Nalbuphine-6-glucuronide is a potent analgesic with superior safety profiles by altering binding affinity and selectivity for mu-/kappa-opioid receptors

Although nalbuphine, a semi-synthetic analgesic compound, is less potent than morphine in terms of alleviating severe pain, our recent findings have revealed that nalbuphine-6-glucuronide (N6G), one of the glucuronide metabolites of nalbuphine, promotes a significantly more robust analgesic effect than its parent drug. Nevertheless, despite these promising observations, the precise mechanisms underlying the analgesic effects of nalbuphine glucuronides have yet to be determined. In this study, we aim to elucidate the mechanisms associated with the analgesic effects of nalbuphine glucuronides. Pharmacokinetic and pharmacodynamic studies were conducted to investigate the relationship between the central and peripheral compartments of nalbuphine and its derivatives. The analgesic responses of these compounds were evaluated based on multiple behavioral tests involving thermal and mechanical stimuli. Radioligand binding assays were also performed to determine the binding affinity and selectivity of these compounds for different opioid receptors. The results of these tests consistently confirmed that the heightened analgesic effects of N6G are mediated through its enhanced binding affinity for both mu- and kappa-opioid receptors, even comparable to those of morphine. Notably, N6G exhibited fewer side effects and did not induce sudden death, thereby highlighting its superior safety profile. Additionally, pharmacokinetic studies indicated that N6G could cross the blood-brain barrier when administered peripherally, offering pain relief. Overall, N6G provides great analgesic efficacy and enhanced safety. These findings highlight the potential value of nalbuphine glucuronides, particularly N6G, as promising candidates for the development of novel analgesic drugs.

Effect of two different doses of nalbuphine for postoperative analgesia in children with cleft palate: a randomized controlled trial

BACKGROUND

Cleft palate repair surgery may result in severe pain in the immediate postoperative period. The aim of this study is to compare the effects of different doses of nalbuphine for postoperative analgesia in children with cleft palate.

METHODS

From November 2019 to June 2021, 90 children (45 males and 45 females, age 9-20 months old, ASA class I-II) were selected for palatoplasty. They were randomly divided into three groups: the control group (Group C), the N1 group (postoperative analgesia with 0.05 mg/kg/h nalbuphine) and the N2 group (postoperative analgesia with 0.075 mg/kg/h nalbuphine). Each group had 30 cases. Nalbuphine was not continuously infused in Group C but was continuously infused in Groups N1 and N2 at rates of 0.05 mg/kg/h and 0.075 mg/kg/h, respectively, for 24 h for postoperative analgesia. The FLACC analgesia score and Ramsay Sedation score were recorded at 10 min (T1), 30 min (T2), 2 h (T3), 12 h (T4) and 24 h (T5) after the operation. Adverse reactions such as nausea, vomiting and respiratory depression were observed and recorded.

RESULTS

Compared with those in Group C, the FLACC scores in the N1 and N2 groups decreased significantly at T1-T5 (p < 0.05); the Ramsay Sedation score in the N1 group was significantly higher at T3 and T4 (p < 0.05), and that in the N2 group was significantly higher at T1-T5 (p < 0.05). Compared with that in the N1 group, the FLACC score in the N2 group was not significantly different, and the Ramsay Sedation score increased significantly at T5 (p < 0.05).

CONCLUSION

Using 0.05 mg/kg/h Nalbuphine continuously for 24 h for postoperative analgesia in children with cleft palate has a better effect and fewer adverse reactions.

TRIAL REGISTRATION

This study was registered at ChiCTR1900027385 (11/11/2019).

Epidural nalbuphine versus dexmedetomidine as adjuvants to bupivacaine in lower limb orthopedic surgeries for postoperative analgesia: a randomized controlled trial

BACKGROUND

Administration of adjuvant drugs epidurally in combination with local anesthetics offers new dimensions in the management of postoperative pain. This study aimed to compare the addition of either nalbuphine or dexmedetomidine to epidural bupivacaine for postoperative analgesia in lower limb orthopedic surgeries under combined spinal-epidural anesthesia.

METHODS

This prospective randomized double-blind study included 69 patients scheduled for lower limb orthopedic surgeries. Anesthesia was started with 15 mg hyperbaric bupivacaine 0.5% intrathecally, and then an epidural bolus dose of 12 ml (10 ml 0.25% bupivacaine with 2 ml normal saline in group C, 2 ml (10 mg) nalbuphine in group N or dexmedetomidine 2 ml (100 µg) in group D was administered when sensory regression to T10. Postoperatively, when visual analogue scale (VAS) was ≥ 3, an epidural top-up dose of 8 ml (6 ml 0.25% bupivacaine plus 2 ml normal saline in group C, 2 ml (2 mg) nalbuphine in group N or 20 µg dexmedetomidine (2 ml) in group D was given. The primary outcome was to evaluate the duration of postoperative analgesia and secondary outcomes were any side effects and patient satisfaction.

RESULTS

The onset of epidural analgesia was 17.83 ± 2.53 versus 13.39 ± 1.27 versus 12.17 ± 1.27 min in groups C, N and D, respectively (p value < 0.001). The mean duration of analgesia was 241.3 ± 14.24 versus 318.38 ± 22.54 versus 365.87 ± 18.01 min in groups C, N and D, respectively (p value < 0.001). The mean sedation score was less in group C than group N and D (P < 0.001). The patient satisfaction score showed the lowest degree of satisfaction in group C (p value < 0.001). Top-up doses consumed and total analgesic requirements were lower in groups N and D than in group C. There was a statistically significant difference between the studied groups regarding VAS over time (p value < 0.001), intraoperative bradycardia (p value 0.029), and shivering (p value 0.029).

CONCLUSION

The addition of either nalbuphine or dexmedetomidine to epidural bupivacaine was effective for postoperative analgesia in terms of onset, duration, and patient satisfaction with the superiority of dexmedetomidine over nalbuphine.

TRIAL REGISTRATION

Approval from the research ethics committee of the Faculty of Medicine, Zagazig University was obtained with the reference number (ZU-IRB#:7045-15-8-2021) and it was registered under clinicaltrials.gov (NCT05041270) on registration date 13/09/2021.

The comparison of the analgesic efficacy of continuous paravertebral block alone compared with continuous paravertebral and intercostal nerve block for thoracotomy in adults: a randomized controlled trial

PURPOSE

The study aims to compare the analgesic efficacy of two analgesic interventions, continuous paravertebral (PVB) nerve block alone with continuous paravertebral and intercostal nerve block (PVB/ICB) in patients undergoing thoracotomy.

METHODS

A total of 70 patients undergoing thoracotomy were randomly enrolled in either continuous paravertebral nerve block (PVB) group or in continuous paravertebral and intercostal nerve block (PVB/ICB) group and received corresponding blocks. Analgesic efficacy measured by Visual Analog Scale (VAS) pain score, hemodynamic effects, total narcotic consumption, sedation score, patient's length of stay in hospital and patient's satisfaction with the analgesic technique were recorded.

RESULTS

Demographic characteristics of the patients were similar in both groups. The mean VAS pain score was not statistically significant in both groups at 24 h. The mean pulse rate and blood pressures were comparable in both groups for the first 24 h. Nalbuphine consumption was significantly higher in PVB group as compared to PVB/ICB group at 1 h (p = 0.01), 6 h (p = 0.03) and 12 h (p = 0.009) and 24 h (p = 0.03). The mean total nalbuphine consumption in the PVB group was higher (28.29 mg vs. 22.63 mg) and statistically significant then PVB/ICB group (p = 0.03). The total tramadol consumption as a rescue analgesic was higher in the PVB group (131.42 mg) as compared to PVB/ICB group (120 mg) after 24 h but not statistically significant (p = 0.17).

CONCLUSION

Continuous paravertebral nerve block with intercostal nerve block provides effective post-operative pain relief after thoracotomy with reduced narcotic consumption compared to continuous paravertebral nerve block alone.

CLINICAL TRIAL REGISTRATION NUMBER

Clinicaltrails.gov NCT04715880.

Comparison of fentanyl and nalbuphine as adjuvants to intrathecal 0.5% bupivacaine in lower limb surgeries: A randomised double-blind prospective study

INTRODUCTION

Local anaesthetics used in spinal anaesthesia have a limited duration of action. To prolong postoperative analgesia, adjuvants, mainly opioids, are used. As µ agonist drugs have side effects, other receptor agonists are considered. Nalbuphine is a safe and effective kappa agonist adjuvant.

AIM

To compare the analgesic efficacy between fentanyl and nalbuphine adjuvants added to 3 mL of 0.5% intrathecal hyperbaric bupivacaine.

MATERIALS AND METHODS

This prospective, double-blind, comparative study was conducted in 60 patients of either sex belonging to the American Society of Anesthesiologists classes I and II aged 18-65 years undergoing lower limb surgery with entropy monitoring, randomly allocated into two groups. Group F (n = 30) received 0.5% hyperbaric bupivacaine (3 mL) + 25 µg (0.5 mL) fentanyl. Group N (n = 30) received 0.5% hyperbaric bupivacaine (3 ml) + 0.8 mg (0.5 mL) nalbuphine intrathecally. Hemodynamics, entropy, motor and sensory block characteristics, and complications were noted.

RESULTS

The nalbuphine group had a significantly longer two-segment regression time of sensory blockade and extended analgesia duration than the fentanyl group. Haemodynamics, entropy, time for onset of sensory and motor blockade and adverse effects were comparable in both groups.

CONCLUSION

Nalbuphine prolongs sensory blockade and postoperative analgesia duration with minimal side effects and is a safe intrathecal adjuvant.

Effect of nalbuphine plus ropivacaine on vaginal labor in epidural analgesia

BACKGROUND

Various approaches using epidural analgesia have been employed for relieving labor pain and promoting spontaneous delivery. We aimed to evaluate the effect of nalbuphine and ropivacaine versus fentanyl and ropivacaine on the duration of delivery in parturients.

