Randomized trial of mifepristone and buccal or vaginal misoprostol for abortion through 56 days of last menstrual period

OBJECTIVE

Mifepristone-misoprostol medical abortion has been approved in the United States since 2000. U.S. providers have preferred to use vaginal misoprostol because of evidence that such a regimen is more effective in later gestations. Buccal administration of misoprostol may be equally effective and more acceptable to some women.

METHODS

This open-label, randomized trial was conducted at two sites in Rochester, NY, and involved healthy women with pregnancies through 56 days since the last menstrual period (LMP) as indicated by sonogram. Women received mifepristone 200 mg orally and were randomized to use 800 mug of misoprostol either buccally or vaginally 1 to 2 days later. They returned within 15 days for repeat sonogram. If the woman's pregnancy had not been completely aborted by day 36, a suction abortion was performed. The primary outcome was a complete abortion without surgical intervention.

RESULTS

Four hundred forty-two women were enrolled in the study, and complete data were available on 429. The efficacy rate was 95% (205/216) in the buccal group and 93% (199/213) in the vaginal group (chi(2)=0.43, p=.51). Nausea was the most commonly reported side effect, affecting 70% in the buccal group and 62% in the vaginal group. There were no differences in the satisfaction with the overall procedure between the buccal (92%) and the vaginal groups (95%) (chi(2)=1.87, p=.17).

CONCLUSION

Buccal administration of misoprostol after low-dose mifepristone for medical abortion appears to be a highly effective and acceptable alternative compared with vaginal administration for medical abortion in pregnancies through 56 days LMP.

Evaluation of relatively low dose of oral transmucosal ketamine premedication in children: a comparison with oral midazolam

BACKGROUND

Oral Transmucosal ketamine (lollipop) has been shown to be an effective, harmless preoperative medication for children. However, its efficacy was not compared with commonly used premedication drugs. We, therefore, compared the efficacy of oral transmucosal ketamine with oral midazolam for premedication in children.

METHODS

Fifty-five children (2-6 years of age) were randomized to receive orally either a lollipop containing 50 mg of ketamine (the group K; n = 27) or syrup containing 0.5 mg.kg(-1) of midazolam (the group M; n = 28) before minor surgery. A five points-sedation score (1 = asleep to 5 = agitated; scores 2 and 3 were defined as 'effective') on arrival in the operating room and a three points-acceptance score of separation from the parents and a three points-mask cooperation score at induction of anesthesia (1 = easy to 3 = markedly resistant; score 3 was defined as 'poor') were used.

RESULTS

Sedation scores in group K were significantly higher than those in group M (P = 0.012), and the incidence of 'effective' in sedation was significantly lower in group K than in group M (P = 0.036). The incidence of 'poor' at separation from the parents and for mask cooperation was significantly higher in group K than in group M (P = 0.017, P = 0.019, respectively).

CONCLUSION

These results indicate that a relatively low dose of oral transmucosal ketamine premedication provides no benefits over oral midazolam in children.

Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomised controlled trial

BACKGROUND

Rectal diazepam and buccal midazolam are used for emergency treatment of acute febrile and afebrile (epileptic) seizures in children. We aimed to compare the safety and efficacy of these drugs.

METHODS

A multicentre, randomised controlled trial was undertaken to compare buccal midazolam with rectal diazepam for emergency-room treatment of children aged 6 months and older presenting to hospital with active seizures and without intravenous access. The dose varied according to age from 2.5 to 10 mg. The primary endpoint was therapeutic success: cessation of seizures within 10 min and for at least 1 hour, without respiratory depression requiring intervention. Analysis was per protocol.

FINDINGS

Consent was obtained for 219 separate episodes involving 177 patients, who had a median age of 3 years (IQR 1-5) at initial episode. Therapeutic success was 56% (61 of 109) for buccal midazolam and 27% (30 of 110) for rectal diazepam (percentage difference 29%, 95% CI 16-41). Analysing only initial episodes revealed a similar result. The rate of respiratory depression did not differ between groups. When centre, age, known diagnosis of epilepsy, use of antiepileptic drugs, prior treatment, and length of seizure before treatment were adjusted for with logistic regression, buccal midazolam was more effective than rectal diazepam.

