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Roma JR, Castro Rebollo P, Bastida C. Sublingual and buccal drug administration in medical emergencies. Med Clin (Barc) 2024:S0025-7753(24)00382-8. [PMID: 39004586 DOI: 10.1016/j.medcli.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 07/16/2024]
Abstract
Drug administration is crucial to achieve effective therapeutic drug outcomes. In medical emergencies, it is particularly convenient to use drugs that could be administered as an alternative to traditional routes (as oral or intravenous routes), that are not always suitable in these situations. Thus, sublingual and buccal routes offer an alternative to traditional routes, when a rapid onset of action is required. The main objective of this narrative review is to summarize the evidence for the use of sublingual and buccal drug administration in medical emergencies. The evidence obtained has been divided into four common scenarios found in the emergency department and intensive care units: cardiovascular emergencies, acute pain, agitation, and epileptic status. Moreover, the main advantages and disadvantages of sublingual and buccal routes are presented, as the future perspectives in the drug delivery field to overcome the limitations of these routes.
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Affiliation(s)
- Joan Ramon Roma
- Servicio de Farmacia, Área del Medicamento, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España.
| | - Pedro Castro Rebollo
- Área de Vigilancia Intensiva, Servicio de Medicina Interna, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España; IDIBAPS
| | - Carla Bastida
- Servicio de Farmacia, Área del Medicamento, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
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Mastery Learning: Origins, Features, and Evidence from the Health Professions. COMPREHENSIVE HEALTHCARE SIMULATION: MASTERY LEARNING IN HEALTH PROFESSIONS EDUCATION 2020. [DOI: 10.1007/978-3-030-34811-3_2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Vaillancourt R, Collins M, Vadeboncoeur C, Jacob P, Graham N, Foster D, Splinter W. Successful treatment of A Seizure Disorder with Chronic High-Dose Chloral Hydrate: A Pediatric Case Report. J Palliat Care 2018. [DOI: 10.1177/082585971002600409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Régis Vaillancourt
- R Vaillancourt (corresponding author): Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario, Canada K1H 8L1
| | - Michael Collins
- M Collins, C Vadeboncoeur, P Jacob, N Graham, D Foster, W Splinter: Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Chris Vadeboncoeur
- M Collins, C Vadeboncoeur, P Jacob, N Graham, D Foster, W Splinter: Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Pierre Jacob
- M Collins, C Vadeboncoeur, P Jacob, N Graham, D Foster, W Splinter: Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nancy Graham
- M Collins, C Vadeboncoeur, P Jacob, N Graham, D Foster, W Splinter: Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Donna Foster
- M Collins, C Vadeboncoeur, P Jacob, N Graham, D Foster, W Splinter: Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - William Splinter
- M Collins, C Vadeboncoeur, P Jacob, N Graham, D Foster, W Splinter: Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Jędrzejczak J, Mazurkiewicz-Bełdzińska M, Szmuda M, Majkowska-Zwolińska B, Steinborn B, Ryglewicz D, Owczuk R, Bartkowska-Śniatkowska A, Widera E, Rejdak K, Siemiński M, Nagańska E. Convulsive status epilepticus management in adults and children: Report of the Working Group of the Polish Society of Epileptology. Neurol Neurochir Pol 2018; 52:419-426. [PMID: 29937151 DOI: 10.1016/j.pjnns.2018.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/11/2018] [Indexed: 10/14/2022]
Abstract
INTRODUCTION The Working Group was established at the initiative of the General Board of the Polish Society of Epileptology (PSE) to develop an expert position on the treatment of convulsive status epilepticus (SE) in adults and children in Poland. Generalized convulsive SE is the most common form and also represents the greatest threat to life, highlighting the importance of the choice of appropriate therapeutic treatment. AIM OF GUIDELINE We present the therapeutic options separately for treatment during the early preclinical (>5-30min), established (30-60min), and refractory (>60min) SE phases. This division is based on time and response to AEDs, and indicates a practical approach based on pathophysiological data. RESULTS Benzodiazepines (BZD) are the first-line drugs. In cases of ineffective first-line treatment and persistence of the seizure, the use of second-line treatment: phenytoin, valproic acid or phenobarbital is required. SE that persists after the administration of benzodiazepines and phenytoin or another second-line AED at appropriate doses is defined as refractory and drug resistant and requires treatment in the intensive care unit (ICU). EEG monitoring is essential during therapy at this stage. Anesthesia is typically continued for an initial period of 24h followed by a slow reversal and is re-established if seizures recur. Anesthesia is usually administered either to the level of the "burst suppression pattern" or to obtain the "EEG suppression" pattern. CONCLUSIONS Experts agree that close and early cooperation with a neurologist and anesthetist aiming to reduce the risk of pharmacoresistant cases is an extremely important factor in the treatment of patients with SE. This report has educational, practical and organizational aspects, outlining a standard plan for SE management in Poland that will improve therapeutic efficacy.
