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Clonidine (see Table 4–2) is an imidazoline derivative with alpha-adrenergic agonist properties that has primarily been used in the treatment of hypertension. At low doses, it appears to stimulate inhibitory presynaptic autoreceptors in the CNS. The most common use of clonidine in pediatric psychiatry is the treatment of Tourette's and other tic disorders (Leckman et al. 1991), ADHD, and ADHD-associated sleep disturbances (Hunt et al. 1990; Prince et al. 1996). In addition, clonidine has been reported to be useful in developmentally disordered patients to control aggression toward self and others. Clonidine is a relatively short-acting compound, with a plasma half-life ranging from approximately 5.5 hours (in children) to 8.5 hours (in adults). Daily dosages should be titrated and individualized. Usual daily dosages range from 3 to 10 micrograms per kilogram, generally given in divided doses, bid, tid, and sometimes qid. Therapy is usually initiated at the lowest manufactured dose of a full or half tablet of 0.1 mg, depending on the size of the child (approximately 1–2 microgram/kilogram) and increased depending on clinical response and adverse effects. Initial dosage can more easily be given in the evening hours or before bedtime due to sedation. The most common short-term adverse effect of clonidine is sedation. It can also, in some cases, cause hypotension, dry mouth, depression, and confusion. Clonidine is not known to be associated with long-term adverse effects. In hypertensive adults, abrupt withdrawal of clonidine has been associated with rebound hypertension. Thus, the drug requires slow tapering when discontinued. Clonidine should not be administered concomitantly with beta-blockers, because adverse interactions have been reported with this combination. Reports of death in several children on the combination of methylphenidate and clonidine generated concerns about its safety. Although more work is needed to evaluate whether an increased risk exists with this combination, a cautious approach is advised, including increased surveillance and cardiovascular monitoring.

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