Efficacy and safety of subcutaneous clonidine for refractory symptoms in palliative medicine: a retrospective study

Abstract

ObjectivesTo investigate the efficacy and safety of subcutaneous clonidine for refractory symptoms in the palliative setting.MethodsA retrospective chart review of the use of subcutaneous clonidine in a single palliative care centre. We reviewed the use of clonidine since it was introduced in our locality 2½ years ago. All clinical notes, medication administration records and infusion monitoring documentation were examined to ascertain therapeutic aim, efficacy and tolerability.ResultsSubcutaneous clonidine was administered to 113 patients. Recipients were generally frail (median Karnofsky Score 20%) and in the last weeks of life (median survival 6 days). The the most common indications were opioid poorly responsive pain (59), agitation refractory to antipsychotics and/or benzodiazepines (18) or both (35). Symptoms appeared to improve in the majority (85/113, 75%). Some (36, 32%) required no further medication changes once clonidine was commenced. Clonidine appeared well tolerated although blood pressure was not monitored in the majority, in line with our practice to discontinue such observations in those who are nursed in bed and receiving symptom-focused care.ConclusionsSubcutaneous administration of clonidine appears to be a promising alternative option for refractory symptoms in the last weeks of life. We suggest some possible next steps for further research.

Review of clinical pharmacokinetics and pharmacodynamics of clonidine as an adjunct to opioids in palliative care

“…The authors conclude that subcutaneous clonidine could be a promising alternative for managing refractory symptoms in patients in the final weeks of life. 8 We commend this work and agree with the authors that further research is desirable. In particular, we think that a wellpowered randomized controlled trial of clonidine as an adjunct to other treatment in the palliative care setting is both realistically possible and ethical-such that the door on this issue can be set right.…”

“…7 The role of clonidine in cancer pain management and refractory agitation in the imminently dying patients has been documented. 8 In that setting, the most described route of use is by epidural or intrathecal routes. The use of epidural in cancer pain management is diminishing-most likely because it requires anaesthetic expertise.…”

“…It is similar to the dose range of 75-150 μg used in the study from Mountbatten Hospice. 8 We measure the blood pressure before and after the first dose is given, to see how well the patient tolerates the treatment.…”

“…Clonidine has been used for the management of delirium in post-operative settings, 37,38 and for refractory agitation in the imminently dying patients. 8,39,40 Different routes of administration of clonidine as adjunct analgesic are mentioned. However, role of subcutaneous clonidine in pain and especially agitation management is unclear.…”

Dexmedetomidine and clonidine in palliative medicine: multicentric qualitative evaluation

“…In PC, clonidine was initially used for its analgesic effects 8. In 2022, Howard published a retrospective cohort of 113 patients followed up in a single PC unit (PCU) to whom subcutaneous clonidine was administered at the end of life (mean survival time=6 days) for refractory symptoms 9. Main indications were pain and end-of-life delirium.…”