Pharmacokinetic Properties of a Sufentanil Sublingual Tablet Intended to Treat Acute Pain

Sublingual sufentanil tablet for analgesia in emergency medical services and search and rescue agencies

OBJECTIVES

Pain management in the potentially austere search and rescue (SAR) and emergency medical services (EMS) environments can be challenging. Intravenous (IV) and intramuscular (IM) routes of administration may be less practical. This study assesses the efficacy and safety of the sublingual sufentanil tablet (SST) in prehospital settings and hypothesizes that its use will reduce pain while maintaining a reasonable safety profile.

METHODS

This was a retrospective case analysis examining patient records from Teton County Search and Rescue, Grand Teton National Park EMS, and Jackson Hole Fire/EMS from 2021-2023, based on the criteria that they were administered SST in a prehospital setting. Cases in which SST was used were examined to assess patient characteristics, injury classification, patient reported pain scale before and after SST, other medications administered, and vital signs.

RESULTS

Seventy patients met the inclusion criteria. Six individuals were excluded due to missing one or more of the key variables, and the analysis was carried out with the remaining (N = 64 cases). The mean pain score decreased from 8.0 ± 1.9 before medication administration to 5.5 ± 2.5 after administration, reflecting a statistically significant difference of 2.6 ± 2.1 (p < 0.001). The results also revealed statistically significant reductions in heart rate (HR) and systolic blood pressure (SBP) following SST administration (mean HR dropped by 4.2 ± 9.1 beats/min, p = 0.004, and mean SBP dropped by 11.1 ± 21.8 mmHg, p = 0.01). Changes in vital signs, although statistically significant, were not clinically significant and did not necessitate additional monitoring or intervention in any patients.

CONCLUSIONS

Our study demonstrated that SST administration led to a significant reduction in pain scores and exhibited a favorable safety profile regarding vital signs, including SBP, HR, respiratory rate (RR), and O2 saturation. These findings support the utilization of SST for pain management in the prehospital setting, particularly in austere environments where traditional routes of administration may be impractical.

Low-dose sufentanil does not affect tolerance to LBNP-induced central hypovolemia or blood pressure responses during a cold pressor test

Hemorrhage is a leading cause of death in the prehospital setting. Since trauma-induced pain often accompanies a hemorrhagic insult, the administered pain medication must not interfere with critical autonomic regulation of arterial blood pressure and vital organ perfusion. The purpose of this study was to test two unrelated hypotheses: 1) sublingual sufentanil (Dsuvia) impairs tolerance to progressive central hypovolemia and 2) sublingual sufentanil attenuates pain sensation and the accompanying cardiovascular responses to a noxious stimulus. Twenty-nine adults participated in this double-blinded, randomized, crossover, placebo-controlled trial. After sublingual administration of sufentanil (30 μg) or placebo, participants completed a progressive lower-body negative pressure (LBNP) challenge to tolerance (aim 1). After a recovery period, participants completed a cold pressor test (CPT; aim 2). Addressing the first aim, tolerance to LBNP was not different between trials (P = 0.495). Decreases in systolic blood pressure from baseline to the end of LBNP also did not differ between trials (time P < 0.001, trial P = 0.477, interaction P = 0.587). Finally, increases in heart rate from baseline to the end of LBNP did not differ between trials (time P < 0.001, trial P = 0.626, interaction P = 0.424). Addressing the second aim, sufentanil attenuated perceived pain (P < 0.001) in response to the CPT, though the magnitude of the change in mean blood pressure during the CPT (P = 0.078) was not different between trials. These data demonstrate that sublingual sufentanil does not impair tolerance to progressive central hypovolemia. Additionally, sublingual sufentanil attenuates perceived pain, but not the accompanying mean blood pressure responses to the CPT.NEW & NOTEWORTHY Addressing two unique aims, we observed that sublingual sufentanil administration does not impair tolerance or cardiovascular responses to lower-body negative pressure (LBNP)-induced progressive central hypovolemia. Second, despite pain perception being reduced, sublingual sufentanil did not attenuate mean blood pressure responses to a cold pressor test (CPT).

Anti-Nociceptive Effect of Sufentanil Polymeric Dissolving Microneedle on Male Mice by Hot Plate Technique

Background

Despite the widespread use of opioids to manage severe pain, its systemic administration results in side effects. Among the subcutaneous and transdermal drug delivery systems developed to deal with adverse effects, microneedles have drawn attention due to their rapid action, high drug bioavailability, and improved permeability. Sufentanil (SUF) is an effective injectable opioid for treating severe pain. In this study, we investigated the analgesic effects of SUF using dissolvable microneedles.