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Affiliation(s)
- J Jędrzejczak
- Department of Neurology and Epileptology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | | | - M Szmuda
- Department of Developmental Neurology, Chair of Neurology, Medical University of Gdańsk, Poland
| | - B Majkowska-Zwolińska
- Centre for Epilepsy Diagnosis and Treatment, Foundation of Epileptology, Warsaw, Poland
| | - B Steinborn
- Department of Developmental Neurology, Poznan Univerity of Medical Sciences, Poznań, Poland
| | - D Ryglewicz
- 1st Neurological Department, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - R Owczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Poland
| | - A Bartkowska-Śniatkowska
- Department of Paediatric Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznań, Poland
| | - E Widera
- Clinic of Pediatrics and Neurology of Developmental Age, Medical University of Silesia, Katowice, Poland
| | - K Rejdak
- Department of Neurology, Medical University of Lublin, Poland
| | - M Siemiński
- Department of Emeregency Medicine, Medical University of Gdansk, Poland
| | - E Nagańska
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland.
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Malakooti MR, McBride ME, Mobley B, Goldstein JL, Adler MD, McGaghie WC. Mastery of Status Epilepticus Management via Simulation-Based Learning for Pediatrics Residents. J Grad Med Educ 2015. [PMID: 26221431 PMCID: PMC4512786 DOI: 10.4300/jgme-d-14-00516.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Management of status epilepticus (SE) in the pediatric population is highly time-sensitive. Failure to follow a standard management algorithm may be due to ineffective provider education, and can lead to unfavorable outcomes. OBJECTIVE To design a learning module using high-fidelity simulation technology to teach mastery achievement of a hospital algorithm for managing SE. METHODS Thirty pediatrics interns were enrolled. Using the Angoff method, an expert panel developed the minimal passing score, which defined mastery. Scoring of simulated performance was done by 2 observers. Sessions were digitally recorded. After the pretest, participants were debriefed on the algorithm and required to repeat the simulation. If mastery (minimal passing score) was not achieved, debriefing and the simulation were repeated until mastery was met. Once mastery was met, participants graded their comfort level in managing SE. RESULTS No participants achieved mastery at pretest. After debriefing and deliberate simulator training, all (n=30) achieved mastery of the algorithm: 30% achieved mastery after 1 posttest, 63% after a second, and 6.7% after a third. The Krippendorff α was 0.94, indicating strong interrater agreement. Participants reported more self-efficacy in managing SE, a preference for simulation-based education for learning practice-based algorithms of critical conditions, and highly rated the educational intervention. CONCLUSIONS A simulation-based mastery learning program using deliberate practice dramatically improves pediatrics residents' execution of a SE management protocol. Participants enjoyed and benefited from simulation education. Future applications include improving adherence to other hospital protocols.
