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FAQs
Analgesia, Sedation,
and Anesthesia
Making the Switch from
Medetomidine to Dexmedetomidine
A Peer-Reviewed Publication
Jeff C. Ko, DVM, MS, DACVA, Marc R. Raffe, DVM, MS,
is a professor in the anesthesiology section in DACVA, DACVECC,
the Department of Veterinary Clinical Sciences, is a veterinary specialist with the Pfizer
School of Veterinary Medicine, Purdue University. Animal Health US Veterinary Operations
He has authored numerous anesthesia articles Group. He holds affiliate faculty
and is a frequent speaker at regional, national, appointments at Colorado State University
and international meetings. Dr. Ko is interested in College of Veterinary Medicine and the
injectable anesthesia and pain management. University of Illinois College of Veterinary
Medicine. He has authored over 100
scientific articles and has coauthored a
textbook in emergency and critical care
medicine.
Ann B Weil, MS, DVM, DACVA, Correspondence should be sent to Dr. Ko, Department of Veterinary
is a clinical associate professor of anesthesiology Clinical Sciences, School of Veterinary Medicine, Purdue University, 625
in the Department of Veterinary Clinical Sciences, Harrison Street, West Lafayette, IN 47907-2026; phone, 765-496-9329;
School of Veterinary Medicine, Purdue University. Her fax, 765-496-1108; email, jcko@purdue.edu. To cite this publication,
research interests include equine anesthesia, pain please use the following: Ko JC, Knesl O, Weil AB, et al. FAQs: Analgesia,
management, and injectable anesthetics. sedation, and anesthesiaMaking the switch from medetomidine to
dexmedetomidine. Compend Contin Educ Vets 2009;31(suppl 1A):1-24.
Dexmedetomidine (Dexdomitor, Pfizer Animal Health) has recently been approved by the
FDA Center for Veterinary Medicine as a sedative and analgesic in dogs and cats and as a
preanesthetic to general anesthesia in dogs.1,2 This drug has been introduced into the United
Kingdom and other European countries with similar indications. Within the United States,
veterinary practitioners are faced with switching from medetomidine (Domitor, Pfizer Animal
Health) to dexmedetomidine (Dexdomitor) because medetomidine has just been phased out
and a generic equivalent is not currently available in this country.
In 1997, Ko and colleagues3 published an article based on questions received from
veterinary practitioners regarding the safe and effective use of medetomidine and its specific
antagonist, atipamezole (Antisedan, Pfizer Animal Health). Since the launch of Dexdomitor in
November 2007, the authors have received numerous questions from veterinarians about this
drug and thought that a compilation of the most commonly asked questions and answers
would be useful during this transitional period. The answers provided in Part I of this article
are based on a review of currently available literature as well as label indications. Part II
provides information about the off-label use of dexmedetomidine in combination with other
sedative, analgesic, and/or anesthetic agents that has been compiled from published studies
and the authors collective clinical experience.
2 FAQs: Analgesia, Sedation, and Anesthesia
Part 1: Introducing Dexmedetomidine
Figure 1
Dexmedetomidine is a synthetic 2-adrenoreceptor Medetomidine
agonist with sedative and analgesic properties.4 It is (Domitor)
the dextrorotary enantiomer of the racemic mixture
medetomidine5 (Figure 1). Dexmedetomidine is 1x
commercially available in the United States for use
in veterinary patients as Dexdomitor and is indicated
for use as a sedative and analgesic in dogs and
cats to facilitate clinical examinations and various
clinical procedures, including minor surgical and 0x 2x
dental procedures. It is also indicated for use as a
premedicant prior to general anesthesia in dogs. It is
approved for intravenous (IV) and intramuscular (IM)
administration in dogs but only IM administration in
cats.1,2 Dexmedetomidine is also commercially available Levomedetomidine Dexmedetomidine
for use in human patients (Precedex, Hospira) and (pharmacologically inactive) (Dexdomitor)
is indicated for sedation of initially intubated and
Dexmedetomidine contains only the active enantiomer of the
mechanically ventilated patients during treatment in an
racemic mixture medetomidine. Because levomedetomidine
intensive care setting.6
has no sedative, analgesic, or cardiorespiratory effects,
dexmedetomidine is twice as potent as medetomidine based
What are the similarities and differences
on a microgram of dexmedetomidine versus a microgram
between dexmedetomidine and
of medetomidine. As currently supplied for veterinary use,
medetomidine?
however, dexmedetomidine (0.5 mg/ml) has been diluted to
Medetomidine is an equal mix of two
be equipotent to medetomidine (1 mg/ml) on a volume-to-
optical enantiomers, dexmedetomidine and
volume basis.
