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l1li.. I I l1li III I

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;nal:lter 1:

use as a Dexmedetomidine Mivazerol Guanabenz Guanfacine Clonidine a2 Numbers in brackets indicate 02: a1 ratio a1 1

Reference List 1. T.I.. A.t, and K. Transfer of clonidine and dexmedetomidine across the isolated Acta 1: 313-319 2. B. Effects of intravenous and metabolic rate. 3. 4. J. K. J. Dexmedetomidine. 263-268 nesthe:slollogy 1 5. 6. 7. De 8. 9. 10. A. and E. J. Dexmedetomidine endovascular of arteriovenous malformations: a 'etnosplec1:jve case 14: 209-212 Tn,nitt\uit'h L, et at Pharmacokinetics of failure elin <>... "'... "'1 Ther. na'''''",''qi overview. International R~l"nAV J. M. D. The effects of concentrations of ri,'''"... ''''ri...,n'''''ri'inq in humans. An4~stlleSIOI()gy 93: 382-394 11. and intramuscular dexmedetomidine and midazolam nn:>m"'t'li abdominal and 79: O'l-t)-o:;;:,,, 12. J. H~rn"'v J. and T. J. UU(IBSIC n.mn'''',.... '.. " of small-'ao~ie dexmedetomidine infusions..... 14.

15. (,,11'l.nitilinA and D. I=nl"lll:uu1 M. ICU SelllcUl(m 17. 18. and agiltati()n after 20. 21. 22. 23. 24. 25. 26. and Cnt Care Clin. 2001, 17: lj.. t\ln'~/""t'\i int1i1~j:!t1 withdrawal. dexmedetomidine in the intensive care unit. in ~""" "'t:i,,,n sedation- R. ~nn"lrullrati\l'" effects of metabolism. in vitro interaction of dexmedetomidine with Metab UI;;l'I-N'i:II. 27. 28. of 2

29. R. M. effects of dexmedetomidine in the intensive care. Crit Care. 4: 302 308 31. R. M. and between dexmedetomidine and DroDotol sedation in the intensive care unit: and clinician,,,:... I"ti~'n'" ; 87: 684 690 32. pn,amlacoklineltics of rljoo10fml:>ri".tnrnirliin intensive care. 3

B. C. 1 Confused and uncontrollable 2 Anxious and 3 calm 4 but rousable to commands 5 but to stimulus or sternal pressure 6 Unrousable 1 Unable to control ventilation 2 ventilator 3 when moved but ventilation for most of the time 4 1 2 3 4 3

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17. 19. 1 47 20. 21 25. 27. and in n... nnnfni as 2

32. 33.. 41. 42. ProlDOfOI A treatment. 43. any 44. 58: 45. 46. care 3

47. c. V!:lIlm:::a C!.hilt!:ll T. S., critical 49. l... t~... """/O care seolatlcm 50. 51. 52. 54. 55. 56. 57. Seic:latlon in S. and sn~:>nrjqr 52: 417-427 143-153 RArnllier:I'ion of... hilltirs::.n T(\Un'Wlni/"! mit~i"ic::.iv ~ I. Setlation neuromuscular DIOCK~lae nr:::lmir'~ in the UK. Pa~H1ialtr "nrln"",n R. sedation with 61. 62. D. A. 252 Intravenous Anaesthetics. 4'

A. 64. 27: 66. models and 69. 70. a """""""'" 71. seolaucm OILJldlelirle on 72. sedlatic)n in ntq'"'''''''''''' care 74. and K..::In"f.::ln,r-e:>Cl: Neuroimmunomodulation. 75. P... 'nnfnl and POl~toIJer;ati\lre 31: U.. I"I... t,... 1 An UIAJICIlC on its 77. amillce!sic nrj:lmlr'e:> in the Anl:le:>Cl:rn 2001; 78....rnlnn''''... sedation in the intensive care 415-421 5

79. 80. in care unit. 81. 1 ljelnzolalalzel:)ln~:!s in the J. Seldation in the,nr",.ncti\,q care unit. care unit 6

