Dexmethylphenidate Hydrochloride and Midazolam Hydrochloride

• Generic Name: dexmethylphenidate
• Dosage Forms: n.a.
• Other Brand Names: Focalin, Focalin XR

Treatment of ADHD, alone or combined with behavioral treatment, as an adjunct to psychological, educational, social, and other remedial measures in carefully selected children ≥6 years of age, adolescents, and adults.

• Generic Name: midazolam
• Dosage Forms: n.a.
• Other Brand Names: Versed, Nayzilam

Used preoperatively to produce sedation, anxiolysis, and anterograde amnesia.

Particularly useful when relief of anxiety and diminished recall of events associated with the surgical procedure are desired.

Some clinicians consider midazolam the benzodiazepine of choice for preoperative use for short surgical procedures because of its relatively rapid onset and short duration of effect and improved local tolerance at the site of injection compared with other currently available parenteral benzodiazepines.

Use only in monitored settings. (See Boxed Warning.)

Used alone or in combination with other CNS depressants for procedural sedation, anxiolysis, and amnesia. Has been administered prior to dental or other minor surgical procedures; diagnostic, therapeutic, or endoscopic procedures such as upper GI endoscopy, bronchoscopy, or cystoscopy; cardiac catheterization; coronary angiography; oncology procedures; radiologic procedures (e.g., computerized tomography); and suture of lacerations.

Particularly useful when relief of anxiety and diminished recall of events associated with the procedure are desired.

Produces amnestic and sedative effects, but no analgesia; therefore, usually administered in conjunction with an analgesic agent.

Some clinicians consider midazolam the benzodiazepine of choice for moderate sedation (formerly known as conscious sedation) prior to short procedures because of its relatively rapid onset, short duration of action, pronounced amnesic effect, and improved local tolerance at the site of injection compared with other currently available IV benzodiazepines.

Use only in monitored settings. (See Boxed Warning.)

Used IV for induction of general anesthesia prior to administration of other anesthetic agents.

Induction with midazolam provides anxiolysis, anterograde amnesia, and dose-related hypnotic effects (progressing from sedation to loss of consciousness), but not analgesia.

Also may be used for maintenance of anesthesia during short surgical procedures, usually in conjunction with inhalation anesthetic agents, balanced anesthesia (e.g., nitrous oxide and oxygen), and/or opiate agonists (e.g., fentanyl). Should not be used alone for maintenance of anesthesia.

Used as a continuous IV infusion for sedation of intubated and mechanically ventilated patients in critical care settings (e.g., ICU).

Nonbenzodiazepine sedatives (dexmedetomidine or propofol) are generally preferred to benzodiazepines in mechanically ventilated critically ill adults because of some modest clinical benefits that have been demonstrated (e.g., reduced duration of mechanical ventilation, shorter time to extubation, reduced risk of delirium).

When selecting an appropriate sedative agent, consider patient's individual sedation goals in addition to specific drug-related (e.g., pharmacology, pharmacokinetics, adverse effects, availability, cost) and patient-related (e.g., comorbid conditions such as anxiety, seizures, or alcohol withdrawal) factors.

Used IM for treatment of status epilepticus.

Benzodiazepines are considered initial drugs of choice for management of status epilepticus because of their rapid onset of action, demonstrated efficacy, safety, and tolerability. Evidence supports use of IV lorazepam, IV diazepam, or IM midazolam. Individualize choice of therapy based on local availability, route of administration, pharmacokinetics, cost, and other factors (e.g., treatment setting).

IM midazolam may be useful when IV administration of a benzodiazepine is not possible (e.g., in a prehospital setting).

Used intranasally for acute treatment of intermittent, stereotypic episodes of frequent seizure activity (i.e., seizure clusters, acute repetitive seizures) that are distinct from the patient's usual seizure pattern.

Has been used for management of acute agitation.