Complex Care Curriculum DYSAUTONOMIA Dysautonomia Formulary Complex Care

Complex Care Curriculum DYSAUTONOMIA Dysautonomia Formulary

Complex Care Curriculum DYSAUTONOMIA Please take note of the following prior to using this formulary: Ø Most of these medications are not FDA approved for the treatment of dysautonomia, particularly in the pediatric population. Ø The dosage information provider here is a combination of recommendations from the Pediatric Dosing Handbook Formulary and expert opinion. Ø It is important for this dosing information to be used with caution and only after full review of the entire dysautonomia module. Ø We highly encourage you to discuss medication dosing with a pharmacist and/or pediatric physiatrist if you have any questions or concerns.

Complex Care Curriculum DYSAUTONOMIA Formulary BROMOCRIPTINE Starting Dose Age<2 years: 0. 625 mg PO BID Age>2 years: 1. 25 mg PO BID Can start with daily dosing if conservative How to Titrate Double the dose 1 -2 times/week until you have reached the desired effect Maximum Dose Children: 12. 5 mg BID Adults: 25 mg BID Onset 1 -2 hours Half-life 15 hours Bromocriptine Clonazepam Clonidine Diazepam Labetalol Propanalol

Complex Care Curriculum DYSAUTONOMIA Formulary CLONAZEPAM Starting Dose 0. 01 -0. 03 mg/kg/day divided BID Maximum STARTING dose: 1. 5 mg/day How to Titrate Increase dose by up to 0. 5 mg q 3 days Maximum Dose Onset Half-life Other 0. 2 mg/kg/day OR 20 mg/day Bromocriptine Clonazepam 20 -60 minutes 22 -33 hours Clonazepam should generally be used twice daily however it can be given up to 4 times a day. If a patient requires more frequent dosing then consider adding other medications as increased frequency will “snow” the patient. If you are titrating the dose upward, start with nighttime dose due to the cognitive suppressive effects. Clonidine Diazepam Labetalol Propanalol

Complex Care Curriculum DYSAUTONOMIA Formulary CLONIDINE Starting Dose 5 -10 MICROGRAMS/kg/day divided q 8 -12 hours How to Titrate Gradually to 5 -25 MICROGRAMS/kg/day divided every 6 hours. Monitor blood pressures closely. Maximum Dose Onset Half-life Other 0. 9 mg/day Bromocriptine Clonazepam Oral: 30 -60 minutes 8 -12 hours Some transdermal patches can be cut in half however, half of a 0. 1 mg patch cannot be considered 0. 05 mg, it must be considered a ½ patch because exact dosing cannot be guaranteed. The patch may take up to 2 -3 days to reach therapeutic levels. Once removed, therapeutic levels may persist for 8 -12 hours and will then slowly decline over 24 -48 hours. Clonidine Diazepam Labetalol Propanalol

Complex Care Curriculum DYSAUTONOMIA Formulary DIAZEPAM Starting Dose PO or IV/IM: 0. 05 -0. 1 mg/kg/dose q 6 -8 hrs How to Titrate If no effect after 1 st dose then repeat in 30 min Re-eval frequently to assess efficacy and increase dose or frequency as needed Maximum Dose 0. 6 mg/kg in 8 hrs May consider higher doses in consultation with PM&R and/or the ICU due to risk of respiratory depression Onset IV: 1 -3 minutes Rectal: 2 -10 minutes Half-life Age 1 mo-2 yrs: 40 -50 hours Age 2 -16 yrs: 15 -21 hours Other Monitor for respiratory depression The half-life of the active metabolite that causes respiratory depression is 50 -100 hours Bromocriptine Clonazepam Clonidine Diazepam Labetalol Propanalol

Complex Care Curriculum DYSAUTONOMIA Formulary LABETALOL Starting Dose 0. 2 -0. 5 mg/kg/dose with range of 0. 21 mg/kg/dose How to Titrate Discuss with physiatrist and pharmacist Maximum Dose 20 mg/dose Onset (IV): 2 -5 minutes Half-life (IV) 5 -8 hours Bromocriptine Clonazepam Clonidine Diazepam Labetalol Propanalol

Complex Care Curriculum DYSAUTONOMIA Formulary PROPRANALOL Starting Dose 0. 25 -0. 5 mg/kg/day divided BID How to Titrate Increase dose by 2. 5 -5 mg/dose Maximum Dose 30 mg q 6 hours Onset 1 -2 hours Half-life 4 -6 hours Other Can initiate at an interval of every other day if conservative. At greater than maximal doses, will cause bronchospasm that is unresponsive to beta agonists. When titrating, if no response in heart rate, increase the next dose or increase q 1 -2 days by the increment noted above—usual dose is 1 -5 mg/kg/day. Look at heart rate to gauge how well it is working Bromocriptine Clonazepam Clonidine Diazepam Labetalol Propanalol