Pharmacokinetics of Nasal Esketamine in Patients with Allergic Rhinitis with and Without Nasal Decongestant Pretreatment and in Healthy Subjects with and Without Nasal Corticosteroid Pretreatment.

BACKGROUND AND OBJECTIVES: Nasal esketamine is indicated for the treatment of adults with treatment-resistant depression and depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior. Primary objectives of this study were to evaluate the effect of nasal decongestant pretreatment in patients with allergic rhinitis and the impact of daily nasal corticosteroid administration by healthy subjects on nasal esketamine pharmacokinetics. METHODS: Patients with allergic rhinitis self-administered 56 mg of nasal esketamine after pretreatment with nasal oxymetazoline (0.05%) at 1 h before esketamine and without oxymetazoline pretreatment. They were exposed to grass pollen in an allergen challenge chamber to induce allergic rhinitis symptoms at approximately 2 h before each esketamine administration until 1 h after. Healthy subjects self-administered esketamine (56 mg) before and after administration for 16 consecutive days of mometasone (200 µg), with the second esketamine dose administered 1 h after the last mometasone dose. The plasma pharmacokinetics of esketamine and noresketamine were assessed after each esketamine administration. The tolerability of esketamine, including effects on dissociative and potential psychotomimetic symptoms and level of sedation and suicidal ideation and behavior, was evaluated. RESULTS: The rate of esketamine absorption was slightly greater in patients exhibiting symptoms of allergic rhinitis (decrease in median tmax from 32 min to 22 min). Increases in esketamine Cmax and AUC were also small (mean, ≤ 21%). The pharmacokinetics of esketamine was not affected by oxymetazoline or mometasone pretreatment. Esketamine was well tolerated when it was administered with or without pretreatment of oxymetazoline or mometasone. CONCLUSIONS: Patients exhibiting symptoms of rhinitis may receive nasal esketamine spray without dose adjustment. In addition, esketamine may be administered 1 h after using a nasal decongestant or corticosteroid. TRIAL REGISTRATION: The study was registered in the Clinical Trials (NCT02154334) and EudraCT (2014-000534-38) registries.

Topical Nasal Decongestant Oxymetazoline: Safety Considerations for Perioperative Pediatric Use.

The over-the-counter nasal decongestant oxymetazoline (eg, Afrin) is used in the pediatric population for a variety of conditions in the operating room setting. Given its vasoconstrictive properties, it can have cardiovascular adverse effects when systemically absorbed. There have been several reports of cardiac and respiratory complications related to use of oxymetazoline in the pediatric population. Current US Food and Drug Administration approval for oxymetazoline is for patients ≥6 years of age, but medical professionals may elect to use it short-term and off label for younger children in particular clinical scenarios in which the potential benefit may outweigh risks (eg, active bleeding, acute respiratory distress from nasal obstruction, acute complicated sinusitis, improved surgical visualization, nasal decongestion for scope examination, other conditions, etc). To date, there have not been adequate pediatric pharmacokinetic studies of oxymetazoline, so caution should be exercised with both the quantity of dosing and the technique of administration. In the urgent care setting, emergency department, or inpatient setting, to avoid excessive administration of the medication, medical professionals should use the spray bottle in an upright position with the child upright. In addition, in the operating room setting, both monitoring the quantity used and effective communication between the surgeon and anesthesia team are important. Further studies are needed to understand the systemic absorption and effects in children in both nonsurgical and surgical nasal use of oxymetazoline.

[A COMPARATIVE ANALYSIS OF THE DISPERSION QUALITY OF NASAL SPRAYS OXYMETAZOLINE].

The subject matter of the investigation is to compare the metered dose nasal sprays containing the long-acting decongestant oxymetazoline from the different manufacturers according to the dispersion quality: the dose quantity in one packing, the dose mass reproducibility, imprint area on the planar imitation model. The tests were conducted: «The number of doses per package¼, «Mass uniformity of the dose¼, «Irrigated area (on the planar imitation model)¼. The analysis of nine oxymetazoline nasal sprays demonstrates that the optimal result is achieved while usingVicks Sinex.

Hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children.