INTERPRETATION

Buccal midazolam was more effective than rectal diazepam for children presenting to hospital with acute seizures and was not associated with an increased incidence of respiratory depression.

Transbuccal tablets of carbamazepine: formulation, release and absorption pattern

Tranbsuccal drug administration is an attractive method, as it has several advantages especially with respect to peroral delivery. Here we report: i) the aptitude of carbamazepine (CBZ) to penetrate porcine buccal mucosa and reconstituted human oral (RHO) epithelium; ii) three different tablet formulations for transbuccal administration; iii) the drug release rate from tablets. CBZ permeation through the buccal mucosa was investigated by using two different bi-compartmental open models: Franz cells for porcine buccal mucosa and Transwell diffusion cells system for RHO epithelium. Results, expressed as drug flux (Js) and permeability coefficients (Kp), indicated that CBZ well penetrates the membrane and arrives in the acceptor phase. Js and Kp resulted 7x10(-2) mg/cm2h and 0.23 cm/h for in vitro experiments and 1.81 x 10(-2) mg/cm2h and 4.57 x 10(-2) cm/h for ex vivo experiments. The flux is extensively affected by the membrane thickness. The CBZ release from three different formulations of tablets, prepared with loaded microspheres, loaded matrices, and conventional compressed physical mixture of components was studied. Using the new formulated "non-conventional" tablets prolonged drug release was obtained. Loaded matrix tablets discharged CBZ faster than microsphere tablets (17% and 12% in about 2.5 h respectively). Results indicate the possibility of administering CBZ on buccal mucosa.

Development of a mucoadhesive and permeation enhancing buccal delivery system for PACAP (pituitary adenylate cyclase-activating polypeptide)

The buccal mucosa providing direct entry into the systemic circulation appears to be a potential site for the delivery of PACAP (pituitary adenylate cyclase-activating polypeptide), a new therapeutic agent in the treatment of type 2 diabetes. In order to reach a sufficient buccal bioavailability a drug delivery system with strong permeation enhancing and mucoadhesive properties is needed. In this study the enhancing effect of a strongly mucoadhesive chitosan-thioglycolic acid (TGA) conjugate in combination with reduced glutathione (GSH) on the permeation of PACAP across the buccal mucosa was investigated. The apparent permeability coefficient (P(app)) of PACAP in buffer only was (5.7 +/- 3.1) x 10(-8), while in the presence of chitosan-TGA conjugate (1%) a P(app) of (20.0 +/- 3.4) x 10(-8) was achieved. The combination of chitosan-TGA (1%) with GSH (2%) led to an improvement of the P(app) up to (57.3 +/- 31.7) x 10(-8). Release studies of PACAP demonstrated that a controlled release can be provided from tablets consisting of chitosan-TGA at a pH of 5, whereas more than twice as much was released from chitosan-TGA tablets pH 4. According to the combination of permeation enhancing properties, controlled drug release and the mucoadhesive character, chitosan-TGA conjugates represent a promising tool for the buccal administration of PACAP.

