Liposomal Bupivacaine: An Innovative Nonopioid Local Analgesic for the Management of Postsurgical Pain

Local anesthetics are a cornerstone of multimodal pain control strategies in the surgical setting as they have a long history of use and an established safety profile. Although effective, their duration of action is relatively short, which usually leads to the use of other agents, such as opioids, for effective postsurgical pain control in most patients. A medical need exists to extend the duration of analgesia with local anesthetics to help reduce the reliance on opioids in the postsurgical setting. Liposomal bupivacaine uses a product delivery platform to release bupivacaine slowly over 96 hours after infiltration at the surgical site. Liposomal bupivacaine was compared with placebo in two pivotal, multicenter, randomized, double-blind, parallel-group trials in 189 adults undergoing soft-tissue surgery (hemorrhoidectomy) and 193 adults undergoing orthopedic surgery (bunionectomy). Among patients undergoing hemorrhoidectomy, liposomal bupivacaine significantly reduced cumulative pain scores for up to 72 hours (primary end point) as measured by the area under the curve of pain scores on the numeric rating scale (p<0.0001), reduced overall opioid consumption (p ≤ 0.0006), increased the proportion of patients who did not receive opioids (p<0.0008), delayed time to first opioid by more than 13 hours (p<0.0001), and was associated with significantly higher rates of patient satisfaction (p=0.0007) compared with placebo. Similarly, in patients undergoing bunionectomy, liposomal bupivacaine significantly reduced total consumption of rescue opioids (p=0.0077) and cumulative pain scores as measured by the area under the curve of pain scores on the numeric rating scale (p=0.0005) during the first 24 postsurgical hours (primary end point) relative to placebo. Furthermore, liposomal bupivacaine also significantly delayed the time to first use of opioid rescue (p<0.0001) and increased the proportion of patients requiring no rescue opioid treatment (p ≤ 0.0404) compared with placebo. The most common adverse events with liposomal bupivacaine were nausea, vomiting, and constipation. No adverse effects on the QTc interval or cardiac safety signal have been detected in the clinical trial development program (823 patients) when liposomal bupivacaine was infiltrated into the surgical site. The beneficial effects of liposomal bupivacaine on postsurgical pain management and opioid use, significantly reducing both, are likely to translate into improved clinical and economic outcomes

Chiropractic Response to a Spontaneous Vertebral Artery Dissection

OBJECTIVE: The purpose of this case report is to describe a case in which early detection and proper follow-up of spontaneous vertebral artery dissection led to satisfactory outcomes. CLINICAL FEATURES: A 34-year old white woman reported to a chiropractic clinic with a constant burning pain at the right side of her neck and shoulder with a limited ability to turn her head from side to side, periods of blurred vision, and muffled hearing. Dizziness, visual and auditory disturbances, and balance difficulty abated within 1 hour of onset and were not present at the time of evaluation. A pain drawing indicated burning pain in the suboccipital area, neck, and upper shoulder on the right and a pins and needles sensation on the dorsal surface of both forearms. Turning her head from side-to-side aggravated the pain, and the application of heat brought temporary relief. The Neck Disability Index score of 44 placed the patient’s pain in the most severe category. INTERVENTION AND OUTCOME: The patient was not treated on the initial visit but was advised of the possibility of a vertebral artery or carotid artery dissection and was recommended to the emergency department for immediate evaluation. The patient declined but later was convinced by her chiropractor to present to the emergency department. A magnetic resonance angiogram of the neck and carotid arteries was performed showing that the left vertebral artery was hypoplastic and appeared to terminate at the left posterior inferior cerebellar artery. There was an abrupt moderately long segment of narrowing involving the right vertebral artery beginning near the junction of the V1 and V2 segments. The radiologist noted a concern regarding right vertebral artery dissection. Symptoms resolved and the patient was cleared of any medications but advised that if symptoms reoccurred she was to go for emergency care immediately. CONCLUSION: Recognition and rapid response by the chiropractic physician provided the optimum outcome for this particular patient

Oral formulation of a novel antiviral agent, PG301029, in a mixture of Gelucire 44/14 and DMA (2∶1, wt/wt)

To develop an oral formulation for PG301029, a novel potent agent for the treatment of Hepatitis C virus infection, that not only has very low aqueous solubility but also degrades rapidly in water. The solubility of PG301029 was determined in water, various aqueous media, and several neat organic solvents. The stability of PG301029 was monitored at room temperature in buffess for 4 days, and in several neat organic solvents for up to 8 mo. Drug concentrations were measured by high-performance liquid chromatography (HPLC). Based on solubility and stability data, Gelucire 44/14 and DMA (N,N-dimethylacetamide) at a weight ratio of 2 to 1 were chosen as the formulation vehicle. After the vehicle was prepared, it was maintained in liquid form at ∼40°C until the PG301029 was dissolved. The final formulation product was a semisolid at room temperature. The bioavailability of the formulation was tested on 4 female BALB/c mice. PG301029 is insoluble in all tested aqueous media, while its solubility is promising in DMA. This compound is unstable in aqueous media and some organic solvents; however, it is stable in DMA. This proposed formulation is able to hold up to 10 mg/mL of drug and is stable at 4°C. The shelf life for this formulation stored at 4°C is extrapolated to be greater than 4 years. This formulation dramatically increases the bioavailability of PG301029. This nonaqueous formulation solves the stability, solubility, and bioavailability problems for PG301029. This semisolid formulation can easily be incorporated into soft elastic capsules