Comparison of sublingually and orally administered triazolam for premedication before oral surgery

Early onset anxiolytic efficacy after a single dose of pregabalin: double-blind, placebo- and active-comparator controlled evaluation using a dental anxiety model

To evaluate acute onset of anxiolytic activity using a dental anxiety model, 89 patients were randomised to double-blind single dose pregabalin 150 mg, alprazolam 0.5 mg or placebo 4 h before a scheduled dental procedure. A Dental Anxiety Total score >12 (moderate-to-severe) without meeting Diagnostic and Statistical Manual of Mental Disorders (Fourth edition) (DSM-IV) anxiety disorder criteria was required. Efficacy and safety, assessed 2, 2.5, 3, 3.5 and 4 h postdose, included 100 mm Visual Analogue Scale for Anxiety (VAS-Anxiety; primary outcome), 100 mm VAS-Sedation and Time-to-Onset of Action Scale (TOAS), a patient-rated anti-anxiety drug-benefit scale (no [0] to full benefit [10]). Mixed model analysis found significantly greater VAS-A improvement slopes for pregabalin (t = -2.47; P = 0.014) and alprazolam (t = -2.39; P = 0.018). There was a significant improvement versus placebo in the TOAS from 2 h through endpoint in alprazolam patients and from 3 h onward in pregabalin patients. Pregabalin produced significantly greater increases in VAS-Sedation versus placebo from 2.5 h through 4 h (2 h onward for alprazolam). Notably, there was a higher correlation between TOAS and VAS-Sedation (r = +0.58) than VAS-Anxiety (r = -0.50) on Spearman's analysis. The majority of Adverse Effects (AEs) were mild, and the most frequent for pregabalin, alprazolam, and placebo, respectively, were fatigue (N = 7, 7, 3), dizziness (N = 6, 3, 3), attention disturbance (N = 3, 1, 0), somnolence (N = 3, 0, 0), feeling abnormal (N = 0, 2, 0) and balance disorder (N = 0, 2, 0). These results suggest that onset of clinically meaningful anxiolytic effect after single-dose pregabalin occurs within the first 3-4 h. Additional research is needed to determine whether anxiolytic effect occurs in generalized anxiety disorder populations by day 1 or within 3-4 h post-first dose.

Expanded studies of the pharmacokinetics and clinical effects of multidose sublingual triazolam in healthy volunteers

Previous work described the pharmacokinetics and clinical effects of multidose sublingual triazolam (Halcion; Pharmacia & Upjohn Co, Kalamazoo, Mich). This laboratory study evaluated the hypothesis that incremental dosing of triazolam produces dose-dependent central nervous system depression that is profound and long lasting. Forty-nine healthy adults between the ages of 21 and 39 years, not receiving dental treatment, were randomly assigned to placebo (n = 12) or 1 of 3 triazolam groups (0.25-mg single dose, n = 12; 0.5 mg divided between 2 equal doses for 60 minutes, n = 12; or 0.75 mg divided among 3 doses for 90 minutes, n = 13). Plasma triazolam concentrations were determined. Bispectral index (BIS) and the Observer Assessment of Alertness/Sedation scale were used to assess sedation. Plasma triazolam concentrations increased with time in all subjects, with Tmax and Cmax both increasing dose dependently. Compared with placebo, all dosing paradigms produced dose-dependent BIS suppression and sedation. The single dose of 0.25 mg reached its peak BIS suppression at 90 (81 +/- 7) minutes and sedation at 120 (3.6 +/- 0.5) minutes and returned to baseline before 360 minutes. In contrast, incremental dosing of 0.5 and 0.75 mg produced profound and long-lasting BIS suppression and sedation that did not plateau until either 180 or 210 minutes as measured by the BIS index (67 +/- 14 and 60 +/- 16 at 0.5 and 0.75 mg, respectively) and 150 minutes as measured by the Observer Assessment of Alertness/Sedation scale (3.2 +/- 1.0 and 2.7 +/- 0.4 at 0.5 and 0.75 mg, respectively). These data more fully characterize the effects of incremental dosing with sublingual triazolam and provide additional insight for discharge safety recommendations.

Rationale for faster oral delivery to overcome the pathophysiology associated with dental pain--biopharmaceutic and pharmacokinetic challenges

Recent published evidences on ibuprofen and meloxicam confirm the need of faster oral drug absorption to overcome the pathophysiological conditions associated with dental pain (due to excessive vagal nerve suppression) in order to provide relief in acute pain management. While the communication provides relevant case studies to support the hypothesis in both dental pain and migraine attacks, it also provides biopharmaceutical and pharmacokinetic challenges of developing such a strategy for faster oral drug absorption. It is envisaged that the unmet need in this area, to overcome the pathophsiological barriers, should provide impetus for further research exploration in formulation strategies and biopharmaceutical/pharmacokinetic integration.

