Could The “New Frontier” in Sedation Be Intranasal?

No needles, no pills, no waiting. It’s an attractive idea for clinicians looking to get patients comfortable right away, but is it as effective and predictable as other sedation methods?

Intranasal administration of medications or herbal therapies has existed for thousands of years, taking advantage of the highly vascularized mucosa of the nasal and sinus cavities to quickly disperse either local or systemically-active substances. Currently, this route of administration is being investigated for a wide range of medications, including migraine treatments, opioid overdose rescue drugs, and hormone therapies aimed at improving the social dysfunction of autism. Along with these and many other treatments, researchers are investigating whether a minimal conscious sedation protocol could be developed using nasal benzodiazepines.

Intranasal administration of sedation medications offers a number of potential benefits, functioning as a sort of “best of both worlds” between IV and oral sedation. Intranasal offers faster onset of action similar to IV, while retaining the ease of administration of oral. It also avoids first-pass metabolism, providing improved bioavailability over orally-administered drugs, and is comfortable and non-threatening to the patient.

However intranasal administration isn’t perfect – uptake is affected by the health of the oral mucosa, and not every medication is suitable for intranasal use. Medications of an excessive volume cannot experience complete uptake, since some of the dose will be lost down the back of the throat. Medicines that are particularly reactive or irritating are also less desired for intranasal administration, as well as ones that may have undesirable local effects, such as vasoconstriction or vasodilation.

Triazolam, the main benzodiazepine used in DOCS sedation protocols, has already been investigated for intranasal sedation, although only in a dog model. Overall, the dogs displayed greater serum triazolam when it was administered nasally over orally, leading to an overall necessary dose reduction and a greatly shortened time to reach sedation. Unfortunately, the study did not address whether the bypassing of the first-pass metabolism might mean patients would not have to be NPO six hours before a procedure. Of course, an empty stomach is desirable for many patients to avoid vomiting and aspiration in an emergency, but patients such as diabetics could have their sedation managed much more comfortably if they were permitted to eat normally.

So far, there have been no major clinical trials for intranasal triazolam on humans, but an innovative method of administering anesthetic for the maxillary arch is already making its way into the dental office. This method of providing anesthetic uses a nasal spray to achieve regional pulpal anesthesia on #4-13. If triazolam follows, this could represent a revolution in convenient, needle-free dentistry.

Sources:

New Intranasally Administered, Needleless Dental Anesthetic Approved by the U.S. Food and Drug Administration. (2017). Ada.org. Retrieved 11 December 2017, from http://www.ada.org/en/science-research/science-in-the-news/new-intransally-administered-needleless-dental-anesthetic-approved-by-the-us-fda

Overview of intranasal medication delivery. (2017). Intranasal.net. Retrieved 11 December 2017, from http://www.intranasal.net/Overview/default.htm

Poonai, N., Canton, K., Ali, S., Hendrikx, S., Shah, A., & Miller, M. et al. (2017). Intranasal ketamine for procedural sedation and analgesia in children: A systematic review. PLOS Medicine. Retrieved 11 December 2017, from

issue_no: 
1
The information contained in this, or any case study post in Incisor should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.