Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc
Journal website https://www.jocmr.org

Review

Volume 15, Number 1, January 2023, pages 10-22

Improving the Emergency Department Management of Sickle Cell Vaso-Occlusive Pain Crisis: The Role and Options of Sublingual and Intranasally Administered Analgesia

Figures

Figure 1.
Figure 1. Vaso-occlusion, inflammation and pain.
Figure 2.
Figure 2. Nasal respiratory epithelium and sublingual area epithelium.
Figure 3.
Figure 3. Technique for intranasal medication administration using an LMA® mucosa atomization device.

Tables

Table 1. Profile of Analgesics Administered via the Intranasal Route
 
DrugAvailable intranasal productsPharmacokineticsIntranasal doseAdverse effectsa
aAdverse events due to local effect of medication, medication-specific systemic adverse events not included. bDepend on dosage. cLimited evidence on pediatric use.
Fentanyl [28, 41, 43-45, 50, 51]Fentanyl citrate 50 µg/mL solutionBioavailability: 55-89%Adult: initial dose of 0.5 - 2 µg/kg (maximum of 100 µg/dose)Nasal congestion, throat irritation, headache, unpleasant taste
Onset of action: 2 - 10 min
Peak effect: 12 - 21 minPediatric (≥ 1 year old and weighing at least 10 kg): initial dose of 1 - 1.5 µg/kg (maximum of 100 µg/dose)
Duration of action: at least 60 minb
Hydromorphone [28, 53-56]Hydromorphone hydrochloride 1 mg/mLBioavailability: 50-60%Adult: initial dose 4 - 8 mgUnpleasant taste, dizziness, rhinitis
Onset of action: about 5 min
Peak effect: 20 - 30 minPediatric: 0.03 - 0.06 mg/kgc
Duration of action: 90 - 180 min
Ketorolac [57, 59, 63-67]8 sprays/1.7 g nasal spray bottle of ketorolac tromethamine (1 spray is equivalent to 15.75 mg in a 100 µL solution)Bioavailability: 67-75%Adult: < 65 years: one 15.75 mg spray in each nostril (31.5 mg/dose) every 6 - 8 h (maximum dose of 63 mg/day)Nasal irritation, dysgeusia
Onset of action: 5 - 20 min≥ 65 years of age, renal impairment, weight < 50 kg: one 15.75 mg spray in one nostril (15.75 mg/dose)
Peak effect: 30 - 52 minPediatric: not recommended
Duration of action: about 180 min

 

Table 2. Profile of Analgesics Administered via the Sublingual Route
 
DrugAvailable productsPharmacokineticsEquivalent dose to 15 mg of oral morphineAdverse effectsa
aAdverse events due to local effect of medication, medication-specific systemic adverse events not included. bNo sublingual formulations are available in the United States. AE: adverse events. N/A: limited information on the pharmacokinetics of sublingual oxycodone.
Fentanyl [81-85]Spray: available in 100, 200, 400, 600, 800, 1,200, and 1,600 µg strengthsBioavailability: 70-76%100 µgNo AE specific to the sublingual route
Onset of action: 5 - 15 min
Tablet: available in 100, 200, 300, 400, 600, and 800 µg strengthsPeak effect: about 60 min
Duration of action: about 180 min
Sufentanil [72-77]Tablet: available in 30 µg strengthsBioavailability: 47-57%30 µgNo AE specific to the sublingual route
Onset of action: 15 - 30 min
Peak effect: 40 - 75 min
Duration of action: at least 60 min
Buprenorphine [86, 88-90, 91]Tablet: available in 2 and 8 mg strengthsBioavailability: 12-94%0.4 mgNo AE specific to the sublingual route
Onset of action: 30 - 60 min
Peak effect: 60 - 240 min
Duration of action: 6 - 12 h (for doses < 4 mg) and 24 - 72 h (for > 16 mg)
Oxycodone [92, 93]5, 10 mg soluble tablets, 20 mg/mL concentrated oral solutionsbBioavailability: < 20%10 mgNo AE specific to the sublingual route
Onset of action: N/A
Peak effect: N/A
Duration of action: N/A