Oral sedation: a primer on anxiolysis for the adult patient

The use of sedatives has established efficacy and safety for managing anxiety regarding dental treatment. This article will provide essential information regarding the pharmacology and therapeutic principles that govern the appropriate use of orally administered sedatives to provide mild sedation (anxiolysis). Dosages and protocols are intended for this purpose, not for providing moderate or deeper sedation levels.

Balancing efficacy and safety in the use of oral sedation in dental outpatients

BACKGROUND

Concerns about the safety of pediatric oral sedation and the incremental use of triazolam in adults prompted a workshop cosponsored by several professional organizations.

OVERVIEW

There is a strong need and demand for adult and pediatric sedation services. Using oral medication to achieve anxiolysis in adults appears to have a wide margin of safety. Mortality and serious morbidity, however, have been reported with oral conscious sedation, especially in young children. Most serious adverse events are related to potentially avoidable respiratory complications.

CONCLUSIONS

Clinical trials are needed to evaluate oral sedative drugs and combinations, as well as to develop discharge criteria with objective quantifiable measures of home readiness. Courses devoted to airway management should be developed for dentists who provide conscious sedation services. State regulation of enteral administration of sedatives to achieve conscious sedation is needed to ensure safety.

PRACTICE IMPLICATIONS

Safety in outpatient sedation is of paramount concern, with enteral administration of benzodiazepines appearing safe but poorly documented in the office setting. Conscious sedation by the enteral route, including incremental triazolam, necessitates careful patient evaluation, monitoring, documentation, facilities, equipment and personnel as described in American Dental Association and American Academy of Pediatric Dentistry guidelines.

Decreasing Pain and Anxiety Associated with Patient-Activated Atrial Shock: A Placebo-Controlled Study of Adjunctive Sedation with Oral Triazolam

INTRODUCTION

Implantable atrial defibrillators (IADs) have proved to be safe and effective in the management of atrial fibrillation. A potential limitation of self-activated IAD therapy is patient-reported pain and anxiety. The main objective of the present study was to determine whether triazolam improved patient perception of the shock experience or altered patient memory of shock discomfort relative to placebo.

METHODS AND RESULTS

A total of 15 men and women (mean age: 59 +/- 6 years) were enrolled in this double-blind, placebo-controlled, crossover study of triazolam. Randomized study medication was administered orally 75 minutes prior to scheduled atrial shock delivery. Patient perception of the shock experience was assessed along with sedation, memory, anxiety, and mood. Triazolam reduced mean pre-shock anxiety (t= 2.98, df = 14, P = 0.01) and shock-related pain (t= 2.74, df = 13, P = 0.01) and intensity (t= 2.64, df = 13, P = 0.018) relative to placebo. Similarly, participants recalled less discomfort the morning after shock with triazolam than with placebo (t= 2.82, df = 11, P = 0.017).

CONCLUSIONS

This study was the first to investigate the use of an oral benzodiazepine administered prior to patient-activated shock delivery with an IAD. Our data indicate that oral triazolam is beneficial in decreasing pain and anxiety associated with self-activated atrial defibrillation. If triazolam provides a similar benefit in the community to that which has been reported here, this medication could be offered to patients as an adjunct to intermittent IAD therapy.

Pharmacokinetics and clinical effects of multidose sublingual triazolam in healthy volunteers

Triazolam is increasing in popularity as a premedication prescribed by dentists to help their fearful and anxious patients tolerate the potentially aversive nature of some dental procedures. Recent anecdotal reports suggest that incremental sublingual dosing of triazolam may be an effective technique for producing conscious sedation in the dental setting. Although promising, no laboratory or clinical data have been available to evaluate the efficacy or safety of this approach. This study was designed to determine the pharmacokinetics and sedative effects of incremental sublingual dosing of triazolam (total, 1.0 mg) in healthy adults. Ten healthy adult volunteers received sublingual triazolam (0.25 mg) followed by additional doses after 60 (0.50 mg) and 90 (0.25 mg) minutes. Plasma triazolam concentrations, clinical effects (Observer's Assessment of Alertness/Sedation score), and processed electroencephalogram (bispectral index score) were measured intermittently for 3 hours. Plasma triazolam concentrations (mean +/- SD, 5.1 +/- 1.1 ng/mL) and drug effects (Observer's Assessment of Alertness/Sedation score, 2 +/- 1; and the bispectral index score, 62 +/- 16) were greatest in all subjects at the end of the 3-hour evaluation period. Eight of the subjects had Observer's Assessment of Alertness/Sedation scores consistent with the definition of deep sedation or general anesthesia (Observer's Assessment of Alertness/Sedation score, <3) at some of the later time points in the 180 minutes of data collection. In comparison, 4 of the subjects had bispectral index scores less than 60 during these later time points of data collection. Given the considerable intersubject variability in triazolam concentrations and effects, additional research is needed to assess this multidosing strategy before it can be endorsed as a useful and safe sedation technique for managing fearful and anxious patients in dental practice.