OBJECTIVES/HYPOTHESIS: Oxymetazoline is an α-adrenergic agonist that is commonly used as a topical hemostatic agent in the operating room during ear, nose, and throat surgery. There are limited data on oxymetazoline pharmacokinetics in children who undergo general anesthesia. We assessed the hemodynamic effects and systemic absorption of topically applied oxymetazoline in children undergoing various nasal procedures. STUDY DESIGN: Prospective trial. METHODS: Children ages 2 to 17 years undergoing functional endoscopic sinus surgery, turbinate resection, or adenoidectomy were enrolled. The surgeon placed oxymetazoline-soaked pledgets (1.5 mL of 0.05% solution) according to our usual clinical practice. Blood samples for oxymetazoline assay were drawn at 5, 10, 20, 45, 90, and 150 minutes, and hemodynamic data were recorded at 5-minute intervals. Data analysis included mixed-effects regression and population pharmacokinetic/pharmacodynamic modeling. RESULTS: The analysis included 27 patients, age 7 ± 4 years, who received between 2 and 12 pledgets (3-18 mL) of oxymetazoline. Relative bioavailability compared to the spray formulation was 2.3 (95% confidence interval [CI]: 1.6-3.2), with slow absorption from the mucosal surface (absorption half-life 64 minutes; 95% CI: 44-90). Mean arterial pressure did not increase with oxymetazoline instillation at the observed oxymetazoline serum concentrations (0.04-7.6 µg/L). CONCLUSIONS: Despite concerns regarding oxymetazoline administration to mucosal membranes, we found that hemodynamic changes were clinically negligible with our usual clinical use of pledgets soaked in oxymetazoline. Compared to data on oxymetazoline in spray formulation, bioavailability was increased twofold with pledgets, but systemic absorption was very slow, contributing to low serum concentrations and limited hemodynamic effects. LEVEL OF EVIDENCE: 1b. Laryngoscope, 129:2775-2781, 2019.

Clinical Pharmacokinetics of Oxymetazoline Cream Following Topical Facial Administration for the Treatment of Erythema Associated With Rosacea.

BACKGROUND: Oxymetazoline cream 1.0% is FDA-approved for the topical treatment of persistent facial erythema associated with rosacea in adults. This phase 2, multicenter, randomized, double-blind, parallel-group study assessed the pharmacokinetics, safety, and tolerability of oxymetazoline in patients with moderate to severe erythema associated with rosacea. METHODS: Eligible patients were randomized to 1 of 8 treatment groups (oxymetazoline cream 0.5%, 1.0%, or 1.5% or vehicle applied topically either once or twice daily for 28 days). Pharmacokinetic analyses were conducted in patients receiving oxymetazoline. Plasma samples for pharmacokinetic assessments were collected prior to dosing and 6 times postdose on days 1 and 28. RESULTS: A total of 356 patients were included in the safety population (oxymetazoline, n=268; vehicle, n=88). Thirty patients (11.2%) in the oxymetazoline group reported treatment-related treatment-emergent adverse events, most of which were mild to moderate application-site reactions. Oxymetazoline, at all concentrations, was generally safe and well tolerated. Mean maximum observed plasma concentrations were ≤115 pg/mL across all groups; the highest mean values for area under the plasma concentration-time curve from time 0 to 24 hours following once- and twice-daily administration of oxymetazoline 1.5% were 1680 pg•h/mL and 2660 pg•h/mL, respectively. Systemic exposure to oxymetazoline increased dose proportionally with once- and twice-daily administration. CONCLUSION: These findings support the use of oxymetazoline for the treatment of persistent facial erythema associated with rosacea. J Drugs Dermatol. 2018;17(2):213-220.

Role of Topical Oxymetazoline for Management of Erythematotelangiectatic Rosacea.

OBJECTIVE: To review and summarize topical oxymetazoline's pharmacology, pharmacokinetics, efficacy, safety, cost, and place in therapy for persistent redness associated with erythematotelangiectatic rosacea. DATA SOURCES: Literature searches of MEDLINE (1975 to September 2017), International Pharmaceutical Abstracts (1975 to September 2017), and Cochrane Database (publications through September 2017) using the terms rosacea, persistent redness, α -agonist, and oxymetazoline. STUDY SELECTION AND DATA EXTRACTION: Results were limited to studies of human subjects, English-language publications, and topical use of oxymetazoline. Relevant materials from government sources, industry, and reviews were also included. DATA SYNTHESIS: Data support the efficacy of oxymetazoline for persistent facial redness. Little study beyond clinical trials cited in the drug approval process has been conducted. Current data suggest that oxymetazoline is similar in safety and efficacy to brimonidine. Head-to-head comparisons of topical α-agonists for erythema caused by rosacea are needed. CONCLUSION: The topical α-agonist, oxymetazoline, is safe and effective for reducing persistent facial redness associated with erythematotelangiectatic subtype of rosacea. Health care practitioners selecting among treatments should consider not only the subtype of rosacea but also individual patient response, preference, and cost.

Population Pharmacokinetics of an Intranasally Administered Combination of Oxymetazoline and Tetracaine in Healthy Volunteers.

