Enteral Guanfacine to Treat Severe Anxiety and Agitation Complicating Critical Care After Cardiac Surgery

Abstract

This article is the first reported case describing the off-label use of enteral immediate-release guanfacine, a long-acting α-2 adrenergic agonist most commonly used in the treatment of attention-deficit hyperactivity disorder, for sedation in a patient with severe anxiety and agitation limiting mechanical ventilation weaning several days after cardiac surgery. In this case, after several days of unsuccessful attempts to control his agitation and anxiety with conventional therapies, guanfacine therapy was initiated, and the patient was rapidly weaned from all other sedatives and mechanical ventilation shortly thereafter. The patient was weaned from guanfacine therapy without evidence of bradycardia, hypotension, or rebound syndrome. Enteral guanfacine therapy should be further studied as a potentially useful and cost-effective sedative therapy for patients with severe anxiety and/or agitation in the intensive care unit following cardiac and thoracic surgical procedures.

Cardiovascular therapeutics: A new potential for anxiety treatment?

“…In a patient after cardiac surgery, guanfacine therapy effectively attenuated agitation and anxiety that was uncontrollable by conventional therapies. 99 In pediatric patients suffering from PTSD, 100 GAD, separation anxiety disorder, and social anxiety disorder, guanfacine extended‐release, was well‐tolerated and lead to global improvements 101 (Table 1 ).…”

Approach to Sedation and Analgesia in COVID-19 Patients on Venovenous Extracorporeal Membrane Oxygenation

“…A similar agent, guanfacine, also acts primarily via the α-2 receptor with less effect on hemodynamics; additionally, its use in critically ill patients has been previously established, and it may also pose further options for management of opioid withdrawal and concomitant agitation and/or delirium frequently seen in the COVID-19 patient population. 45,47 Although the majority of these agents lack published clinical data advocating for their use in the ECMO population, their overall use may be advantageous for patients in whom sedation challenges limit weaning from mechanical ventilation. The benefits of lung-protective ventilation and minimization of aggressive mechanical ventilation techniques in patients with ARDS on ECMO support have been previously established, and these agents may play a role in this unique subset of patients.…”

Ambulatory detoxification in alcohol use disorder and opioid use disorder

“…This allows guanfacine and lofexidine to retain the sedative/hypnotic properties while causing less hypotension. [30][31][32][33][34][35][36][37] Due to guanfacine and lofexidine having less affinity for alpha-2b and imidazoline receptors, it might be a less effective analgesic agent. 31 Clinical trials suggest a decreased incidence of hypotension and sedation with lofexidine compared with clonidine.…”