A dose-finding study of sufentanil sublingual microtablets for the management of postoperative bunionectomy pain

Bunionectomy as an Acute Postoperative Pain Model: Overview of Common Experimental Methods, and Insights from Past Clinical Trials

To obtain broad regulatory approval for a new analgesic agent in acute postoperative pain, US and European regulatory authorities require pivotal studies in both hard (bony) tissue pain and soft tissue pain. Bunionectomy is by far the most common hard tissue pivotal trial model, in spite of the fact that the model has limited relevance to clinicians prescribing pain drugs (pain from bunionectomy is not extreme or long-lasting, and is adequately treated by existing drugs). The authors outline the experimental characteristics that make bunionectomy an appealing study model for researchers despite its lack of clinical relevance compared to larger surgeries. These include bunionectomy's high signal-to-noise ratio (secondary to the ability to standardize surgical procedures, anesthesia and perioperative care) and relative operational simplicity (including relatively easy subject enrollment). They present an overview of the surgical and anesthetic protocols typical to modern bunionectomy studies, as well as common design paradigms, common endpoints, and other key design features of bunionectomy trials. They also provide an informal qualitative review of bunionectomy acute pain studies performed in the past 15 years, and a master table of acute pain bunionectomy trials performed from 2006-2023. Drawing from their informal review of past studies, the authors discuss trends in rescue medication, study enrollment rates, subject demographics, and the advantages and disadvantages of bunionectomy compared with another common acute pain model, dental impaction pain (third molar extraction).

Efficacy and safety of sufentanil sublingual tablet system in postoperative pain management: a systematic review and meta-analysis

BACKGROUND

Sufentanil sublingual tablet system (SSTS) is a recently approved formulation for postoperative pain management that has become popular due to its pharmacokinetic properties such as good bioavailability, rapid attainment of equilibrium and elimination without any metabolites, along with its pharmacodynamic properties such as rapid onset and effective pain reduction. It is also relatively well tolerated by patients.

OBJECTIVE

This is a quantitative analysis of the efficacy and safety of SSTS in patients with moderate to severe postoperative pain.

DESIGN

This is a systematic review and meta-analysis. Databases such as Cochrane Library, MEDLINE and EMBASE were searched for eligible articles.

SETTINGS

Randomised controlled trials published after 2000 in English language and which assessed at least one of the outcome measures of interest with pain intensity difference between 12 hours and a maximum of 96 hours.

PARTICIPANTS

Adults with moderate to severe postoperative pain and taking SSTS for pain management.

METHODS

Data were analysed using Review Manager (RevMan) V.5.3. Risk of bias (RoB) assessment was done using RoB-2 scale, and overall grading of evidence of each outcome was done using GRADEpro Guideline Development Tool.

RESULTS

Analysis of SSTS versus control indicates a statistically significant reduction in summed pain intensity difference at 12 hours (mean difference (MD)=-12.33 (95% CI -15.5 to -9.17), p<0.00001), summed pain intensity difference at 48 hours (MD=-43.57 (95% CI -58.65 to -28.48), p<0.00001), time-weighted total pain relief over 12 hours (MD=-4.77 (95% CI -6.28 to -3.27), p<0.00001) and pain intensity difference (MD=-0.73 (95% CI -1.00 to -0.46), p<0.00001) with SSTS, alongside high quality of evidence. Success of treatment as assessed by Patient Global Assessment (OR=4.01 (95% CI 2.74 to 5.89), p<0.00001) and Healthcare Professional Global Assessment (OR=4.46 (95% CI 3.03 to 6.56), p<0.00001) scoring at 72 hours was observed in a significantly high number of individuals using SSTS, with high quality of evidence. There was no difference in adverse events except for dizziness (RR=1.90, 95% CI 1.02 to 3.52). There was a significantly higher number of total adverse events in orthopaedic surgery in the SSTS group than in the comparator.

CONCLUSION

SSTS is effective in postoperative pain management in patients with moderate to severe pain. It also has good tolerability and high patient satisfaction.

PROSPERO REGISTRATION NUMBER

CRD42018115458.

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

Rapid Determination of Sufentanil in Human Plasma by UHPLC-QqQ-MS-MS

This paper presents a rapid, sensitive and precise method developed and validated for the quantification of sufentanil in biological samples using ultra-performance liquid chromatography coupled with QqQ-MS-MS. Plasma samples were extracted with simple and fast liquid-liquid extraction (ethyl acetate, pH 9). Calibration curve showed linearity in the concentration range of 0.005-30 µg/L. The lower limit of quantification was 0.010 µg/L. The most important method features are low lower limit of quantification value, simple plasma extraction and small sample volume. This method is suitable not only for evaluation of the pharmacokinetics, toxicology, bioavailability and clinical pharmacology of sufentanil but also for the detection and identification of this compound in human plasma samples for forensic purposes.

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.

An Open-Label Study of Sufentanil Sublingual Tablet 30 Mcg in Patients with Postoperative Pain

Objective

To evaluate sufentanil sublingual tablet 30 mcg (SST 30 mcg) for postoperative pain in an older patient population with comorbidities.

Design

Multicenter, open-label, single-arm study.

Setting

Nine hospitals across the United States.

Subjects

Adults aged ≥40 years who had undergone a surgical procedure.

Methods

Patients with a postoperative pain intensity score ≥4 on an 11-point numeric rating scale (NRS) were allowed to enter the study and receive SST 30 mcg as requested for pain (minimum 60-minute redosing interval) over the 12-hour study period. Efficacy was assessed by patient reports of pain intensity on the NRS and a five-point pain relief scale. Safety was monitored throughout the study; plasma sufentanil concentrations were also measured. The primary efficacy endpoint was the time-weighted summed pain intensity difference (SPID) to baseline over 12 hours (SPID12).