Zaleplon (Sonata) Oral Sedation for Outpatient Third Molar Extraction Surgery

Zalpelon was compared with triazolam for oral sedation in a third molar surgery model using a double-blind crossover design. Factors such as anxiolysis, amnesia, and quality of sedation were assessed. Of the 14 participants who completed the study, zaleplon sedation was found to be similar to triazolam sedation in all regards except that recovery from zaleplon was more rapid.

Oral triazolam sedation in implant dentistry

Triazolam can be helpful for sedating dental implant patients when administered orally or sublingually in low dosages of 0.125 or 0.25 mg, but not exceeding 0.5 mg. It is a fast- but short-acting benzodiazepine with few side effects, and it has a long record of successful use. Its effects can be reversed with incremental intravenous flumazenil, although there is a risk of seizure. Triazolam has not been shown to be carcinogenic, and it has a low potential for abuse and addiction. It is contraindicated in patients who are pregnant, breast-feeding, and those concomitantly taking ethanol, macrolid antibiotics, some protease inhibitors, psychotropic medications, ketoconazole, itraconazole, nefaxodone, or other medications that impair oxidative metabolism mediated by cytochrome P450 3A (CYP 3A). Triazolam should be used with caution in patients taking grapefruit juice, cyclosporine, and other drugs such as calcium channel blockers including nifedipine, verapamil, and diltiazem. The lowest effective dose should be used.

Preoperative alprazolam reduces anxiety in ambulatory surgery patients: a comparison with oral midazolam

Because an oral formulation of midazolam is not approved in certain countries, we evaluated oral alprazolam as an alternative. Forty-five outpatients scheduled for gynecological laparoscopic surgery participated in a double-blinded study to compare the effectiveness and side effects of oral alprazolam 0.5 mg with midazolam 7.5 mg, as a reference drug, and placebo. We evaluated psychomotor function by means of the Trieger Dot Test (TDT) and the Digit-Symbol Substitution Test. Simple memory tests were performed. Data were analyzed with chi(2) or paired Student's t-tests, or with one-way analysis of variance with the Student-Newman-Keuls or Kruskal-Wallis test, as appropriate; P < 0.05 was considered statistically significant. Alprazolam and midazolam both decreased anxiety scores more than placebo (P < 0.05). One hour after premedication, the Digit- Symbol Substitution Test score was similar in all groups, whereas the TDT score was greater (indicating impairment of performance) in the alprazolam group than in the placebo group (P < 0.05). Sedation scores, extubation time, and discharge times in the active drug groups did not differ from placebo. At discharge from the postanesthesia care unit, the TDT score was greater in both active drug groups compared with placebo (P < 0.05). Five patients, exclusively in the midazolam group, had amnesia (P < 0.05). We conclude that alprazolam may be an effective alternative to midazolam for anxiety reduction without causing amnesia. However, it may cause greater impairment of psychomotor function in the early postoperative period.

IMPLICATIONS

Oral alprazolam 0.5 mg and midazolam 7.5 mg comparably reduce anxiety in ambulatory surgery patients. Despite early psychomotor impairment, neither drug delays postanesthetic extubation nor prolongs discharge from the postanesthesia care unit.

Inhalational and enteral conscious sedation for the adult dental patient

There are clearly many safe and effective sedatives available to the dental practitioner for reducing patient fear and improving their level of comfort. Careful consideration needs to be given to the objectives of the sedation when deciding which pharmacologic agents to use because they all possess slightly different clinical characteristics and various degrees of risk. Patient selection also is critical when making decisions about sedation because the patient's expectations and general health status factor into keeping the procedure safe. N2O/O2 sedation is an excellent choice for managing the mildly fearful dental patient or when minimal sedation is desirable. Among the sedatives administered enterally, the benzodiazepines are the most commonly used, and for good reason. These drugs are safe, effective, and offer a host of different personalities from which the dentist can choose. If used wisely and thoughtfully, the dentist can tailor the effects and duration of onset and recovery to the needs of the patient and the expected parameters of the appointment. When N2O/O2 sedation is combined with a single enteral sedative, a more profound level of CNS depression is achieved that can be modestly altered by changing the concentration of inhaled nitrous oxide. With these many pharmacologic alternatives, many different dental patient populations can be sedated in a safe, effective manner, thus allowing the delivery of most dental treatments in a setting of reduced psychologic and physiologic stress. These pharmacologic sedatives have truly opened up a wonderful world of possibilities for the comfortable delivery of dental care, and should be integrated into every office's repertoire for delivery of care.

