Clonidine withdrawal

When clonidine is withdrawn abmpdy, patients may experience a rebound hypertensive phenomenon, whereia blood pressure rises rapidly to a level higher than the predmg level. These patients may experience symptoms of headache, tachycardia, agitation, and nervousness. If rebound hypertension occurs, resumption of clonidine therapy or adrninistration of phentolamine reduces the blood pressure. For clonidine withdrawal, the dose should be reduced gradually over a two-week period. The principal side effects are sedation, dry mouth, drowsiaess, di22iQess, and fatigue. 

Clonidine Beta-adrenoceptor blocking drugs Increased risk of clonidine withdrawal hypertension. 

Dillon JE. Self-injurious behavior associated with clonidine withdrawal in a child with Tourette s disorder. J Child Neurol 1990 5(4) 308-10. 

Berge KH, Lanier WL. Myocardial infarction accompanying acute clonidine withdrawal in a patient without a history of ischemic coronary artery disease. Anesth Analg 1991 72(2) 259-61. 

Discuss the use of receptor antagonist therapy in conjunction with clonidine withdrawal. 

Clonidine withdrawal may result in an excess of circulating catecholamines. Therefore, caution should be exercised in concomitant use of drugs which effect the metabolism or tissue uptake of these amines (monoamine oxidase inhibitors or tricyclic antidepressants, respectively) (1). 

Stiff JL, Harris DB. Clonidine withdrawal complicated by amitriptyline therapy. Anesthesiology ( 9S3) 59, 73-4. 

A common strategy for treating chronic opiate addiction iavolves the substitution of methadone which can either be provided as maintenance therapy or tapered until abstinence is achieved. Naltrexone and buprenorphine [52485-79-7] have also been used ia this manner. The a2 adrenergic agonist clonidine [4205-90-7] provides some rehef from the symptoms of opiate withdrawal, probably the result of its mimicking the inhibitory effect of opiates on the activity of locus coerukus neurons. 

At present, no diugs exist that can selectively activate a2-receptor subtypes. Clonidine stimulates all three a2-subtypes with similar potency. Clonidine lowers blood pressure in patients with hypertension and it decreases sympathetic overactivity during opioid withdrawal. In intensive and postoperative care, clonidine is a potent sedative and analgesic and can prevent postoperative shivering. Clonidine and its derivative brimonidine lower... 

Dobrydnjov I, Axelsson K, Berggren L, et al Intrathecal and oral clonidine as prophylaxis for postoperative alcohol withdrawal syndrome a randomized double-blinded study. Anesth Analg 98 738—744, 2004... 

Note. Clonidine alone may not adequately treat insomnia, diarrhea, muscle aches, restlessness, irritability, or other withdrawal symptoms, which may require other medications. For this reason many programs use lower doses of clonidine than outlined in this table, in combination with oral... 

Detoxification is more successful when the patient is transitioned from a stable methadone dose with the support of ongoing therapy than when the patient comes directly from the street for detoxification from heroin. Some practitioners believe that detoxification with clonidine can be more rapid than with methadone, at least on an outpatient basis. One important hmitation of clonidine is that, although it suppresses autonomic signs of withdrawal, subject-reported symptoms, such as lethargy, restlessness, insomnia, and craving, are not well relieved (Charney et al. 1981 Jasinski et al. 1985). Anxiety may... 

Carroll KM, Ball SA, Nich C, et al Targeting behavioral therapies to enhance naltrexone treatment of opioid dependence. Arch Gen Psychiatry 38 755-761, 2001 Centers for Disease Control and Prevention Recommendation for prevention and control of hepatitis (virus (HCV) infection and HCV-related chronic disease. MMWR Recommendations and Reports 47(RR19) l-39, 1998 Charney DS, Steinberg DE, Kleber HD, et al The clinical use of clonidine in abrupt withdrawal from methadone. Arch Gen Psychiatry 38 1273-1277, 1981 Charney D S, Heninger OR, Kleber H D The combined use of clonidine and naltrexone as a rapid, safe, and effective treatment of abrupt withdrawal from methadone. Am J Psychiatry 143 831-837, 1986... 

