maternal toxicity with subcutaneous administration of dexmedetomidine to pregnant rats during organogenesis at doses 5 times the maximum recommended human dose [MRHD] of 360 mcg/day based on mg/m2 body surface area (BSA). Increased post-implantation losses and reduced live fetuses occurred with subcutaneous administration of dexmedetomidine to pregnant rats during organogenesis at doses 1.8 times the MRHD of 17.8 mcg/kg/day based on BSA. Adverse developmental effects, including early implantation loss and decreased viability of second generation offspring, occurred when pregnant rats were subcutaneously administered doses less than or equal to the MRHD based on mg/m2 from late pregnancy through lactation and weaning. The safety of dexmedetomidine during labor and obstetric delivery has not been studied.

There is no information regarding the effects of dexmedetomidine on the breast-fed child or the effects on milk production; caution is advised when dexmedetomidine is used during breast-feeding. Available published literature report the presence of dexmedetomidine in human milk after IV administration. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for dexmedetomidine and any potential adverse effects on the breast-fed child from dexmedetomidine or the underlying maternal condition. Advise persons who resume breast-feeding after recent exposure to dexmedetomidine sublingual film to monitor the infant for irritability. To minimize potential drug exposure to the breast-fed infant, a lactating person may consider pumping and discarding breast milk for 10 hours (approximately 5 half-lives) after receiving dexmedetomidine. The relative infant dose of dexmedetomidine was estimated to range from 0.02% to 0.098% after 6 mcg/kg/hour IV for 10 minutes after delivery followed by 0.2 to 0.7 mcg/kg/hour continuous IV infusion. The milk-to-plasma ratio from single paired maternal milk and plasma concentrations at each measurement time point (0, 6, 12, and 24 hours after dexmedetomidine discontinuation) ranged from 0.53 to 0.95. After discontinuation, plasma and milk concentrations were detectable up to 6 hours in most subjects, up to 12 hours in 1 subject, and undetectable in all subjects at 24 hours.