Buccal drug delivery

Buccal formulations have been developed to allow prolonged localised therapy and enhanced systemic delivery. The buccal mucosa, however, while avoiding first-pass effects, is a formidable barrier to drug absorption, especially for biopharmaceutical products (proteins and oligonucleotides) arising from the recent advances in genomics and proteomics. The buccal route is typically used for extended drug delivery, so formulations that can be attached to the buccal mucosa are favoured. The bioadhesive polymers used in buccal drug delivery to retain a formulation are typically hydrophilic macro-molecules containing numerous hydrogen bonding groups. Newer second-generation bioadhesives have been developed and these include modified or new polymers that allow enhanced adhesion and/or drug delivery, in addition to site-specific ligands such as lectins. Over the last 20 years a wide range of formulations has been developed for buccal drug delivery (tablet, patch, liquids and semisolids) but comparatively few have found their way onto the market. Currently, this route is restricted to the delivery of a limited number of small lipophilic molecules that readily cross the buccal mucosa. However, this route could become a significant means for the delivery of a range of active agents in the coming years, if the barriers to buccal drug delivery are overcome. In particular, patient acceptability and the successful systemic delivery of large molecules (proteins, oligonucleotides and polysaccharides) via this route remains both a significant opportunity and challenge, and new/improved technologies may be required to address these.

Comparing vaginal and buccal misoprostol when used after methotrexate for early abortion

OBJECTIVE

The primary objective of this study was to determine if buccal misoprostol was as effective as vaginal misoprostol in medical abortions. The secondary objectives were to compare side effects and acceptability.

METHODS

This was a randomized controlled trial of 600 microg misoprostol by the buccal or vaginal routes used 3 to 6 days after 50 mg/m2 methotrexate. The participants were women presenting for abortion at 49 days or less gestation. The outcome measures were the number of women who had aborted by Day 8, side effects and acceptability.

RESULTS

Day 8 completion rate was 53.5% for the buccal route and 67.5% for the vaginal route (p = 0.012). Side effects were similar in the two groups except that there was more burning with the buccal route. Overall acceptability and route acceptability were similar in the two groups.

CONCLUSIONS

When used after methotrexate for early abortion, the vaginal route for misoprostol is more effective and preferred to the buccal route.

Formulation and in vitro evaluation of prednisolone buccoadhesive tablets

In this research, the effect of mucoadhesive polymers such as hydroxyl propyl methyl cellulose (HPMC) with viscosity grade 60 and 500 mPas, sodium carboxy methyl cellulose (NaCMC) and carbopol 934 (Cp 934) alone or in combination with each other on the release profile of prednisolone was studied and mucoadhesion strength of these buccoadhesive formulations was evaluated. The results showed that the release of prednisolone from HPMC with viscosity grade 60 mPas and Cp 934 alone was fast and their mucoadhesion strengths was low. On the other hand, the release rates of prednisolone from the HPMC viscosity grade 500 mPas and NaCMC and mucoadhesion strengths were moderate and suitable. The results showed that with different blends of HPMC viscosity grade 500 mPas or NaCMC and Cp 934 with increasing in HPMC or NaCMC/Cp 934 ratio a remarkable decrease in the rate of drug release and an appreciable increase in the mucoadhesion strength was observed. Except from the formulations prepared with HPMC viscosity grade 60 and 500 mPas, other formulation had more fluctuations in release profiles and their kinetics of release were not fitted to zero order model.

Enhanced Buccal Mucosal Retention and Reduced Buccal Permeability of Estradiol in the Presence of Padimate O and Azone®: A Mechanistic Study

In previous experiments, it was suggested that the reduction in estradiol (E2) buccal permeability after pretreatment with some skin penetration enhancers was attributed to enhanced membrane storage. To verify this, further in vitro permeability experiments were performed and the kinetics of E2 buccal mucosal uptake and permeability was assessed. Porcine buccal mucosa was pretreated with the skin penetration enhancers octisalate, padimate O (PO), or Azone (AZ) and placed in modified Ussing chambers. The disappearance of E2 from the donor chamber and appearance of E2 in the receptor chamber was then monitored over 4 h. The final concentration of E2 associated with the buccal mucosa and donor chamber walls in the presence of each enhancer was also determined. The rate of E2 disappearance from the donor chamber was 3.1-fold greater than the rate of E2 appearance in the receptor chamber, indicating significant membrane storage of E2. Pretreatment with PO and AZ significantly increased the rate of E2 disappearance and reduced the rate of E2 appearance in the receptor chamber. The corresponding enhancement in E2 tissue concentration after PO and AZ pretreatment was 1.7- and 3-fold, respectively. However, PO and AZ also increased the amount of E2 adsorbed to the walls of the donor chamber, which contributed to the reduction in E2 flux through the buccal mucosa.

