Presentation on theme: "Lecture outline Why use intranasal medications?"— Presentation transcript:
1 Intranasal Drug Delivery – Advantages of use in Rural and Remote practice
2 Lecture outline Why use intranasal medications? Intranasal drugs indications with clinical cases and personal insights:• Pain Control• Sedation• Seizures• Opiate overdoseDrug doses and optimizing absorptionResources
3 Why nasal drugs in rural practice? Ease of use and convenienceSaves time / reduces human resource utilizationRapidly effective - onset within 2-10 minutesSafe – No high peak serum levels yet rapidly therapeuticNo special training is required to deliver the medicationNo injection is neededPainlessNo needle stick riskExtensive literature supportPatients (& Parents & clinicians) really like this approachFaster care and discharge3
5 Case: Pediatric Hand burn A 5 year old burned her hand with boiling waterClinical Needs: Pain control, debride, clean and dress the wound.Treatment: 2.0 mcg/kg of intranasal fentanyl (40 mcg – 0.8 ml of generic “IV” fentanyl)Within 3-5 minutes her pain is improved15 minutes later the patient easily tolerates cleansing of the burn and dressing application.She is discharged with an oral painkiller less than one hour after arrival.5
6 Case: Injured ankle A 25 year old injured his ankle and has significant ankle swelling, bruising and pain.Clinical Needs: Pain control, x-ray, splint.Treatment: 0.5 mcg/kg of intranasal sufentanil (45 mcg – 0.9 ml of generic “IV” sufentanil)5-10 minutes later the pain is gone and he is calmHe is taken off to x-ray for diagnostic evaluation of his ankle, followed by a splint, crutches and referral to followup.He leaves with very little pain, pleased with the timely care
7 Literature to support these cases – long bone fractures in pediatrics NasalIntravenousBorland, Ann Emerg Med 20077
8 Literature to support these cases – extremity trauma in adults Steenblik, Am J Emerg Med 20128
10 Pain control – Literature support Over a decade of EMS and ER literature exists for burn, orthopedic trauma and visceral pain in both adults and children showing the following:Faster drug delivery (no IV start needed) so faster onset20-30 min vs minutes to drug deliveredEquivalency to IV morphine (even if they have an IV)Superior to IM morphineCare givers are more likely to treat pediatric severe painHighly satisfied patients and providersSafe
11 IN opiates for Pain control – My insights This is the most common use of IN drugs in my practice - daily.Generic concentrations available in U.S. work fine and areinexpensive ($1-4/vial)Great patient and parent satisfier: Rapid pain resolution with noneed for a painful injection.Efficacy: Very effective – and it can be titrated.Use a pulse oximeter with sufentanil:Sufentanil is especially potent and must be treated withrespect.Fentanyl seems fine and can safely be given with minimalriskGive an oral pain killer as well: It kicks in as IN drug wears off
12 NasalThe Doubters: Surely IN drugs can’t be as good as an injection for pain control!IntravenousACTUALLY – They are equivalent or better (in these settings)Borland 2007 – IN fentanyl onset of action and quality of pain control was identical to IV morphine in patients with broken legs and armsBorland 2008, Holdgate 2010, Crellin time to delivery of IN opiates was half that of IV and more patients get treatedKendal 2001 – IN opiate superior to IM opiate for pain controlConclusionsIN opiates are just as good as IVIN opiates are delivered in half the waiting time as IVIN opiate are preferred by patients, providers and parents over injections12
14 Case: CT scan childA 5-year old boy requires a CT scan (computed tomography) of his head due to head injury.He does not have an IV in place and is mildly agitated.He will not remain still enough to obtain quality images.The clinician administers topical lidocaine followed by 0.5 mg/kg of IN midazolam (or 2 ug/kg dexmedetomidine if longer duration of sedation is needed for MRI) and 10 minutes later he is dozing off and remains calm and still for the CT scan.14
15 Case: Abscess Drainage A 21 year old autistic male complains of redness, swelling and pain on his thigh. Exam reveals a large pus filled abscess, terrified patient.Clinical Needs: Pain control, sedation, incision and drainage of the abscessTreatment:40 mcg of IN sufentanil then 5 mg intranasal midazolam15 minutes later he is asleep, mildly sedatedThe abscess is incised, drained and patient is discharged when awake.