METHODS

Clinical data of 160 full-term primiparous women who received either nalbuphine or fentanyl in combination with ropivacaine infusion for epidural labor analgesia in our hospital from December 2020 to May 2022 were retrospectively analyzed. The participants were divided into two groups based on anesthesia methods: nalbuphine group (NR group, n = 78) received 0.2 mg/mL nalbuphine combined with 0.1% ropivacaine hydrochloride for patient-controlled epidural analgesia (PCEA) and fentanyl group (FR group, n = 82) received 2 ug/mL fentanyl citrate and 0.1% ropivacaine hydrochloride for PCEA. Both groups received an epidural blockade for labor analgesia at lumbar 2-3 interspace. The duration of the first, second, and third stages of labor, the onset of analgesia, and time before delivery (T0), 15 min of analgesia (T1), 30 min of analgesia (T2), full opening of the uterine opening (T3),exerts force during childbirth(T4), heart rate (HR), blood pressure (BP), blood saturation (SpO2), visual analogue pain scale (VAS) score, Ramsay sedation score, and modified Bromage score, and 5 min were recorded at 2 h postpartum (T5). The neonatal Apgar score, neonatal behavioral neurological assessment (NBNA) score, maternal nausea, vomiting, and itchy skin were recorded.

RESULTS

Compared with the FR group, the first stage of labor duration (p < 0.05) and total duration of labor (p < 0.05) were shortened and the onset of analgesia (p < 0.05) was increased in the NR group. NR group had lower incidence of urinary retention than FR group (p < 0.05). The maternal and neonatal investigational parameters and scores had no significant difference between the two groups.

CONCLUSIONS

Nalbuphine combined with ropivacaine in epidural block labor has a faster onset of analgesia and has a lower incidence of urinary retention than fentanyl combined with ropivacaine, and nalbuphine shortens the duration of the first and total stages of labor. Both nalbuphine and fentanyl can reduce pain during labor, have little effect on maternal hemodynamics, and have no significant effect on neonatal Apgar or NBNA scores.

Effect of propofol combined with different anesthetic drugs on respiratory circulation function and erythrocyte immunity in patients undergoing intestinal endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) is a difficult procedure with disadvantages of long operating time, intraoperative stimulation of sympathetic nerve excitation and postoperative pain, and suppression of immune function.

AIM

To investigate the effect of propofol combined with different anesthesia drugs in patients undergoing intestinal ESD.

METHODS

One hundred and fifty patients who planned to undergo intestinal ESD at our hospital from January 2019 to August 2022 were selected and randomly divided into three groups: A, B, and C, with 50 patients in each group. Group A was given propofol + sufentanil + nalbuphine, group B was given propofol + sufentanil, and group C was given propofol. Mean arterial pressure (MAP) and respiratory and circulatory function (pressure airway, Paw), partial pressure of end-expiratory carbon dioxide (P_ETCO₂), bispectral index (BIS), red blood cell immunity [RBC immunocomplex rosette rate (RBC-ICR), erythrocyte cell membrane C3b receptor rosette rate (RBC-C3bR), and cooperative tumor erythrocyte rosette rate (ATER)], intraoperative and post-operative conditions, and adverse reactions were compared among the groups.

RESULTS

Paw and P_ETCO₂ in group A were significantly lower than those in group B and group C from T1 to T3 (P < 0.05). There was no statistically significant difference in BIS values among the three groups from T0 to T3 (P < 0.05). The amount of propofol used, the number of analgesic pump compressions within 48 h after surgery, and the consumption of analgesic pump drugs were significantly lower in group A than in group B and group C (P < 0.05). There was no significant difference in the incidence of adverse reactions among the three groups (P > 0.05).

CONCLUSION

Propofol combined with sufentanil and nalbuphine can better alleviate respiratory and circulatory function inhibition, improve red cell immunity, and reduce the dosage of analgesic drugs in patients with intestinal ESD, with high safety.

Nalbuphine reduces the incidence of emergence agitation in children undergoing Adenotonsillectomy: A prospective, randomized, double-blind, multicenter study

OBJECTIVE

To evaluate the effect of nalbuphine on emergence agitation (EA) in children undergoing adenotonsillectomy.

DESIGN

Multicenter, prospective, double-blind, randomized controlled trial.

SETTING

The First People's Hospital of Foshan and three other participating institutions in China, from April 2020 to December 2021.

PATIENTS

Eight hundred patients, 3-9 years of age, American Society of Anesthesiologists (ASA) classification I or II, undergoing elective adenotonsillectomy were included.

INTERVENTIONS

Nalbuphine (0.1 mg/kg) or saline was administered intravenously.

MEASUREMENTS

The incidence of EA; the pediatric anesthesia emergence delirium (PAED) scale; and the faces, legs, activity, cry, and consolability (FLACC) scales. Extubation time, duration of post-anesthesia care unit (PACU) stay, anesthesia nurses' and parents' satisfaction, and other side effects.

MAIN RESULTS

The incidence of EA in the nalbuphine group was lower than that in the saline group 30 min after extubation (10.28% vs. 28.39%, P = 0.000). In addition, the FLACC scores in the nalbuphine group were lower than those in the saline group 30 min after extubation (P < 0.05). Furthermore, the proportion of moderate-to-severe pain cases (FLACC scores >3) was significantly lower in the nalbuphine group than in the saline group (33.58% vs. 60.05%, P = 0.000). Adjusting the imbalance of postoperative pain intensity, the risk of EA was still lower in the nalbuphine group at 0 min (OR, 0.39; 95% CI, 0.26-0.60; P = 0.000), (OR, odds ratio; CI, confidence interval), 10 min (OR, 0.39; 95% CI, 0.19-0.79; P = 0.01), and 20 min (OR, 0.27; 95% CI, 0.08-0.99; P = 0.046) than in the saline group. There were no significant differences in extubation time, duration of PACU stay, nausea and vomiting, or respiratory depression between the two groups (P > 0.05).

CONCLUSION

Nalbuphine reduced the incidence of EA in children after adenotonsillectomy under general anesthesia, which may be involved in both analgesic and non-analgesic pathways.

Population pharmacokinetics of nalbuphine in patients undergoing general anesthesia surgery

Purpose: The aim of this study was to build a population pharmacokinetics (PopPK) model of nalbuphine and to estimate the suitability of bodyweight or fixed dosage regimen. Method: Adult patients who were undergoing general anesthetic surgery using nalbuphine for induction of anesthesia were included. Plasma concentrations and covariates information were analyzed by non-linear mixed-effects modeling approach. Goodness-of-fit (GOF), non-parametric bootstrap, visual predictive check (VPC) and external evaluation were applied for the final PopPK model evaluation. Monte Carlo simulation was conducted to assess impact of covariates and dosage regimens on the plasma concentration to nalbuphine. Results: 47 patients aged 21-78 years with a body weight of 48-86 kg were included in the study. Among them, liver resection accounted for 14.8%, cholecystectomy for 12.8%, pancreatic resection for 36.2% and other surgeries for 36.2%. 353 samples from 27 patients were enrolled in model building group; 100 samples from 20 patients were enrolled in external validation group. The results of model evaluation showed that the pharmacokinetics of nalbuphine was adequately described by a two-compartment model. The hourly net fluid volume infused (HNF) was identified as a significant covariate about the intercompartmental clearance (Q) of nalbuphine with objective function value (OFV) decreasing by 9.643 (p < 0.005, df = 1). Simulation results demonstrated no need to adjust dosage based on HNF, and the biases of two dosage methods were less than 6%. The fixed dosage regimen had lower PK variability than the bodyweight regimen. Conclusion: A two-compartment PopPK model adequately described the concentration profile of nalbuphine intravenous injection for anesthesia induction. While HNF can affect the Q of nalbuphine, the magnitude of the effect was limited. Dosage adjustment based on HNF was not recommended. Furthermore, fixed dosage regimen might be better than body weight dosage regimen.

Nalbuphine May Be Superior to Sufentanil in Relieving Postcesarean Uterine Contraction Pain in Multiparas: A Retrospective Cohort Study

Purpose

Postcesarean pain remains a major complaint from puerperium women who have undergone cesarean section, especially uterine contraction induced visceral pain. The optimal opioid for pain relief after cesarean section (CS) is still unclear. The goal of this study was to compare the analgesic effect of Nalbuphine to Sufentanil in patients who underwent CS.

Patients and Methods

In this single-center retrospective cohort study, we included patients who received Nalbuphine or Sufentanil Patient-Controlled Intravenous Analgesia (PCIA) after CS between 1 January 2018 and 30 November 2020. Data on a Visual Analog Scale (VAS) at uterine contraction, at rest, and at movement, analgesic consumption, and side effects were collected. We performed logistic regression to identify predictors of severe uterine contraction pain.

Results

A total of 674 patients were identified in the unmatched cohort, and 612 patients in the matched one. Compared to the Sufentanil group, lower VAS-contraction was recorded in the Nalbuphine group in both the unmatched and matched cohorts, the mean difference (MD) on POD1 was 0.35 (95% CI: 0.17 to 0.54, p<0.001) and 0.28 (95% CI: 0.08 to 0.47, p<0.001), respectively, and the MD of POD2 was 0.12 (95% CI: 0.03 to 0.40, P=0.019) and 0.12 (95% CI: 0.03 to 0.41, P=0.026), respectively. On POD1 but not POD2, VAS-movement was lower in the Nalbuphine group as compared to the Sufentanil group. No difference was found between VAS-rest on POD1 and POD2 in both unmatched and matched cohorts. Less analgesic consumption, and side effects were recorded in the Nalbuphine group. Logistic regression indicated that multipara and analgesic consumption were risk factors for severe uterine contraction pain. In subgroup analysis, VAS-contraction was meaningfully reduced in the Nalbuphine group compared with the Sufentanil group in multipara patients, but not primiparas.

Conclusion

Compared to Sufentanil, Nalbuphine may provide better analgesia on uterine contraction pain. The superior analgesia may only exhibit in multiparas.

Nalbuphine suppresses leukemia stem cells and acts synergistically with chemotherapy drugs via inhibiting Ras/Raf/Mek/Erk pathway

AIMS

Retrospective clinical studies have shown that opioids could potentially affect the risk of cancer recurrence and metastasis. Better understanding of the effects of opioids on cancer will help to select the optimal anesthetic regimens to achieve better outcomes in cancer patients.

BACKGROUND

Increasing evidence has shown the direct effects of opioids on bulk cancer cells and cancer stem cells. Opioid such as nalbuphine is approved to control cancer-associated pain but little is known on their possible cancer effects.

OBJECTIVE

To assess the biological effects of nalbuphine on acute myeloid leukemia (AML) differentiated and stem/progenitor CD34+ cells.

METHOD

AML CD34+ cells were isolated with colony formation, growth and apoptosis assays performed. Biochemical and immunoblotting analyses were conducted in AML cells exposed to nalbuphine.

