Pharmacokinetics and Pharmacodynamics of 3 Doses of Oral-Mucosal Dexmedetomidine Gel for Sedative Premedication in Women Undergoing Modified Radical Mastectomy for Breast Cancer

Comparison of plasma concentration and sedative effect of sublingual and intranasal dexmedetomidine in children: A double-blind randomised controlled study

BACKGROUND

Pharmacokinetics and sedative effects of sublingual dexmedetomidine have not been established in children. The primary aim was to compare peak plasma concentration, time to reach peak plasma concentration and area under the curve with 2 μg/kg sublingual and intranasal dexmedetomidine. The secondary aims were to compare the depth of sedation, parental separation anxiety, mask acceptance, heart rate changes, analgesic requirements and recovery time with 2 μg/kg sublingual and intranasal dexmedetomidine in children.

METHOD

Thirty children between 2 and 12 years, weighing 10-30 kg, scheduled for surgeries were divided into two groups. Thirty minutes before the induction of anaesthesia, children were premedicated with 2 μg/kg dexmedetomidine either by intranasal drops (Group N) or sublingual wafer (Group S). Five venous blood samples were collected to measure dexmedetomidine plasma concentrations at 15, 30, 45, 60 and 120 min from dexmedetomidine administration. Sedation, parental separation anxiety, mask acceptance and heart rate were recorded. Recovery, pain and fentanyl requirements were assessed.

RESULTS

Demographic data was comparable. Median interquartile range (IQR) dexmedetomidine peak plasma concentration in Group N (0.764 [0.650-0.820]) ng/mL was significantly higher than in Group S (0.593 [0.364-0.754]) ng/mL (p = .014). Plasma concentration was significantly higher at 30 and 45 min in Group N as compared to Group S (p < .05). The median (IQR) time to reach peak plasma concentration was shorter in Group N (45 [45-120]) minutes than in Group S (60 [45-60]) minutes, (p = .814). The median (IQR) area under the concentration-time curve was significantly higher in Group N (1.062 [0.848-1.20]) ng/mL.h in comparison to Group S (0.866 [0.520-1.05]) ng/mL.h (p = .031). Comparable sedation was achieved at 25 min in both groups. No child required treatment for decreased heart rate. Parental separation anxiety, mask acceptance, recovery and analgesic requirements were comparable.

CONCLUSIONS

Intranasal 2 μg/kg dexmedetomidine resulted in significantly higher peak plasma concentration and time to reach peak plasma concentration than sublingual wafers. Sublingual and intranasal dexmedetomidine resulted in comparable sedation, parental separation and mask acceptance.

EDITORIAL COMMENT

This study compared the pharmacokinetics and sedative effects of sublingual versus intranasal dexmedetomidine in children, finding that intranasal administration resulted in significantly higher peak plasma concentration and faster time to peak concentration. Both routes achieved comparable sedation, parental separation anxiety scores and mask acceptance, with no significant adverse effects observed.

Population Pharmacokinetics of Intranasal Dexmedetomidine in Infants and Young Children

BACKGROUND

Intranasal dexmedetomidine provides noninvasive, effective procedural sedation for pediatric patients, and has been widely used in clinical practice. However, the dosage applied has varied fourfold in pediatric clinical studies. To validate an appropriate dosing regimen, this study investigated the pharmacokinetics of intranasal dexmedetomidine in Chinese children under 3 yr old.

METHODS

Intranasal dexmedetomidine 2 µg · kg-1 was administered to children with simple vascular malformations undergoing interventional radiological procedures. A population pharmacokinetic analysis with data from an optimized sparse-sampling design was performed using nonlinear mixed-effects modeling. Clearance was modeled using allometric scaling and a sigmoid postmenstrual age maturation model. Monte Carlo simulations were performed to assess the different dosing regimens.

RESULTS

A total of 586 samples from 137 children aged 3 to 36 months were included in the trial. The data were adequately described by a two-compartment model with first-order elimination. Body weight with allometric scaling and maturation function were significant covariates of dexmedetomidine clearance. The pharmacokinetic parameters for the median subjects (weight 10 kg and postmenstrual age 101 weeks) in the authors' study were apparent central volume of distribution 7.55 l, apparent clearance of central compartment 9.92 l · h-1, apparent peripheral volume of distribution 7.80 l, and apparent intercompartmental clearance 61.7 l · h-1. The simulation indicated that at the dose of 2 µg · kg-1, 95% of simulated individuals could achieve a target therapeutic concentration of 0.3 ng · ml-1 within 20 min, and the average peak concentration of 0.563 ng · ml-1 could be attained at 61 min.

CONCLUSIONS

The pharmacokinetic characteristics of intranasal dexmedetomidine were evaluated in Chinese pediatric patients aged between 3 and 36 months. An evidence-based dosing regimen at 2 µg · kg-1 could achieve a preset therapeutic threshold of mild to moderate sedation that lasted for up to 2 h.

