Gilbert J. Grant

A novel liposomal bupivacaine formulation to produce ultralong-acting analgesia

Background:Currently available local anesthetics have relatively brief durations of action. An ultralong-acting local anesthetic would benefit patients with acute and chronic pain. The authors prepared and characterized a novel liposomal bupivacaine formulation using remote loading of bupivacaine along an ammonium sulfate gradient and assessed its efficacy in humans. Methods:A large multivesicular liposomal bupivacaine formulation was prepared by subjecting small unilamellar vesicles to successive freeze-and-thaw cycles. Bupivacaine hydrochloride was then remotely loaded into the liposomes along an ammonium sulfate gradient ([(NH4)2SO4)]intraliposome/[(NH4)2SO4)]medium > 1,000). The liposomes were then characterized for size distribution; drug-to-phospholipid ratio; in vitro release profile at 4°, 21°, and 37°C; sterility; and pyrogenicity. Six subjects each received six intradermal injections in the lower back with 0.5 ml of 0.5, 1.0, and 2% liposomal bupivacaine; 0.5% standard bupivacaine; saline; and “empty” liposomes. Duration of analgesia was assessed using pinprick testing of the skin directly over the injection sites. Results were compared using the log-rank test. Results:The mean large multivesicular vesicle size was 2,439 ± 544 nm, with a drug-to-phospholipid ratio of 1.8, fivefold greater than results previously reported. In vitro release was slowest at 4°C. The median duration of analgesia with 0.5% standard bupivacaine was 1 h. The median durations of analgesia after 0.5, 1.0, and 2.0% liposomal bupivacaine were 19, 38, and 48 h, respectively. Neither saline nor “empty” liposomes produced analgesia. Conclusions:This novel liposomal formulation had a favorable drug-to-phospholipid ratio and prolonged the duration of bupivacaine analgesia in a dose-dependent manner. If these results in healthy volunteers can be duplicated in the clinical setting, this formulation has the potential to significantly impact the management of pain.

HOT PLATE VERSUS TAIL FLICK : EVALUATION OF ACUTE TOLERANCE TO CONTINUOUS MORPHINE INFUSION IN THE RAT MODEL

The development of tolerance to continuous morphine infusion (2, 4 and 6 mg x kg(-1) x hr(-1) was assessed in rats using two different methods for evaluation of nociception, tail flick (TF) and hot plate (HP). The influence of repeated testing on nociception was evaluated using two regimens; series 1 was tested repeatedly 1, 2, 4, 6, and 8 hr after initiating the morphine infusion and series 2 was tested only twice, at maximum morphine effect and at 8 hr. Both, TF and HP showed pain threshold elevation after the morphine administration of 4 or 6 mg x kg(-1) x hr(-1), which reached a maximum at 2 hr after the start of the infusion. HP: reduction of the effect was found in group 4 mg x kg(-1) x hr(-1) in the series subjected to repeated testing; group 6 mg x kg(-1) x hr(-1) showed reduced effect in both sides. TF: the response latencies did not show reduction at 8 hr. Since TF is predominantly a spinal response and HP is predominantly supraspinal, the results suggest that tolerance during the first 8 hr of morphine infusion develops mainly at supraspinal level.

DRV Liposomal Bupivacaine: Preparation, Characterization, and In Vivo Evaluation in Mice

AbstractPurpose. To evaluate the dehydration-rehydration technique to prepare a formulation of liposomal bupivacaine, and to assess its analgesic efficacy. Methods. Bupivacaine hydrochloride (BUP) was encapsulated into dehydration-rehydration vesicles (DRV) of varying phospholipid (PL) compositions. Two bilayer-forming phospholipids were used, the “fluid” dimyristoyl-phosphatidylcholine and the “solid” dis- tearoyl-phosphatidylcholine (DSPC), with 20 or 40 mol% cholesterol, in the presence of bupivacaine at a 1.28 or 0.64 BUP/PL mole ratio. After rehydration, drug/lipid ratios were determined. The formulation with the highest drug/lipid ratio (DSPC/cholesterol in an 8:2 mole ratio prepared in the presence of bupivacaine in a 1.28 BUP/PL mole ratio) was adjusted to a final bupivacaine concentration of 3.5% or 0.5%. The duration of skin analgesia after subcutaneous injection in mice produced by these formulations was compared with the conventional administration of a plain 0.5% solution of BUP. In addition, the concentration of residual bupivacaine at the injection site was followed for 96 h. Results. The relatively low organic solvent/aqueous phase and membrane/aqueous phase partition coefficients, together with liposomal trapped volume and BUP/PL mole ratio, indicated that most of the drug was encapsulated in the intraliposome aqueous phase of the DRV. The DSPC/cholesterol 8:2 mole ratio had the best drug encapsulation (BUP/PL = 0.36). Compared to plain BUP, these BUP-DRV produced significant prolongation of analgesia, which is explained by longer residence time of the drug at the site of injection. Conclusions. Bupivacaine-DRV may have a role in achieving safe, effective, and prolonged analgesia in humans.