The primary objective of the current investigation was to establish the pharmacokinetic characteristics of oxymetazoline and tetracaine's primary metabolite, para-butylaminobenzoic acid (PBBA), after the intranasal administration of oxymetazoline/tetracaine. Thirty-six subjects contributing a total of 1791 plasma concentration results from 2 open-label trials were utilized. Model development was achieved using data from the second trial (N = 24) in which 0.3 mg oxymetazoline/18 mg tetracaine was administered. External model validation utilized data from the first trial (N = 12), which included doses of 0.3 mg oxymetazoline/18 mg tetracaine and 0.6 mg oxymetazoline/36 mg tetracaine. Oxymetazoline and PBBA dispositions were described by a 2-compartment model with first-order absorption. An allometric model for body weight was included on volumes and clearances to describe unexplained between-subject variability. The final oxymetazoline parameter estimates were ka 4.41 h-1 ; peripheral volume 418 L; clearance 66.4 L/h; central volume 6.97 L; and intercompartmental clearance 419 L/h for a 70-kg subject. The final PBBA parameter estimates were ka 8.51 h-1 ; peripheral volume 32.0 L; clearance 16.7 L/h; central volume 29.8 L; and intercompartmental clearance 2.43 L/h for a 70-kg subject. Between-subject variability ranged from 14% to 39% for oxymetazoline and from 10% to 94% for PBBA.

Assessment of nasal spray deposition pattern in a silicone human nose model using a color-based method.

PURPOSE: To develop a simple and inexpensive method to visualize and quantify droplet deposition patterns. METHODS: Deposition pattern was determined by uniformly coating the nose model with Sar-Gel (a paste that changes from white to purple on contact with water) and subsequently discharging sprays into the nose model. The color change was captured using a digital camera and analyzed using Adobe Photoshop. Several tests were conducted to validate the method. Deposition patterns of different nasal sprays (Ayr, Afrin, and Zicam) and different nasal drug delivery devices (Afrin nasal spray and PARI Sinustar nasal nebulizer) were compared. We also used the method to evaluate the effect of inhaled flow rate on nasal spray deposition. RESULTS: There was a significant difference in the deposition area for Ayr, Afrin, and Zicam. The deposition areas of Afrin nasal spray and PARI Sinustar nasal nebulizer (2 min and 5 min) were significantly different. Inhaled flow rate did not have a significant effect on the deposition pattern. CONCLUSIONS: Lower viscosity formulations (Ayr, Afrin) provided greater coverage than the higher viscosity formulation (Zicam). The nebulizer covered a greater surface area than the spray pump we evaluated. Aerosol deposition in the nose model was not affected by air flow conditions.

Passive and oxymetazoline-enhanced delivery with a lens device: pharmacokinetics and efficacy studies with rabbits.

PURPOSE: The aims of this study were to assess the trans-scleral delivery of dexamethasone phosphate (DexP) with a prototype lens device and a formulation comprising a vasoconstrictor and to determine the efficacy of this delivery system in treating experimentally induced uveitis in a rabbit model. METHODS: Passive trans-scleral delivery was performed on New Zealand white rabbits in vivo, using the lens device and a formulation of 0.034 M oxymetazoline (OMZ, the vasoconstrictor) and 0.5 M of dexamethasone sodium phosphate (DexNaP). Trans-scleral delivery of DexP without OMZ was the control. The amounts of DexP delivered into the eye and its distributions in the eye were determined by dissection of the eye and high-performance liquid chromatography assay in the pharmacokinetics study. The efficacy of the DexP delivery system in treating lipopolysaccharide-induced uveitis was also evaluated in the rabbit model in vivo. The effect of OMZ upon DexP delivery and its treatment efficacy was studied by comparing the DexP results with and without OMZ. RESULTS: In the pharmacokinetics study, the amounts of DexP delivered into the eye using the lens system with OMZ were significantly higher than those without OMZ. The results in the efficacy study showed a better treatment outcome with OMZ to relieve the symptoms of endotoxin-induced uveitis in rabbits. CONCLUSIONS: The potential of vasoconstrictors to enhance eye disease treatments in passive trans-scleral drug delivery was demonstrated. The higher DexP level in the eye and the improvement of the outcome in the efficacy study in the presence of the vasoconstrictor are consistent with the hypothesis that the vasoconstrictor enhances drug delivery by decreasing clearance.

The effect of inferior turbinate hypertrophy on nasal spray distribution to the middle meatus.

The distribution of topical nasal sprays is suboptimal, the main obstruction to adequate delivery in normal volunteers being the nasal valve. We aimed to test the hypothesis that, in patients with rhino-sinusitis, hypertrophy of the inferior turbinate also limits the distribution of administered drug to the middle meatus. We modelled the effect of inferior turbinate hypertrophy and reduction by effecting congestion (by ipsilateral isometric exercise) and decongestion (topical oxymetazoline) in normal volunteers. The method chosen to estimate drug delivery to the middle meatus used endoscopic photography after the administration of dyed aqueous spray. A randomized cross-over study design was used and 20 nasal cavities were studied. The congestion/decongestion manoeuvres significantly altered nasal airflow, as measured by peak inspiratory nasal flow (P < 0.001). Congestion diminished significantly drug delivery to the middle meatus, as compared with decongestion (P = 0.026). This may support a clinical role for inferior turbinate reduction to improve the efficacy of topical nasal therapy, as well as improving nasal airflow.

