There is a reason why clonidine is not routinely used in the elderly. It has a high incidence of adverse effects in the elderly and can contribute to CNS changes, orthostasis, dry mouth etc.
An 88 year old gentleman was started on clonidine for hypertension. His other medications include:
- Acetaminophen as needed
- Biotene
- Diphenhydramine at bedtime
- Lisinopril
- Methotrexate
- Naproxen
He does seem to be tolerating the clonidine per his report. When specifically asked if he feels he is having any side effects from his medication he replies that he doesn’t think so. Upon further questioning, he attributes his dry mouth and use of Biotene to him “just getting older”. His blood pressure is under good control following the clonidine initiation and you feel as if there have been no CNS adverse effects from the new medication.
As we look at the medication list in relation to his dry mouth, the timing of medications is going to be important. Given the limited information which often happens in real life, here’s a few questions I would think about when assessing the dry mouth.
- How necessary is the diphenhydramine? How strongly does this patient feel about continuing it and certainly we need to ask if he taking it routinely as well as how much?
- Are we using diphenhydramine for sleep (most likely) or something else?
- What allergies does this patient have, if any?
- Clonidine does have a good possibility of causing dry mouth. Clonidine use in the elderly is definitely not a first line agent for hypertension. What alternative BP medications would be acceptable (factoring in compelling indications, labs, previous trials etc.)?
Ideally in this situation, given the age of this patient, I would like to find alternatives to both the diphenhydramine and clonidine. What did I miss?
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Shouldn’t we avoid also methotrexat + naproxen ?
Very interesting case, i would also ask about the naproxen. NSAIDS could cause blood pressurecelevetion themselves…and they are really bad in combination with ACE inhibitors. Besides i’d make sure the patient swallowes thevmethotrexate and doesnt hold it in the mouth to exclude damage and sore which could be erroneously interpretated as dry mouth…
Thiazide, CCB, ACEi or ARB first line antihypertensives for most. Not sure what compelling reason to use clonidine.
Diphenhydramine not good for elderly. Dry mouth, dry eyes, urinary retention, constipation and confusion/CNS side effects. Try topicals/locals or 2nd gen antihistamines if allergies. Try sleep hygiene, melatonin, low dose trazodone if insomnia.
Agree. Only when all other antihypertensive medications fail, should clonidine be used in the elderly.
I am 80 years old. I have been taking Valsartan 320 mg once in am and once at bedtime. They have recalled Valsartan. It wasn’t keeping my BP down anyway. Dr. put me on Lisinapril and Clonindine if BP gets too high, with HCTZ in the morning and potassium. Second day of this, my heart has a slow, irregular heart beat. My Dr. said if my blood pressure gets over 200 (top number) or over 100 (bottom number) to take Clonindine. I don’t like to take it. It makes me dizzy but lowers my blood pressure. It isn’t that high but my heart beat is slow and irregular… and a slight headache pounding in back of my head. I don’t know whether to take Clonindine or not. I don’t think I will. It is not during Dr.’s hours now.
Why would the Dr. give potassium with Lisinopril ?
because he was also prescribed HCTZ, a diuretic.
I have the exact same problem with clonidine. I am very frustrated and would like to have a different rescue medicine. The doctor seems not to want to change me. But, it is ruining half of my week every week. Don’t know what to do!