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Guide
Drug Safety-related Labeling Changes (SrLC) Database
| ANDA | Abbreviated New Drug Application |
| BLA | Biologics License Application |
| CDER | Center for Drug Evaluation and Research |
| MG | Medication Guide |
| NDA | New Drug Application |
| PCI | Patient Counseling Information |
| PI | Patient Information |
| PLR | Physician Labeling Rule |
| PLLR | Pregnancy and Lactation Labeling Rule |
| Italics | For the most part, italics indicate an FDA comment such as:
Additions and/or revisions underlined These italics usually appear at the beginning of the section. In some cases, italics may be an inherent part of the label, and will most often appear in the body of the section. |
| Underlines | Any text that is underlined indicates text that has been added or revised. There are exceptions where underlining occurs in a section subtitle or heading. This is the case when there is just one word underlined in the body of the text. |
Sections
| BW | Box Warning |
| WP | Warnings and Precautions all in one section (PLR-format) Warnings as one section (pre-PLR format) Precautions as one section (pre-PLR format) |
| AR | Adverse Reactions (in pre-PLR format, this may be a subheading under precautions). |
| DI | Drug Interactions (in pre-PLR format, this may be a subheading under precautions). |
| USP | Use in Specific Populations (Inclusive on one or more of the following: Pregnancy; Lactation (PLLR- format); Nursing Mothers (pre-PLLR format); Females and Males of Reproductive Potential (PLLR format only); Pediatric Use, Geriatric Use, Renal Impairment, Hepatic Impairment, Sex, Race (these last six may be a subheading of precautions if label in pre-PLLR format. |
| PCI/PI/MG | Patient Counseling Information (PLR format only) - summarizes the information that a health care provider should convey to a patient (or caregiver when applicable) when a counseling discussion is taking place (e.g., a physician prescribing a drug during an office visit, a nurse providing discharge instructions at a hospital, or a pharmacist conveying information at a pharmacy). Patient Information - FDA approved patient labeling. Medication Guide - paper handouts that come with many prescription medicines. The guides address issues that are specific to particular drugs and drug classes, and they contain FDA-approved information that can help patients avoid serious adverse events. |
Only NDAs and CDER regulated BLAs are included in this database. ANDAs are not included.
Applications that remain active, even if the product has been discontinued, undergo safety-related labeling changes.
DEXMEDETOMIDINE HYDROCHLORIDE (NDA-206628)
(DEXMEDETOMIDINE HYDROCHLORIDE)
Safety-related Labeling Changes Approved by FDA Center for Drug Evaluation and Research (CDER)
05/01/2026 (SUPPL-24)
5 Warnings and Precautions
5.6 Diabetes Insipidus
Newly added subsection:
Cases of diabetes insipidus (DI) have been reported with use of dexmedetomidine in the setting of sedation. Signs of DI in this setting include polyuria (output > 125 mL/hr), diluted urine (osmolality < 300 mOsm/kg), and hypernatremia (serum sodium > 145 mmol/L). If unrecognized, this condition can lead to hemodynamic instability including unstable blood pressure and increased risk of other cardiovascular sequelae.
In reported cases, signs of DI have spontaneously resolved following discontinuation of dexmedetomidine, with resolution often occurring after 24 hours. Monitor urine output and laboratory data for signs of DI during and after dexmedetomidine administration. If DI is suspected, adjust fluid management, provide supportive care, and consider discontinuing dexmedetomidine. If such care is insufficient, or in a setting where dexmedetomidine is used for an extended treatment period, consider expert consultation to assist with patient management.
6 Adverse Reactions
6.2 Postmarketing Experience
Additions and/or revisions in table underlined:
Investigations: Alanine aminotransferase increased, aspartate aminotransferase increased, blood alkaline phosphatase increased, blood urea increased, electrocardiogram T wave inversion, gammaglutamyltransferase increased, electrocardiogram QT prolonged
Metabolism and Nutritional Disorders: Acidosis, hyperkalemia, hypoglycemia, hypovolemia, hypernatremia, diabetes insipidus (Cases of diabetes insipidus, with associated polyuria, dilute urine, and hypernatremia, have been reported)
. . .