Pharmacodynamics and pharmacokinetics of recombinant hirudin via four non-parenteral routes

One of recombinant hirudin variants, rHV2, a polypeptide used as an anticoagulant agent in clinic, was administered to anesthetized rats via intratracheal, buccal, nasal and rectal routes. Prolongation in clotting time and thrombin time was measured to calculate pharmacological bioavailability. Plasma concentration of rHV2 was determined using a chromogenic thrombin substrate assay and pharmacokinetic parameters were obtained on the basis of a non-compartmental model. Intravenous administration was also performed as the gold standard by which the other routes were compared. Difference in pharmacological bioavailability (P.A.), bioavailability (F) and absorption rate of rHV2 was found for the four non-parenteral routes. The rank order for both P.A. and F was intratracheal>nasal>buccal>rectal. Absorption was more rapid after both intratracheal and rectal administration (tmax approximately 20-40 min), compared with that after nasal and rectal administration. It is evident that the pulmonary route is preferable to other three routes for successful systemic delivery of rHV2.

Effect of a buccal bioadhesive nystatin tablet on the lifetime of a Provox silicone tracheoesophageal voice prosthesis

CONCLUSION

Daily application of a buccal bioadhesive slow-release nystatin tablet (100,000 IU per tablet) significantly increased the voice prosthesis lifetime in laryngectomized patients compared to conventional local cleaning of the prosthesis with an antimicrobial agent on a brush.

OBJECTIVE

To investigate the effect of a buccal bioadhesive nystatin tablet on the lifetime of a Provox tracheoesophageal voice prosthesis in post-laryngectomy patients.

MATERIAL AND METHODS

A buccal bioadhesive tablet, based on a spray-dried Amioca/Carbopol 974P mixture containing 10% (w/w) Carbopol 974P, was loaded with 100,000 IU of nystatin. Patients were included in the study when replacement of their voice prosthesis was required and were divided into three groups. Conventional daily local cleaning of the voice prosthesis by means of an oral nystatin suspension on a brush (Group 1; n = 7) was compared with application of one nystatin buccal bioadhesive tablet per day, after breakfast, on the gingiva above the upper canine (Group 2; n = 7). The control group (n = 5) used no antimicrobial agents. The lifetime of the prosthesis was followed and expressed in days.

RESULTS

The lifetime of the voice prosthesis was significantly increased in Group 2 compared to Group 1 (p < 0.05; paired t-test), indicating that sustained release of nystatin in the oral cavity, by means of erosion of the tablet over a period of approximately = 8 h, is more effective at preventing microbial colonization of the prosthesis than local cleaning.

Transbuccal delivery of lamotrigine across porcine buccal mucosa: in vitro determination of routes of buccal transport

PURPOSE

To determine the major routes of buccal transport of lamotrigine and to examine the effects of pH on drug permeation.

METHODS

Transbuccal permeation of lamotrigine across porcine buccal mucosa was studied by using in-line Franz type diffusion cell at 37 degrees C. The permeability of lamotrigine was determined at pH 4.0 to 9.0. The permeability of unionized (Pu) and ionized (Pi) species of drug were calculated by fitting the data to a mathematical model. Lamotrigine was quantified by using the HPLC method.

RESULTS

The steady state flux increased linearly with increasing the donor concentration (r2 = 0.9639) at pH 7.4. The permeability coefficient and the partition coefficient of the drug increased with increasing the pH. The values of Pu and Pi were 0.7291 x 10(-5) cm/sec and 0.2500 x 10(-5) cm/sec, respectively. The observed permeability coefficients and the permeability coefficients calculated from mathematical model at various pH showed good linearity (r(2) = 0.9267). The total permeability coefficient increased with increasing the fraction of unionized form of the drug. CONCLUSION. Lamotrigine permeated through buccal mucosa by a passive diffusion process. The partition coefficient and pH dependency of drug permeability indicated that lamotrigine was transported mainly via the transcellular route by a partition mechanism.

