Starting Dose of Clonidine
For adults with hypertension, start clonidine at 0.1 mg twice daily (morning and bedtime), and for pediatric patients with ADHD, start at 0.05-0.1 mg orally at bedtime. 1, 2
Adult Hypertension Dosing
The FDA-approved starting dose for hypertension is 0.1 mg tablet twice daily (morning and bedtime), with elderly patients potentially benefiting from a lower initial dose. 1
Maintenance and Titration
- Increase by 0.1 mg per day at weekly intervals if necessary until desired blood pressure response is achieved 1
- Therapeutic doses most commonly range from 0.2 mg to 0.6 mg per day given in divided doses 1
- Taking the larger portion of the daily dose at bedtime may minimize transient side effects of dry mouth and drowsiness 1
- Maximum effective daily dose is 2.4 mg, though doses this high are rarely employed 1
Special Populations
- Patients with renal impairment should start at a lower initial dose and be carefully monitored 1
- Routine hemodialysis removes only minimal amounts of clonidine, so no supplemental dosing is needed following dialysis 1
Hypertensive Emergencies (Alternative Approach)
- For rapid blood pressure control in hypertensive urgencies, an initial oral loading dose of 0.1-0.2 mg can be given, followed by hourly doses of 0.05-0.1 mg until goal blood pressure is attained or a total of 0.7-0.8 mg is administered 3, 4, 5
- This approach achieves significant blood pressure reduction in approximately 82-93% of patients 3, 5
Pediatric ADHD Dosing
For children and adolescents aged 6-17 years with ADHD, begin with 0.05-0.1 mg orally at bedtime (QHS) to minimize initial sedation. 2, 6
Titration Schedule
- Increase by 0.1 mg increments, divided into BID-TID dosing, based on clinical response and tolerability 2, 6
- Maximum dose is 0.4 mg per day 2, 6
- Therapeutic effects require 2-4 weeks before clinical benefits become apparent, unlike stimulants which work immediately 7
Clinical Positioning
- Clonidine functions as an adjunct or second-line agent for ADHD, not first-line monotherapy 6
- Extended-release clonidine and extended-release guanfacine are the only two medications with FDA approval for adjunctive use with stimulants in ADHD 7
- Evening administration is generally preferable to minimize daytime somnolence 2
Monitoring Requirements
- Assess blood pressure and heart rate at baseline and during dose adjustments 6
- Monitor for common side effects including orthostatic hypotension, drowsiness, dry mouth, and sedation 8
Critical Safety Warning
Never abruptly discontinue clonidine—it must be tapered by 1 mg every 3-7 days to avoid rebound hypertension, which may precipitate hypertensive crisis. 8, 6
Common Pitfalls to Avoid
- Do not expect immediate results in ADHD treatment—counsel families that 2-4 weeks are required for therapeutic effects 7
- Do not use clonidine as first-line monotherapy for ADHD; stimulants remain first-line due to superior effect sizes 6
- Avoid using clonidine for anxiety disorders, as this represents off-label use without established dosing protocols or strong efficacy evidence 6