Intranasal and rectal diazepam for rescue therapy: assessment of pharmacokinetics and tolerability.

Abstract

The use of rectal diazepam has improved the management of acute repetitive seizures (ARS) outside a health care facility. Two placebo controlled trials have shown that rectal administration of diazepam is safe and effective for treatment of this condition. Diastat® is the only FDA approved treatment for ARS in the United States. Although some older children and adults are willing to use Diastat®, many patients in these age groups as well as physicians and caregivers object to the route of administration and instead use other therapies not approved for this purpose, receive no treatment, or use emergency medical services or acute care systems. We developed and evaluated three nasal spray formulations of diazepam which can be easily administered with rapid absorption characteristics intended as an alternative to rectal administration. One formulation used a supersaturated glycofurol based co-solvent system while the remaining two (Nas-A & Nas-B) used microemulsion based co-solvent systems. These formulations were studied for their pharmacokinetics and tolerability in healthy adult volunteers. Data from these studies were then compared to the pharmacokinetics after rectal administration using both model-based analysis (NONMEM) and graphical methods. The primary finding from this work was that, only the microemulsion-based formulations, particularly Nas-B could be used for further development as the glycofurol formulation was not well tolerated by subjects. The pharmacokinetic profiles after intranasal administration were associated with high variability. However, we are able to show that the dose-normalized partial area under the curve (AUC - an exposure parameter) after nasal administration, at times when the drug concentrations are most important, are 60-80 % of that when given via the rectal route. Given the ease and social acceptability of nasal administration compared to rectal, equivalent exposures can be easily attained by giving a second nasal dose, and we thus conclude that intranasal diazepam is a feasible and preferable alternative to rectal diazepam in the management of ARS outside a hospital. This work also provides some recommendations for future studies in the development of an intranasal product.