Recent developments in the use of bioadhesive systems for delivery of drugs to the oral cavity

The delivery of therapeutic agents to, or via, the oral cavity is limited by the efficient removal mechanisms that exist in this area. Bioadhesive formulations have been developed to allow prolonged localized therapy and enhanced systemic delivery. The oral mucosa however, while avoiding first-pass effects, is a formidable barrier to drug absorption, especially for "biopharmaceutical" products arising from the recent innovations in genomics and proteomics. Bioadhesive polymers are typically hydrophilic macromolecules containing numerous hydrogen-bonding groups. Second-generation bioadhesives include modified or new polymers that allow enhanced adhesion and/or drug delivery, along with site-specific ligands such as lectins. Over the last 20 years, a range of bioadhesive formulations have been developed for the oral cavity, but only comparatively few have found their way onto the market. This review will consider some recent developments in the use of bioadhesive buccal systems, notably the development of new polymers, advanced delivery systems, and the exploitation of the multifunctional properties of some bioadhesives.

Pharmacokinetics and Dose Proportionality of Fentanyl Effervescent Buccal Tablets in Healthy Volunteers

BACKGROUND AND OBJECTIVES

Fentanyl effervescent buccal tablets (FEBT) are designed to enhance the rate and efficiency of fentanyl absorption through the buccal mucosa. This study was undertaken to characterise the pharmacokinetics and assess the dose proportionality of FEBT in healthy volunteers within the potential therapeutic dose range.

METHODS

Twenty-five healthy adults (mean age 33 years) completed a single-dose, randomised, open-label, four-dose, four-period, crossover study of FEBT. They were administered FEBT 200, 500, 810 or 1080microg. The subjects in this study were not opioid tolerant; therefore, naltrexone was administered to block any opioid receptor-mediated effects of fentanyl. Venous blood samples for measurement of serum fentanyl concentrations were obtained over 36 hours following dosing. Adverse events were recorded throughout the study.

RESULTS

The pharmacokinetics of FEBT were characterised by an absorption phase with a median time to reach maximum serum concentration (tmax) of 0.75-0.99 hours that was consistent irrespective of dose. Mean serum fentanyl concentrations exhibited a biexponential decline from peak after FEBT 200 and 500microg doses and a triexponential decline after FEBT 810 and 1080microg doses. The maximum serum concentration (Cmax) of fentanyl was proportional up to and including the 810microg dose. The increase in Cmax was 20% less than proportional at the 1080microg dose. Systemic exposure to fentanyl, as measured by the area under the serum concentration-time curve from time zero to infinity (AUCinfinity), increased proportionally with increasing doses of FEBT (200-1080microg). No serious adverse events were reported during the study.

CONCLUSION

The pharmacokinetics of FEBT were characterised by a high early fentanyl concentration as a result of absorption across the buccal mucosa of the oral cavity, which results in bypassing first-pass metabolism. This high early tmax contributed to enhanced early systemic fentanyl exposure. Maximum concentration and AUCinfinity of FEBT increased in a dose-proportional manner from 200 to 810microg. This study provides preliminary pharmacokinetic data for FEBT across the potential therapeutic dose range.

[Oral manifestations during herpes virus infection. Case report]

The infections due to herpes viruses are widely spread, people being every day at high risk of contamination starting early age. The characteristic of the herpes virus infection consists of a symptom less evolution following the prime infection. As for any other herpetic infection, episodes infection exacerbation is due to some determining factors. Clinical symptom in herpes virus infection varies according to the virus type, age of the patient and site. Oral signs and symptoms are numerous, extremely intense and often, difficult to diagnose. Progressing in so many ways and being diagnosed and treated by so many medical specialties it is difficult to evaluate the actual number of cases. Consequently it is mandatory to train dentists in order to be able to accurately diagnose and treat the herpetic infection and to prevent nosocomial cross infections in dental office.