03/21/2024 (SUPPL-5)
5 Warnings and Precautions
5.1 Drug Administration
Newly added subsection
Dexmedetomidine should be administered only by persons skilled in the management of patients in the intensive care or operating room setting. Due to the known pharmacological effects of dexmedetomidine, patients should be continuously monitored while receiving dexmedetomidine.
5.2 Hypotension, Bradycardia, and Sinus Arrest
Additions and/or revisions underlined:
Clinically significant episodes of bradycardia and sinus arrest have been reported with dexmedetomidine administration in young, healthy adult volunteers with high vagal tone or with different routes of administration including rapid intravenous or bolus administration.
Reports of hypotension and bradycardia have been associated with dexmedetomidine infusion. Some of these cases have resulted in fatalities. If medical intervention is required, treatment may include decreasing or stopping the infusion of dexmedetomidine, increasing the rate of intravenous fluid administration, elevation of the lower extremities, and use of pressor agents. Because dexmedetomidine has the potential to augment bradycardia induced by vagal stimuli, clinicians should be prepared to intervene. The intravenous administration of anticholinergic agents (e.g., glycopyrrolate, atropine) should be considered to modify vagal tone. In clinical trials, glycopyrrolate or atropine were effective in the treatment of most episodes of dexmedetomidine-induced bradycardia. However, in some patients with significant cardiovascular dysfunction, more advanced resuscitative measures were required.
Caution should be exercised when administering dexmedetomidine to patients with advanced heart block and/or severe ventricular dysfunction. Because dexmedetomidine decreases sympathetic nervous system activity, hypotension and/or bradycardia may be expected to be more pronounced in patients with hypovolemia, diabetes mellitus, or chronic hypertension and in elderly patients.
In clinical trials where other vasodilators or negative chronotropic agents were co-administered with dexmedetomidine an additive pharmacodynamic effect was not observed. Nonetheless, caution should be used when such agents are administered concomitantly with dexmedetomidine.
5.3 Transient Hypertension
Additions and/or revisions underlined:
Transient hypertension has been observed primarily during the loading dose in association with the initial peripheral vasoconstrictive effects of dexmedetomidine. Treatment of the transient hypertension has generally not been necessary, although reduction of the loading infusion rate may be desirable.
5.5 Withdrawal
Additions and/or revisions underlined:
Procedural Sedation
In adult subjects, withdrawal symptoms were not seen after discontinuation of short-term infusions of dexmedetomidine (< 6 hours).
In pediatric patients, mild transient withdrawal symptoms of emergence delirium or agitation were seen after discontinuation of short-term infusions of dexmedetomidine (<2 hours).
5.7 Hyperthermia or Pyrexia
Newly added subsection
Dexmedetomidine may induce hyperthermia or pyrexia, which may be resistant to traditional cooling methods, such as administration of cooled intravenous fluids and antipyretic medications. Discontinue dexmedetomidine if drug-related hyperthermia or pyrexia is suspected and monitor patients until body temperature normalizes.
6 Adverse Reactions
Additions and/or revisions underlined:
The following clinically significant adverse reactions are described elsewhere in the labeling:
Hypotension, bradycardia and sinus arrest [see Warnings and Precautions (5.
6.1 Clinical Trials Experience
Extensive changes; please refer to label for complete information
6.2 Postmarketing Experience
Addition of System Organ Class and Preferred Team to heading on Table 7 and hypotension to vascular disorders; please refer to label for complete information
Additions and/or revisions underlined:
Hypotension and bradycardia were the most common adverse reactions associated with the use of dexmedetomidine during post approval use of the drug.
