Severe hypotension following sublingual dexmedetomidine administration in an elderly patient

Sublingual dexmedetomidine is a recently introduced α2-adrenergic agonist approved for management of agitation in patients with schizophrenia or bipolar disorder. Published safety data on the use of this drug outside of clinical trials is limited.

We describe an 88-year-old patient with hypertension, vascular dementia, and non-ST segment elevation myocardial infarction who experienced profound hypotension after receiving sublingual dexmedetomidine for agitation. The patient was boarding in the emergency department due to hospital overcrowding and developed delirium with severe agitation. After QT interval prolongation limited further antipsychotic use, a 120-µg dose of sublingual dexmedetomidine was administered. Within 1 hour, the patient's blood pressure fell from 102/49 to 62/40 mm Hg. Concomitantly, her hemoglobin declined from 12.1 to 6.9 g/dL, prompting a blood transfusion and investigation of active bleeding. Imaging revealed a large intramuscular hematoma possibly related to intramuscular injections in the setting of therapeutic anticoagulation and dual antiplatelet therapy. The Naranjo score was 4, indicating a possible adverse drug reaction to dexmedetomidine; however, the strong temporal association with sublingual administration supports a contributory role.

This case highlights the hemodynamic vulnerability of older adults, especially those with comorbidities and recent anticoagulation. While sublingual dexmedetomidine offers a noninvasive option for agitation management, its hypotensive potential may be clinically significant in this population. Our findings underscore the need for careful patient selection, dose optimization, and close monitoring when using dexmedetomidine in elderly patients, especially those with limited cardiovascular reserve. Further research is needed to guide safe dosing in geriatric and medically complex populations.