[Therapeutic local anesthesia for the management of atypical odontalgia. A clinical case series]

The management of patients diagnosed with atypical odontalgia (AO) is a challenging task. The aim of this longitudinal clinical case series was to document the effect of a 4% carticaine solution without epinephrine among ten patients with AO. Once or on two successive days, 1.7 ml of the local anesthetics was injected buccally in the area of the perceived pain. Pain intensity was recorded four times daily by each participant, beginning at least two weeks prior to the treatment and ending at least four weeks thereafter. The main outcome parameter was pain reduction (in percent) four weeks after treatment compared to the average pain intensity before the injection(s). In addition, study participants were asked to rate their satisfaction with the treatment. Four weeks after treatment, seven of the ten patients experienced significantly less pain than before. Among five individuals, there was a significant pain decrease (about 30% or more). Patient satisfaction was not significantly associated with the amount of pain reduction. Considering the limited treatment options and their side effects, injections with epinephrine-free carticaine seem to be a measure worth to be taken into consideration. Although results gained from uncontrolled case series have to be interpreted with caution, the findings of this observational study sound promising.

Depression during pegylated interferon-alpha plus ribavirin therapy: prevalence and prediction

BACKGROUND

Interferon-alpha (IFN-alpha) plus ribavirin is used to treat hepatitis C virus (HCV) infection and is associated with a high rate of depression. Newer, pegylated preparations of IFN-alpha have a longer half-life, require once-per-week dosing, and may be associated with reduced neuropsychiatric burden. Limited data exist on depression during pegylated IFN-alpha therapy.

METHOD

Depressive symptoms were assessed using the Zung Self-Rating Depression Scale (SDS) in 162 HCV-infected patients at baseline and after 4, 8, 12, and 24 weeks of treatment with pegylated IFN alpha-2b (PEG IFN) plus weight-based (N = 86) versus standard dose (N = 76) ribavirin. Data were collected from March 2001 to April 2003.

RESULTS

Compared with baseline, mean SDS index scores were significantly increased by week 4 and remained elevated throughout the study. Thirty-nine percent of the sample experienced moderate to severe depressive symptoms (SDS index score > or = 60) at some point during PEG IFN/ribavirin therapy. Baseline depression scores significantly predicted severity of depressive symptoms during PEG IFN/ribavirin treatment (simple regression analysis: Y = 0.55X + 32.7, p < .0001). In addition, assignment to weight-based ribavirin treatment and history of depression were associated with increased likelihood of developing moderate to severe depressive symptoms (odds ratio [OR] = 2.7, 95% CI = 1.3 to 5.6, p < .01, and OR = 3.3, 95% CI = 1.3 to 8.1, p < .01, respectively).

CONCLUSIONS

Development of moderate to severe depressive symptoms occurred frequently during PEG IFN/ribavirin treatment and was predicted by baseline depression scores and higher doses of ribavirin. History of major depressive disorder was also a significant predictive factor, but only through association with elevated baseline depression status. All of these factors can be evaluated and addressed to limit neuropsychiatric morbidity during HCV treatment.

Comparison of misoprostol plasma concentrations following buccal and sublingual administration

BACKGROUND

New indications for misoprostol include medical abortion, cervical softening, induction of labor and treatment of postpartum hemorrhage. Various routes of misoprostol administration under study include oral, vaginal, buccal, sublingual and rectal.

MATERIALS AND METHODS

This was an open-label, randomized, cross-over study of the pharmacokinetic differences of buccal vs. sublingual misoprostol 800 mug in 10 healthy women.

RESULTS

Of the 10 women enrolled, 2 withdrew after experiencing excessive cramping from the sublingual route of misoprostol. The mean misoprostol plasma concentration-time curves at 4 h [area under the curve (AUC)0-4)] and the maximum concentration (C(max)) showed that levels were significantly higher for sublingual administration than the buccal route. Buccal misoprostol administration resulted in fewer symptoms and was found to be more acceptable.