7 Drug Interactions
7.1 Anesthetics, Sedatives, Hypnotics, Opioids
Additions and/or revisions underlined:
Co-administration of dexmedetomidine with anesthetics, sedatives, hypnotics, and opioids is likely to lead to an enhancement of effects. Specific studies have confirmed these effects with sevoflurane, isoflurane, propofol, alfentanil, and midazolam. No pharmacokinetic interactions between dexmedetomidine and isoflurane, propofol, alfentanil and midazolam have been demonstrated. However, due to possible pharmacodynamic interactions, when co-administered with dexmedetomidine, a reduction in dosage of dexmedetomidine or the concomitant anesthetic, sedative, hypnotic or opioid may be required.
7.2 Neuromuscular Blockers
Additions and/or revisions underlined:
In one study of 10 healthy adult volunteers, administration of dexmedetomidine for 45 minutes at a plasma concentration of one ng/mL resulted in no clinically meaningful increases in the magnitude of neuromuscular blockade associated with rocuronium administration.
8 Use in Specific Populations
8.1 Pregnancy
Risk Summary
Available data from published randomized controlled trials and case reports over several decades of use with intravenously administered dexmedetomidine during pregnancy have not identified a drug-associated risk of major birth defects and miscarriage; however, the reported exposures occurred after the first trimester. Most of the available data are based on studies with exposures that occurred at the time of caesarean section delivery, and these studies have not identified an adverse effect on maternal outcomes or infant Apgar scores. Available data indicate that dexmedetomidine crosses the placenta.
In animal reproduction studies, fetal toxicity that lower fetal viability and reduced live fetuses occurred with subcutaneous administration of dexmedetomidine to pregnant rats during organogenesis at doses 1.8 times the maximum recommended human dose (MRHD) of 17.8 mcg/kg/day.
Developmental toxicity (low pup weights and adult offspring weights, decreased F1 grip strength, increased early implantation loss and decreased viability of second-generation offspring) occurred when pregnant rats were subcutaneously administered dexmedetomidine at doses less than the clinical dose from late pregnancy through lactation and weaning (see Data).
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15- 20%, respectively.
Data
Animal Data
Increased post-implantation losses and reduced live fetuses in the presence of maternal toxicity (i.e. decreased body weight) were noted in a rat embryo-fetal development study in which pregnant dams were administered subcutaneous doses of dexmedetomidine 200 mcg/kg/day (equivalent to 1.8 times the intravenous MRHD of 17.8 mcg/kg/day based on body surface area [BSA]) during the period of organogenesis (Gestation Day [GD] 6 to 15). No malformations were reported.
No malformations or embryo-fetal toxicity were noted in a rabbit embryo-fetal development study in which pregnant does were administered dexmedetomidine intravenously at doses of up to 96 mcg/kg/day (approximately half the human exposure at the MRHD based on AUC) during the period of organogenesis (GD 6 to 18).
Reduced pup and adult offspring birth weights, and grip strength were reported in a rat developmental toxicology study in which pregnant females were administered dexmedetomidine subcutaneously at doses of 8 mcg/kg/day (0.07 times the MRHD based on BSA) during late pregnancy through lactation and weaning (GD 16 to postnatal day [PND] 25).
Decreased viability of second generation offspring and an increase in early implantation loss along with delayed motor development occurred in the 32 mcg/kg/day group (equivalent to less than the clinical dose based on BSA) when first generation offspring were allowed to mate. This study limited dosing to hard palate closure (GD 15 to 18) through weaning instead of dosing from implantation (GD 6 to 7) to weaning (PND 21).
In a study in the pregnant rat, placental transfer of dexmedetomidine was observed when radiolabeled dexmedetomidine was administered subcutaneously.
8.2 Lactation
Additions and/or revisions underlined:
Risk Summary
Available published literature reports the presence of dexmedetomidine in human milk following intravenous administration (see Data). There is no information regarding the effects of dexmedetomidine on the breastfed infant or the effects on milk production. Advise women to monitor the breastfed infant for irritability. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for dexmedetomidine and any potential adverse effects on the breastfed infant from dexmedetomidine or from the underlying condition.
