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Alpha-2 Adrenergic Agonist Pregnancy: Avoid — limited data; systemic absorption possible

Brimonidine

Brand names: Alphagan, Combigan (with timolol), Mirvaso (for rosacea)

Adult dose

Dose: Glaucoma: 1 drop BD–TDS in affected eye(s). Mirvaso gel (rosacea): apply pea-sized amount to cheeks, nose, chin, forehead daily.
Route: Topical ophthalmic (glaucoma); topical gel (rosacea)
Frequency: BD–TDS (glaucoma); OD (rosacea)
Max: 1 drop TDS
Second-line for glaucoma (after prostaglandins/beta-blockers). May be preferred when systemic beta-blocker is contraindicated. Rebound erythema common with Mirvaso rosacea gel.

Paediatric dose

Route: Ophthalmic
Frequency: BD
Max: Do NOT use in children <2 years (apnoea risk)
Concentration: 0.15% or 0.2% solution drop/ml
NEVER use in children <2 years — profound CNS depression (apnoea, hypotension, lethargy). Older children: specialist only.

Dose adjustments

Renal

Caution in renal impairment

Hepatic

Caution in hepatic impairment

Clinical pearls

  • Children <2 years: systemic absorption from eye drops causes profound CNS depression — apnoea, coma, hypotension; absolutely contraindicated
  • High rate of contact allergy (10%) with prolonged use — if worsening redness/irritation after weeks-months, suspect allergy; stop and perform patch test
  • Mirvaso (rosacea): apply to dry skin; improves within 30 min; rebound erythema common within 24h in some patients

Contraindications

  • Age <2 years (CNS depression risk)
  • Concurrent MAOIs
  • Severe cardiovascular disease

Side effects

  • Local: burning/stinging, allergy (contact dermatitis — 10%)
  • Systemic: dry mouth, drowsiness, fatigue, hypotension
  • Apnoea (neonates and infants — absolute contraindication <2 years)
  • Rebound erythema (Mirvaso)

Interactions

  • MAOIs — hypertensive crisis/enhanced CNS effects
  • Antihypertensives — additive hypotension
  • CNS depressants — additive sedation

Monitoring

  • IOP
  • Allergic reactions (contact dermatitis)
  • Blood pressure (systemic absorption)

Reference: BNFc; BNF; RCOphth Glaucoma Guidelines; MHRA Brimonidine Paediatric Warning. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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