Pharmacokinetic comparison of nalbuphine with single injection and patient-controlled analgesia mimic method in healthy Chinese volunteers

A randomized, double-blind study to compare the efficacy and safety of nalbuphine nasal spray and injectable solution in patients after orthopaedic interventions and traumatological procedures

AIMS

Our previous 3-period crossover study in healthy volunteers comparing the pharmacokinetics of nalbuphine nasal spray Apain with parenteral nalbuphine solution demonstrated high bioavailability of the nasal spray and close similarity of pharmacokinetic profiles after intranasal and intramuscular administration, especially within 30 min postdose. The aim of the present study was a noninferiority assessment of nalbuphine nasal spray vs. intramuscular injection for pain relief in postoperative patients.

METHODS

Ninety orthopaedic and traumatology patients were enrolled in this double-blind, randomized study of the effectiveness and tolerance of a single 10.5 mg dose of nalbuphine nasal spray vs. 10 mg intramuscular injection. The summed pain intensity difference (SPID0-6) calculated using visual analogue scale scores was the primary study endpoint.

RESULTS

Of 90 subjects enrolled, the per-protocol efficacy population comprised 79 patients; 6 patients in the reference group and 5 patients in the test group were excluded due to remedication. The mean values of study endpoints with 95% confidence interval were as follows in reference and test groups, respectively: SPID0-6 = 228.08 (205.73-250.43) vs. 248.73 9 (225.83-271.63), time to pain relief onset = 0.28 h (0.25-0.31) vs. 0.27 h (0.25-0.29), duration of analgesia = 5.55 h (5.17-5.93) vs. 5.51 h (5.10-5.92), area under the curve = 119.30 (91.17-147.43) vs. 99.81 (74.52-107.10). No statistically significant differences were revealed.

CONCLUSION

Nalbuphine nasal spray Apain has been proven to be a safe, noninvasive alternative to intramuscular nalbuphine to relieve severe postoperative pain. Designed for self-administration and dose-adjusting, the noncontrolled opioid analgesic nalbuphine spray can be used for patient-controlled analgesia in out-of-hospital, field and home settings.

Comparative pharmacokinetics of nalbuphine nasal spray and solution for injection in healthy volunteers

AIMS

Nalbuphine is a synthetic opioid with comparable analgesic activity to morphine but with a better safety profile. Nalbuphine is only available in injectable form due to low oral bioavailability. Nasal nalbuphine spray provides advantages in drug safety, avoids hepatic first-pass metabolism, is non-invasive and is convenient for patient-controlled analgesia by self-administration. This study aimed to evaluate the safety and pharmacokinetics (PK) of the newly developed nalbuphine nasal spray in comparison with a solution for injections.

METHODS

Twenty-four healthy Caucasian volunteers were enrolled in this randomized, open-label, cross-over study. Subjects were administered one of the drugs: nasal spray 7.0 mg/dose, nalbuphine hydrochloride solution for injection 10 mg/dose intravenously (IV) or intramuscularly (IM). High-performance liquid chromatography-tandem mass spectrometry was used to determine nalbuphine concentrations.

RESULTS

A comparison of PK profiles for IV, IM and intranasal (IN) routes of nalbuphine administration revealed a close similarity of absorption phases for nasal spray and IM injection. Differences between the mean Tmax and dose-adjusted Cmax values for nasal spray and IM injection were statistically insignificant. The median values of the elimination rate constants and the terminal elimination half-life following IV, IM and IN nalbuphine administration were similar. The mean absolute bioavailability of the nasal spray equalled 65.04%.

CONCLUSIONS

The similarity of PK parameters of IM-injected nalbuphine solution and the nasal spray allows us to assume the latter is a feasible alternative to intramuscular nalbuphine injections appropriate for self-administration and field environments for managing moderate and severe pain of various aetiologies.

Effect of Multimodal Preemptive Analgesia of Flurbiprofen Axetil, Nalbuphine, and Retrobulbar Block on Postoperative Pain and Enhanced Recovery in Patients Undergoing Oculoplastic Day Surgery: A Prospective, Randomized, Double-Blinded Study

PURPOSE

To evaluate the effect of either flurbiprofen axetil or nalbuphine combined with retrobulbar block (RB) before surgery on postoperative pain control and enhanced recovery in day-care patients undergoing orbital implantation.

METHODS

A total of 45 patients undergoing orbital implantation with general anesthesia were randomly divided into three groups: flurbiprofen axetil (1 mg/kg) combined with RB (group F), nalbuphine (0.1 mg/kg) combined with RB (group N), and placebo as normal saline with RB (group C). The primary outcome was the average pain score (numeric rating scale: 0-10) within the first 24 hours. Other outcomes including the peak pain score, paracetamol requirement, quality of recovery (QoR)-15, and adverse effects (AEs) were assessed.

RESULTS

The average and peak pain scores within 24 hours after surgery in group F were significantly lower than in other groups ( p < 0.0167). Compared with group C, the NRS scores were significantly decreased at 2 and 4 hours in group F, and 2 hours in group N after surgery ( p < 0.0167), but without significant differences at other measured time points. The time to first paracetamol oral intake displayed a significant difference among the three groups ( p < 0.0167).

CONCLUSION

Preemptive use of flurbiprofen axetil 1 mg/kg combined with RB is an optimal choice for multimodal analgesia for day-care patients undergoing orbital implantation in terms of efficient acute pain control, without impeding patient-enhanced recovery.