Methods

SUF polymeric dissolvable microneedles were constructed through the mold casting method and characterized by SEM and FTIR analysis. Its mechanical strength was also investigated using a texture analyzer. Fluorescence microscopy was applied in vitro to measure the penetration depth of microneedle arrays. Irritation and microchannel closure time, drug release profile, and hemocompatibility test were conducted for the validation of microneedle efficiency. Hot plate test was also used to investigate the analgesic effect of microneedle in an animal model.

Results

Local administration of SUF via dissolving microneedles had an effective analgesic impact. One hour after administration, there was no significant difference between the subcutaneous and the microneedle groups, and the mechanical properties were within acceptable limits.

Conclusion

Microneedling is an effective strategy in immediate pain relief compared to the traditional methods.

Postoperative effect of sufentanil preemptive analgesia combined with psychological intervention on breast cancer patients

OBJECTIVES

To explore the postoperative effects of sufentanil preemptive analgesia combined with psychological intervention on breast cancer patients undergoing radical surgery.

METHODS

112 female breast cancer patients aged 18-80 years old who underwent radical surgery by the same surgeon were randomly divided into 4 groups, and there were 28 patients in each group. Patients in group A were given 10 µg sufentanil preemptive analgesia combined with perioperative psychological support therapy (PPST), group B had only 10 µg sufentanil preemptive analgesia, group C had only PPST, and group D were under general anesthesia with conventional intubation. Visual analogue scoring (VAS) was used for analgesic evaluation at 2, 12 and 24 h after surgery and compared among the four groups by ANOVA method.

RESULTS

The awakening time of patients in group A or B was significantly shorter than that in group C or D, and the awakening time in group C was significantly shorter than that in group D. Moreover, patients in group A had the shortest extubation time, while the group D had the longest extubation time. The VAS scores at different time points showed significant difference, and the VAS scores at 12 and 24 h were significantly lower than those at 2 h (P < 0.05). The VAS scores and the changing trend of VAS scores were varied among the four groups (P < 0.05). In addition, we also found that patients in group A had the longest time to use the first pain medication after surgery, while patients in group D had the shortest time. But the adverse reactions among the four groups showed no difference.

CONCLUSIONS

Sufentanil preemptive analgesia combined with psychological intervention can effectively relieve the postoperative pain of breast cancer patients.

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

Vaso-occlusive crisis (VOC), characterized by periods of excruciating pain is the most common clinical manifestation of sickle cell disease (SCD), often resulting in emergency room presentation. These patients often experience long wait times in the emergency department before receiving their first dose of analgesia. This delay results from the complexities of the emergency care system. Using the intranasal or sublingual approach to administering analgesia to SCD patients with VOC offers a fast, safe, noninvasive, atraumatic, and easily accessible route of administration which could reduce the time to first dose of analgesia. With the evolving advances in the development and delivery of analgesic medications, providers should be conversant with the nuances of intranasal and sublingual analgesia in the management of acute vaso-occlusive pain crisis. This review explores the pharmacokinetic profiles, dosages, and administration of intranasal and sublingual analgesics with relevance to the SCD population.

Sublingual Sufentanil vs. Intravenous Fentanyl for the Treatment of Acute Postoperative Pain in the Ambulatory Surgery Center: A Randomized Clinical Trial

Objectives

Sublingual sufentanil is a novel opioid medication to treat moderate to severe pain postoperatively. This study's aim was to determine if a single dose of a sublingual sufentanil tablet (SST) is as efficacious as a single dose of intravenous (IV) fentanyl in readiness to discharge from ambulatory surgery.

Methods

This was a two-arm, parallel group, randomized prospective outcomes study conducted at a single, free-standing ambulatory surgery center. Patients aged 18–80 undergoing general anesthesia who developed a postoperative pain score of ≥ 4 were enrolled and randomized to receive either 30 mcg SST or 50 mcg IV fentanyl. After their initial randomized dose, rescue IV fentanyl followed by oral oxycodone if needed. Recovery length of stay from arrival in the postanesthesia care unit until readiness to discharge criteria was met based on phase 2 discharge criteria.

Results

75 patients were analyzed. Readiness to discharge from the recovery room was not significantly different between either group (IV fentanyl median 65 minutes; IQR 56–89; SST 73 min, IQR 58–89; p=0.903). There was no significant difference in the amount of morphine equivalents (MME) of rescue opioids needed (IV fentanyl median rescue MME of 22.5, IQR 13.1–23.4; SST median rescue MME of 15.0, IQR 7.5–30.0; p=0.742). The change in pain from PACU initially, and on discharge was not significantly different (IV fentanyl initial pain minus pain on discharge median 3, IQR 2–4; SST initial pain minus pain on discharge median 4, IQR 2–5.5; p=0.079). There was no difference in the six-item screener and the Overall Benefit of Analgesic Survey Score. Discussion. In conclusion, patients who received a sublingual sufentanil 30 mcg tablet had no significant differences in PACU length of stay or rescue analgesic usage when compared to intravenous fentanyl 50 mcg.