CONCLUSIONS

Sublingual administration of misoprostol had a higher AUC and C(max) compared with buccal administration. The pharmacokinetics may help to determine the best application of misoprostol depending on the indication.

[Lysalbinic acid--a new absorption enhancer for the buccal delivery of peptide drugs]

The delivery of peptide drugs via the buccal mucosa is more convenient and safe approach than most other delivery methods. However, the efficiency of the buccal system of protein delivery is not yet able to compete with injection method. To improve its efficacy a new generation of absorption promoters that would be sufficiently enchance penetration and at the same time cause no irritation or unpleasant taste should be developed. Lysalbinic acid, a product of the alkaline hydrolysis of egg albumin, meets those requirements. The paper describes production and general physico-chemical properties of the lysalbinic acid. Lysalbinic acid has been shown to increase permeability of the oral mucosa for some peptide compounds. It is recommended to use lysalbinic acid as an absorption enhancer for the development of novel buccal peptide drugs.

Preparation and evaluation of a chitosan salt–poloxamer 407 based matrix for buccal drug delivery

The aim of this work was to prepare and evaluate a matrix for buccal drug delivery composed of a chitosan salt and poloxamer 407. Different chitosan salts were formed by reacting chitosan with acetic, citric, and lactic acid. Various proportions of poloxamer 407 were added to the aqueous solution of chitosan salt, and the residue obtained by lyophilisation was compressed into discs, using a 30 kN compression force. An experimental design (3(2)) was used to study the influence of the type of chitosan salt and of the relative amount of poloxamer on drug release capacity, swelling, erosion, and mucoadhesiveness of matrices. The results showed that matrix properties depended significantly on both relative amount of poloxamer and chitosan salt type. The rank orders of chitosan salts for the four processes evaluated were as follows: drug release: chitosan acetate>chitosan citrate>chitosan lactate; swelling: chitosan lactate>chitosan acetate=chitosan citrate; erosion: chitosan citrate>chitosan lactate>chitosan acetate; mucoadhesion: chitosan lactate>chitosan acetate=chitosan citrate. Mucoadhesion was particularly favoured when poloxamer 407 was present at about 30% (w/w). The matrix composed of chitosan lactate and poloxamer 407 showed the best characteristics for buccal administration.

Advances in Buccal Drug Delivery

The buccal route offers an attractive alternative for systemic drug delivery of drugs because of better patient compliance, ease of dosage form removal in emergencies, robustness, and good accessibility. Use of buccal mucosa for drug absorption was first attempted by Sobrero in 1847, and since then much research was done to deliver drugs through this route. Today, research is more focused on the development of suitable delivery devices, permeation enhancement, and buccal delivery of drugs that undergo a first-pass effect, such as cardiovascular drugs, analgesics, and peptides. In addition, studies have been conducted on the development of controlled or slow release delivery systems for systemic and local therapy of diseases in the oral cavity. In this review, the anatomy and physiology of buccal mucosa, followed by discussion of recent literature on the buccal permeation enhancement, and pathways of enhancement for various molecules are detailed. In addition, bioadhesion theories from historic perspective and current status are discussed. The various dosage forms on the market and in different stages of development are also reviewed.

