Intranasal diamorphine for acute sickle cell pain

Abstract

The painful crisis is the commonest acute presentation of sickle cell disease (SCD), yet effective pain control in hospital is often delayed, inadequate and dependent on injected opiates. Intranasal diamorphine (IND) has been used in paediatric emergency departments for management of acute pain associated with fractures, but the analgesic effect is short lived. We evaluated its efficacy and safety when given in combination with intravenous or oral morphine for rapid analgesia for children presenting to our emergency department with painful crisis of SCD. In phase 1, nine patients received IND plus intravenous morphine. In phase 2, 13 received IND plus oral morphine. There was a rapid improvement in pain score; the proportions in severe pain at t = 0, 15, 30 and 120 minutes in phase 1 were 78%, 11%, 0% and 11%, respectively; in phase 2, 77%, 30%, 15% and 0%, respectively. There were no serious side effects and questionnaire scores indicated that children found IND effective and acceptable. IND can be recommended for acute control of sickle pain in children presenting to hospital.

Lidocaine Pretreatment Reduces the Discomfort of Intranasal Midazolam Administration: A Randomized, Double‐blind, Placebo‐controlled Trial

“…Topical lidocaine has been proposed to mitigate the discomfort associated with a few IN medications . Lugo et al were the first in the medical literature to share their anecdotal success with lidocaine prior to IN midazolam.…”

“…Topical lidocaine has been proposed to mitigate the discomfort associated with a few IN medications. 11,17 Lugo et al 12 were the first in the medical literature to share their anecdotal success with lidocaine prior to IN midazolam. In their population of children undergoing upper endoscopy, they theorized that midazolam causes irritation either by pH, its preservative, or the drug itself, and they felt that lidocaine counteracted this discomfort.…”

Intranasal lidocaine and midazolam for procedural sedation in children

“…In our study, administering lidocaine spray prior to administration of INM, as previously suggested by Lugo et al, 18 prevented children from experiencing unpleasant nasal sensations. Based on this experience, lidocaine spray may be used also for preventing nasal discomfort related to other drugs administered by the intranasal route, such as diamorphine recently utilised in the management of acute sickle cell pain 25. All patients achieved an adequate level of sedation throughout each procedure, without requiring additional drugs or additional doses of midazolam.…”

Sickle cell disease in the United States: Looking back and forward at 100 years of progress in management and survival

“…Another recent study looked at the efficacy and safety of intranasal diamorphine in pediatric patients, when given in combination with intravenous or oral morphine. The study found rapid improvements in pain scores with no serious side effects, making intranasal diamorphone a potential therapy for acute control of sickle cell pain in the hospital [84].…”