Population pharmacokinetics of nalbuphine in patients undergoing general anesthesia surgery

Purpose: The aim of this study was to build a population pharmacokinetics (PopPK) model of nalbuphine and to estimate the suitability of bodyweight or fixed dosage regimen. Method: Adult patients who were undergoing general anesthetic surgery using nalbuphine for induction of anesthesia were included. Plasma concentrations and covariates information were analyzed by non-linear mixed-effects modeling approach. Goodness-of-fit (GOF), non-parametric bootstrap, visual predictive check (VPC) and external evaluation were applied for the final PopPK model evaluation. Monte Carlo simulation was conducted to assess impact of covariates and dosage regimens on the plasma concentration to nalbuphine. Results: 47 patients aged 21-78 years with a body weight of 48-86 kg were included in the study. Among them, liver resection accounted for 14.8%, cholecystectomy for 12.8%, pancreatic resection for 36.2% and other surgeries for 36.2%. 353 samples from 27 patients were enrolled in model building group; 100 samples from 20 patients were enrolled in external validation group. The results of model evaluation showed that the pharmacokinetics of nalbuphine was adequately described by a two-compartment model. The hourly net fluid volume infused (HNF) was identified as a significant covariate about the intercompartmental clearance (Q) of nalbuphine with objective function value (OFV) decreasing by 9.643 (p < 0.005, df = 1). Simulation results demonstrated no need to adjust dosage based on HNF, and the biases of two dosage methods were less than 6%. The fixed dosage regimen had lower PK variability than the bodyweight regimen. Conclusion: A two-compartment PopPK model adequately described the concentration profile of nalbuphine intravenous injection for anesthesia induction. While HNF can affect the Q of nalbuphine, the magnitude of the effect was limited. Dosage adjustment based on HNF was not recommended. Furthermore, fixed dosage regimen might be better than body weight dosage regimen.

Pharmacokinetic Study of Nalbuphine in Surgical Patients Undergoing General Anesthesia with Varying Degrees of Liver Dysfunction

Purpose

This study aimed to characterize the pharmacokinetics of nalbuphine in patients undergoing general anesthesia with varying degrees of liver dysfunction.

Patients and Methods

Twenty-four patients were enrolled and divided into three cohorts based on liver function: normal liver function (n = 13), mild liver dysfunction (n = 5), and moderate/severe liver dysfunction (n = 6). During the induction of anesthesia, they received 15 mg of nalbuphine intravenously. Venous blood samples were collected from each patient. The plasma concentration of nalbuphine was determined using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). The pharmacokinetic parameters of nalbuphine were calculated by non-compartmental analysis (NCA) using Phoenix WinNonlin software.

Results

Compared with the normal liver function group, the plasma elimination half-life (T_1/2) of nalbuphine was increased by approximately 33% in the moderate/severe liver dysfunction group (2.66 h vs 3.54 h, P<0.05), and the volume of distribution (V_d) increased by approximately 85% (100.08 L vs 184.95 L, P<0.05). Multivariate analysis revealed that weight and platelet were associated with clearance (CL); total bilirubin as an independent factor was associated with T_1/2, and weight associated with area under the curve (AUC_(0→∞)) independently.

Conclusion

The T_1/2, mean residence time, and V_d of nalbuphine in patients with moderate/severe liver dysfunction were prolonged or increased significantly compared with those in the normal liver function group. These data suggest that it may need to be used with caution when nalbuphine is administered to patients with moderate or severe liver dysfunction.

Protective Effect of Nalbuphine Combined With Dexmedetomidine on the Lungs of Children With Atelectasis and Foreign Body in the Bronchus During the Perioperative Period

Objective: The present study aims to explore the protective effect of nalbuphine combined with dexmedetomidine on the lungs of children with atelectasis who have a foreign body in a bronchus during the perioperative period.

Methods: A total of 180 patients whose computed tomography scan showed atelectasis and a foreign body in a bronchus were randomly divided into three groups: group C (conventional anesthesia group), group D (dexmedetomidine group), and group N + D (nalbuphine combined with the dexmedetomidine group). The following indicators were recorded: 1) heart rate (HR) and mean arterial pressure (MAP) prior to induction (T0), at bronchoscope placement (T1), at intubation after surgery (T2), at tube removal (T3), 10 min after tube removal (T4), 20 min after tube removal (T5), and at awaking (T6); 2) monocyte toll-like receptors (TLRs) TLR⁃2, TLR⁃4, tumor necrosis factor α, interleukin 6, oxygenation index, and the B-line sum at T0, T3, 2 h (T7), and 24 h (T8) after tube removal; and 3) hospital stay after surgery.

Results: Compared with group C, in group D and group N + D, 1) the HR and MAP at T1∼T6 were lower; 2) the inflammatory factor indicator and B-line sum were lower, and the oxygenation index was higher at T7 and T8; 3) the agitation and cough scores were decreased during tube removal; and 4) the Ramsay sedation score was higher, and ventilator weaning time was shortened at T4∼T6 (p &lt; 0.05). Compared with group D, in group N + D, 1) the inflammatory factor indicator and B-line sum were lower at T8; 2) the oxygenation index was higher (p &lt; 0.05). Compared with groups C and D, in group N + D, the length of hospital stay was decreased (p &lt; 0.05).

Conclusion: In patients with atelectasis and a foreign body in a bronchus during the perioperative period, nalbuphine combined with dexmedetomidine may be capable of reducing the oxidative stress response, improving the oxygenation index, decreasing the pulmonary fluid content, protecting the lung, and facilitating postoperative recovery.