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Figure 1 Comparison between mean weights of drug groups _30 ~---- C) ~ 20 -s::..21 10 G) ~ 0 II III whole Drug group South African Canadian (Control subjects excluded) Figure 2 Comparison of 8M1 between two sites for different drug groups 20 ~------------------~ 15 N E C, 10.l< 5 o (Control subjects excluded) III Drug Groups whole!-sal ~ Since body surface area (BSA) may playa role in the pharmacokinetics the BSA for the different groups was also compared. (Figure 3) The Canadian subjects had larger BSA's in groups I and III, but in group II the BSA's for the two sites were similar. (Weight in the three groups showed the same distribution.) A comparison of the ages of drug recipients at the two sites revealed that the subjects in Group I and III in Canada were older than their South African counterparts, but that the ages in Group II were similar. (Table 2). ~ a bl e 2. C omparlson 0 f ages 0 fd rug recipients South Africa Canada Group I 2.5 5.7 Group II 6.75 6.05 Group III 4 8.6 Mean age given in years All 36 enrolled subjects completed the study. 2

Figure 3 Comparison of BSA between sites for different drug groups N E 1.2 1 0.8 0.6 0.4 0.2 0 III Drug groups whole!-sal ~ (Control subjects excluded) Pharmacokinetic results Plasma concentrations of dexmedetomidine were determined from each of the blood samples taken for this purpose. The pharmacokinetic parameters for each of the three groups are shown in table 3. Plasma concentrations for subject 4 (South African site) could not be determined, as the blood samples had haemolysed. Table 3 Pharmacokinetics of Dexmedetomidine per dose group (mean±sd) Pharmacokinetic Group I Group II Group III Parameter 2mcg/kg/h 4mcg/kg/h 6mcg/kg/h (max (ng/ml) O.298±O.168 O.623±O.312 1.lS0±O.633 tvzp (h) 2. 18±0.46 2.12±O.77 1.61±O.28 Vss (L/kg) 2.33±O.S7 2.13±O.32 1.6S±O.43 CI (L/h/kg) O.894±O.231 O.83S±O.296 O.848±O.223 T max (h) O.186±O.04S O.223±O.116 O.187±O.O40.. See text for explanation of abbreviations The maximum plasma concentration «(max) and the time to the maximum concentration (T max) were read directly from the plasma-concentration data. The other values were calculated using methods described in the previous chapter. In all three dosage groups, clearance (CI) was higher (see table) in this paediatric study group than in adults (0.49SL/h/kg). Volume of distribution (Vss) was higher for all dosage groups than for adults (1.33L/kg), with a marked difference in the 2 and 4mcg/kg/h groups. The terminal elimination half-life (t1kp) 3

The maximum plasma concentration at 30 minutes for the South African subject 11 cannot be explained in the same way, and it has to be questioned whether this was due to a sampling or measuring error. The 12-hour sample of Canadian subject 102 showed a dexmedetomidine level more than three times the level at 6 hours, and it is most probable that this was due to measuring error. Also of interest is the markedly higher maximum plasma levels (Cmax) in the Canadian group, particularly obvious at 10 minutes after the start of the infusion. (Figure 4) At 15 minutes this marked difference is not apparent in groups I and II anymore, with the difference in group III remaining obvious until the 30 minute values.. - Minutes after starting drug infusion Subject Site Dose* 10 15 30 1 SA 2 0.136 0.166 0.129 2 SA 2 0.113 0.116 0.078 5 SA 2 0.217 0.213 0.162 101 C 2 0.231 0.168 0.131 102 C 2 0.571 0.28 0.171 104 C 2 0.306 0.262 0.158 105 C 2 0.479 0.26 0.144 7 SA 4 0.431 0.429 0.275 8 SA 4 0.528 0.425 0.322 10 SA 4 0.303 0.408 0.294 11 SA 4 0.093 0.187 0.377 107 C 4 0.708 0.526 0.295 108 C 4 1.341 0.583 0.318 110 C 4 0.637 0.296 0.209 112 C 4 0.555 0.361 0.31 13 SA 6 0.619 0.595 0.366 14 SA 6 0.589 0.629 0.452 16 SA 6 0.544 0.541 0.386 17 SA 6 0.551 0.587 0.418 114 C 6 1.69 0.797 0.4 115 C 6 1.696 1.103 0.554 117 C 6 1.308 0.558 0.385 118 C 6 2.127 1.066 0.622 Bold figures In blue Indicate maximum concentration levels In the SA group T a bl e 4. I n d""d IVI ua I d exm eel etoml "d" me concentrations m ng, I m I * - dexmedetomidine dose in mcgjkgjh Site - SA := South Africa, C := canada Subject 4 in SA group excluded as samples haemolysed 75 0.09 0.059 0.093 0.083 0.083 0.068 0.08 0.161 0.165 0.245 0.158 0.161 0.165 0.245 0.158 0.24 0.257 0.236 0.261 0.258 0.277 0.173 0.385 Since the dosage was adjusted to the weight of each subject, the reason for the higher levels in the Canadian group must be sought elsewhere. If one assumes that dexmedetomidine is not a highly fat-soluble drug (this information has never been published to my knowledge), the higher weight and BMI in the canadians for groups I and III may explain their higher Cmax. All group II's comparisons for weight, BMI and BSA are similar between the two sites, and this argument therefore does not hold true. Altering dosing schedules to BSA, which may be a more accurate way of calculating dose, would not have altered the dose 5