RESULT

Nalbuphine at clinically relevant concentrations was active against a panel of AML cell lines with varying IC50. Importantly, nalbuphine augmented the efficacy of cytarabine and daunorubicin in decreasing AML cell viability/growth. Besides bulk AML cells, we noted that nalbuphine was effective and selective in decreasing viability and colony formation of AML CD34+ cells while sparing normal hematopoietic CD34+ cells. The action of nalbuphine on AML cells is not associated with opioid receptors but via inhibiting Ras/Raf/MEK/ERK signaling pathway. Overexpression of constitutively active Ras partially but significantly reversed the inhibitory effects of nalbuphine on AML cells.

CONCLUSION

Our findings reveal the selective anti-AML activity of nalbuphine and its ability in inhibiting Ras signaling. Our work suggests that nalbuphine may be beneficial for leukemia patients.

Efficacy of Nalbuphine as a Local Anesthetic Adjuvant for Brachial Plexus Block: A Systematic Review and Meta-analysis

BACKGROUND

Nalbuphine has been increasingly used as a local anesthetic adjuvant to extend the duration of analgesia in brachial plexus block (BPB).

OBJECTIVES

To systematically and firstly evaluate the available evidence on the efficacy of nalbuphine as an adjuvant to local anesthetics in BPB.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Cochrane Central Register of Controlled Clinical Trials, Cochrane Database of Systematic Reviews, Medline, Embase, Scopus, Web of Science, EBSCO, PubMed, and additional databases were searched. Randomized controlled trials comparing combination of perineural nalbuphine with local anesthetics to local anesthetics alone in BPB for upper extremity surgical procedures were eligible for inclusion.

RESULTS

Nineteen randomized controlled trials involving 1,355 patients met the inclusion criteria. Perineural use of nalbuphine prolonged the duration of analgesia in BPB (mean difference [MD], 162.5; 95% confidence interval [CI], 119.0 to 205.9; P < 0.00001; very low quality of evidence). The duration of sensory block was also extended (MD, 141.6; 95% CI, 100.3 to 182.9; P < 0.00001; very low quality of evidence). Furthermore, nalbuphine shortened the onset time of sensory block (MD, -2.6; 95% CI, -3.6 to -1.5; P < 0.00001; very low quality of evidence). There were no significant differences in side effect-related outcomes, including nausea (risk radio [RR], 1.56; 95% CI, 0.82 to 2.59; P = 0.17; moderate quality of evidence) and vomiting (RR, 1.41; 95%  CI, 0.66 to 3.02; P = 0.38; moderate quality of evidence).

LIMITATIONS

The study was limited by substantial heterogeneity, a relatively small sample size and difference-in-differences in how outcomes of interest were described and assessed.

CONCLUSIONS

Perineural use of nalbuphine in BPB is an effective strategy for analgesia in adult patients undergoing upper extremity surgery.

Analgesic efficacy and safety of nalbuphine versus morphine for perioperative tumor ablation: a randomized, controlled, multicenter trial

Background

The study will compare the efficacy and safety of nalbuphine hydrochloride injection and morphine hydrochloride injection for perioperative analgesia in tumor ablation and the differences between the two groups regarding duration of surgery, average daily dose, patient satisfaction with analgesia, quality of life, and other indicators. Furthermore, it will evaluate the clinical application of nalbuphine and morphine for perioperative analgesia in ablation surgery and provides important reference and guidance for clinical practice.

Methods

This is a randomized controlled study. Patients who were diagnosed by clinicians and required tumor ablation are enrolled and randomized to the experimental groups. In the test group, nalbuphine 80 mg + 0.9% normal saline (72 ml) is set in the patient-controlled analgesia pump, which is connected 15 min before ablation under electrocardiogram monitoring and surgery is performed immediately. The doses are as follows: initial,: 0.15 ml/kg,; background:, 0.5 ml/h,; compression:, 2 ml,; and lockout time:, 15 min. If the numeric rating scale is ≥ 4 points, the drug is administered by compression. The control group receives similar treatment under similar conditions as the test group except morphine (80 mg) is administered instead of nalbuphine (80 mg). The primary endpoints are the effective rate of analgesia and the incidence of adverse reactions (nausea and vomiting, dizziness, itching, constipation, hypoxemia, and urinary retention); the secondary endpoints are pain intensity, satisfaction with analgesia, duration of surgery, postoperative hospital stay, average daily dose, uninterrupted completion rate of surgery without complaints of pain, quality of life assessment, and vital signs.

Discussion

This study, to the best of our knowledge, is the first randomized controlled trial of nalbuphine patient-controlled analgesia in ablation surgery.

Trial registration

U.S. Clinical Trials Network Registration No.: NCT05073744. Registered on 11 October, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06825-5.

Effect of Ultrasound-Guided Fascia Iliac Compartment Block with Nalbuphine and Ropivacaine on Preoperative Pain in Older Patients with Hip Fractures: A Multicenter, Triple-Blinded, Randomized, Controlled Trial

INTRODUCTION

Pain management for older patients with hip fractures is challenging. This study aimed to investigate the effect of ultrasound-guided fascia iliac compartment block (UGFICB) using different doses of nalbuphine in combination with ropivacaine on preoperative analgesia in older patients with hip fractures.

METHODS

In this multicenter randomized controlled trial, 280 elderly patients with hip fracture were randomly allocated into four UGFICB groups (n = 70 in each group): a ropivacaine group (30 mL 0.1% ropivacaine + 0.9% normal saline) and three ropivacaine plus nalbuphine groups (5, 10, and 20 mg nalbuphine, respectively). The primary outcomes were the duration of analgesia at rest and on passive movement. Secondary outcomes included sensory block area, side effects, and vital signs. The doses of rescue analgesia with parecoxib sodium were also analyzed.

RESULTS

The addition of nalbuphine dose-dependently increased the duration of analgesia at rest and on passive movement (P < 0.05) and expanded the area of sensory block (P < 0.05). Compared with the ropivacaine group, the pain scores at rest and on movement at 6 and 8 h after the block were lower in three ropivacaine plus nalbuphine groups (P < 0.05), without between-group differences at 2, 4, and 12 h. The four groups had comparable side effects (nausea and vomiting) and vital signs (P > 0.05).

CONCLUSIONS

UGFICB with 5, 10, and 20 mg nalbuphine added to ropivacaine prolonged the analgesia duration, increased sensory block area, reduced pain, and decreased the doses of rescue parecoxib sodium for older patients after hip fracture, without obvious side effects. Among these three doses, nalbuphine 20 mg in combination with ropivacaine provided the longest duration of analgesia and the largest sensory block area.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2000029934).

Nalbuphine alleviates inflammation by down-regulating NF-κB in an acute inflammatory visceral pain rat model

Introduction

Nalbuphine can relieve patients’ inflammation response after surgery compared to other opioid drugs. However, its molecular mechanism has not been clear. Activation of NF-κB signaling pathway under oxidative stress and inflammation can maintain pain escalation.

Methods

We firstly investigated the effect of nalbuphine on writhing test and mechanical allodynia using a rat model of inflammatory visceral pain (acetic acid (AA) administrated). Cytokines (including tumor necrosis factor (TNF)-α, Interleukin (IL)-1β, IL-2, and IL-6 in plasma were tested with ELISA technology. Expression levels of TNF-α, IκBα and p-NF-κB p65 at the spinal cord (L3–5) were measured by western blot or RT-qPCR.

Results

We found that the paw withdrawal threshold (PWT) values of rats were reduced in the model group, while the numbers of writhing, levels of IL-1β, IL-2, IL-6, and TNF-α in plasma, and p-NF-κB protein and its gene expressions in the lumbar spinal cord were up-regulated. Subcutaneously injection of nalbuphine (10 μg/kg) or PDTC (NF-κB inhibitor) attenuated acetic acid-induced inflammatory pain, and this was associated with reversal of up-regulated IL-1β, IL-2, IL-6, and TNF-α in both plasma and spinal cord. Furthermore, acetic acid increased p-NF-κB and TNF-α protein levels in the white matter of the spinal cord, which was attenuated by nalbuphine. These results suggested that nalbuphine can significantly ameliorate inflammatory pain via modulating the expression of NF-κB p65 as well as inflammation factors level in the spinal cord.

Conclusion

In conclusion, nalbuphine inhibits inflammation through down-regulating NF-κB pathway at the spinal cord in a rat model of inflammatory visceral pain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40360-022-00573-7.

Application of Ultrasound-Guided Transversus Abdominis Plane Block Combined with Nalbuphine Patient-Controlled Intravenous Analgesia in Postoperative Analgesia After Laparotomy: A Randomized Controlled Trial

Introduction

Pain is a common postoperative complication. The ideal postoperative analgesia is awake, safe, mobile, and without side effects. The objective of this study is to provide new ideas for postoperative analgesia by observing the safety and analgesic effect of different analgesic methods in patients undergoing laparotomy after surgery.

Methods

Patients, who underwent laparotomy between September 2019 and December 2020, were randomly divided into three groups: group S received sufentanil, group N received nalbuphine, group T + N received postoperative bilateral transversus abdominis plane block (TAPB) and nalbuphine. The primary outcomes included visual analog scale (VAS) score and the use of postoperative analgesic pump. Secondary outcomes included quality of life recovery (QoR-15) scale score and incidence of postoperative adverse reactions.

Results

Compared with group S and N, there were significant differences in the resting VAS score within 48 h after surgery, dynamic VAS score within 12 h after surgery, the first compression time, and cumulative use of patient-controlled intravenous analgesia (PCIA) drugs at 24 h in group T + N (P < 0.05). The QoR-15 score within 48 h after surgery in group T + N was significantly higher than group N (P < 0.05). The first exhaust time and the incidence of nausea and vomiting in group T + N were significantly lower than those in group N (P < 0.05).

Conclusions

Sufentanil PCIA and nalbuphine PCIA have equivalent analgesic effects, while TAPB combined with nalbuphine PCIA can ensure a good analgesic effect, thereby reducing the incidence of adverse reactions.

Comparison of propofol-nalbuphine and propofol-fentanyl sedation for patients undergoing endoscopic retrograde cholangiopancreatography: a double-blind, randomized controlled trial

Background

Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly used to treat patients with biliary/pancreatic duct obstruction or stricture outside the operating room. Effective and safe sedation techniques are needed because of painful stimuli and the long duration of the ERCP procedure.Nalbuphine has been shown to cause less respiratory depression during sedation than similar cases without nalbuphine. This study compared the effects of propofol-nalbuphine (PN) and propofol-fentanyl (PF) sedation in patients undergoing ERCP.