Data
In two published clinical studies, a total of 14 women were given intravenous dexmedetomidine 6 mcg/kg/hour for 10 minutes after delivery followed by continuous infusion of 0.2–0.7 mcg/kg/hour. Breast milk and maternal blood samples were collected at 0, 6, 12, and 24 hours after discontinuation of dexmedetomidine. Plasma and milk dexmedetomidine concentrations were detectable up to 6 hours in most subjects, up to 12 hours in one subject and undetectable in all at 24 hours. The milk-to-plasma ratio from single paired maternal milk and plasma concentrations at each time point ranged from 0.53 to 0.95. The relative infant dose was estimated to range from 0.02 to 0.098%.
8.5 Geriatric Use
Additions and/or revisions underlined:
Procedural Sedation
A total of 131 patients in the clinical studies were 65 years of age and over. A total of 47 patients were 75 years of age and over. Hypotension occurred in a higher incidence in dexmedetomidine-treated patients 65 years or older (72%) and 75 years or older (74%) as compared to patients <65 years (47%). A reduced loading dose of 0.5 mcg/kg given over 10 minutes is recommended and a reduction in the maintenance infusion should be considered for patients greater than 65 years of age.
17 PCI/PI/MG (Patient Counseling Information/Patient Information/Medication Guide)
PATIENT COUNSELING INFORMATIONAdditions and/or revisions underlined:
Dexmedetomidine is indicated for short-term intravenous sedation. Dosage must be individualized and titrated to the desired clinical effect. Blood pressure, heart rate and oxygen levels will be monitored both continuously during the infusion of dexmedetomidine and as clinically appropriate after discontinuation.
When dexmedetomidine is infused for more than 6 hours, patients should be informed to report nervousness, agitation, and headaches that may occur for up to 48 hours.
Additionally, patients should be informed to report symptoms that may occur within 48 hours after the administration of dexmedetomidine such as: weakness, confusion, excessive sweating, weight loss, abdominal pain, salt cravings, diarrhea, constipation, dizziness or light-headedness.
Advise breastfeeding mothers who were exposed to dexmedetomidine to monitor breastfed neonates for irritability [see Use in Specific Populations (8.2)].
09/19/2016 (SUPPL-2)
5 Warnings and Precautions
5.5 Withdrawal Adverse Reactions (revised)Intensive Care Unit Sedation
With administration up to 7 days, regardless of dose, 12 (5%) 120 dexmedetomidine HCl adult subjects experienced at least 1 event related to withdrawal within the first 24 hours after discontinuing study drug and 7 (3%) dexmedetomidine HCl adult subjects experienced at least 1 event 24 to 48 hours after end of study drug. The most common events were nausea, vomiting, and agitation.
In adult subjects, tachycardia and hypertension requiring intervention in the 48 hours following study drug discontinuation occurred at frequencies of <5%. If tachycardia and/or hypertension occurs after discontinuation of dexmedetomidine HCl supportive therapy is indicated.
Procedural Sedation
In adult subjects, withdrawal symptoms were not seen after discontinuation of infusions of dexmedetomidine HCl less than 6 hours in duration.
6 Adverse Reactions
6.1 Clinical Trials ExperienceIntensive Care Unit Sedation (addition)
Adverse reaction information is derived from the continuous infusion trials of dexmedetomidine HCl for sedation in the Intensive Care Unit setting in which 1007 adult patients received dexmedetomidine HCl. The mean total dose was 7.4 mcg/kg (range: 0.8 to 84.1), mean dose per hour was 0.5 mcg/kg/hr (range: 0.1 to 6.0) and the mean duration of infusion of 15.9 hours (range: 0.2 to 157.2). The population was between 17 to 88 years of age, 43% greater than or equal to 65 years of age, 77% male and 93% Caucasian. Treatment-emergent adverse reactions occurring at an incidence of greater than 2% are provided in Table 2.
Table 2: Adverse Reactions with an Incidence greater than 2% - Adult Intensive Care Unit Sedation Population less than 24 hours (Table 2 renamed)
Table 2 extensively revised; please refer to label.