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Oral transmucosal drug delivery for pediatric use. Adv Drug Deliv Rev 2014; 73:50-62. [PMID: 23999459 DOI: 10.1016/j.addr.2013.08.011] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 07/13/2013] [Accepted: 08/22/2013] [Indexed: 12/25/2022]
Abstract
The formulation of medicines for children remains a challenge. An ideal pediatric formulation must allow accurate dose administration and be in a dosage form that can be handled by the target age group. It is also important to consider the choices and the amount of excipients used in the formulation for this vulnerable age group. Although oral formulations are generally acceptable to most pediatric patients, they are not suitable for drugs with poor oral bioavailability or when a rapid clinical effect is required. In recent years, oral transmucosal delivery has emerged as an attractive route of administration for pediatric patients. With this route of administration, a drug is absorbed through the oral mucosa, therefore bypassing hepatic first pass metabolism and thus avoiding drug degradation or metabolism in the gastrointestinal tract. The high blood flow and relatively high permeability of the oral mucosa allow a quick onset of action to be achieved. It is a simple and non-invasive route of drug administration. However, there are several barriers that need to be overcome in the development of oral transmucosal products. This article aims to provide a comprehensive review of the current development of oral transmucosal delivery specifically for the pediatric population in order to achieve systemic drug delivery. The anatomical and physiological properties of the oral mucosa of infants and young children are carefully examined. The different dosage forms and formulation strategies that are suitable for young patients are discussed.
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Klotz U. The role of pharmacogenetics in the metabolism of antiepileptic drugs: pharmacokinetic and therapeutic implications. Clin Pharmacokinet 2007; 46:271-9. [PMID: 17375979 DOI: 10.2165/00003088-200746040-00001] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Several different factors, including pharmacogenetics, contribute to interindividual variability in drug response. Like most other agents, many antiepileptic drugs (AEDs) are metabolised by a variety of enzymatic reactions, and the cytochrome P450 (CYP) superfamily has attracted considerable attention. Some of those CYPs exist in the form of genetic (allelic) variants, which may also affect the plasma concentrations or drug exposure (area under the plasma concentration-time curve [AUC]) of AEDs. With regard to the metabolism of AEDs, the polymorphic CYP2C9 and CYP2C19 are of interest. This review summarises the evidence as to whether such polymorphisms affect the clinical action of AEDs. In the case of mephenytoin, defects in its metabolism may be attributable to >10 mutated alleles (designated as *2, *3 and others) of the gene expressing CYP2C19. Consequently, poor metabolisers (PMs) and extensive metabolisers (EMs) could be differentiated, whose frequencies vary among ethnic populations. CYP2C19 contributes to the metabolism of diazepam and phenytoin, the latter drug also representing a substrate of CYP2C9, with its predominant variants being defined as *2 and *3. For both AEDs, there is maximally a 2-fold difference in the hepatic elimination rate (e.g. clearance) or the AUC between the extremes of EMs and PMs which, in the case of phenytoin (an AED with a narrow 'therapeutic window'), would suggest a dosage reduction only for patients who are carriers of mutated alleles of both CYP2C19 and CYP2C9, a subgroup that is very rare among Caucasians (about 1% of the population) but more frequent in Asians (about 10%). The minor contribution of CYP2C19 to the metabolism of phenobarbital (phenobarbitone) can be overlooked. In rare cases, valproic acid can be metabolised to the reactive (hepatotoxic) metabolite, 4-ene-valproic acid. It is not yet clear whether genetic variants of the involved enzyme (CYP2C9) are responsible for this problem. Likewise, the active metabolite of carbamazepine, carbamazepine-10,11-epoxide, is transformed by the microsomal epoxide hydrolase, an enzyme that is also highly polymorphic, but the pharmacokinetic and clinical consequences still need to be evaluated. Pharmacogenetic investigations have increased our general knowledge of drug disposition and action. As for old and especially new AEDs the pharmacogenetic influence on their metabolism is not very striking, it is not surprising that there are no treatment guidelines taking pharmacogenetic data into account. Therefore, the traditional and validated therapeutic drug monitoring approach, representing a direct 'phenotype' assessment, still remains the method of choice when an individualised dosing regimen is anticipated. Nevertheless, pharmacogenetics and pharmacogenomics can offer some novel contributions when attempts are made to maximise drug efficacy and enhance drug safety.
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Affiliation(s)
- Ulrich Klotz
- Dr Margarete Fischer-Bosch Institut für Klinische Pharmakologie, Stuttgart, Germany.
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