Methods

Four hundred patients scheduled for ERCP procedures were divided into two groups: the PF group (receiving PF sedation,n = 199) and the PN group (receiving PN sedation,n = 201). Vital signs, adverse events during surgery, patient movement scores, pain scores, and adverse events one day post-ERCP were recorded.

Results

Stable haemodynamics were observed in both groups.Compared to the PF group, the PN group showed significantly decreased respiratory depression (P < 0.0001) and surgical interruptions (P = 0.048).Nalbuphine decreased patient movement by reducing pain from ERCP.

Conclusion

Nalbuphine, instead of fentanyl, precipitated less respiratory depression while permitting adequate/equivalent sedation for ERCP and therefore provides more efficient and safer sedation.

Trial registration

ChiCTR, ChiCTR1800016018, Registered 7 May 2018, http://www.chictr.org.cn/showproj.aspx?proj=27085

The use of topical nalbuphine in different concentrations to control pain after photorefractive keratectomy

PURPOSE

This is a randomized controlled study aiming to evaluate the safety and efficacy of two different concentrations of topical nalbuphine hydrochloride, when used to relieve pain in the first days following photorefractive keratectomy (PRK).

METHODS

This is a prospective double blinded randomized clinical trial that included 189 patients who had PRK for correction of low and moderate refractive errors. Patients were randomly assigned to three groups according to the eye drops given to relieve pain in the first three postoperative days; the first group received topical nalbuphine with a concentration of 2 mg/ml (Group A = 64 patients), the second group received topical nalbuphine in a concentration of 1 mg/ml (Group B = 69 patients) and the third group received topical artificial tears only (Group C = 56 patients).The patients were asked to rate their pain daily using a numeric rating scale and to record the number of drops instillation times/day. The time needed for complete epithelial healing, best-corrected visual acuity (BCVA) and spherical equivalent after three months were recorded in each group.

RESULTS

In the first three days, there was a statistically significant difference in pain score among the three groups with lower values in the two topical nalbuphine groups when compared with the control group receiving artificial tears. Moreover, the higher concentration group showed significantly lower pain score and less number of drops used /day in comparison with the lower concentration group.There were no statistically significant differences in epithelial healing time, BCVA and spherical equivalent after three months among the three groups.

CONCLUSION

The use of topical nalbuphine is effective in relieving pain in the first few days following PRK and this pain relief is not associated with any compromise regarding epithelial healing nor refractive outcome. The pain control with 2 mg/ml concentration is significantly higher than that with 1 mg/ml concentration of nalbuphine. Trial registration numberISRCTN21394752 https://doi.org/10.1186/ISRCTN21394752 The trial is retrospectively registered in ISRCTN registry at March 08, 2021.

Influences of Gender on Intravenous Nalbuphine Actions After Major Abdominal Surgery: A Multicenter Study

INTRODUCTION

Nalbuphine, a synthetic kappa-opioid receptor (KOR) agonist and a partial µ-opioid receptor (MOR) antagonist, has been used for years as an effective analgesic. It has been shown to have a better safety profile than morphine. Considering the long history of use of this drug, it is interesting that only a limited amount of information exists on how gender differences influence nalbuphine responses. In this randomized double-blind comparative trial after major abdominal surgery, the analgesic effects of two doses of continuous intravenous infusion of nalbuphine were evaluated based on gender.

METHODS

Enrolled patients were divided into four groups (two females and two males with 32 patients in each group). Two of them (groups A1 and A2), one male and one female, received postoperative continuous intravenous infusions of nalbuphine at 2 mg/h via patient-controlled analgesia (PCA). Each patient had the potential of receiving a rescue bolus of 1 mg of nalbuphine with a lock out time of 15 min. The other two groups (groups B1 and B2) received half the infusion dose, 1 mg/h, and half the nalbuphine rescue dose with the PCA pump, 0.5 mg maximum every 15 min as needed. Patients' vital signs, numerical pain rating scores, rescue nalbuphine, and incidence of side effects were assessed immediately after the operation, and every 3 h during the first 12 h.

RESULTS

Nalbuphine 2 mg/h dosing led to significantly lower pain scores amongst females compared to males at 6, 9, and 12 h; while the 1 mg/h infusion pain scores were only lower at the 9-h time period. Females receiving the nalbuphine 2 mg dose at 6 h, and the 1 mg dose at 6, 9, and 12-h measurements needed significantly lower doses of rescue nalbuphine. Females on the 1 mg dose experienced significantly more nausea, vomiting, and sedation at the 6-, 9-, and 12-h measurement times. In the multivariate analysis, female gender was a negative predictor at all measurement times.

CONCLUSIONS

The current study supports the hypothesis that although nalbuphine was found to be an effective and well-tolerated analgesic after major abdominal surgery, females were statistically more responsive than males.

TRIAL REGISTRATION

The study was registered at the Pan African Clinical trials Registry PACTR201304000486309, and approved for the Ethical aspects.

ED50 of Propofol Combined with Nalbuphine on the Sedative Effect in Painless Hysteroscopy

INTRODUCTION

Nalbuphine has gradually become a commonly used clinical analgesic drug for painless hysteroscopy. The aim of our study was to identify the median effective dose (ED50) of propofol combined with nalbuphine for painless hysteroscopy.

METHODS

Sixty-one patients aged 18-60 years were recruited to undergo elective painless hysteroscopy. Patients were administered 0.1 μg/kg nalbuphine (group A) or 0.2 μg/kg nalbuphine (group B) intravenously 3 min before endoscopic placement. The Dixon sequential method was used with an initial intravenous propofol dose of 2 mg/kg, which varied by 0.5 mg per kilogram.

RESULTS

The ED50 of propofol was 1.729 mg/kg (95% confidence interval [CI] 1.526-1.856 mg/kg) in group A and 1.658 mg/kg (95% CI 1.359-1.799 mg/kg) in group B. The 95% effective dose (ED95) of propofol was 2.051 mg/kg (95% CI 1.899-3.331 mg/kg) in group A and 2.020 mg/kg (95% CI 1.849-3.832 mg/kg) in group B.

CONCLUSION

For safety and effective painless hysteroscopic, the ED50 values of propofol combined with nalbuphine were 1.729 mg/kg (0.1 mg/kg nalbuphine) and 1.658 mg/kg (0.2 mg/kg nalbuphine). The recommended dose of nalbuphine is therefore 0.1 mg/kg.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2100042342 ( http://www.chictr.org.cn/edit.aspx?pid=66342&htm=4 ; registration date 19 Jan 2021).

Comparison of Analgesic Effects between Nalbuphine and Sufentanil in First-Trimester Surgical Abortion: A Randomized, Double-Blind, Controlled Trial

Introduction

Surgical abortion is one of the commonly conducted procedures worldwide. Nevertheless, pregnant women still complain of procedural and postoperative pain despite the use of advanced anesthesia. It is vital to women’s reproductive healthcare to improve postsurgical pain management to achieve the lowest level of pain.

Methods

This randomized, double-blind, parallel-controlled clinical trial compared the analgesic effects between nalbuphine and sufentanil in patients who underwent first-trimester surgical abortion. In total, 224 patients were allocated randomly into (a) the sufentanil group that received sufentanil (0.1 ug/kg) combined propofol, and (b) the nalbuphine group that received nalbuphine (0.1 mg/kg) combined propofol. Postoperative pain scores, propofol injection pain, intraoperative analgesic effect, adverse events, and degree of satisfaction were recorded as outcome measures.

Results

The pain scores in the nalbuphine group were lower than those in the sufentanil group at 15 min, 30 min, 1 h, and 6 h after surgical abortion. In addition, the incidence and intensity of propofol injection pain were lower in the nalbuphine group. The degree of satisfaction of the patients in the nalbuphine group was higher than that in the sufentanil group. The intraoperative analgesic effect, hemodynamic fluctuation, and adverse events were comparable between the two groups.

Conclusions

Nalbuphine combined with propofol is superior to sufentanil combined with propofol for first-trimester abortion surgeries.

Clinical Trial Registration

The trial was registered at www.chictr.org.cn, identifier ChiCTR2000040243.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-021-00334-0.

Nalbuphine: a candidate for treatment of women overwhelmed with sudden, intense labor pain?

AIM

On very rare occasions, women are overwhelmed with sudden, intense labor pain in the context of ultra-rapid late second stage of labor, especially when the head is crowning. The consequences may comprise serious pelvic floor damage for the mother and hypoxia for the fetus. Drugs like nalbuphine for immediate maternal analgesia and sedation would be helpful. This mixed opioid agonist-antagonist, that was used in obstetric anesthesia in the 1980s, acts quickly while side effects for the mother are minor. To better estimate possible complications for the fetus of a use shortly before birth, it is important to find out how quickly i.v. administered nalbuphine reaches fetal circulation. Therefore, we characterized the transplacental transfer of nalbuphine using an ex vivo model.

METHODS

Placentas were obtained from cesarean sections after mothers gave their informed consent. Upon cannulation of one cotyledon, nalbuphine was added to the maternal circuit (calculated final concentration 100 ng/mL) and the ex vivo placenta perfusions were performed. To determine nalbuphine transfer from maternal to fetal circuit in the successful perfusions (n = 5), samples were collected at different time points.

RESULTS

At perfusion start, the measured initial nalbuphine concentrations in the maternal and fetal circuits are 93.1 and <0.1 ng/mL, respectively. After 5 min of placenta perfusion, 2.5 ng/mL nalbuphine (i.e. 3% of the initial nalbuphine concentration in the maternal circuit) is reached in the fetal circuit; after 15 and 30 min, 9.7 and 15.8 ng/mL (approximately 10 and 16% of initial maternal, respectively).

CONCLUSIONS

Only a small amount of nalbuphine is likely to reach the fetus during the first minutes after (i.v.) maternal administration. Nalbuphine might be a valuable candidate for clinical use in the i.v. analgesia and sedation of women overwhelmed with sudden labor pain in the context of ultra-rapid second stage of labor.

Co-administration of nalbuphine attenuates the morphine-induced anxiety and dopaminergic alterations in morphine-withdrawn rats

INTRODUCTION

The classical effects of exogenous opioids, such as morphine, are predominantly mediated through μ-opioid receptors. The chronic use of morphine induces anxiety-like behavior causing functional changes in the mesolimbic dopaminergic system. The mixed μ/κ-agonist, nalbuphine, used either as an analgesic or as an adjuvant with morphine, produces different and opposite effects. However, whether nalbuphine can be used to antagonize morphine-induced anxiety and dopaminergic alterations is not fully known.

