Home Use of Intranasal Dexmedetomidine in a Child With An Intractable Sleep Disorder

Abstract

Sleep disturbance is a crucial issue in pediatric palliative care, with a dramatic impact on the quality of life of children and families. Dexmedetomidine (DEX) is a selective α-2 agonist, with anxiolytic, hypnotic, and analgesic properties, that could play a role in the management of refractory sleep disturbances. We describe the use of intranasal DEX as a sleep inductor in a 10-year-old female with dystrophic epidermolysis bullosa and a severe sleep disorder. After treatment with melatonin, benzodiazepines, and niaprazine had failed, she was admitted to the hospital where 3 mcg/kg/day of intranasal DEX was administered before bedtime. She received 0.7 mL of the IV formulation at a concentration of 100 mcg/mL with half the dose given in each nostril via a Mucosal Atomization Device. During this time, she was also monitored for potential side effects (e.g., bradycardia, blood pressure derangements). After 2 weeks of hospitalization, she was discharged with ready-to-use doses of DEX for home treatment. The child's heart rate and blood oxygen saturation were monitored at home. There was a definite improvement in sleep quality and duration, daytime alertness, pain control, and quality of life. No side effects were reported and the drug retained its effect over time (the patient is currently taking the drug). Intranasal DEX could be a safe and effective strategy to manage refractory sleep disturbances in children in pediatric palliative care.

A Pragmatic Approach to Assessment of Chronic and Recurrent Pain in Children with Severe Neurologic Impairment

“…In cases of severe pain and dystonia, with no benefit from any conventional pharmacological treatment, clonidine administered through an epidural, intrathecal and local/topical route may be effective in chronic pain conditions where neuropathy is a predominant component. In the setting of future trends of research, the symptomatic intranasal use of dexmedetomidine at home has been anecdotally reported in the context of palliative care [ 38 , 39 ]. In the setting of chronic pain (persistent, with recurrence of more than 3 months), some authors suggest that no routine diagnostic tests should be carried out, and the goal should be solely directed to the pain relief [ 40 ].…”

Disturbi del sonno. Consigli pratici di gestione nei pazienti eleggibili alle cure palliative pediatriche

“…Il trattamento dei disturbi del sonno prevede [9][10][11]: 1. Trattamento delle cause sottostanti (dolore, crisi epilettiche, distonie, RGE).…”

Dexmedetomidine: What’s New for Pediatrics? A Narrative Review

“…Infusions up to a maximum of 12 days were associated with a statistically significant decrease in pain scores and a downward trend in opioid use. Recently, The Italian Drug Agency passed a landmark decision, approving DEX via IN and intravenous route for the palliative care of children outside of the ICU setting (in hospital or at home) and unresponsive to conventional therapy [ 131 , 132 ].…”

“…IN DEX in doses of 2–3 mcg/kg have been effective for sedating a child with epidermolysis bullosa and one with refractory dystonia, without significant adverse events or tachyphylaxis when used at home for up to three months [ 132 , 133 ].…”