Sufentanil Sublingual Tablet Reduces Postoperative Opioid Use Following Outpatient Plastic Surgery

Background

The emphasis on better pain control with less narcotic use represents an ongoing challenge for outpatient plastic surgery procedures. Intravenous (IV) bolus opioids during surgery can lead to short-term relief, but often repeat dosing is required in the postanesthesia care unit (PACU), prolonging recovery time. The sufentanil sublingual tablet (SST) has recently shown efficacy in reducing overall opioid use and postsurgical recovery time for outpatient general surgery procedures.

Objectives

To examine the effect of SST on PACU opioid use, adverse events, and recovery time compared with traditional IV opioid drug regimens in patients undergoing aesthetic surgical procedures.

Methods

A retrospective chart review was performed on SST patients (n = 61) receiving a single 30 mcg SST 30 minutes before surgery (for short procedures) or 45 minutes before surgical extubation (longer procedures). A control group (n = 32) underwent similar surgical procedures utilizing standard IV opioid treatment without SST.

Results

Control and study groups were of similar age and sex. Procedure duration (approximately 3 hours) and intraoperative opioid administration were similar in both groups, with 92% of patients receiving SST before extubation due to the length of the case. Almost all control patients (90.6%) required rescue opioids during recovery in the PACU compared with a few SST patients (16.4%; P < 0.001), averaging 5-fold higher dosing in the control group. Recovery duration did not differ between groups as factors other than pain management and adverse events affected discharge.

Conclusions

SST substantially reduced opioid administration in the PACU for patients undergoing outpatient plastic surgery procedures.

Level of Evidence 3

Awake Plastic Surgery Procedures: The Use of a Sufentanil Sublingual Tablet to Improve Patient Experience

Background

Awake plastic surgery performed under minimal sedation has advantages including patient preference, affordability, and easier recovery compared to when performed under deeper sedation. Commonly used oral analgesics may not be adequate for awake procedures resulting in moderate to severe pain. Sufentanil sublingual tablet (SST) 30 mcg has been shown to provide timely analgesia with a safety profile appropriate for minimal-sedation settings.

Objectives

To examine perioperative outcomes in patients who underwent awake plastic surgery with local anesthesia and SST 30 mcg for pain control.

Methods

This study was a prospective single-group cohort study conducted at a single plastic surgery center. SST 30 mcg was administered approximately 30 minutes prior to the procedure. Outcome measures included the number of patients with adverse events, the number of patients requiring medications in the post-anesthesia care unit (PACU), and recovery time.

Results

Among the 31 patients, the most common procedures were liposuction (71%), facelift (10%), and blepharoplasty (6%). The mean (± standard error [SE]) procedural duration was 81 ± 9 minutes. No vital sign instability or oxygen desaturation was observed. Three patients (10%) experienced nausea, only one of which required treatment with oral ondansetron 4 mg in the PACU. One patient (3%) experienced dizziness that did not require treatment. No patients required opioids or other analgesics in the PACU for pain. The mean (±SE) recovery time was 15 ± 4 minutes.

Conclusions

Awake plastic surgery can be performed using SST 30 mcg with minimal side effects and a rapid recovery time.

Level of Evidence: 4

A Review of Sublingual Sufentanil Tablet (SST) and its Utility as an Analgesic Agent for Pain Procedures

Purpose of Review

Recent Findings

Summary

The Newest Battlefield Opioid, Sublingual Sufentanil: A Proposal to Refine Opioid Usage in the U.S. Military

There is an ongoing opioid epidemic in the USA, and the U.S. military is not immune to the health threat. To combat the epidemic, the Department of Defense (DoD) and Department of Veterans' Affairs (DVA) issued new clinical practice guidelines and launched the Opioid Safety Initiative aimed at reducing opioid prescriptions. Furthermore, the DoD continually refined opioid protocols for acute pain on the battlefield, evolving from intramuscular morphine to intravenous morphine administration to oral transmucosal fentanyl citrate lollipops (Actiq) to finally sublingual sufentanil tablets (SSTs, Dsuvia). Interestingly, the newest introduction of SSTs into the military sparked great controversy, as there are concerns over the drug's potential for misuse. However, although the opioid crisis may understandably foster an aversion to new candidate opioids, the therapeutic benefits of effective opioids in acute trauma settings should not be overlooked. SSTs may offer an improved analgesic option to meet the battlefield's unmet needs with its non-invasive, sublingual delivery system and favorable pharmacologic properties that mitigate the risk for side effects, addiction, and adverse outcomes. Accordingly, this commentary aims to (1) review the evolution of opioid use on the battlefield and discuss the medical benefits and limitations of SSTs in acute trauma settings, (2) highlight the importance of chronic pain management post-deployment through evidence-based non-opioid modalities, and (3) explore avenues of future research. Ultimately, we propose that SSTs are an important improvement from existing battlefield opioids and that refining, not abandoning, opioid usage will be key to effectively managing pain in the military.