OBJECTIVE

This study aimed to compare acute and chronic effects of nalbuphine on morphine-induced anxiety and dopaminergic alterations in rats.

METHODS

Male adult Wistar albino rats were made opioid-dependent by administering increasing doses of morphine (5-25 mg/kg; i.p.; b.i.d.). Withdrawal was induced by naloxone (1 mg/kg, i.p.), 4 h after the last morphine injection. Anxiety-like behavior was measured using Activity Monitor (Coulbourn Instruments, Inc. USA). Thereafter, the animals were sacrificed and the brain dissected out and the level of cAMP and the transcriptional and translational expression of TH was measured. Nalbuphine was co-administered with morphine, acutely and chronically, at various doses (0.1, 0.3, 1.0, 3.0 mg/kg, i.p.).

RESULTS

Morphine-dependent rats showed a significant higher anxiety and cAMP levels and a significant decrease in the expression of TH. Co-administration of chronic doses of nalbuphine attenuates the higher anxiety, cAMP levels, and upregulates the TH expressions; however, the acute nalbuphine treatment does not attenuate the morphine-induced side effects.

CONCLUSION

Therefore, nalbuphine might have an important role in attenuating the anxiety and the effects of the dopaminergic pathway and may have potential in the treatment of opioid addiction.

NB-33, a bioreversible opioid derivative of Nalbuphine, shows enhanced pharmacodynamics

Developing non-addictive and safer opioids for pain management is unmet medical need. Among a number of bioreversible derivatives of Nalbuphine - an equipotent to morphine opioid without serious side effects - NB-33 was identified in silico and confirmed in vivo as a superior analgesic agent. Apart from enhanced pharmacodynamics profile, NB-33 outperformed the parent compound on equimolar bases in cold ethanol tail-flick and mechanical models of pain in rats. With no β-arrestin engagement liability, good stability in simulated gastro-intestinal fluid and slow release of Nalbuphine by plasma NB-33 is being developed as an oral and safer alternative of its parent drug.

Randomized Double-Blinded Comparative Study of Intravenous Nalbuphine and Tramadol for the Treatment of Postspinal Anesthesia Shivering

Context:

Shivering is one of the most commonly recognized complications of the central neuraxial blockade. For optimal perioperative care, control of postspinal anesthesia shivering is essential.

Aims:

The present study designed to compare the clinical efficacy, hemodynamic parameters, and side effects of nalbuphine and tramadol for control of postspinal anesthesia shivering.

Settings and Design:

This was a prospective, randomized, double-blind study.

Materials and Methods:

This study was conducted on 90 American Society of Anesthesiologists Physical Status I and II patients of either gender, aged between 18 and 60 years, who subsequently developed shivering grade 3 or 4, scheduled for different surgical procedures under spinal anesthesia. The patients were randomized into two groups of 45 patients each to receive either nalbuphine 0.06 mg.kg⁻¹ (Group N) or tramadol 1 mg.kg⁻¹ (Group T). Grade of shivering, onset of shivering, time interval for cessation of shivering, response rate at 5 and 30 min, rescue dose, hemodynamic parameters, and side effects were observed at scheduled intervals.

Statistical Analysis Used:

Independent t-test and Chi-square/Fisher's exact test were used to analyze the data.

Results:

The time taken for cessation of shivering was significantly less with nalbuphine in comparison with tramadol (P < 0.05). It was observed that the response time at 5 and 30 min and rescue dose requirement for control of shivering were not much difference (P > 0.05).

Conclusions:

Both nalbuphine and tramadol are effective; however, the time taken for cessation of shivering is significantly less with nalbuphine when compared to tramadol. Furthermore, tramadol causes significantly more nausea and vomiting; however, nalbuphine causes significantly more sedation.

Nalbuphine Versus Ketorolac as an Adjuvant to Local Wound Infiltration Anesthesia in Open Colorectal Surgery: A Prospective Randomized Controlled Study

INTRODUCTION

Adding adjuvants to local wound infiltration (LWI) provides long analgesic duration with fewer adverse effects. We aimed to compare the clinical effects of nalbuphine and ketorolac as an adjuvant to LWI in patients undergoing open colorectal cancer surgery.

METHOD

A total of 126 ASA I-III patients aged ≥ 18 years who were scheduled for open colorectal cancer surgery were included. Patients were randomly assigned to receive LWI using 10 mL 0.75% ropivacaine, with 20 mL normal saline (group R), 10 mg nalbuphine in 1 mL (group RN), or 25 mg ketorolac in 0.8 mL (group RK). Analgesia duration was the primary outcome. The total 48-h postoperative morphine-equivalent consumption and additional rescue analgesia rates were recorded as key secondary outcomes.

RESULTS

Among 126 patients randomized, 124 completed the trial. The duration until the first press of the analgesia pump was significantly shorter in group R (median: 320.0 min) compared with group RN (median: 829.5 min) and group RK (median: 820.0 min) (P < 0.001). The median difference in morphine consumption was 113.0 mg for group R vs. group RN (P < 0.001), and 115.5 mg for group R vs. group RK (P < 0.001). The proportion of patients using additional morphine within the first day after surgery in group R showed a higher relative risk (RR) compared with group RN (RR, 3.89; P = 0.001) and group RK (RR, 3.17; P = 0.001). There were no apparent differences between the RN and RK groups in any outcomes, whether in adjusted or unadjusted analysis.

CONCLUSIONS

Among patients undergoing open colorectal cancer surgery, both nalbuphine and ketorolac infiltration achieved equally prolonged duration of analgesia and reduced morphine consumption compared with ropivacaine alone after surgery, suggesting that the equivalent analgesic dose of nalbuphine and ketorolac as local anesthetic adjuvants in LWI could have a similar analgesic effect.

TRIAL REGISTRATION

ChiCTR1800019209.

Nasal nalbuphine analgesia in prehospital trauma managed by first-responder personnel on ski slopes in Switzerland: an observational cohort study

BACKGROUND

Pain is one of the major symptoms complained about by patients in the prehospital setting, especially in the case of trauma. When there is mountainous topography, as in Switzerland, there may be a time delay between injury and arrival of professional rescuers, in particular on ski slopes. Administration of a safe opioid by first responders may improve overall treatment. We therefore assessed administration of nasal nalbuphine as an analgesic treatment for trauma patients in Switzerland.

METHODS

This observational cohort study examined 267 patients who were treated with nasal nalbuphine by first responders in six ski resorts in Switzerland. All first responders were instructed to begin treatment by assessing the feasibility of using nalbuphine to treat pain in the patient. A treatment algorithm was developed and distributed to assure that nalbuphine was only administered following a strict protocol. Data regarding pain scores and pain reduction after administration of nalbuphine were collected on-site. Refills were handed out to the first responders with the return of each completed questionnaire.

RESULTS

Nalbuphine provided effective pain relief, with the median level of pain on the numeric rating scale for pain reduced by 3 units on average, from 8 points (p < 0.001). The multivariate regression model showed that pain reduction was more pronounced in patients with higher initial pain levels. Nalbuphine was more effective in adolsecents than in patients aged 20 to 60 years (p = 0.006). No major side effects were observed.

CONCLUSION

Nasal administration of nalbuphine by first responders is a presumably safe and effective noninvasive pain management strategy for acutely injured patients in the prehospital setting. This may be an alternative, especially in the case of severe pain and prolonged time between arrival of the first responders and arrival of EMS/HEMS personnel on scene.

Intranasal solid lipid nanoparticles for management of pain: A full factorial design approach, characterization & Gamma Scintigraphy

Pain is a noxious stimulus caused due to tissue damage and varies from mild to severe. Nalbuphine (NLB) is an approved, inexpensive, non-controlled, opioid agonist/antagonist analgesic used worldwide in various clinical settings for pain management. The current study aims to formulate NLB loaded solid lipid nanoparticles (SLNs) using solvent injection technology. The morphological and chemical structure of the developed SLNs were characterized using Field Emission Scanning Electron Microscopy (FESEM), Transmission Electron Microscopy (TEM) and Fourier Transformation Infrared Spectroscopy (FTIR). The results revealed from the point prediction confirmation in design expert software was the formulation of NLB-SLNs with an average particle size of (170.07 ± 25.1 nm), encapsulation efficiency (93.6 ± 1.5%) & loading capacity of 26.67%. The in-vitro permeation of developed NLB-SLNs was observed to be 94.18% at 8 h when compared with NLB solution whose maximum permeation was seen within 3 h of application. Efficacy of the formulation was also evaluated using eddy's hot plate method, where the onset of action started within 10 min of administration, and the maximum effect was observed at 1 h. The NLB-SLNs was screened for cytotoxicity in human embryonic kidney cells (HEK-293), and the dosage was considered safe when administered intranasally in animal since no detectable effect to the brain was observed. Biodistribution and gamma scintigraphy study of NLB-SLNs showed the prepared formulation reaching the target site, i.e. brain and was retained. Conclusively, the prepared NLB-SLNs formulation was safe and effective in producing an analgesic effect in vivo.

Opioid effect on the autonomic nervous system in a fetal sheep model

PURPOSE

Opioid use during labour can interfere with cardiotocography patterns. Heart rate variability indirectly reflects a fluctuation in the autonomic nervous system and can be monitored through time and spectral analyses. This experimental study aimed to evaluate the impact of nalbuphine administration on the gasometric, cardiovascular, and autonomic nervous system responses in fetal sheep.

METHODS

This was an experimental study on chronically instrumented sheep fetuses (surgery at 128 ± 2 days of gestational age, term = 145 days). The model was based on a maternal intravenous bolus injection of nalbuphine, a semisynthetic opioid used as an analgesic during delivery. Fetal gasometric parameters (pH, pO₂, pCO₂, and lactates), hemodynamic parameters (fetal heart rate and mean arterial pressure), and autonomic nervous system tone (short-term and long-term variation, low-frequency domain, high-frequency domain, and fetal stress index) were recorded. Data obtained at 30-60 min after nalbuphine injection were compared to those recorded at baseline.