Oral mucosal drug delivery: clinical pharmacokinetics and therapeutic applications

Oral mucosal drug delivery is an alternative method of systemic drug delivery that offers several advantages over both injectable and enteral methods. Because the oral mucosa is highly vascularised, drugs that are absorbed through the oral mucosa directly enter the systemic circulation, bypassing the gastrointestinal tract and first-pass metabolism in the liver. For some drugs, this results in rapid onset of action via a more comfortable and convenient delivery route than the intravenous route. Not all drugs, however, can be administered through the oral mucosa because of the characteristics of the oral mucosa and the physicochemical properties of the drug. Several cardiovascular drugs administered transmucosally have been studied extensively. Nitroglycerin is one of the most common drugs delivered through the oral mucosa. Research on other cardiovascular drugs, such as captopril, verapamil and propafenone, has proven promising. Oral transmucosal delivery of analgesics has received considerable attention. Oral transmucosal fentanyl is designed to deliver rapid analgesia for breakthrough pain, providing patients with a noninvasive, easy to use and nonintimidating option. For analgesics that are used to treat mild to moderate pain, rapid onset has relatively little benefit and oral mucosal delivery is a poor option. Oral mucosal delivery of sedatives such as midazolam, triazolam and etomidate has shown favourable results with clinical advantages over other routes of administration. Oral mucosal delivery of the antinausea drugs scopolamine and prochlorperazine has received some attention, as has oral mucosal delivery of drugs for erectile dysfunction. Oral transmucosal formulations of testosterone and estrogen have been developed. In clinical studies, sublingual testosterone has been shown to result in increases in lean muscle mass and muscle strength, improvement in positive mood parameters, and increases in genital responsiveness in women. Short-term administration of estrogen to menopausal women with cardiovascular disease has been shown to produce coronary and peripheral vasodilation, reduction of vascular resistance and improvement in endothelial function. Studies of sublingual administration of estrogen are needed to clarify the most beneficial regimen. Although many drugs have been evaluated for oral transmucosal delivery, few are commercially available. The clinical need for oral transmucosal delivery of a drug must be high enough to offset the high costs associated with developing this type of product. Drugs considered for oral transmucosal delivery are limited to existing products, and until there is a change in the selection and development process for new drugs, candidates for oral transmucosal delivery will be limited.

Pharmacokinetics and clinical effects of sublingual triazolam in pediatric dental patients

The purpose of this investigation was to describe the pharmacokinetics of sublingual triazolam in children. Nine healthy children (64-98 months old) received 0.25 or 0.375 mg of sublingual triazolam before dental treatment. Plasma triazolam concentrations were measured by gas chromatography/mass spectrometry and analyzed by noncompartmental methods. The peak concentration was 4.9 +/- 2.0 ng/mL (mean +/- SD), time to peak was 75 +/- 32 minutes, the elimination half-life was 91 +/- 32 minutes, and apparent clearance was 17.6 +/- 8.8 mL x kg(-1) x min(-1). Children were tested for gait ataxia, amnesia, and diplopia during a screening session and again after triazolam. Ninety minutes after drug administration, seven of nine children demonstrated ataxia, and three of nine demonstrated amnesia. Peak triazolam concentrations were similar in children with or without ataxia, but they were significantly higher in children with amnesia compared with those without amnesia. Six children demonstrated diplopia 30 and 120 minutes after triazolam; however, peak triazolam concentrations were similar in both groups. Sublingual administration was an acceptable alternative route of triazolam delivery in children.

Assessing the need for anesthesia and sedation in the general population

The authors used a national telephone survey to examine the relationship between dental anxiety and the use of pain and anxiety control measures in the general population. Nearly 30 percent of respondents reported being somewhat nervous, very nervous or terrified about going to the dentist. There was a threefold difference between the reported use of anesthesia and sedation and respondents' preference for these treatment modalities. These data suggest that fear of dentistry is still prevalent and that patients who are fearful would seek oral health care more regularly if general anesthesia or conscious sedation were more readily available.