Adverse reaction information was also derived from the placebo- controlled, continuous infusion trials of dexmedetomidine HCl for sedation in the surgical intensive care unit setting in which 387 adult patients received dexmedetomidine HCl for less than 24 hours. (sentence added following Table 2)
Table 3: Treatment-Emergent Adverse Events Occurring in greater than 1% Of All Dexmedetomidine-Treated Adult Patients and at an Incidence Greater than Plaecbo in the Randomized Placebo-Controlled Continuous Infusion less than 24 Hours ICU Sedation Studies
New table added to this subsection; please refer to label.
In a controlled clinical trial, dexmedetomidine HCl was compared 157 to midazolam for ICU sedation exceeding 24 hours duration in adult patients. Key treatment emergent adverse events occurring in dexmedetomidine or midazolam treated patients in the randomized active comparator continuous infusion long-term intensive care unit sedation study are provided in Table 4. The number (%) of subjects who had a dose-related increase in treatment-emergent adverse events by maintenance adjusted dose rate range in the dexmedetomidine HCl group is provided in Table 5. (sentences added following Table 3)
Table 4: Key Treatment-Emergent Adverse Events Occurring in Dexmedetomidine- or Midazolam-Treated Adult Patients in the Randomized Active Comparator Continuous Infusion Long-Term Intensive Care Unit Sedation Study
New table added to this subsection; please refer to label.
The following adverse events occurred between 2 and 5% for dexmedetomidine HCl and Midazolam, respectively: renal failure acute (2.5%, 0.8%), acute respiratory distress syndrome (2.5%, 0.8%), and respiratory failure (4.5%, 3.3%). (sentence added following Table 4)
Table 5. Number (%) of Adult Subjects Who Had a Dose-Related Increase in Treatment Emergent Adverse Events by Maintenance Adjusted Dose Rate Range in the Dexmedetomidine HCl Group
New table added to this subsection; please refer to label.
Procedural Sedation (addition)
Adverse reaction information is derived from the two trials for procedural sedation in which 318 adult patients received dexmedetomidine HCl (Studies 1 and 2). The mean total dose was 1.6 mcg/kg (range: 0.5 mcg/kg to 6.7 mcg/kg), mean dosage per hour was 1.3 mcg/kg/hour (range: 0.3 mcg/kg/hour to 6.1 mcg/kg/hour) and the mean duration of infusion was 1.5 hours (range: 0.1 hour to 6.2 hours). The population was between 18 to 93 years of age, 30% greater than or equal to 65 years of age, 52% male and 61% Caucasian.
Adverse reactions that occurred at an incidence of greater than 2% of patients receiving dexmedetomidine HCl and at an incidence greater than placebo are provided in Table 6. Pre-specified criteria for the vital signs to be reported as adverse reactions are footnoted below the table. The decrease in respiratory rate and hypoxia was similar between dexmedetomidine HCl and comparator groups in both studies.
Table 6: Adverse Reactions* in Clinical Trials of Dexmedetomidine HCl for Adult Procedural Sedation
New table added to this subsection; please refer to label.
Table 7: Adverse Reactions Experienced During Post-approval Use of Dexmedetomidine HCl
This is the same table that was previously labeled as Table 3 from the Postmarketing Experince section.
8 Use in Specific Populations
8.4 Pediatric UseSafety and efficacy of dexmedetomidine HCl have not been established for Procedural or ICU Sedation in pediatric patients. (addition is underlined).
Intensive Care Unit Sedation (added subheading)
A total of 729 patients in the clinical studies were 65 years of age and over. A total of 200 patients were 75 years of age and over. In patients greater than 65 years of age, a higher incidence of bradycardia and hypotension was observed following administration of dexmedetomidine HCl. Therefore a dose reduction may be considered in patients over 65 years of age.
Procedural Sedation (subheading title added over pre-existing text)
A total of 131 patients in the procedural sedation clinical studies were 65 years of age and over…