RESULTS

Eleven experiments were performed. Fetal heart rate, mean arterial pressure, and activities at low and high frequencies were stable after injection. Short-term variation decreased at T30 min (P = 0.02), and long-term variation decreased at T60 min (P = 0.02). Fetal stress index gradually increased and reached significance at T60 min (P = 0.02). Fetal gasometric parameters and lactate levels remained stable.

CONCLUSION

Maternal nalbuphine use during labour may lead to fetal heart changes that are caused by the effect of opioid on the autonomic nervous system; these fluctuations do not reflect acidosis.

Extended-Release Dinalbuphine Sebacate Versus Intravenous Patient-Controlled Analgesia with Fentanyl for Postoperative Moderate-to-Severe Pain: A Randomized Controlled Trial

INTRODUCTION

Post-operative pain control remains unsatisfactory in patients after laparotomy. This study aimed to evaluate the efficacy, safety, and quality of life with a single dose of extended-release dinalbuphine sebacate (ERDS) pre-operatively to intravenous patient-controlled analgesia (PCA) with fentanyl in patients undergoing laparotomy.

METHODS

This was a prospective, open-label, randomized controlled study. Of 110 randomized patients, 107 completed all assessments. The area under the curve (AUC) of visual analogue scale (VAS) from baseline to 48 h after surgery, VAS throughout 7 days after surgery, post-operative analgesics use, quality of life, satisfaction, and safety were evaluated.

RESULTS

The AUC of VAS from baseline to 48 h after surgery were 118.6 [97.5% confidence interval (CI) 95.6-141.6] in ERDS group and 176.13 (97.5% CI 150.8-201.4) in PCA group, which showed the non-inferiority because the upper limit of the 97.5% CIs of ERDS group was lower than the lower limit of PCA group (P < 0.001), but also had superiority in favor of ERDS group (P < 0.001). ERDS group reported a significant reduction in VAS pain intensity at 4, 24, 32, 72, 120, and 144 h after surgery, and better quality of life (P < 0.05). The safety profile was comparable between ERDS and PCA groups.

CONCLUSIONS

In patients undergoing laparotomy, a single dose of dinalbuphine sebacate was superior to intravenous PCA with fentanyl on lower pain intensity and better quality of life.

TRIAL REGISTRATION

NCT03296488.

Pt-Pd-doped NiO nanoparticle decorated at single-wall carbon nanotubes: An excellent, powerful electrocatalyst for the fabrication of An electrochemical sensor to determine nalbuphine in the presence of tramadol as two opioid analgesic drugs

In this study, a Pt-Pd-doped NiO nanoparticle decorated at the surface of single-wall carbon nanotubes (Pt-Pd/NiO-NPs/SWCNTs) was synthesized using a simple chemical precipitation method and characterized by XRD, TEM, and EDS methods. The results confirmed that Pt-Pd/NiO-NPs/SWCNTs were synthesized with good purity and at the nanoscale size. Moreover, a highly sensitive electroanalytical sensor was fabricated by incorporating synthesized Pt-Pd/NiO-NPs/SWCNT nanocomposites into a carbon paste electrode (CPE) in the presence of 1-ethyl-3-methylimidazolium methanesulfonate (EMICH₃SO₃^-) as binder. The Pt-Pd/NiO-NPs/SWCNTs/EMICH₃SO₃^-/CPE showed a powerful electro-catalytic activity for electro-oxidation of nalbuphine, and the results confirmed that the oxidation of nalbuphine was improved 6.34 times and relative oxidation potential was decreased about 110 mV compared to unmodified electrodes. The Pt-Pd/NiO-NPs/SWCNTs/EMICH₃SO₃^-/CPE also showed good catalytic activity for the determination of nalbuphine in the presence of tramadol and the oxidation potential of these opioid analgesic drugs separated with ΔE =460 mV. In the final step, the Pt-Pd/NiO-NPs/SWCNTs/EMICH₃SO₃^-/CPE was used to determine nalbuphine with a detection limit of 0.9 nM and tramadol with a detection limit of 50.0 nM in drug samples. The results confirmed the powerful and interesting ability of the sensor in the analysis of a real sample.

Submental nalbuphine exhibits improved efficacy in ameliorating acute pain in prehospital emergent conditions; a comparative study with conventional intramuscular using gamma scintigraphy

BACKGROUND

Nalbuphine (NLB) is a kappa-agonist and mu-partial antagonist, widely used for opioid withdrawal de-addiction, opioid-induced pruritis and as emergent analgesia.

OBJECTIVE

The present study aimed to assess the safety and efficacy of NLB in pain sensitization, through a submental route so as to provide faster management in emergent situations.

MATERIALS & METHODS

In-vivo efficacy and safety studies of NLB-submental injection were assessed in Sprague-Dawley(SD) rats. For eddy's hot plate study, animals were allocated into three groups, the first group served as normal control; group II received NLB (through submental route at 1.2 mg/kg); group III received NLB (through intramuscular route at 1.2 mg/kg). Response latency (in terms of response latency) was measured at 10, 30 & 60 min in all the experimental groups. Safety studies were carried out according to OECD 423. In-vitro release study was conducted using a cellulose dialysis membrane (12,000 KDa). The biodistribution and release kinetics studies were carried out using gamma scintigraphy studies in New Zealand rabbits and humans respectively.

RESULTS

The response latency of NLB from the submental route was found to be 7.17 (SD 1.47) seconds and in the case of the intramuscular route it was calculated as 4.00 (SD 1.26) seconds at 10 min. The data depicts the better efficacy of submental injection in ameliorating pain than the intramuscular injection. Toxicity studies predict the safe profile through a submental route. The release kinetics in humans of submental NLB was 46% faster as compared to the intramuscular site of injection. The NLB injection through both routes was compared by non-invasive gamma scintigraphy technique and we found that submental injection has faster (within 10 min) onset of action & distributes rapidly.

CONCLUSION

The submental route of NLB is faster, more efficacious than the intramuscular route. Thus, we conclude that in the case of emergent scenarios (i.v or i.m. route is compromised), where immediate relief is necessary, the submental route is a preferred choice.

Effects of nalbuphine on the cardioprotective effect of morphine in rats

BACKGROUND

When combined with morphine, nalbuphine not only does not affect the analgesic effect but also prevents opioid-induced side effects. The authors investigated whether nalbuphine interferes with morphine-induced cardioprotection in rats.

METHODS

Anesthetized male Sprague-Dawley rats were randomly assigned to 1 of 4 treatment groups. Nalbuphine (NAL, 1 mg/kg) and morphine (MOR, 0.3 mg/kg) were administered 10 and 5 min prior to myocardial ischemia, respectively. Additionally, the NAL + MOR group received the combination of NAL and MOR prior to myocardial ischemia. An in vivo animal model was established by occluding the left anterior descending artery for 30 min and reperfusing it for 2 h. After 2 h of reperfusion, the infarcted area of heart was measured by Evans blue/triphenyl tetrazolium staining, and the levels of creatine kinase isoenzymes (CK-MB) in serum were detected by enzyme-linked immunosorbent assay.

RESULTS

Nalbuphine had no protective effect against the infarct area compared with the control treatment (NAL, 52.5 ± 5% versus CON, 52.6 ± 4%; *P < 0.01), and the infarct size-sparing effects of morphine were not affected by nalbuphine (NAL + MOR, 42.6 ± 7% versus MOR, 40.4 ± 3%; P > 0.05). The nalbuphine group did not show a change the levels of serum CK-MB compared with the control group, and nalbuphine did not affect the levels of serum CK-MB in the MOR group.

CONCLUSIONS

Nalbuphine does not interfere with the cardioprotective effect of morphine in vivo. Therefore, nalbuphine could be safely used or combined with morphine in patients with acute myocardial infarction.

Pain management after ambulatory surgery: a prospective, multicenter, randomized, double-blinded parallel controlled trial comparing nalbuphine and tramadol

Background

Postoperative pain in ambulatory surgery is a multifactorial issue affecting patient satisfaction, time of discharge, and rehospitalization. This study evaluated the efficacy and safety of nalbuphine for the treatment of postoperative pain after ambulatory surgery, relative to tramadol.

Methods

This multi-center, randomized, double blind, and controlled study was conducted at 10 centers. In accordance with the inclusion criteria, 492 ambulatory surgery patients were recruited. These patients had moderate to severe pain after ambulatory surgery, with a visual analogue scale (VAS) score > 3 cm. They were randomly divided into an experimental (n = 248) or control (n = 244) group and treated for analgesia with 0.2 mg/kg of nalbuphine or 2 mg/kg of tramadol, respectively. VAS scores, adverse events, and vital signs of the patients were recorded before administration (baseline; T₁); and 30 min (T₂), 2 h (T₃), 4 h (T₄), and 6 h (T₅) after administration of analgesia. A decrease in pain intensity of more than 25% compared with the baseline was used as an indicator of analgesic efficacy. The experimental and control groups were compared with regard to this indicator of efficacy at each timepoint.

Results

The VAS scores of the experimental and control groups were statistically comparable at timepoints T₁-T₄. At T₅, the VAS scores of the experimental group were significantly lower than that of the control. The pain intensity was significantly higher in the experimental group compared with the control at T₂ and T₃. Adverse events and vital signs were similar for the two groups at each timepoint.

Conclusions

Nalbuphine can provide effective and safe pain relief in patients after ambulatory surgery.

Trial registration

The registration number is ChiCTR-IOR-16010032, the date of registration was 2016-11-28.

Comparison Between Intravenous Nalbuphine and Lidocaine in Reducing Propofol-Induced Injection Pain During Gastroscopy: A Randomized Controlled Trial

Introduction

Intravenous propofol anesthesia is widely used in painless endoscopy. However, propofol injection pain is a common adverse effect. This study investigated the effects of nalbuphine and lidocaine in reducing propofol-induced injection pain.

Methods

In this double-blind, randomized study, 330 patients were randomly divided into three groups by using a random number table: the nalbuphine group (N), lidocaine group (L), and control group (C). The N, L, and C groups received either 0.1 mg/kg nalbuphine, 0.5 mg/kg lidocaine, or an equivalent volume of normal saline, respectively, as pretreatment drug. Then propofol was manually injected. The primary outcome of this study was the incidence of propofol-induced injection pain, and secondary outcomes included the severity of propofol-induced injection pain, vital signs, and adverse events, including hypotension, bradycardia (< 50 beats/min), hypoxemia (SpO₂ < 90%), drowsiness, physical movement, and cough.

