Transcript CCC Dysautonomia -

Complex Care
Curriculum
DYSAUTONOMIA
Dysautonomia
Formulary
Complex Care
Curriculum
DYSAUTONOMIA
Please take note of the following prior to using this
formulary:
 Most of these medications are not FDA approved for the treatment
of dysautonomia, particularly in the pediatric population.
 The dosage information provider here is a combination of
recommendations from the Pediatric Dosing Handbook Formulary
and expert opinion.
 It is important for this dosing information to be used with caution
and only after full review of the entire dysautonomia module.
 We highly encourage you to discuss medication dosing with a
pharmacist and/or pediatric physiatrist if you have any questions or
concerns.
Complex Care
Curriculum
DYSAUTONOMIA Formulary
BROMOCRIPTINE
Starting Dose
Age<2 years: 0.625mg PO BID
Age>2 years: 1.25mg PO BID
Can start with daily dosing if conservative
How to Titrate
Double the dose 1-2 times/week until you have
reached the desired effect
Maximum Dose
Children: 12.5mg BID
Adults: 25mg BID
Onset
1-2 hours
Half-life
15 hours
Bromocriptine
Clonazepam
Clonidine
Diazepam
Labetalol
Propanalol
Complex Care
Curriculum
DYSAUTONOMIA Formulary
CLONAZEPAM
Starting Dose
0.01-0.03mg/kg/day divided BID
Maximum STARTING dose: 1.5mg/day
How to Titrate
Maximum Dose
Onset
Increase dose by up to 0.5mg q3 days
Half-life
Other
22-33 hours
Bromocriptine
0.2mg/kg/day OR 20mg/day
20-60 minutes
Clonazepam should generally be used twice
daily however it can be given up to 4 times a
day. If a patient requires more frequent dosing
then consider adding other medications as
increased frequency will “snow” the patient. If
you are titrating the dose upward, start with
nighttime dose due to the cognitive suppressive
effects.
Clonazepam
Clonidine
Diazepam
Labetalol
Propanalol
Complex Care
Curriculum
DYSAUTONOMIA Formulary
CLONIDINE
Starting Dose
5-10 MICROGRAMS/kg/day divided q8-12 hours
How to Titrate
Gradually to 5-25 MICROGRAMS/kg/day divided
every 6 hours. Monitor blood pressures closely.
Maximum Dose
Onset
0.9mg/day
Half-life
Other
8-12 hours
Bromocriptine
Oral: 30-60 minutes
Some transdermal patches can be cut in half
however, half of a 0.1mg patch cannot be
considered 0.05mg, it must be considered a ½
patch because exact dosing cannot be guaranteed.
The patch may take up to 2-3days to reach
therapeutic levels. Once removed, therapeutic
levels may persist for 8-12 hours and will then
slowly decline over 24-48hours.
Clonazepam
Clonidine
Diazepam
Labetalol
Propanalol
Complex Care
Curriculum
DYSAUTONOMIA Formulary
DIAZEPAM
Starting Dose
PO or IV/IM: 0.05-0.1mg/kg/dose q6-8hrs
How to Titrate
If no effect after 1st dose then repeat in 30 min
Re-eval frequently to assess efficacy and increase dose
or frequency as needed
Maximum Dose
0.6mg/kg in 8hrs
May consider higher doses in consultation with PM&R
and/or the ICU due to risk of respiratory depression
Onset
IV: 1-3minutes
Rectal: 2-10 minutes
Half-life
Age 1mo-2yrs: 40-50 hours
Age 2-16yrs: 15-21 hours
Other
Monitor for respiratory depression
The half-life of the active metabolite that causes
respiratory depression is 50-100 hours
Bromocriptine
Clonazepam
Clonidine
Diazepam
Labetalol
Propanalol
Complex Care
Curriculum
DYSAUTONOMIA Formulary
LABETALOL
Starting Dose
0.2-0.5mg/kg/dose with range of 0.21mg/kg/dose
How to Titrate
Discuss with physiatrist and pharmacist
Maximum Dose
20mg/dose
Onset
(IV): 2-5 minutes
Half-life
(IV) 5-8 hours
Bromocriptine
Clonazepam
Clonidine
Diazepam
Labetalol
Propanalol
Complex Care
Curriculum
DYSAUTONOMIA Formulary
PROPRANALOL
Starting Dose
0.25-0.5mg/kg/day divided BID
How to Titrate
Increase dose by 2.5-5mg/dose
Maximum Dose
30mg q6 hours
Onset
1-2 hours
Half-life
4-6 hours
Other
Can initiate at an interval of every other day if
conservative. At greater than maximal doses,
will cause bronchospasm that is unresponsive
to beta agonists. When titrating, if no response
in heart rate, increase the next dose or increase
q1-2 days by the increment noted above—usual
dose is 1-5mg/kg/day. Look at heart rate to
gauge how well it is working
Bromocriptine
Clonazepam
Clonidine
Diazepam
Labetalol
Propanalol