Sublingual Dexmedetomidine for Bipolar Disorder - An Overview

Introduction

The management of acute agitation can constitute a significant challenge for doctors in the emergency department. An early prospective study in an urban trauma care unit screened 43,000 patients, of which 2.6 % were admitted to the emergency department due to agitation. The National Hospital Ambulatory Medical Care Survey estimated that 2,15,000 visits to emergency care for bipolar disorder with agitation as common among many. The prevalence of one to five percent of the world population has been affected by bipolar disorder over the last 30 years.

What Is Bipolar Disorder?

A mood-related disorder or illness associated with a range of moods from low depressive to high manic state is known as bipolar disorder. The exact cause of the bipolar disorder is still unknown, but several elements constitute genetic, environmental, and chemical factors that alter the normal physiology of the brain. As the name suggests, the bi+polar comprises two poles or two mood states. Depression is the persistent feeling of sadness, while mania is a state of hyperexcitability. The features of the two poles of bipolar disorder are the following.

• The manic state shows symptoms of high energy and activity, reduced sleep, and loss of relationship with reality.

• The low depressive state exhibits symptoms of low energy, sadness, loss of motivation, and loss of attentiveness in daily activities.

In addition, the person exhibits mood swings, anxiety, anger, irritability, disorganized behavior, impulsivity, restlessness, unusual thoughts, and distorted concentration. The particular mood episode lasts a day to months, varying on each patient.

What Does Bipolar Agitation Look Like?

An agitation is a state of anxiety or nervous excitement with rapid, unusual action. The person in a state of agitation exhibits nervousness, tension, excitement, confusion, and irritability. An example of agitation is when one rapidly tap their toes in agitation. This condition is typical and problematic in psycho-related disorders. Patients with bipolar disorder experience agitation during mania as their energy levels are elevated and their sleep is disturbed. Patients in mixed and depressive states often encounter agitation, fluctuating energy levels, and irritability. The presentation of agitation in bipolar disorders differs between men and women, children and adolescents. The following are the two forms of agitation.

• Mild with symptoms of restlessness and uneasiness.

• Severe exhibits symptoms of aggression and violation.

Why Sublingual Dexmedetomidine for Bipolar Agitation?

Acute agitation is a common theme in patients with bipolar disorders, and it requires immediate management. The agitation would result in aggression, and the elevation to severe form occurs abruptly. The evaluation and management should relieve agony and prevent further aggressive action or behavior, as they could often injure themselves or others. The late shreds of evidence recommend verbal and nonverbal de-escalation methods for agitation. Agitation with bipolar patients is formally prescribed with Olanzapine intramuscularly and Loxapine inhalation. And medications like antipsychotics, benzodiazepine sedatives, and Ketamine are commonly given. Recent clinical studies evaluated the effect of sublingual Dexmedetomidine on acute agitation over placebo.

What Is the Action of Dexmedetomidine?

A sedative-analgesic pharmacological drug is used to sedate a patient in an emergency or intensive care unit. Dexmedetomidine possesses the properties of sedative, analgesic, and anxiolytic and maintains a stable hemodynamic profile. The drug is primarily used for sedation and further against acute agitation in bipolar disorders and schizophrenia. As it acquires a rapidly differentiated approach to debilitating agitation in the diseases, medical practitioners consider sublingual Dexmedetomidine the first new treatment. The clinicians welcome the new oral, sublingual film Dexmedetomidine for the management of agitation.

How Does Sublingual Dexmedetomidine Relieve Agitation?

Dexmedetomidine is a new generation alpha-two adrenergic receptor agonist, a type of sedative. The primary function is sedation by inhibiting the transmission of pain signals. And for calming agitation, Dexmedetomidine reduces thermoregulatory vasoconstriction and shivering threshold. The clinical improvement of acute agitation in bipolar disorders has been observed after 2 hours of first dose administration.

Which Dosage of Sublingual Dexmedetomidine Is Beneficial for Bipolar Agitation?

The Food and Drug Administration (FDA) has approved the sublingual formulation of Dexmedetomidine for the treatment of agitation associated with schizophrenia, bipolar I, and II disorders. The drug dosage of 120 mcg is recommended for mild to moderate agitation in adults and 180 mcg for the severe phase in adults. So, based on the severity of agitation in bipolar disorders and a history of hepatic impairment, the doctor alters the dosage between 60 mcg and 180 mcg. After the initial dose, if the aggressive action persists, then additional doses are recommended only after reviewing the vital signs due to the risk of hypotension.

What Are the Contraindications of Sublingual Dexmedetomidine?

There are no absolute contraindications for Dexmedetomidine. However, patients with hypotension and bradycardia( low heart rate) should be cautious at administering the medication. In addition, an evident study says that Dexmedetomidine could exacerbate myocardial dysfunction, so patients with known cardiac failure should have care. Inform priorly the doctor of medical illness, allergy, pregnancy, or breastfeeding.

What Are the Side Effects of Dexmedetomidine?

The common side effects of the medication are the following.

• Shortness of breath.

• Decreased heart rate.

• Anemia.

• Dryness of mouth.

• Fever.

• Nausea.

• dizziness.

At times, Dexmedetomidine exhibits serious side effects on cardiovascular and respiratory functions like hives, difficulty in breathing, hypotension, agitation, slow heartbeats, swelling of the face and tongue, nervousness, lightheadedness, anxiety, blurred vision, constipation, headache, chest discomfort, excessive sweating, and loss in weight. In that case, tell the doctor right away.

What Are the Warnings for Dexmedetomidine?

• Dexmedetomidine should be taken only under the supervision of a doctor. He will prescribe it after inspecting the vitals and eventually monitor the signs and alertness after dispensing the drug.

• Sublingual Dexmedetomidine should be placed under the tongue. The film then sticks to that place. Do not swallow or chew it with water.

• Do not drink water or eat something for 15 minutes after being administered.

Conclusion

The management of bipolar disorders presenting aggressive behavior is directed primarily at relieving the agitation. Following the doctor's instructions, sublingual Dexmedetomidine is self-administered alone or with other drugs to calm the person encountering agitation in bipolar disorder.