Results

The percentages of patients with propofol injection pain were higher in group C than in group N and group L (64, 34, and 27%, respectively, p < 0.05). The percentage of patients with severe pain after propofol injection was significantly higher in group C than in group N and group L (12, 1, and 0%, respectively, p < 0.05). The doses of propofol in group C and group L were significantly higher than that in group N. More patients suffered hypoxemia in group N than in group C and group L. Then, less patients got physical movement and cough in group N.

Conclusions

Pretreatment with nalbuphine 0.1 mg/kg was effective in reducing propofol-induced injection pain and propofol consumption. Propofol combined with nalbuphine can be safely and effectively used during gastroscopy.

Trial Registration

Chinese Clinical Trial Registry; ChiCTR1900025438.

Efficacy of Serratus Anterior Plane Block Using Bupivacaine/ Magnesium Sulfate Versus Bupivacaine/ Nalbuphine for Mastectomy: A Randomized, Double-Blinded Comparative Study

Background

Mastectomy is a common surgical procedure associated with intra and postoperative pain if untreated adequately will lead to chronic pain.

Objectives

This study aimed to evaluate the efficacy of serratus anterior plane block using bupivacaine/magnesium sulfate versus bupivacaine/ nalbuphine for mastectomy.

Methods

40 ASA I and II female patients age 25 - 60 years underwent breast cancer surgery received the block before induction of general anesthesia were divided into two groups GBM (n = 20): (bupivacaine/magnesium sulphate): received bupivacaine 30 mL 0.25% and 500 mg magnesium sulphate, GBN (n = 20): (bupivacaine/nalbuphine): received bupivacaine 30 mL 0.25% and nalbuphine 0.2 mg/kg. The following parameters were recorded: The sensory block, motor block, postoperative heart rate, noninvasive mean blood pressure: at 1, 6, 12, 24 h, postoperative time to first request of analgesics (hours), VAS at rest and movement at 1, 6, 12, 24 h, postoperative analgesic requirements (pethidine mg/24 h).

Results

The sensory block was statistically significantly lower in the GBM group than the GBN group at 24 hours postoperatively. The Medical Research Council scale was statistically significantly lower in the GBN group than the GBM group at 24 hours postoperatively. Postoperative time to first request of analgesics (hours) was statistically significantly longer in the GBN group than the GBM group, VAS at rest was statistically significantly lower in the GBN group than GBM group at 6th and 24th hours, VAS at movement showed no statistically significant differences between the two groups. Intraoperative fentanyl and postoperative analgesic requirements (pethidine mg/24 h) showed no statistically significant differences between the two groups.

Conclusions

Serratus anterior plane block using bupivacaine/nalbuphine provided effective postoperative analgesia, reduced postoperative pain than bupivacaine/magnesium sulfate in a mastectomy.

Conventional and first derivative synchronous spectrofluorimetric methods for the simultaneous determination of cisatracurium and nalbuphine in biological fluids

Cisatracurium besylate has been determined by fast and highly sensitive spectrofluorimetric method based on measuring the fluorescence intensity of its methanolic solution at 312 nm after excitation at 230 nm (Method I). The linearity occurred over the concentration range of 10.0-130.0 ng/mL with detection limit of 1.07 ng/mL. The method was further extended for the determination of the studied drug in spiked human plasma with good percentage recoveries (97.43-103.50%). Cisatracurium is co-administered with nalbuphine during surgery. The simultaneous determination of both drugs was based on synchronous spectrofluorimetric technique. First derivative synchronous spectrofluorimetric amplitude was measured in methanol at Δ λ = 60 nm and each drug could be estimated at the zero crossing point of the other. Hence, cisatracurium could be measured at 284.6 nm while nalbuphine at 276.3 nm (Method II). The method was linear over the ranges of 50.0-750.0 ng/mL and 0.5-7.0 μg/mL with the detection limits of 2.16 ng/mL and 0.04 μg/mL for cisatracurium and nalbuphine, respectively. The method was further extended for the simultaneous determination of both drugs in spiked human urine with mean percentage recoveries of 99.99 ± 2.06 and 99.53 ± 6.17 for cisatracurium and nalbuphine, respectively. Both methods were validated in agreement with Guidelines adopted by International Council of Harmonization (ICH).

Antipruritic Effects of Kappa Opioid Receptor Agonists: Evidence from Rodents to Humans

Centrally administered bombesin induces scratching and grooming in rats. These behaviors were blocked by early benzomorphan kappa opioid receptor (KOR) agonists as reported by Gmerek and Cowan in 1984. This was the first evidence that KORs may be involved in the sensation of itch-like behaviors. Subsequent development of additional animal models for acute and chronic itch has led to important discoveries since then. For example, it was found that (a) gastrin-releasing peptide (GRP), natriuretic polypeptide b and their cognate receptors are keys for the transmission of itch sensation at the spinal cord level, (b) dynorphins (Dyns), the endogenous KOR agonists, work as inhibitory neuromodulators of itch at the spinal cord level, (c) in a mouse model for acute itch, certain KOR antagonists elicit scratching, (d) in mouse models of acute or chronic itch, KOR agonists (e.g., U50,488, nalfurafine, CR 845, nalbuphine) suppress scratching induced by different pruritogens, and (e) nalfurafine, CR 845, and nalbuphine are in the clinic or in clinical trials for pruritus associated with chronic kidney disease and chronic liver disease, as well as pruritus in chronic skin diseases.

Comparison of nalbuphine, ondansetron and placebo for the prevention of shivering after spinal anaesthesia for urgent caesarean delivery: a randomised double-blind controlled clinical trial

BACKGROUND

Shivering is a common complication of caesarean delivery with neuraxial anaesthesia. The effective prevention and treatment of shivering, especially before delivery, is important and difficult. We tested the hypothesis that prophylactic nalbuphine and ondansetron can prevent post-spinal anaesthesia shivering in parturients undergoing urgent caesarean delivery.

METHODS

Sixty parturients scheduled for urgent caesarean delivery before spinal anaesthesia were selected and divided randomly into three groups. After peripheral venous catheterisation, parturients were given intravenous nalbuphine 0.08 mg/kg (group N), ondansetron 8 mg (group O), or normal saline (group C).

RESULTS

The incidence of shivering and of severe (grade ≥3) shivering was significantly lower in group N (15% and 15%, respectively) than in group C (80% and 65%) before delivery (P <0.001 and P=0.003); and significantly less shivering was observed in group N than in group C in the first 30 min after anaesthesia (P=0.001). Up to 60 min after anaesthesia, the incidence of grade ≥3 shivering remained lowest in group N (P=0.003). According to the data during the period from anaesthesia until delivery, the number needed-to-treat for nalbuphine was 1.54 (95%CI 1.13 to 2.41). No significant differences were found between groups O and N or groups O and C at any time. The incidence of dizziness in group N was significantly higher than that of groups O or C (P=0.009).

CONCLUSION

Nalbuphine 0.08 mg/kg can prevent post-spinal anaesthesia shivering in parturients undergoing urgent caesarean delivery but causes transient dizziness, while ondansetron 8 mg had no significant effect.

Nalbuphine, a kappa opioid receptor agonist and mu opioid receptor antagonist attenuates pruritus, decreases IL-31, and increases IL-10 in mice with contact dermatitis

Chronic itch is one of the disturbing symptoms of inflammatory skin diseases. Kappa opioid receptor agonists are effective in suppressing scratching in mice against different pruritogens. Nalbuphine, a nonscheduled kappa opioid receptor agonist and mu opioid receptor antagonist, has been in clinical use for post-operative pain management since the 1980s and recently has been in clinical trials for chronic itch of prurigo nodularis (https://www.trevitherapeutics.com/nalbuphine). We studied whether nalbuphine is effective against chronic scratching induced by rostral neck application of 1-fluoro-2,4-dinitrobenzene (DNFB), an accepted mouse model of contact dermatitis to study pruritoceptive itch. Mice were treated once a week with either saline or nalbuphine 20 min before the third, fifth, seventh, and ninth sensitizations with DNFB and the number of scratching bouts was counted for 30 min. Skin samples from the neck of mice at week 4 were used to measure protein levels and mRNA expressions of chemokines and cytokines. Different sets of mice were used to study sedation and anhedonic-like behavior of nalbuphine. We found that: nalbuphine (a) antagonized scratching in a dose- and time-dependent manner without affecting locomotion, b) decreased IL-31, and increased anti-inflammatory IL-10, and c) induced more elevations in the levels of CCL2, CCL3, CCL12, CXCL1, CXCL2, CXCL9, CXCL10, IL-1β, IL-16, TIMP-1, M-CSF, TREM-1 and M1-type macrophages compared to saline. Increases in chemokines and cytokines and M1 macrophages by nalbuphine suggest an inflammatory phase of healing in damaged skin due to scratching. Our data indicate that nalbuphine is an effective antipruritic in murine model of pruritoceptive itch.

A novel finding of nalbuphine-6-glucuronide, an active opiate metabolite, possessing potent antinociceptive effects: Synthesis and biological evaluation

Nalbuphine, a partial agonist/antagonist opioid analgesic, is structurally related to morphine. It is equipotent to morphine and has no serious side effects. In the past few decades, studies focusing on morphine metabolism have indicated that one of its sugar-conjugated metabolites, morphine-6-glucuronide, exerts a higher analgesic effect than its parent drug. Considering that nalbuphine is a morphine analog that follows a similar metabolic scheme, nalbuphine glucuronides were synthesized in this study and their potential analgesic effects were assessed. Nalbuphine-3-glucuronide (N3G) and nalbuphine-6-glucuronide (N6G) were synthesized based on Schmidt's glycosylation with OPiv protections on the glycosyl donor. In a pharmacodynamic study, paw pressure and cold-ethanol tail-flick tests were conducted in rats to evaluate the analgesic response after intracisternal and intraperitoneal administrations of nalbuphine, N3G, or N6G. The antinociceptive response was evaluated for each compound by calculating the area under the curve and the duration spent at greater than 50% maximum possible analgesia. In conclusion, intracisternal administration of N6G exhibited a stronger analgesic response than nalbuphine in the pain tests after both cold and mechanical stimuli, but N3G had no obvious effect. Similar to that of morphine, the glucuronide metabolite of nalbuphine at the 6-O-position exerted at least three-fold higher antinociceptive potency and five-fold longer analgesic duration than nalbuphine.