Results

Of the 140 patients enrolled, 69% were American Society of Anesthesiologists Physical Class II or III, 44% had a body mass index (BMI) ≥30 mg/kg², and 29% had hepatic and/or renal impairment. Average age was 54.7 years (SD = 9.9 years), and average baseline pain intensity was 6.2 (SD = 1.9). The most common surgeries were abdominal (59%) and orthopedic (20%). The mean SPID12 was 36.0 (standard error of the mean = 2.2); mean scores were similar, regardless of age, sex, race, and BMI. From baseline, mean pain intensity decreased significantly starting 30 minutes postdose, and mean pain relief increased significantly starting 15 minutes postdose, remaining relatively stable through 12 hours (P < 0.001 at each time point). Four (3%) patients discontinued due to inadequate analgesia, and 45 (32%) patients had one or more adverse events that were considered possibly or probably related to the study drug. Mean plasma sufentanil concentrations were generally similar regardless of age, sex, BMI, or organ impairment status.

Conclusions

SST 30 mcg was effective and well tolerated for the management of moderate-to-severe acute postoperative pain.

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.

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.

Evaluation of the safety and efficacy of an intravenous nanocrystal formulation of meloxicam in the management of moderate-to-severe pain after bunionectomy

Objective

This randomized, double-blind, placebo-controlled study evaluated the safety and efficacy of an intravenous (IV) nanocrystal formulation of meloxicam in subjects with moderate-to-severe pain following a standardized unilateral bunionectomy.

Methods

Fifty-nine subjects aged 18–72 years were randomized to receive doses of either 30 mg (n=20) or 60 mg (n=20) meloxicam IV or placebo (n=19), administered once daily as bolus IV injections over 15–30 seconds (two or three doses). Safety, the primary objective, was assessed by physical examination, clinical laboratory tests, and the incidence of adverse events (AEs). Efficacy was evaluated by examining summed pain intensity differences over the first 48 hours (SPID₄₈) using analysis of covariance models. Use of opioid rescue analgesic agents was evaluated.

Results

Generally, AEs were mild-to-moderate in intensity, and their incidence was similar across the three treatment groups. No serious AEs were reported; there were no withdrawals due to AEs, including injection-related AEs. The estimated effect size for SPID₄₈ versus placebo was 1.15 and 1.01 for meloxicam IV doses 30 mg and 60 mg, respectively (P≤0.01). Both doses produced significantly greater pain reductions versus placebo (P≤0.05) at all evaluated times/ intervals during the 48-hour period. The proportions of subjects with ≥30% and ≥50% overall reduction in pain from baseline after 6 and 24 hours were significantly higher with meloxicam IV 30 mg doses versus placebo, but not with meloxicam IV 60 mg doses. The time to first use of rescue medication was significantly longer versus placebo with meloxicam IV 60 mg (P<0.05), but not with meloxicam IV 30 mg doses.

Conclusion

Meloxicam IV was generally safe and well tolerated in subjects with moderate-to-severe post-bunionectomy pain. Once-daily administration of meloxicam IV 30 mg and 60 mg exhibited rapid onset of analgesia (as early as 15 minutes) with maintenance of analgesic effect for two consecutive 24-hour periods.

Exploring the Interplay between Rescue Drugs, Data Imputation, and Study Outcomes: Conceptual Review and Qualitative Analysis of an Acute Pain Data Set

In placebo-controlled acute surgical pain studies, provisions must be made for study subjects to receive adequate analgesic therapy. As such, most protocols allow study subjects to receive a pre-specified regimen of open-label analgesic drugs (rescue drugs) as needed. The selection of an appropriate rescue regimen is a critical experimental design choice. We hypothesized that a rescue regimen that is too liberal could lead to all study arms receiving similar levels of pain relief (thereby confounding experimental results), while a regimen that is too stringent could lead to a high subject dropout rate (giving rise to a preponderance of missing data). Despite the importance of rescue regimen as a study design feature, there exist no published review articles or meta-analysis focusing on the impact of rescue therapy on experimental outcomes. Therefore, when selecting a rescue regimen, researchers must rely on clinical factors (what analgesics do patients usually receive in similar surgical scenarios) and/or anecdotal evidence. In the following article, we attempt to bridge this gap by reviewing and discussing the experimental impacts of rescue therapy on a common acute surgical pain population: first metatarsal bunionectomy. The function of this analysis is to (1) create a framework for discussion and future exploration of rescue as a methodological study design feature, (2) discuss the interplay between data imputation techniques and rescue drugs, and (3) inform the readership regarding the impact of data imputation techniques on the validity of study conclusions. Our findings indicate that liberal rescue may degrade assay sensitivity, while stringent rescue may lead to unacceptably high dropout rates.

A review of sufentanil and the sufentanil sublingual tablet system for acute moderate to severe pain

The sufentanil sublingual tablet system (SSTS) is a novel patient-controlled analgesia (PCA) system that is pending approval from the US FDA for the management of moderate to severe acute pain in hospitalized patients. SSTS offers a noninvasive alternative to intravenous (iv.) PCA and optimized on-demand analgesia with the rapid onset and titratibility of sublingual sufentanil. Phase III clinical trials have demonstrated that SSTS has greater efficacy for the treatment of pain during the 72-h postoperative period after open abdominal and major orthopedic (total knee or total hip arthroplasty) surgery compared with iv. PCA with morphine sulfate (MS) or a placebo system. Safety assessments indicate that adverse events are typical for postoperative patients taking opioid analgesics. While the frequency of adverse events is comparable between patients using SSTS and iv. PCA MS, the incidence of oxygen desaturation is lower in those using SSTS.