administered, at least not for group TI, and thus cannot account for the higher peak concentration levels. This difference is Intriguing, but - unless there was an unknown or unspoken difference in protocol interpretation between the two sites, the explanation remains out of reach. Figure 4 Comparison between mean concentration values for 2 different sites 1.8 1.6 1.4 _ 1.2 E 1 -g» 0.8 0.6 0.4 0.2 o \ \ \ \ \ "- "- -,- ~'" :,---~ ~ 10 15 30 75 150 240 360 720 1440 Minutes after start of infusion Pharmacodynamic data Sedation - SA Group I - Canada Group I SA Group II - Canada Group II - SA Group III - Canada Group 81 The sample size was too small to draw exact conclusions regarding the sedative properties of the study drug or its dose-response relationship, but the figures indicate that the subjects who received the study drug were more sedated than the control subjects. Sedation also increased with increasing dexmedetomidine dose. Since the canadian data for this parameter is not complete, only the South African data is reported here. (figures 5-8) For the sake of clarity, the term 'drowsy but responds to stimulation' (as explained in the previous chapter), which refers to a deeper state of sedation than 'appropriately asleep', has been shown as 'deeper sedation' in the figures. No subject was noted to be in the deepest sedation category (category 3) at any stage. The number of subjects (y-axis) in each sedation category at each time interval (x-axis) after the start of the infusion is indicated for the three drug groups (4 subjects per group) as well as for the combined control group (6 subjects). 6

Fi ure 5 Fi ure 6 Sedation Scores in Group I Sedation Scores in Group" =DD- Time II _awake and alert oppropriato/y asleep [] deeper sedation - - [ [ r- r- [ r- '- '-' '-.:i 60 1'20 ttl 15 30 TIme wall:. and... rt ppt'opriat.1y S'MP D cte.per dltion Figure 7 Sedation Scores in Group III -r ] [ u II 8.rRIne 10 15 XI ot5 fij 121] Blood pressure and heart rate awake and alert appropriately asleep Ddeeper_on Figure 8 Sedation Scores in Control Group aawake and alert appropriately asleep D deeper sedation Reductions in systolic and diastolic blood pressure, and heart rate were seen in the study drug group compared to the control group (Table 5), although the small numbers in each group preclude statistically correct conclusions. (Data presented here reflect both sites' subjects.) The drop in blood pressure (systolic and diastolic) in all three dosage groups was most marked at 30, 45 and 60 minutes, with the maximum decrease (in the order of 20 % ) occurring in the 6mcg/kg/h dosage group. In this latter group, the heart rate decreased notably more than in the other groups, starting earlier than the drop in blood pressure. The maximum decrease in heart rate in this group occurred early, at ten minutes after the start of the infusion, with the order of change around 23%. 7