Nalbuphine versus dexmedetomidine for treatment of combined spinal-epidural post-anesthetic shivering in pregnant women undergoing cesarean section

Objective

This study aimed to compare the clinical efficacy and side effects of nalbuphine and dexmedetomidine for treatment of combined spinal-epidural anesthetic shivering in women after cesarean section.

Methods

A total of 120 pregnant women, who underwent elective cesarean section under combined spinal-epidural anesthesia, were enrolled in a double-blind, randomized study. These women were randomized into three groups of 40 pregnant women each to receive either saline (group C), nalbuphine 0.07 mg/kg (group N), or dexmedetomidine 0.5 µg/kg (group D) for treatment of shivering after anesthesia. The main outcome measure was a significant reduction in the time required for shivering after intervention.

Results

The mean time to cessation of shivering in groups N and D was significantly shorter than that in group C (3.5±2.7 and 4.2±3.7 versus 14.5±1.4 minutes). The success rate of shivering treatment and Observer’s Assessment of Alertness/Sedation scores in groups N and D were significantly higher than those in group C, while the recurrence rate was lower than that in group C.

Conclusion

Nalbuphine 0.07 mg/kg can be used safely and effectively for shivering in pregnant women under combined spinal-epidural anesthesia.

Nalbuphine suppresses breast cancer stem-like properties and epithelial-mesenchymal transition via the AKT-NFκB signaling pathway

BACKGROUND

Cancer pain is a debilitating disorder of human breast cancer and a primary determinant of the poor quality of life, and relieving pain is fundamental strategy in the cancer treatment. However, opioid analgesics, like morphine and fentanyl, which are widely used in cancer pain treatment have been reported to enhance stem-like traits and epithelial-mesenchymal transition (EMT) of breast cancer cells. As such, it is vital to make the best choice of analgesic for breast cancer management.

METHODS

MTT assays and colony formation assays were performed to examine tumor cell proliferation upon nalbuphine treatment. RT-PCR, western blot, flow cytometry, sphere formation, immunohistochemistry, transwell assays, wound healing assays and mouse xenograft were used to assess the biological effects of nalbuphine treatment.

RESULTS

Nalbuphine inhibited breast cancer cell growth and tumorigenesis, with little effect on noncancerous breast cell lines. Nalbuphine suppressed cancer stem-like traits and EMT in both breast cancer cells and mouse xenograft tumor tissues. Additionally, activation of AKT reversed the nalbuphine-induced inhibition of cancer stem-like properties, tumorigenesis and EMT.

CONCLUSIONS

Our results demonstrate a new role of nalbuphine in inhibiting cancer stem-like properties and EMT in addition to relieving pain, which suggests that nalbuphine may be effective in breast cancer treatment.

Efficacy and Safety of Intravenous Ketorolac versus Nalbuphine in Relieving Postoperative Pain after Tonsillectomy in Children

BACKGROUND

Pain is a major postoperative complication worldwide, which in turn impairs normal body performance and increases postoperative morbidity, hospitalisation, and the susceptibility to infections which also lead to chronic pain development.

AIM

The purpose of this study was to evaluate the efficacy of intravenous ketorolac versus nalbuphine as analgesia after adenotonsillectomy surgery to determine the optimal procedure for pain control and postoperative reduction of analgesic use.

METHODS

A group of 100 pediatric patients undergoing tonsillectomy or adenotonsillectomy were assigned as follows to two equal groups: Group A: 50 patients received intravenous ketorolac 0.9 mg/Kg. Group B: 50 patients received intravenous nalbuphine 0.25 mg/Kg.

RESULTS

FLACC (Face, Legs, Activity, Cry, Consolability) pain score was measured after recovery from anaesthesia (postoperative). There was a statistically significant difference concerning pain score between group 'A' and group 'B' as pain score in 'A' (ranging from 3.18 ± 0.87 to 4.68 ± 0.74) is lower compared to 'B' (ranging from 3.90 ± 0.76 to 5.54 ± 0.73) and probability value < 0.05 except at 90 & 120 min which was observed statistically insignificant. There was no serious postoperative complication detected in either group.

CONCLUSION

It is concluded that intravenous ketorolac is more effective than intravenous nalbuphine in reducing pain intensity and postoperative analgesic requirements after adenotonsillectomy in children.

Use of nalbuphine as a substitute for butorphanol in combination with dexmedetomidine and tiletamine/zolazepam: a randomized non-inferiority trial

OBJECTIVES

The goal of this study was to determine whether a drug combination using nalbuphine with dexmedetomidine and tiletamine/zolazepam is non-inferior to one that uses butorphanol.

METHODS

All healthy cats presenting solely for gonadectomy to two trap-neuter-return mobile clinic days were randomly assigned to induction with a combination of tiletamine/zolazepam 3 mg/kg, dexmedetomidine 7.5 µg/kg and either butorphanol or nalbuphine at 0.15 mg/kg. All participants were blinded to the identity of the combinations. The primary endpoint was clinician satisfaction, comprised of the mean of four satisfaction ratings on a 7-point Likert scale (highly dissatisfied through to highly satisfied) recorded for induction, maintenance of anesthesia, surgery and recovery. Exploratory endpoints included each individual score, number of injections, duration of induction, duration of recovery and need for reversal agent. To assess non-inferiority for the primary endpoint and individual scores, the difference and 95% confidence intervals (CIs) of the difference between the mean clinical scores for the nalbuphine and butorphanol-based combinations were calculated and compared with a prespecified non-inferiority margin of 20% (1.4 points).

RESULTS

Seventy-two cats were enrolled, 36 in each group. The mean ± SD composite score for the combination with nalbuphine was 6.06 ± 0.59 (95% CI 5.86-6.25) points, while the combination with butorphanol was 6.22 ± 0.62 (95% CI 6.01-6.43). The difference between mean scores was 0.17 (-0.12 to 0.45), which did not exceed the prespecified boundary of 1.4, establishing the non-inferiority of nalbuphine. No individual clinical score for nalbuphine was inferior to butorphanol, and there were no significant differences for any secondary endpoints.

CONCLUSIONS AND RELEVANCE

The clinical experience of the nalbuphine-based combination was non-inferior to the butorphanol-based combination. Nalbuphine is an effective substitute for butorphanol, providing another option if butorphanol is unavailable due to shortage, controlled status or cost, without requiring a change in anesthetic workflow.

In vitro and in vivo functional profile characterization of 17-cyclopropylmethyl-3,14β-dihydroxy-4,5α-epoxy-6α-(isoquinoline-3-carboxamido)morphinan (NAQ) as a low efficacy mu opioid receptor modulator

Evidence has shown that downstream signaling by mu opioid receptor (MOR) agonists that recruit β-arrestin2 may lead to the development of tolerance. Also, it has been suggested that opioid receptor desensitization and cyclic AMP overshoot contributes to the development of tolerance and occurrence of withdrawal, respectively. Therefore, studies were conducted with 17-cyclopropylmethyl-3,14β-dihydroxy-4,5α-epoxy-6α-(isoquinoline-3-carboxamido)morphinan (NAQ), a MOR selective partial agonist discovered in our laboratory, to characterize its effect on β-arrestin2 recruitment and precipitation of a cyclic AMP overshoot. DAMGO, a MOR full agonist dose-dependently increased β-arrestin2 association with the MOR, whereas NAQ did not. Moreover, NAQ displayed significant, concentration-dependent antagonism of DAMGO-induced β-arrestin2 recruitment. After prolonged morphine treatment of mMOR-CHO cells, there was a significant overshoot of cAMP upon exposure to naloxone, but not NAQ. Moreover, prolonged incubation of mMOR-CHO cells with NAQ did not result in desensitization nor downregulation of the MOR. In functional studies comparing NAQ with nalbuphine in the cAMP inhibition, Ca2+ flux and [35S]GTPγS binding assays, NAQ did not show agonism in the Ca2+ flux assay but showed partial agonism in the cAMP and [35S]GTPγS assays. Also, NAQ significantly antagonized DAMGO-induced intracellular Ca2+ increase. In conclusion, NAQ is a low efficacy MOR modulator that lacks β-arrestin2 recruitment function and does not induce cellular hallmarks of MOR adaptation and fails to precipitate a cellular manifestation of withdrawal in cells pretreated with morphine. These characteristics are desirable if NAQ is pursued for opioid abuse treatment development.

Effect of Dexmedetomidine Versus Nalbuphine as an Adjuvant on Paravertebral Block to Manage Postoperative Pain After Mastectomies

Background and Objective

Breast cancer is the commonest cancer in women worldwide. Many patients are frequently admitted to the operating theaters for mastectomies. Thoracic paravertebral block (PVB) is increasingly used as an effective means for post-operative pain relief. The present study aimed at evaluating the effectiveness and safety of dexmedetomidine and nalbuphine as an adjuvant to bupivacaine local anesthetic in thoracic paravertebral block in breast cancer surgeries.

Methods

A total of 60 female patients aged 18 to 78 were included in the study, and ASA I, II, III were scheduled for mastectomy. These patients were unsystematically assigned into three 20-member groups: group PB received bupivacaine (0.3 mL/ kg) + 1 mL (0.9% sodium chloride) normal saline; group PBD received bupivacaine (0.3 mL/kg) + dexmedetomidine 1 μg/kg; and Group PBN received bupivacaine (0.3 mL/kg) and 10 mg (1 mL) nalbuphine. Demographic data, intraoperative SPO₂, ETCO₂, HR, SBP and DBP, pain scores (at rest and movement), and sedation scores were recorded every 30 minutes during the initial 2 hours and 4, 8, 24, and 48 hours from T0. Also, postoperative tramadol consumption, the time to the first analgesic request, and any complications were also recorded.

Results

There were no statistically significant differences among the three groups regarding demographic data, SPO₂, ETCO₂, HR, SBP and DBP intraoperatively. Moreover, no significant difference was found in HR, SBP and DBP postoperatively. Postoperative pain scores were significantly higher in group BP, whether at rest or movement. The sedation was significantly higher in PBD group in the first 12 hours postoperatively. There was a significantly lower postoperative tramadol consumption in PBN group and a significantly longer time to the first analgesic request than other groups. No complications were reported in any group.

Conclusions

Addition of nalbuphine 10 mg as an adjuvant to bupivacaine local anesthetic in PVB improved the quality of the block and decreased postoperative analgesic requirements than the bupivacaine only group and dexmedetomidine and bupivacaine group. However, adding dexmedetomidine to bupivacaine increased the time to the first analgesic request and more sedation than bupivacaine and bupivacaine and nalbuphine.