Patient and Healthcare Professional Satisfaction Ratings and Safety Profile of Sufentanil Sublingual Tablets for Treatment of Acute Pain: A Pooled Demographic Analysis

Objective

This analysis reports the healthcare professional global assessment (HPGA) and patient global assessment (PGA) scores and the adverse event (AE) profile by age, body mass index (BMI), sex, and race from the three Phase III registration studies for sufentanil sublingual tablet (SST) 30 mcg.

Methods

Global assessments and treatment-related AEs were analyzed from patients treated with SST 30 mcg for moderate-to-severe acute pain following surgery or in the emergency department (ED). Pooled data were analyzed across patient demographic subgroups.

Results

A total of 283 patients were included in the HPGA/PGA analyses. The majority underwent abdominal surgery, with the remaining patients undergoing orthopedic or “other” types of surgery. Overall, SST 30 mcg was highly rated by both healthcare professionals and patients across the demographic subgroups. A total of 323 patients were included in the safety evaluation. The majority of patients did not experience any SST-related AEs; however, those that did experienced common opioid-related side effects such as nausea, headache, dizziness, and vomiting. No patients experienced unexpected AEs or required the use of naloxone.

Conclusion

SST 30 mcg was highly rated and well tolerated across demographic subgroups with the majority of patients not experiencing any adverse event related to SST 30 mcg. These findings support the use of sublingual sufentanil in all adult patients, regardless of age, BMI, sex, or race for the treatment of moderate-to-severe acute pain.

Pooled Dosing and Efficacy Analysis of the Sufentanil Sublingual Tablet 30 mcg Across Demographic Subgroups for the Management of Moderate-to-Severe Acute Pain

PURPOSE

To aid nurses in dosing sufentanil sublingual tablet (SST) 30 mcg administered via a single-dose applicator, dosing requirements and efficacy of SST 30 mcg were analyzed across age, sex, race, and body mass index subgroups.

DESIGN

Patient characteristics were pooled from three postoperative studies (two placebo-controlled and one open-label) and one open-label emergency department study. Drug dosing and efficacy data were pooled from the postoperative studies.

METHODS

Efficacy was assessed through summed pain intensity difference to baseline during 12 hours across subgroups.

FINDINGS

Mean (standard deviation) drug doses administered from 0 to 12 hours was 3.9 (2.0) for SST 30 mcg and was less frequent for older (≥65 years) versus younger patients. The summed pain intensity difference to baseline during 12 hours was superior with SST 30 mcg versus placebo across all subgroups.

CONCLUSIONS

SST 30 mcg is a sublingual opioid analgesic with efficacy across demographic subgroups.

Sufentanil Sublingual Tablet: A New Option for Acute Pain Management

Objective: The purpose of this article is to review the safety and efficacy of sufentanil sublingual tablet (SST) and suggest its place in therapy for managing acute pain in patients requiring intravenous (IV) opioids. Data Sources: A MEDLINE/PubMed search was performed (2010 to April 2019) using the following keywords: sufentanil sublingual tablet, sufentanil, opioid, moderate to severe acute pain. Study Selection and Data Extraction Quantification: We included English language articles evaluating SST pharmacology, pharmacokinetics, efficacy, and safety in humans for the treatment of acute pain. Data Synthesis: SST is Food and Drug Administration approved and considered safe and effective for the treatment of acute pain in Risk Evaluation and Mitigation Strategy–certified and medically supervised health care settings. Phase III clinical trials showed a statistically significant decrease in summed pain intensity score when SST was compared with placebo. Relevance to Patient Care and Clinical Practice: SST can be a useful option in patients requiring a parenteral opioid who do not have IV access, or it may be unnecessary or difficult to obtain. Because of its quick onset and sustained analgesia, SST may also be useful for procedural pain in the critically ill, to expedite discharges for outpatient procedures, in emergency departments (EDs), and in the battlefield. Conclusions: SST can satisfy an unmet need in patients with acute pain, who require parenteral opioids, and either have no IV access or require prolonged time to achieve IV access such as patients in outpatient surgical centers, EDs, and the battlefield. During periods of parenteral opioid shortage, SST may provide another option for adequate analgesia.