levomedetomidine.5 Levomedetomidine has been
found to have no sedative or analgesic effects. As
such, the pharmacologic activity of medetomidine (which contains both dexmedetomidine and
is primarily attributable to dexmedetomidine.5 levomedetomidine). Differences in drug metabolism
Dexmedetomidine is approximately twice as potent between dexmedetomidine and medetomidine can
as medetomidine in terms of its ability to produce therefore be expected.
sedation and analgesia.5,7 Clinically, this is reflected Levomedetomidine has been shown to interfere
in the fact that administration of dexmedetomidine with the metabolism of other anesthetic drugs in the
requires less drug on a g/kg or body surface area liver.13,16 In human studies, levomedetomidine has
(BSA) basis. In contrast to Domitor, which is supplied been shown to have a greater inhibitory effect than
as a 1 mg/ml solution, Dexdomitor is supplied as a dexmedetomidine on ketamine metabolism by the
0.5 mg/ml solution, allowing clinicians to use the liver, which may slow recovery after completion of a
same injection volume because the dexmedetomidine procedure.16
dilution has the same potency as medetomidine. A recent study comparing dexmedetomidine and
A review of current literature revealed a number of medetomidine premedication before ketamine
studies suggesting that dexmedetomidine differs from anesthesia in 72 cats found that dexmedetomidine-
medetomidine in several respects.1,4,5,716 How these premedicated cats recovered more quickly than cats
differences translate into clinical practice in dogs and cats premedicated with racemic medetomidine.17
remains to be fully elucidated. For comparative purposes, Results of other studies in cats have been equivocal
a brief overview of these differences is provided. with respect to differences between medetomidine
Dexmedetomidine contains only the active and dexmedetomidine in this species. One small
enantiomer without levomedetomidine. As such, study (six cats) showed no difference between the
only half the amount of the racemic mixture of two drugs in terms of their effects on heart rate,
medetomidine needs to be administered, and therefore respiratory rate, or body temperature.11 A more recent
metabolized, when compared with medetomidine study (120 cats) demonstrated that the percentage
The total doses in ml and doses in ml/kg in this table have been derived from the g/kg BSA dose and have been rounded up or down, as appropriate,
to accommodate practical dosing. As a result, a perfect match in values based on calculation conversions between columns will not necessarily occur.
of cats with normal heart rate and normal pulse to select a dexmedetomidine dosage for a given canine
character after drug administration was higher with body weight based on the level of sedation/analgesia
dexmedetomidine than medetomidine.12 desired (i.e., premedication/cooperative sedation or full
In one study,5 analgesia provided by clinical sedation) and the route of administration. The
dexmedetomidine at a dose of 20 g/kg IV was shown chart provides both an injection volume of Dexdomitor
to last longer than that provided by medetomidine in milliliters as well a dose in g/kg. In dogs, there are
at 40 g/kg IV, suggesting the possibility of greater two FDA-approved Dexdomitor doses for sedation and
analgesic duration for dexmedetomidine in dogs. analgesia (500 g/m2 IM and 375 g/m2 IV) and two
The analgesic effects of dexmedetomidine (20 g/kg) approved doses for premedication (125 g/m2 IM and
last for approximately an hour and can extend into 375 g/m2 IM). The small range in feline body weights
the recovery period if the drug is not reversed with resulted in a single FDAapproved Dexdomitor dose (40
the antagonist, atipamezole.8 g/kg) for sedation and analgesia in cats.2 This dose is based
on the BSA of a 4.5-kg cat, and BSA dosing may still be an
How is dexmedetomidine dosed? important consideration for cats weighing less than 4.5 kg.
The available concentration of dexmedetomidine (0.5 In dogs, body weights and mass-specific metabolic
mg/ml; Dexdomitor) provides practitioners with a simple rates vary across breeds.18 Within-breed differences also
volume-for-volume substitution of dexmedetomidine exist because individual animals have different body
for medetomidine. Without this formulation, dose conformations and may be under- or overweight relative
determination could be confusing. The package insert to the breed standard. As such, dexmedetomidine doses
of Dexdomitor provides a chart of canine body weight are based on an animals BSA rather than body weight
ranges in pounds and kilograms. Practitioners are required to minimize variations in sedative and analgesic effects.
