Rethink clonidine for patients undergoing noncardiac surgery

Close to 1 in 3 Americans has hypertension, and the American Heart Association estimates that number will increase by more than 7% by 2030. The prevalence of obesity, a sedentary lifestyle, cigarette smoking, and a variety of other risk factors create a perfect storm for cardiovascular topsy-turviness.

Hypertension is so common among hospitalized patients, most of us have already chosen our "drugs of choice" to treat it. Unlike the case in primary care, in which physicians may have the luxury of starting with a first-line drug, and perhaps adding a second-line agent a few months later, in the hospital setting, we are often faced with hypertensive emergencies and urgencies that require immediate treatment. The expert opinions outlined in the new JNC-8 guidelines may not be appropriate for our acutely ill patient with a blood pressure of 240/135.

While decreasing the blood pressure is a top priority, there are frequently complicating factors, such as uncontrolled pain, intravenous fluids, or glucocorticoid use that make maintaining a consistently safe blood pressure challenging, to say the least. One reading may be an acceptable 140/85, while a few hours later it may spike to 200/120, and this roller coaster ride may continue for days on end. That\'s when we often reach for a PRN medication to help keep the patient out of danger as we manage a host of other conditions.

Many remember when sublingual nifedipine was the drug of choice for rapid reduction of severe blood pressure elevations, until the rapid drop proved to be devastating to the cerebral perfusion for some very unfortunate patients. Over the years, clonidine has become a highly favored drug if an oral agent is deemed appropriate. Its onset is rapid, and it drops the blood pressure to a moderate degree in most patients. However, a recent article in the New England Journal of Medicine, Clonidine in Patients Undergoing Noncardiac Surgery, may make many rethink their use of clonidine in this subpopulation of patients.

Researchers found clonidine 0.2 mg daily started just before surgery and continued until 72 hours postop was associated with an increase in nonfatal cardiac arrest (0.3% vs. 0.1%) and clinically significant hypotension (47.6% vs. 37.1%). Myocardial infarction occurred in 5.9% in the placebo group, compared to 6.6% in the clonidine group (N. Engl. J. Med. 2014;370:1504-13).

This article is highly significant to me, a frequent prescriber of PRN clonidine. Though the article did not address PRN use of clonidine perioperatively, in my opinion, the results are concerning enough to warrant thoughtful consideration. While it will not likely affect my prescribing practice for most patients, I plan to expand my armamentarium of drugs for those who I think may require surgery in the near future.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

Close to 1 in 3 Americans has hypertension, and the American Heart Association estimates that number will increase by more than 7% by 2030. The prevalence of obesity, a sedentary lifestyle, cigarette smoking, and a variety of other risk factors create a perfect storm for cardiovascular topsy-turviness.

Hypertension is so common among hospitalized patients, most of us have already chosen our "drugs of choice" to treat it. Unlike the case in primary care, in which physicians may have the luxury of starting with a first-line drug, and perhaps adding a second-line agent a few months later, in the hospital setting, we are often faced with hypertensive emergencies and urgencies that require immediate treatment. The expert opinions outlined in the new JNC-8 guidelines may not be appropriate for our acutely ill patient with a blood pressure of 240/135.

While decreasing the blood pressure is a top priority, there are frequently complicating factors, such as uncontrolled pain, intravenous fluids, or glucocorticoid use that make maintaining a consistently safe blood pressure challenging, to say the least. One reading may be an acceptable 140/85, while a few hours later it may spike to 200/120, and this roller coaster ride may continue for days on end. That\'s when we often reach for a PRN medication to help keep the patient out of danger as we manage a host of other conditions.

Many remember when sublingual nifedipine was the drug of choice for rapid reduction of severe blood pressure elevations, until the rapid drop proved to be devastating to the cerebral perfusion for some very unfortunate patients. Over the years, clonidine has become a highly favored drug if an oral agent is deemed appropriate. Its onset is rapid, and it drops the blood pressure to a moderate degree in most patients. However, a recent article in the New England Journal of Medicine, Clonidine in Patients Undergoing Noncardiac Surgery, may make many rethink their use of clonidine in this subpopulation of patients.

Researchers found clonidine 0.2 mg daily started just before surgery and continued until 72 hours postop was associated with an increase in nonfatal cardiac arrest (0.3% vs. 0.1%) and clinically significant hypotension (47.6% vs. 37.1%). Myocardial infarction occurred in 5.9% in the placebo group, compared to 6.6% in the clonidine group (N. Engl. J. Med. 2014;370:1504-13).

This article is highly significant to me, a frequent prescriber of PRN clonidine. Though the article did not address PRN use of clonidine perioperatively, in my opinion, the results are concerning enough to warrant thoughtful consideration. While it will not likely affect my prescribing practice for most patients, I plan to expand my armamentarium of drugs for those who I think may require surgery in the near future.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

Close to 1 in 3 Americans has hypertension, and the American Heart Association estimates that number will increase by more than 7% by 2030. The prevalence of obesity, a sedentary lifestyle, cigarette smoking, and a variety of other risk factors create a perfect storm for cardiovascular topsy-turviness.

Hypertension is so common among hospitalized patients, most of us have already chosen our "drugs of choice" to treat it. Unlike the case in primary care, in which physicians may have the luxury of starting with a first-line drug, and perhaps adding a second-line agent a few months later, in the hospital setting, we are often faced with hypertensive emergencies and urgencies that require immediate treatment. The expert opinions outlined in the new JNC-8 guidelines may not be appropriate for our acutely ill patient with a blood pressure of 240/135.

While decreasing the blood pressure is a top priority, there are frequently complicating factors, such as uncontrolled pain, intravenous fluids, or glucocorticoid use that make maintaining a consistently safe blood pressure challenging, to say the least. One reading may be an acceptable 140/85, while a few hours later it may spike to 200/120, and this roller coaster ride may continue for days on end. That\'s when we often reach for a PRN medication to help keep the patient out of danger as we manage a host of other conditions.

Many remember when sublingual nifedipine was the drug of choice for rapid reduction of severe blood pressure elevations, until the rapid drop proved to be devastating to the cerebral perfusion for some very unfortunate patients. Over the years, clonidine has become a highly favored drug if an oral agent is deemed appropriate. Its onset is rapid, and it drops the blood pressure to a moderate degree in most patients. However, a recent article in the New England Journal of Medicine, Clonidine in Patients Undergoing Noncardiac Surgery, may make many rethink their use of clonidine in this subpopulation of patients.

Researchers found clonidine 0.2 mg daily started just before surgery and continued until 72 hours postop was associated with an increase in nonfatal cardiac arrest (0.3% vs. 0.1%) and clinically significant hypotension (47.6% vs. 37.1%). Myocardial infarction occurred in 5.9% in the placebo group, compared to 6.6% in the clonidine group (N. Engl. J. Med. 2014;370:1504-13).

This article is highly significant to me, a frequent prescriber of PRN clonidine. Though the article did not address PRN use of clonidine perioperatively, in my opinion, the results are concerning enough to warrant thoughtful consideration. While it will not likely affect my prescribing practice for most patients, I plan to expand my armamentarium of drugs for those who I think may require surgery in the near future.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].