Jennifer Marsh, PharmD
Clinical Pharmacist
Tampa General Hospital
Tampa, Florida
Disclosure information not submitted.
Maresa Glass, PharmD, BCCCP,FCCM
Pharmacotherapy Specialist Coordinator- Critical Care
Tampa General Hospital, United States
Disclosure information not submitted.
Title: Evaluation of guanfacine use, safety, and efficacy for management of agitation
Introduction: Guanfacine (Tenex) is an alpha-2 agonist. Immediate release guanfacine has an indication for hypertension and extended release is labeled for use in Attention Deficit Hyperactivity Disorder. Recent case reports suggest a possible role in delirium and alcohol withdrawal. At Tampa General Hospital, guanfacine was added to the medication formulary for the management of ICU delirium. This medication use evaluation assessed the use of guanfacine and its associated safety and efficacy for this indication.
Methods: This was a retrospective, quality improvement project that included patients admitted January 1, 2019-April 30, 2020. Patients were included if they were at least 18 years of age and received at least two doses of guanfacine specifically for agitation. Patients were excluded if taking guanfacine prior to admission or if they had incomplete Intensive Care Delirium Screening Checklist (ICDSC) records. The primary objective was to evaluate guanfacine dosing strategies. Secondary objectives included the assessment of the efficacy and safety parameters to optimize use, mitigate risk, and identify educational opportunities.
Results: There were 27 patient records reviewed, with most patients starting on guanfacine 1 mg twice daily. The median duration of guanfacine therapy was 7 days (IQR, 4-13), and only 9 patients had dose titrations. Of the 18 patients on restraints at time of drug initiation, restraint orders were discontinued in 61% while on guanfacine. Of the 17 patients on a continuous sedative at time of guanfacine initiation, the sedative was discontinued in all but one patient. There were 17 patients with a positive ICDSC screening prior to the first dose of guanfacine and 65% of these patients had a negative screen at the time of drug discontinuation. Median daily haloperidol and intravenous lorazepam requirements both decreased on guanfacine. More than 50% of patients experienced at least one episode of bradycardia or hypotension while on guanfacine.
Conclusions: These findings of this quality improvement project support continuing unrestricted use of guanfacine for agitation but identified opportunities for education related to hemodynamic monitoring and hold parameters. Prospective studies are needed to solidify the role of guanfacine for this indication.