Rapid liquid chromatographic-mass spectrometric assay for oxymetazoline in whole rat blood.

A rapid HPLC-electrospray mass spectrometric assay for the quantitation of oxymetazoline in whole rat blood has been developed. Sample preparation was a single liquid-liquid extraction after addition of a deuterated internal standard (IS) and pH adjustment. An aliquot of reconstituted extract was injected onto a narrow-bore octadecyl reversed-phase column at a flow-rate of 400 microliters/min. Using a 20:1 post-column split, 5% of the eluent was introduced into the mass spectrometer interface. Elution of the analyte and IS occurred in less than 2 min. This rapid separation was made possible because of the sample cleanup and the selectivity of the mass spectrometric detection. The [M+H]+ ions for oxymetazoline (m/z 261) and [2H9]oxymetazoline (m/z 270) were detected using selected ion monitoring. The linear range of the assay was 0.67-167 ng/g of blood and the limit of quantitation with a 0.30-g sample was 1.0 ng/g. The assay permitted the analysis of nine samples per hour with the requisite sensitivity and selectivity and was used to determine the blood pharmacokinetics of oxymetazoline in rats dosed via intravenous and intranasal routes.

Gap junctions modulate tissue contractility and alpha 1 adrenergic agonist efficacy in isolated rat aorta.

Immunocytochemical analysis, using antibodies directed against connexin43, revealed abundant gap junctions between smooth muscle cells in intact aorta from Fischer 344 rats. Therefore, the authors evaluated the potential contribution of these intercellular junctions to contractile responses elicited by alpha 1 adrenergic receptor activation in rat aortic rings. Preincubation with the selective junctional uncoupling agent heptanol (200 microM) diminished the magnitude of contractions induced by the low-efficacy partial agonist oxymetazoline (1-3 microM) by 50.6 +/- 4.5% (P < .01; n = 16 rings from 16 rats) but had no effect on equivalent contractions induced by the high-efficacy agonist phenylephrine (0.1 microM; n = 16 rings from 16 animals). Reduced phenylephrine contractility was observed at higher heptanol concentrations (500 microM). However, neither 200 nor 500 microM heptanol altered the magnitude of contractions elicited by 60 mM KCl, indicating that tissue contractility per se was unaffected by heptanol. In calcium-free solution, the magnitude of the phasic contraction induced by phenylephrine was three-fold greater than the magnitude of the oxymetazoline-induced phasic contraction (P < .001) but the phasic responses to both agonists were unaffected by the same heptanol concentrations that significantly diminished their steady-state responses. Because heptanol, at the concentrations used, has selective pharmacological actions on gap junctions, these studies provide additional support for a role of gap junctions in the maintenance and modulation of vasomotor tone. In rat aorta, junctional transfer of alpha 1 adrenergic-receptor activated second-messenger molecules appears to be an important modulator of tissue contractility and agonist efficacy.

A comparative distribution study of two procedures for administration of nose drops.

The intranasal distribution of nose drops has been studied in 12 healthy subjects, comparing an administration followed by two rapid inhalations through the nose, with an administration followed by turning the head to five positions. Insoluble particles of human serum albumin labelled with 99Tcm were suspended in the liquid before administration. A significantly larger area (p less than 0.05) in the nasal cavity was covered by the labelled nose drops when the subjects used the turning-the-head procedure. It appears that this procedure gave a larger passive distribution of the particles. The differences were about 10 to 15% between 3 and 45 min after administration. Some particles were rapidly transported into the pharynx. The retention of the particles at the initial site of deposition did not differ significantly between the two procedures and about 50% of the particles seemed to have penetrated to the ciliated region in the main nasal passages and were cleared. The results indicate that the procedure for administration of the nose drops influences the distribution in the nasal cavity, but the clinical relevance should be studied with respect to the efficacy of the active drug in patients.

A new nasal decongestant, A-57219: a comparison with oxymetazoline.

2-(4-Amino-3,5-dichlorobenzyl)imidazoline hydrochloride (A-57219), has alpha 1-agonist/alpha 2-antagonist activity and was more effective and long-acting than oxymetazoline on canine nasal mucosa, in-vitro and in-vivo. Upon intranasal administration to dogs, the compound was devoid of systemic effects up to a concentration 1000 times that needed for local decongestant effect (1.65 micrograms, atomized from a 1 microgram mL-1 solution) suggesting limited mucosal absorption. After nasal administration to rats for 15 days at a concentration 1000 times greater than that required for nasal decongestion, no mucosal tissue toxicity or systemic effects were seen.