Terapie intranasali nelle emergenze pediatriche
Un articolo di Pediatr Emer Care (2014;30: 496-504) fa il punto della straordinaria utilità in pediatria della modalità di somministrazioni di alcuni farmaci di emergenza
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Antonio Clavenna (Laboratorio Materno Infantile Istituto M. Negri) e Maurizio Montalto (Ospedale Cervello Palermo)L’articolo è stato discusso nel JC del 11/1/2017
L’elenco dei farmaci utilizzabili in situazioni di emergenza per via intranasale (con un atomizzatore, come più sotto descritto) è riprodotto di seguito. Per molti però la somministrazione extra-ospedaliera in Italia con questa modalità è impossibile. Si pensi al Midazolam disponibile in farmacia solo nella costosa formulazione orale (circa 130 Euro, il prezzo) mentre la confezione in fiale, che potrebbe essere utilizzata per via nasale, dal costo decisamente più contenuto (circa 5 Euro) è disponibile solo nelle farmacie ospedaliere.
Nella tabella successiva i principali suggerimenti da tenere a mente:
Notizie di background (credit: Medscape)
https://www.medscape.com/viewarticle/730093
“The administration of medications via the intranasal (IN) route is of great interest to the medical community. IN drug administration allows for rapid delivery of medications to a rich vascular plexus for quick absorption into the bloodstream and even directly across the cribriform plate to the cerebrospinal fluid for rapid uptake into the brain. There is great utility in this method of medication in the pre-hospital and emergency medical care arenas, where rapid onset of medication effect is desired, and where often it is difficult to obtain access for medication delivery by alternate routes. (…) There are several methods of IN drug administration (…). The most basic method of delivery of medication to the nasal mucosa is that of snorting. This method is employed by illicit drug users and involves “sniffing” a highly concentrated powder form of drug or medication through a nostril, with subsequent absorption of drug through the nasal mucosa. This method of medication administration is uncomfortable and requires the active and willing participation of the patient, and for this reason is less desirable.
Another manner of IN drug administration is by instilling the drug as a liquid in the nose with a dropper or syringe. For the most part, studies have found that this can be an effective method of drug delivery. However, the disadvantages include a relatively small surface area of mucosa for absorption, and runoff of the medication into the back of the throat. This method of delivery necessitates a recumbent patient who is compliant and will not immediately blow the nose after drug administration.
A more effective technique for IN drug administration is through atomized, or sprayed, delivery. A syringe or unit dose pump of medication is attached to an atomizer tip that sprays the medication into fine particles as they leave the reservoir. Studies have shown that atomizers optimize distribution of drug across the nasal mucosa and lead to an overall increase in bioavailability of medication. Furthermore, the atomizer is more “user-friendly” for both the patient and the healthcare provider. Patients are not required to be in a certain position, and time of administration is so rapid that restraints are not necessary. Because the medication is atomized into a fine mist, it is less likely to be blown out of the nose by the patient before it is absorbed. Several commercially available devices exist today for atomization of medication for IN delivery, including:
1) the MAD (Mucosal Atomization Device) (Sito internazionale) (In vendita in Italia via Aluneb MAD Nasal) (pubblicizzato per altri scopi)
2) the Accuspray Nasal Atomizer (SITO Internazionale: non risulta in vendita in Italia)
3) the Optinose (Sito internazionale, poco utile per le caratteristiche nei bambini, non in vendita in Italia)
4) the ViaNasa Electronic Atomizer.
Una panoramica più completa dei prodotti disponibili a livello internazionale a questo link e a quest’altro
Il full text dell’articolo è disponibile nella nostro dropbox per i soci (vedi nota riservata a fianco)
Question 1
Intranasal medications have the following advantages over oral medications except for
A. less irritation with administration.
B. faster absorption.
C. greater bioavailability.
D. shorter onset of action.Question 2
Which of the following medications would be most suitable for intranasal administration?
A. a high-molecular-weight, lipophilic, high-concentration medication that is slightly acidic
B. a low-molecular-weight, hydrophilic, high-concentration medication with a pH of 7
C. a low-molecular-weight, hydrophilic, low-concentration medication with a pH of 8.2
D. a low-molecular-weight, lipophilic, high-concentration medication with a pH of 7Question 3
Which of the following can interfere with intranasal medication absorption?
A. copious nasal secretions
B. epistaxis
C. nasal polyp
D. all of the aboveQuestion 4
The best absorption of intranasal medication occurs when to a single nostril one delivers volumes less than
A. 1 mL.
B. 0.5 mL.
C. 0.3 mL.
D. 0.1 mL.Question 5
When dripping in intranasal medications, which of the following is the preferred positioning?
A. lying supine
B. standing upright
C. sitting upright
D. lying prone