Oral transmucosal fentanyl citrate in the management of breakthrough pain in cancer: an open, multicentre, dose-titration and long-term use study

Sixty-six patients with cancer-related pain entered an open multicentre study to examine the safety and efficacy of oral transmucosal fentanyl citrate (OTFC) in the treatment of breakthrough pain. Patients were eligible for the study if they were stabilized on a long-acting opioid but were experiencing up to four episodes of breakthrough pain a day and achieving at least partial relief from breakthrough pain using conventional medication (normal release oral morphine in the majority of patients). The efficacy of the conventional medication was documented in a run-in phase and patients then changed to OTFC. All patients were treated initially with a 200 mcg unit of OTFC and the dose was increased if necessary to a level that produced relief of breakthrough pain without troublesome adverse effects. Fifty-eight patients completed the run-in phase using their usual medication and entered the dose titration phase with OTFC and 57 patients received at least one dose of OTFC. Forty-two patients (72%) found a successful dose of OTFC. The primary outcome measures were the Summed Pain Intensity Differences (SPID) and Total Pain Relief (TOTPAR) scores at 60 min. There was a significant difference in both measures in favour of OTFC compared with conventional medication in these patients. Twenty-eight of the 42 patients (67%) preferred OTFC to their usual medication. The most common adverse effects attributed to OTFC were nausea, stomatitis, vomiting and dizziness but there were no unpredicted or severe problems. Thirty-seven patients continued into the long-term study and 12 of these completed six months treatment. Most drop-outs in this phase were associated with progression of the underlying disease. No patient stopped using OTFC because of dissatisfaction with the drug. OTFC appears to be a safe and effective treatment for breakthrough pain in cancer patients and may have advantages over currently available opioid formulations.

Managing breakthrough pain: a clinical review with three case studies using oral transmucosal fentanyl citrate

Pain management begins with the use of appropriate assessment tools and includes planning, implementing, and evaluating a comprehensive treatment plan that addresses persistent and breakthrough pain. Persistent pain is present to some degree throughout the day and primarily is controlled with around-the-clock medication. However, it often is accompanied by episodes of short, intermittent pain, also known as breakthrough pain. From a clinical perspective, breakthrough pain is characterized as a transitory exacerbation of pain that occurs on a background of otherwise stable pain in a patient receiving chronic opioid therapy. Breakthrough pain typically is moderate to severe in intensity and can be triggered by various activities (incident pain), be entirely unpredictable (idiopathic pain), or occur toward the end of around-the-clock medication (end-of-dose failure). Breakthrough pain occurs in as many as 86% of patients with cancer even when persistent pain is well controlled. Clinicians and patients should address persistent and breakthrough pain as distinct entities to accurately assess it and develop appropriate pain management plans. This article provides an overview of the clinical characteristics of persistent and breakthrough pain and, through the use of three case studies, illustrates practical strategies for managing breakthrough pain effectively.

Buccal Misoprostol to Decrease Blood Loss After Vaginal Delivery: A Randomized Trial

OBJECTIVE

To assess the efficacy of buccal misoprostol to decrease bleeding after vaginal delivery.

METHODS

This was a randomized study of patients between 22 weeks and 42 weeks of gestation with anticipated vaginal delivery. Patients were given either a 200-mug misoprostol tablet or placebo in the buccal space at the time of cord clamping. A continuous dilute intravenous oxytocin infusion was given to all patients at delivery of the placenta. Postpartum hemorrhage was defined as blood loss exceeding 500 mL. Sample size calculations based on previous studies assumed a 13% incidence of postpartum hemorrhage in the control group. To show a statistically significant reduction of postpartum hemorrhage a total of 1,604 patients would be required in each group.

RESULTS

A total of 848 patients were enrolled and 756 randomly assigned, 377 in the misoprostol group and 379 in the placebo group. Demographic, antepartum, and intrapartum characteristics were similar between the groups. The incidence of postpartum hemorrhage, 3% compared with 5%, (relative risk 0.65, 95% confidence interval 0.33-1.29, P = .22), mean estimated blood loss, 322 compared with 329 mL, (P = .45), and mean minutes of the third stage of labor, 6.7 compared with 6.9 (P = .52) were similar between the groups, misoprostol and placebo, respectively. Hemoglobin difference before and after delivery, need for second or third uterotonic agent, and all measured neonatal variables including birth weights, and umbilical cord pH were similar between the groups.

CONCLUSION

Buccal misoprostol at cord clamping is no more effective than placebo in reducing postpartum hemorrhage.