Toxic clonidine ingestion in children

Spiller, Henry A.; Klein‐Schwartz, Wendy; Colvin, Jonathan; Villalobos, Danny; Johnson, Paul; Anderson, Deborah

doi:10.1016/j.jpeds.2004.09.027

Cited by 57 publications

(39 citation statements)

References 17 publications

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“…Classic signs, such as somnolence and respiratory depression, may have been more pronounced at night when he was unstimulated. Our patient returned to baseline status at approximately 48 hours, consistent with other cases of clonidine overdose, despite the very high serum level [6,[8][9][10].…”

Section: Discussionsupporting

confidence: 85%

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Toxicity from a clonidine suspension

et al. 2009

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Background: Clonidine is frequently prescribed to children. Clonidine overdose in children has resulted in major clinical effects and deaths.Case Report: A 3.5-year-old male with a history of a seizure disorder and night terrors presented following difficulty walking, excessive sleeping, agitation when awake, and possible seizure activity. Chronic medications were valproic acid (VPA) and clonidine. On presentation, he alternated between poor responsiveness and agitation, with initial vitals: blood pressure, BP 144/76 mmHg; heart rate, 65 bpm; respiratory rate, 18 bpm; temperature 99.5°F; and pulse oximetry 96% on room air. VPA level was 35 g/mL. A toxicology consult the next day noted a dry mouth, 2-mm pupils, intermittent gasping, and central nervous system (CNS) depression, with a diagnostic impression of clonidine overdose. The caregiver had been giving 1 mL (0.1 mg) qd of a pharmacy-compounded clonidine suspension by a provided syringe. The pharmacy procedure record agreed with the physicians order. The amount dispensed was a 30-day supply but the bottle was empty on day 19, leading us to suspect a possible accelerated dosing error. The concentration in the bottle thus could not be confirmed. The child slowly returned to his baseline state over 48 hours. A serum clonidine level drawn approximately 18 hours after his last dose later returned at 300 ng/mL (reference range = 0.5-4.5 ng/mL).Case Discussion: Compounding and liquid dosing errors are common in children and may result in massive overdoses. There was an accelerated dosing error, but whether a compounding or suspension error or even an acute overdose occurred as well is unknown.Conclusion: Particular care should be taken with medications that have low therapeutic indices, that are extemporaneously compounded, and are prepared as liquids, where medication errors are more likely.

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Section: Discussionsupporting

confidence: 85%

“…Finally, clonidine has a low therapeutic index ( Table 1). Symptoms and signs of toxicity have been reported with doses as low as 0.1 mg [8] and significant toxicity (coma, respiratory depression, or hypotension) has been reported with doses at or above 0.2 mg [9,10].…”

Section: Discussionmentioning

confidence: 99%

Toxicity from a clonidine suspension

et al. 2009

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“…The test is associated with several untoward effects [6], including hypotension, bradycardia, moderate sedation and hypoglycemia. At higher dose levels (accidental intoxication), more serious effects such as coma, respiratory depression and generalized hypotonia have been reported [7]. Both the intended (GH release) and unintended effects may well be related to serum levels of clonidine during the test, but this has not been studied so far.…”

Section: Introductionmentioning

confidence: 99%

Pharmacokinetics and Pharmacodynamics of Orally Administered Clonidine: A Model-Based Approach

Álvarez-Jiménez

Sukhai²,

Oostdijk³

et al. 2013

Horm Res Paediatr

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Background/Aims: The oral clonidine test is a diagnostic procedure performed in children with suspected growth hormone (GH) deficiency. It is associated with untoward effects, including bradycardia, hypotension and sedation. Serum clonidine levels have not previously been assessed during this test. Methods: In 40 children referred for an oral clonidine test, blood samples were drawn for clonidine and GH. Vital statistics and sedation scores were recorded until 210 min post-dose. We explored the relationship between clonidine concentrations and effects such as GH peak and blood pressure. Results: Of 40 participants, 5 children were GH deficient. Peak clonidine concentrations of 0.846 ± 0.288 ng/ml were reached after 1 h. Serum levels declined slowly, with concentrations of 0.701 ± 0.189 ng/ml 210 min post-dose. A large interindividual variation of serum levels was observed. During the procedure, systolic blood pressure dropped by 12.8%, diastolic blood pressure by 19.7% and heart rate by 8.4%. Moderate sedation levels were observed. Concentration-effect modeling showed that the amount of GH available for secretion as determined by previous bursts was an important factor influencing GH response. Conclusion: Clonidine concentrations during the test were higher than necessary according to model-based predictions. A lower clonidine dose may be sufficient and may produce fewer side effects.

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“…Multiple studies showed that onset of symptoms are rapid and usually within 2 h, and most of the children showed complete resolution of symptoms within 24 h [41][42][43]. Prolonged hypothermia up to 24 h has been reported [44].…”

Section: What Is the Expected Onset And Duration Of Imidazoline Toxicmentioning

confidence: 99%

Unintentional Pediatric Ophthalmic Tetrahydrozoline Ingestion: Case Files of the Medical Toxicology Fellowship at the University of California, San Francisco

2014

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An 18-month-old child was brought to the emergency department (ED) by his mother for evaluation of diarrhea, vomiting, and somnolence. He was lethargic, with "pinpoint" pupils. Blood pressure was 125/77 mmHg, heart rate was 70/min, temperature was 36.5°C, respiratory rate was 25/min, and pulse oximetry saturation (SpO 2 ) was 99 % on room air. Blood glucose was 101 mg/dL. Other initial laboratory investigation was unremarkable. Ethanol, acetaminophen, and aspirin were below detection limits. Urine drug screening was negative for amphetamine, methamphetamine, MDMA, barbiturates, benzodiazepines, cocaine, methadone, oxycodone, and opiates. Initial ECG done 3 h after ED arrival showed bradycardia with first-degree heart block. There was no response to 1 mg IV naloxone.

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Toxic clonidine ingestion in children

Cited by 57 publications

References 17 publications

Toxicity from a clonidine suspension

Toxicity from a clonidine suspension

Pharmacokinetics and Pharmacodynamics of Orally Administered Clonidine: A Model-Based Approach

Unintentional Pediatric Ophthalmic Tetrahydrozoline Ingestion: Case Files of the Medical Toxicology Fellowship at the University of California, San Francisco

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