16 Literature to support these cases - pediatrics Klein, Ann Emerg Med 201116
17 Sedation – Literature support Hundreds of articles dating back into the 1980’s. Most used midazolam.Effective only if adequate dose is given (0.4 to 0.5 mg/kg)Burns upon application – pretreat with lignocaineEffective in children and adults (even exited delirium in EMS)Safe – no reports of respiratory depression
19 Case: Seizing childThe ambulance is transporting a 4 y.o. girl suffering a grand mal seizure.Despite trying, no IV can be successfully established.Rectal diazepam is unsuccessful at controlling the seizure.IV attempts in the clinic / hospital are also unsuccessful.However, on patient arrival a dose of 0.2 mg/kg of nasal midazolam (Versed, Dormicum) is given and within 3 minutes of drug delivery the child stops seizing.19
20 Seizure Therapy - Literature support Lahat 2000; Fisgin 2002; Holsti 2006; Ahmad 2006; Arya 2011; Holsti 2011; Javadzadeh 2012; Thakker 2012:IN midazolam is superior to rectal diazepam for seizure control and is preferred by care giversIN midazolam is superior to intramuscular injection of paraldehydeIN midazolam/lorazepam is equivalent to intravenous delivery for stopping seizures, much faster at stopping them due to no IV start needed and it leads to less respiratory depressionIN midazolam can be delivered by family at home safely and effectively
21 Nasal vs buccalAnderson 2011: IN vs buccal lorazepam
22 The Doubters: Surely IN drugs can’t be as good as IV for seizures! ACTUALLY – They are equivalent or better (in these settings)Lahat 00, Mahmoudian 04, Arya 11, Thakker 12, Javadzadeh 12 – IV and IN are equivalent for stopping seizures rapidly, but IN works faster due to no delaysHolsti 2007, Fisgin 2002 – IN is superior to rectalHolsti 2011 – IN is safe at home with immediate resultsConclusionsIN seizure medication are just as good as IV, better than rectalIN seizure medication are delivered much more rapidly so seizure stops sooner.Anyone (Parents, care givers, nursing home staff, ambulance driver, etc.) can administer the medication so seizure length is shorter.22
23 IN benzodiazepines for seizures – My insights Very effective, very fast: Rapid seizure resolution without IV access.Should be first line therapy in ALL prolonged acute seizures while IV access is being established (if at all)Effective and safe at home, in EMS setting, in hospitalMore effective, less expensive and preferred by providers when compared to alternative (rectal diazepam).
25 Case: Methadone induced coma A mother enters her daughters room to find her unconscious, barely breathing, blue color. Since her daughter is on methadone maintenance, the family was trained to deliver rescue naloxone (see photo of kit above).The mother quickly delivers the naloxone intranasally.She provides 2-3 minutes of rescue breathing until her daughter begins to arouse. She gradually awakens over 10 minutes.The patient is transferred to the hospital for observation due to the long half life of methadone, but makes an uneventful recovery.
26 Opiate overdose – Literature support Intranasal naloxone literatureBarton 02, 05; Kelly 05; Robertson 09; Kerr 09; Merlin 2010; Doe Simkins 09; Walley 12:IN naloxone is at least 80-90% effective at reversing opiate overdoseWhen compared directly it is equivalent in efficacy to IV or IM therapy.IN naloxone results in less agitation upon arousalIN naloxone is lay person approved in many places. It safe and has saved many lives.
27 IN naloxone for opiate overdose – my insights Why not? Is there a downside?High risk population for HIV, HCV, HBVDifficult IV to establish due to scarring of veinsElimination of needle eliminates needle stick riskThey awaken more gently than with IV naloxoneNew epidemiology shows prescription drugs (methadone, etc) are causing many deaths that naloxone at home could reverse.Simple enough that lay public can administerEvery ambulance system, police agency and many clinics and families with high risk patients should be utilizing this approach.
28 Drug doses Scenario Drug and Dose Important Reminders Pain Control Fentanyl: 2 mcg/kgSufentanil: 0.5 mcg/kgTitration is possibleSufentanil – use pulse oxHalf up each nostrilSedationMidazolam: 0.5 mg/kg(combination w/ pain)Use lidocaine to prevent burningUse concentrated formulaSeizuresMidazolam: 0.2 mg/kgLorazepam 0.1 mg/kgSupport breathing while waitingOpiate OverdoseNaloxone: 2 mgSupport breathing while awaiting onsetEpistaxisOxymetazoline orPhenylephrine +LidocaineBlow nose prior to applicationSpray, then apply soaked cotton ballPinch nose for 10 minutesNasal ProceduresWait 3 full minutes for anesthetic effect
29 Optimizing absorption of IN drugs CriticalConceptMinimize volume - Maximize concentration0.2 to 0.3 ml per nostril ideal, 1 ml is maximumMost potent (highly concentrated) drug should be usedMaximize total absorptive mucosal surface areaUse BOTH nostrils (doubles your absorptive surface area)Use a delivery system that maximizes mucosal coverage and minimizes run-off.Atomized particles across broad surface area29
30 Dropper vs Atomizer Absorption Usability / acceptance Drops = Oral drug via the nasal passageAtomizer = nasal mist onto broad mucosal surfaceUsability / acceptanceDrops = Minutes to give, cooperative patient, head position criticalAtomizer = seconds to deliver, better accepted
32 Intranasal medications summary Another tool for drug delivery to supplement standard IV, IM, PO–very useful when appropriateSupported by extensive literatureInexpensiveSpeeds up care in many situationsSafe
34 IN Benzos for sedation – my insights Nasal Midazolam burns on application: Pretreat with lignocaine, warn the parents, this lasts seconds then dissipatesTiming: Children become sedated at about 5-10 minutes, maximal at and starts to wear off at so be ready to do prep and suture or do procedure in this time frame.Efficacy: Sedation is not deep. OK for minor procedures, calming an agitated patient, CT/ MRI. It is not good enough for complex face laceration repair.34