Group I Group II Group III Control Dex2 Control Dex4 Control Dex6 n=4 n=8 n=4 n=7 n=3 n=8 SBP 112 104.4 95 105.1 108.7 115.4 DBP 66.3 59.3 52 59.4 62.3 69.3 Pulse 85.3 103.5 89.3 97.4 109.3 98.5 n=4 n=8 n=4 n=7 n=3 n=8 10min SBP -1 0.8 8.8-2.9 11.7-5.1 DBP -2-0.3 15.3 3.9 8-4.9 Pulse 3-3 -2.8-5.1 6-23.6 n=4 n=8 n=4 n=7 n=2 n=8 15min SBP -1-1.4 2.5-3.3 6-9.9 DBP -0.3 3.3 5.3 0.9 0-10.5 Pulse 3-5.6 6.5-3.3 4-20.8 n=4 n=8 n=4 n=7 n=4 n=8 30min SBP -6-6.5 3.3-8.7 3.5-14.3 DBP -2.6-0.3-4 3.3-13.5 Pulse 5.8-8.1 15.5-16.8 22.5-20 n=4 n=8 n=3 n=5 n=4 n=8 45min SBP -0.8-5.4-4 -14.4 0.3-22.4 DBP 0.8-3.1-2 -8.4-0.3-19.1 Pulse 0.5-5.1 12-17.6 13-17.4 n=3 n=7 n=3 n=6 n=4 n=8 60min SBP 3.7-7.3 1.3-11.2-4.5-24.5 DBP 7.7-1.8-0.3-11.7-0.5-26.4 Pulse -2.3.0.1 5-9.1 10.8-17.8 Mean SBP and DBP given in mmhg; Mean heart rate in Ut:CIl::I/lII!nute 8

Respiratory parameters The Canadian data for these parameters were not available. Amongst the South African subjects, no respiratory effect of dexmedetomidine could be shown, probably because of the small sample size. Apart from the subjects who developed hypoxia in the initial period after drug infusion (discussed under adverse events), no other subjects showed a change in their oxygenhaemoglobin saturations after drug infusion. Figure 9 Comparison of breath rates between drug and control group CII :; c: ~... CII Q. 27 25 -- 23... 21 A ~ 2... ~ ~-~ ~ 19 r------------------- '1ii ~ 17r-------------------- m 15 +- --~--~-- ~--_ Baseline 10mn 15mn 30mn 45mn 50rr'n Time Interval Drug dosel concentration relationship to response./ The relationship between drug dose (or plasma concentration), and combined sedation and vital sign changes was not assessed. From the previous discussion it seems obvious that the highest drug group showed the biggest drop in blood pressure and heart rate. The differences between sedation scores in the three groups show that the subjects were more sedated the higher drug dose they received. The absence of influence of the drug on respiratory parameters corresponds with the known effects of the drug, as discussed in chapter one. 9

Respiratory parameters The canadian data for these parameters were not available. Amongst the South African subjects, no respiratory effect of dexmedetomidine could be shown, probably because of the small sample size. Apart from the subjects who developed hypoxia in the initial period after drug infusion (discussed under adverse events), no other subjects showed a change in their oxygenhaemoglobin saturations after drug infusion. Figure 9 Comparison of breath rates between drug and control group GI :; c 27 ~ ~ 21 D-.. III.c 19 1;j GI 17 ai 15 25 -- ~ ~ "'" 23......./ ~ ~-- Baseline 10mn 15mn 30mn 45mn 60mn Time Interval Drug dose I concentration relationship to response The relationship between drug dose (or plasma concentration), and combined sedation and vital sign changes was not assessed. From the previous discussion it seems obvious that the highest dose drug group showed the biggest drop in blood pressure and heart rate. The differences between sedation scores in the three groups show that the subjects were more sedated the higher drug dose they received. The absence of influence of the drug on respiratory parameters corresponds with the known effects of the drug, as discussed in chapter one. 9

2 5 6 # dexmedetomidine in '" time from start of infusion ** defined as 10