EDITOR’S PERSPECTIVE

Perioperative Breast Analgesia: a Systematic Review of the Evidence for Perioperative Analgesic Medications

PURPOSE OF REVIEW

Breast surgery is common and may result in significant acute as well as chronic pain. A wide range of pharmacologic interventions is available including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), N-methyl-D-aspartate (NMDA) receptor antagonists, anticonvulsants, and other non-opioids with analgesic properties. We present a review of the evidence for these pharmacologic interventions. A literature search of the MEDLINE database was performed via PubMed with combined terms related to breast surgery, anesthesia, and analgesia. Articles were limited to randomized controlled trial (RCT) design, adult patients undergoing elective surgery on the breast (not including biopsy), and pharmacologic interventions only. Article titles and abstracts were screened, and risk of bias assessments were performed.

RECENT FINDINGS

The search strategy initially captured 7254 articles of which 60 articles met the full inclusion criteria. Articles were organized according to intervention: 6 opioid agonists, 14 NSAIDs and acetaminophen, 4 alpha-2 agonists, 7 NMDA receptor antagonists, 6 local anesthetics, 7 steroids, 15 anticonvulsants (one of which also discussed an NMDA antagonist), 1 antiarrhythmic, and 2 serotonin reuptake inhibitors (one of which also studied an anticonvulsant). A wide variety of medications is effective for perioperative breast analgesia, but results vary by agent and dose. The most efficacious are likely NSAIDs and anticonvulsants. Some agents may also decrease the incidence of chronic postoperative pain, including flurbiprofen, gabapentin, venlafaxine, and memantine. While many individual agents are well studied, optimal combinations of analgesic medications remain unclear.

Development of Sedative Dexmedetomidine Sublingual In Situ Gels: In Vitro and In Vivo Evaluations

Intravenous dexmedetomidine (DEX) is currently approved by the FDA for the sedation of intubated patients in intensive care units to reduce anxiety and to augment postoperative analgesia. Bradycardia and hypotension are limitations associated with the intravenous administration of DEX. In this study, DEX sublingual in situ gels were developed and assessed for their pH, gelling capacity, viscosity, mucoadhesion and in vitro drug release. The optimized gelling system demonstrated enhanced mucoadhesion, superior gelling capacity, reasonable pH and optimal rheological profile. In vivo, compared to the oral solution, the optimal sublingual gel resulted in a significant higher rate and extent of bioavailability. Although the in situ gel had comparable plasma levels to those observed following intravenous administration, significant amelioration of the systemic adverse reactions were attained. As demonstrated by the hot plate method, a sustained duration of analgesia in rats was observed after sublingual administration of DEX gel compared to the intravenously administered DEX solution. Furthermore, no changes in systolic blood pressure and heart rate were recorded in rats and rabbits, respectively, after sublingual administration of DEX. Sublingual administration of DEX in situ gel provides a promising approach for analgesia and sedation, while circumventing the reported adverse reactions associated with intravenous administration of DEX.

Pharmacokinetics and Pharmacodynamics of Dexmedetomidine Administered as an Adjunct to Bupivacaine for Transversus Abdominis Plane Block in Patients Undergoing Lower Abdominal Cancer Surgery

Background

Despite the growing interest in dexmedetomidine as an adjunct to truncal blocks, little is known about the systemic absorption of dexmedetomidine after these blocks and its role in analgesia and in hemodynamics.

Objective

We investigated the pharmacokinetics and pharmacodynamics of dexmedetomidine as an adjunct to transversus abdominis plane (TAP) block in patients undergoing lower abdominal cancer surgery.

Methods

Twenty-four adult patients were randomized to receive a bilateral single-injection TAP block before surgery with 20 mL of bupivacaine 0.5% (TAP group, n = 12) or combined with 1 µg/kg dexmedetomidine (TAP-DEX group, n = 12) and diluted with saline to a volume of 40 mL (20 mL on each side). Plasma concentrations of dexmedetomidine and its pharmacokinetics were investigated using non-compartmental methods, postoperative analgesia, hemodynamics, and adverse events (nausea, vomiting, itching, hypotension, bradycardia, and respiratory depression).

Results

Dexmedetomidine was detected in the plasma of 11 patients in the TAP-DEX group. The mean dexmedetomidine peak plasma concentration (Cmax) was 0.158 ± 0.085 (range, 0.045-0.31) ng/mL. The median time to reach peak plasma concentration of dexmedetomidine (Tmax) was 15 (15-45) min. From 2 to 8 h postoperatively, visual analog pain scale (VAS) scores at rest and during movement were significantly lower in the TAP-DEX group. Analgesia time was (11.3 ± 3.12 vs 9.0 ± 4.69 h; P = 0.213) and postoperative morphine consumption was (7.4 ± 3.24 vs 11.5 ± 4.46 mg; P = 0.033) in TAP-DEX and TAP groups, respectively. Lower mean heart rate and mean blood pressure were recorded in the TAP-DEX group intraoperatively and 2 h postoperatively (P < 0.05). Except for mild nausea and vomiting, no adverse events were recorded in either group.

Conclusion

Systemic absorption of dexmedetomidine administered in a TAP block is common. Direct central effects on the locus coeruleus caused by this systemic absorption may play a role in the analgesia and hemodynamic effects produced by TAP-dexmedetomidine in addition to local mechanisms.

Trial Registration

ClinicalTrial.gov (identifier: NCT03328299).