2026 Eastern States Conference

Authors: Halle Markle, PharmD; Lauren Albertina, PharmD, BCCCP; Bobbie McLeod, PharmD, BCCP; Maggie Shushe, PharmD, BCCCP
Objective: At the conclusion of this presentation, participants will be able to define the role of guanfacine in dexmedetomidine withdrawal management.  
Self-assessment question: Based on the results from this study, guanfacine should be routinely recommended for all patients in the ICU who are on prolonged dexmedetomidine infusions?
Background: Prolonged dexmedetomidine infusions may cause withdrawal. Guanfacine, an oral α2-agonist with greater central selectivity than clonidine, may aid in weaning. This study evaluated whether guanfacine reduces wean duration or withdrawal outcomes.
Methods: This was a retrospective, single-center, matched cohort study that included adult patients admitted to the intensive care unit (ICU) who received continuous dexmedetomidine infusions for more than 48 hours. Patients who received guanfacine during active dexmedetomidine infusions were compared to matched controls who received dexmedetomidine alone. 1:1 propensity score matching was performed using age, sex, and weight within broad diagnosis categories. The primary endpoint was time to dexmedetomidine discontinuation following the initiation of weaning. Secondary endpoints included successful discontinuation within 48, 72, and 120 hours, dexmedetomidine restart within 48 hours, and adjunctive sedative use. Time-to-event outcomes were analyzed using Kaplan-Meier methods with the Mann-Whitney U Test. Secondary outcomes were compared using Fisher's exact test. 
Results: A total of 94 patients were included in this study, with 47 patients in both the dexmedetomidine plus guanfacine and dexmedetomidine-only groups. Median time to dexmedetomidine discontinuation was 75.4 hours (IQR 31.8-182.8) in the guanfacine group versus 52.5 hours (IQR, 26.7-95.4) in the dexmedetomidine-only group (p=0.072). Patients receiving guanfacine had significantly longer total dexmedetomidine exposure (274.5 vs 163.5 hours; p<0.001). Discontinuation rates at 48 and 72 hours were similar between groups; however, by 120 hours, more patients in the dexmedetomidine-only group were successfully weaned (91.5% vs 59.6%; p<0.001). Rates of dexmedetomidine restart and adjunctive sedative use were similar between groups.  
Conclusion: In this matched cohort, guanfacine did not reduce dexmedetomidine weaning duration or withdrawal-related outcomes. Longer dexmedetomidine exposure in the guanfacine group suggests potential confounding by baseline sedation complexity and/or the subjective definition of the start of weaning in the control group. Further prospective studies are needed to clarify the role of guanfacine in dexmedetomidine withdrawal management.