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2-Receptor Agonists for Treatment and Prevention of Iatrogenic Opioid Abstinence Syndrome in Critically Ill PatientsPGY2 Pediatric Pharmacy Resident; now, Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences-Tulsa, College of Pharmacy, University of Oklahoma, Oklahoma City, OK
PGY1 Pharmacy Practice Resident, University of Oklahoma College of Pharmacy; now, PGY2 Infectious Diseases Pharmacy Resident, Oklahoma City Department of Veterans Affairs Medical Center
Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma
Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma
Reprints: Dr. Johnson, Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma, 1110 N. Stonewall Ave., CPB 206, Oklahoma City, OK 73117, fax 405/271-6430, peter-johnson{at}ouhsc.edu
OBJECTIVE: To review the literature regarding the use of
2-agonists in the treatment and prevention of
iatrogenic opioid abstinence syndrome (IOAS) in critically ill patients.
DATA SOURCES: Primary literature was identified through a search of
MEDLINE (1950-June 2009), EMBASE (1988-June 2009), International
Pharmaceutical Abstracts (1970-June 2009), and the Cochrane Library
(1996-June 2009), using the names of individual
2-agonists and the following key words: children,
opioid withdrawal, opioid, and adult. Relevant abstracts from the Society of
Critical Care Medicine, reference citations from selected articles, and
manufacturers' product information were also reviewed.
STUDY SELECTION AND DATA EXTRACTION: All English-language articles identified from the data sources were evaluated. Three retrospective studies and 6 case reports/series representing 44 patients were included for analysis.
DATA SYNTHESIS: Central 2-agonists are
thought to minimize symptoms of IOAS by decreasing presynaptic outflow of
catecholamines. Successful use of clonidine and dexmedetomidine for management
of IOAS has been reported. Lofexidine, an 2-agonist
not yet approved in the US, may offer similar withdrawal symptom relief but
has yet to be studied in the intensive care setting. Although the quality of
studies identified was limited, preliminary evidence does provide some support
for the use of transdermal clonidine and injectable dexmedetomidine in the
treatment and prevention of IOAS. These agents were shown to facilitate
discontinuation of opioids and to minimize withdrawal symptoms with few
reported adverse events.
CONCLUSIONS: Central 2-agonists appear to
be effective and safe second-line agents for treatment and prevention of IOAS.
Further studies should be conducted to determine their role in the therapy of
patients with IOAS.
Key Words: 2-agonists, clonidine, dexmedetomidine, lofexidine, opioid, opioid withdrawal
Published Online, August 18, 2009. www.theannals.com, DOI 10.1345/aph.1M161
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