Written by Kimi Dunbar
Spoon Feed
Infants who received clonidine, as opposed to morphine, for treatment of neonatal opioid withdrawal syndrome (NOWS) have similar length of treatment and neurodevelopmental outcomes but are more likely to require an adjunct medication during treatment.
I’d rather use one drug than two
This randomized double-blind clinical trial evaluated clonidine as monotherapy for neonatal opioid withdrawal syndrome (NOWS) compared to morphine. Conducted on 120 infants (gestational age ≥ 35 weeks) requiring pharmacologic treatment, the primary outcomes were treatment duration and neurobehavioral performance. Median treatment duration was comparable: 17 days for clonidine and 15 days for morphine (p=0.48). However, 45% of clonidine-treated infants required adjunct therapy versus 10% in the morphine group (OR 8.85; 95%CI 2.87–27.31).
The use of clonidine, as opposed to morphine, methadone, or phenobarbital for NOWS is an exciting proposition. Advantages of clonidine include stabilization of breathing and temperature as opposed to disruption with opioid therapy, suppression of cytokines, and downregulation of opioid receptor expression. While this study finds no difference in long-term outcomes (i.e. neurobehavioral outcomes, total length of treatment), it seems to me that infants who received clonidine alone didn’t do as well in the withdrawal process. Finnegan Scores were overall higher for patients receiving clonidine as compared to morphine, and far more infants needed adjunct therapy, such as phenobarbital or morphine. While I like the idea of using clonidine, the chances of needing a second drug are just too high. I’d rather use morphine alone than end up using both clonidine and morphine. Authors posit that the higher Finnegan Scores and thus the need for an adjunct are due to the delayed onset of action of clonidine and that dose adjustment could solve these problems. I look forward to seeing future studies, but in the meantime, I don’t think we are ready to transition to clonidine monotherapy for NOWS.
Source
Clonidine as Monotherapy for Neonatal Opioid Withdrawal Syndrome: A Randomized Trial. Pediatrics. 2024 Nov 1;154(5):e2023065610. doi: 10.1542/peds.2023-065610. PMID: 39403061