Sufentanil 30 µg Sublingual Tablet: A Review in Acute Pain

The sufentanil 30 μg sublingual tablet (hereafter referred to as the sufentanil ST) is approved in the EU for acute moderate to severe pain in adults (Dzuveo™) and in the USA for acute pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate (Dsuvia™). It is a single-strength tablet housed in a single-dose applicator (which may minimize the likelihood of dosing errors) and is strictly for use in medically supervised/monitored settings. It is administered by a healthcare professional and has a minimum re-dose interval of 1 h and no drug delivery setup requirements. In placebo-controlled or noncomparative phase 2 or 3 trials, the sufentanil ST provided effective analgesia for adults with moderate to severe acute pain due to surgery or trauma/injury, reducing the intensity of pain within 15-30 min after the first dose and maintaining analgesic benefit over the 2-24 h study periods. Such short-term use of the sufentanil ST was also generally well tolerated. Studies directly comparing the sufentanil ST with other opioids in terms of efficacy, tolerability, usability and cost effectiveness would be beneficial, as would analyses of its abuse potential, given sufentanil is considerably more potent than fentanyl or morphine. In the meantime, current data indicate that the sufentanil ST is a noninvasive, fast-acting, opioid formulation for managing moderate to severe acute pain in medically supervised/monitored settings that may be of particular use when oral or intravenous opioid analgesia is not possible/feasible.

Fentanyl Family at the Mu-Opioid Receptor: Uniform Assessment of Binding and Computational Analysis

Interactions of 21 fentanyl derivatives with μ-opioid receptor (μOR) were studied using experimental and theoretical methods. Their binding to μOR was assessed with radioligand competitive binding assay. A uniform set of binding affinity data contains values for two novel and one previously uncharacterized derivative. The data confirms trends known so far and thanks to their uniformity, they facilitate further comparisons. In order to provide structural hypotheses explaining the experimental affinities, the complexes of the studied derivatives with μOR were modeled and subject to molecular dynamics simulations. Five common General Features (GFs) of fentanyls' binding modes stemmed from these simulations. They include: GF1) the ionic interaction between D147 and the ligands' piperidine NH⁺ moiety; GF2) the N-chain orientation towards the μOR interior; GF3) the other pole of ligands is directed towards the receptor outlet; GF4) the aromatic anilide ring penetrates the subpocket formed by TM3, TM4, ECL1 and ECL2; GF5) the 4-axial substituent (if present) is directed towards W318. Except for the ionic interaction with D147, the majority of fentanyl-μOR contacts is hydrophobic. Interestingly, it was possible to find nonlinear relationships between the binding affinity and the volume of the N-chain and/or anilide's aromatic ring. This kind of relationships is consistent with the apolar character of interactions involved in ligand⁻receptor binding. The affinity reaches the optimum for medium size while it decreases for both large and small substituents. Additionally, a linear correlation between the volumes and the average dihedral angles of W293 and W133 was revealed by the molecular dynamics study. This seems particularly important, as the W293 residue is involved in the activation processes. Further, the Y326 (OH) and D147 (Cγ) distance found in the simulations also depends on the ligands' size. In contrast, neither RMSF measures nor D114/Y336 hydrations show significant structure-based correlations. They also do not differentiate studied fentanyl derivatives. Eventually, none of 14 popular scoring functions yielded a significant correlation between the predicted and observed affinity data (R < 0.30, n = 28).

Pooled Phase III safety analysis of sufentanil sublingual tablets for short-term treatment of moderate-to-severe acute pain

Aim: To evaluate the pooled safety of sufentanil sublingual tablets (SSTs) administered at 30-mcg dose equivalents over ≤72 h for moderate-to-severe acute pain management in medically supervised settings. Patients & methods: Safety data from SST 30 mcg Phase III studies were pooled with an additional patient subset from studies in which two SST 15 mcg were self-administered within 20-25 min (30-mcg dose-equivalent). Results: Analyses included 804 patients. Median (range) SST 30-mcg dosing over 24 h was 7.0 (1-15) tablets. Adverse events (AEs) were experienced by 60.5% (SST) and 61.4% (placebo) and treatment-related AEs by 43.8% (SST) and 33.5% (placebo; 10.3% difference; 95% CI: 2.0-18.6) of patients. No dose-dependent increase in oxygen desaturation was observed with SST. Conclusion: SST was well-tolerated, with most AEs considered mild or moderate in severity.