Gold MS, Redmond DE, Kleber HD Clonidine in opiate withdrawal. Lancet 1 929-930, 1978... 

Jasinski DR, PevnickJS, Griffith JD Human pharmacology and abuse potential of the analgesic buprenorphine. Arch Gen Psychiatry 35 501-516, 1978 Jasinski DR, Johnson RE, Kocher TR Clonidine in morphine withdrawal differential effects on signs and symptoms. Arch Gen Psychiatry 42 1063-1066, 1983... 

Kleber HD, Weissman MM, Rounsaville BJ, et al Imipramine as treatment for depression in addicts. Arch Gen Psychiatry 40 649-633, 1983 Kleber HD, Riordan CE, Rounsaville BJ, et al Clonidine in outpatient detoxification from methadone maintenance. Arch Gen Psychiatry 42 391-394, 1983 Kleber HD, Topazian M, Gaspari J, et al Clonidine and naltrexone in the outpatient treatment of heroin withdrawal. Am J Drug Alcohol Abuse 13 1-17, 1987 Kornetsky C. Brain stimulation reward, morphine-induced stereotypy, and sensitization implications for abuse. Neurosci Biobehav Rev 27 777-786, 2004 Kosten TR, Kleber HD Buprenorphine detoxification from opioid dependence a pilot study. Life Sci 42 633-641, 1988... 

Goodman WK, Charney DS, Price LH, et al Ineffectiveness of clonidine in the treatment of the benzodiazepine withdrawal syndrome report of three cases. Am J Psychiatry 143 900—903, 1986... 

Cionidine. Clonidine dampens sympathetic activity originating at the locus coeruleus by stimulation of presynaptic a2-adrenergic receptors in the sympathetic chain (Covey and Classman 1991 Hughes 1994). It appears to have some efficacy for alcohol and opioid withdrawal and thus was evaluated for treatment of nicotine withdrawal as well (Covey and Classman 1991 Hughes 1994). Several clinical trials used oral or transdermal clonidine in doses of 0.1—0.4 mg/day for 2—6 weeks with or without behavior therapy. Three meta-analytic reviews reported that clonidine improved quit rates (Covey and Classman 1991 Courlay and Benowitz 1995 Law and Tang 1995). 

TABLE 33-7. Sample Regimen of Clonidine for Withdrawal from All Opioids Except Methadone and Fentanyl (Duragesic ) Patches... 

Withdrawal from nicotine is treated in the outpatient setting. Symptomatic detoxification from nicotine is achieved with any single or combination of NRTs. Additional nonnicotine medications such as bupropion, nortriptyline, and clonidine may be helpful to reduce craving and various other withdrawal symptoms. Including a behavioral therapy component increases abstinence rates when combined with pharmacologic treatment. 

The answer is a. (Hardman, p 789. Katzung, pp 162—163.) Withdrawal of clonidine, particularly doses greater than 1 mg/d, is well known to cause such a syndrome (including severe hypertension, tachycardia, anxiety tremor, headache, abdominal pain, and sweating), even after one or two missed doses. 

There are two main treatments for the opiate withdrawal syndrome. One is replacement therapy with methadone or other X agonists that have a longer half-life than heroin or morphine, and produce mild stimulation rather than euphoria. They also produce cross-tolerance to heroin, lessening heroin s effect if patients relapse. Withdrawal is also treated with the 0C2 agonist clonidine, which inhibits LC neurons, thus counteracting autonomic effects of opiate withdrawal — such as nausea, vomiting, cramps, sweating, tachycardia and hypertension — that are due in part to loss of opiate inhibition of LC neurons. 

For treatment of hypertensive rebound after withdrawal of clonidine, 0.2 mg is given initially, followed by 0.2 mg hourly until the DBP falls below 110 mm Hg or a total of 0.7 mg has been administered a single dose may be sufficient. 

---