1 (A) A 25-kg, 4-year-old Labrador retriever in good health was presented for dental cleaning and tooth
extractions. Basic blood work was normal. The dog was premedicated with dexmedetomidine (0.23 ml IM) in
combination with hydromorphone (0.05 mg/kg IM). The dexmedetomidine dose used was based on the values
provided in Table 1 (preanesthetic/cooperative sedation, 125 g/m2 or 0.22 ml for a body weight of 25 kg =
4.31 g/kg). The dexmedetomidine and hydromorphone were drawn up separately, mixed in the same syringe,
and administered as a single IM injection. The dog appeared to be moderately sedated within 8 minutes after drug
administration. (B) When prompted, the dog was able to walk to the induction table 10 minutes after receiving the
dexmedetomidinehydromorphone preanesthetic combination.
2 3
Table 3
Dexmedetomidine*Opioid Combinations in Dogs and Cats for Profound Sedation
Drug Dose
Dexmedetomidine Butorphanol Hydromorphone Morphine Buprenorphine
Species (g/kg) (mg/kg) (mg/kg) (mg/kg) (mg/kg)
Dogs 510 IV 0.10.2 IV 0.030.05 IV 0.250.5 IV
1520 IM 0.30.4 IM 0.050.1 IM 0.51 IM
Cats 1525 IV 0.20.3 IV 0.030.05 IV 0.010.02 IV
2040 IM 0.30.4 IM 0.050.1 IM 0.020.04 IM
*Note that dexmedetomide dosages in this table are higher than the 125 g/m2 IM doses listed in Table 1.
Note that buprenorphine has a slower onset than other opiods.
Table 5
DexmedetomidineButorphanolMidazolam and DexmedetomidineButorphanolDiazepam
Combinations for Profound Sedation and Immobilization of Healthy Dogs and Cats*
Drug Dose
Species Dexmedetomidine (g/kg) Butorphanol (mg/kg) Midazolam or Diazepam (mg/kg)
Dogs 2.55 IV 0.2 IV 0.2 IV
510 IM 0.3 IM 0.4 IM
Cats 1015 IV 0.2 IV 0.2 IV
2025 IM 0.3 IM 0.4 IM
*Butorphanol can be replaced with another opioid at the doses listed in Table 3.
Table 6
DexmedetomidineButorphanolKetamine (Kitty Magic) Combination in Cats*
Drug Dose
Dexmedetomidine Butorphanol Ketamine Atipamezole
Level of Sedation/Procedure (0.5 mg/ml) (10 mg/ml) (100 mg/ml) (5 mg/ml)
Profound sedationanalgesia 0.1 ml 0.1 ml 0.1 ml 0.1 ml
(11.1 g/kg) (0.22 mg/kg) (2.2 mg/kg) (111.1 g/kg)
Castration or laceration repair 0.2 ml 0.2 ml 0.2 ml 0.2 ml
(22.2 g/kg) (0.44 mg/kg) (4.4 mg/kg) (222.2 g/kg)
Ovariohysterectomy, onychectomy, 0.3 ml 0.3 ml 0.3 ml 0.3 ml
abdominal procedures (33.3 g/kg) (0.66 mg/kg) (6.6 mg/kg) (333.3 g/kg)
*Based on a 4.5-kg (10-lb) cat. All drugs (except atipamezole) can be mixed in one syringe and administered as a single IM injection. If given
IV, the drug doses in this combination should be halved; however, if a deeper plane of anesthesia is desired, the full IM dose can be given IV.
If reversal is necessary for safe recovery.
Table 7
TiletamineZolazepamButorphanolDexmedetomidine (TTDex) Combination in Dogs and Cats
Volume (ml/kg IM) of
Desired Purpose IM Dosages of Individual Components* Reconstituted TTDex
Premedication (mild to Tiletaminezolazepam, 1 mg/kg 0.01
moderate sedation) Butorphanol, 0.05 mg/kg
Dexmedetomidine, 2.5 g/kg
Chemical restraint (profound Tiletaminezolazepam, 2 mg/kg 0.02
sedation) Butorphanol, 0.1 mg/kg
Dexmedetomidine, 5 g/kg
Surgical plane of anesthesia Tiletaminezolazepam, 3 mg/kg 0.03
Butorphanol, 0.15 mg/kg
Dexmedetomidine, 7.5 g/kg
*Each agent (tiletaminezolazepam [Telazol, Fort Dodge Animal Health], butorphanol, and dexmedetomidine) may be drawn up
separately according to the dosage listed in this table. If given IV, drug doses in this combination should be halved; however, if a deeper
plane of anesthesia is desired, the full IM dose can be given IV.
Alternately, Telazol powder can be reconstituted using 2.5 ml of butorphanol (10 mg/ml) and 2.5 ml of dexmedetomidine (Dexdomitor,
0.5 mg/ml) as diluents. If given IV, drug doses in this combination should be halved; however, if a deeper plane of anesthesia is desired,
the full IM dose can be given IV.
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