Liposomal delivery systems for local anesthetics

The use of local anesthetics to treat pain has many potential advantages compared to the systemic administration of opioid analgesics. Local infiltration of an analgesic at the painful site avoids possible opioid side effects, including respiratory depression, sedation, nausea, vomiting, pruritus, urinary retention, impaired bowel motility, and development of tolerance. However, the results of clinical trials of local anesthetic infiltration to manage postoperative pain have often been disappointing, primarily due to local pharmacokinetic factors. Being relatively small-sized molecules, local anesthetics readily traverse blood vessel walls and are thus removed from the injection site. This rapid redistribution from the site limits the duration of effective analgesia, and the usefulness of this approach to pain control. Despite this limitation, the concept of local anesthetic infiltration to manage postoperative or posttraumatic pain remains appealing. Often in the past, research efforts to prolong local anesthetic duration centered on structural alterations of the local anesthetic molecule and identification of new agents with local anesthetic action. More recently, the focus has shifted to drug delivery systems that act as reservoirs for local anesthetics. Two essential criteria for an effective drug delivery system are residence time at the injection site and drug release rate. The carrier vehicle must be of sufficient size to resist rapid redistribution from the injection site. Furthermore, slow and sustained drug release from the carrier vehicle is needed to produce significant prolongation of analgesia. Investigators have been experimenting with a variety of matrices as carrier vehicles for local anesthetics. This review is limited to examining one type of carrier vehicle, liposomes, which have already been shown to effectively prolong analgesia in an animal-wound model.1 Liposomes, microscopic lipid vesicles formed when dry lipids are suspended in an excess of water, were first described in 1965. Since then, many types of liposomes have been elaborated. When amphipathic lipid molecules with a polar “head” and 2 hydrophobic hydrocarbon “tails” are suspended in aqueous medium, they spontaneously associate into bilayers. The structure of each bilayer resembles that of animal cell membranes, with the hydrocarbon chains oriented toward one another and the polar head group moieties in contact with the surrounding aqueous phase. The resulting vesicle structure consists of an aqueous compartment surrounded by one or more lipid bilayer(s). The lipid bilayer is relatively impermeable to entrapped substances. Liposome architecture is determined by the nature of the interactions between the lipids and the aqueous medium that occur during the preparation process. Liposomes with a single bilayer, or lamella, are known as unilammellar vesicles, and liposomes with many concentric bilayers are known as multilamellar vesicles. Other liposomes, composed of many smaller vesicles within larger vesicles, are known as multivesicular vesicles. In addition to differing structures, liposome size may vary from less than 20 nm to many microns in diameter. Both water-soluble and lipid-soluble drugs may be incorporated into the aqueous and lipid phases of liposomes, respectively. The liposomes function as vehicles to deliver drugs in high concentrations to specific targets while avoiding systemic drug toxicity, because only a fraction of the drug is bioavailable at any time. Liposomal behavior in vivo and drug release characteristics are dictated by liposome size, structure, and composition. Liposomal size affects in vivo distribution. For example, after subcutaneous administration, liposomes less than 120 nm in diameter readily gain access to capillaries and are thus rapidly redistributed from the site of injection, whereas relatively large liposomes tend to remain From the Department of Anesthesiology, New York University School of Medicine, New York, New York. Accepted for publication August 12, 2000. Reprint requests: Gilbert J. Grant, M.D., Associate Professor, Department of Anesthesiology, New York University School of Medicine, 550 First Ave, New York, NY 10016. E-mail: gilbert.grant@med.nyu.edu

Wound infiltration with liposomal bupivacaine prolongs analgesia in rats

Background:Wound infiltration with local anesthetics does not reliably produce satisfactory postoperative analgesia, and the dose of local anesthetic which may be safely administered is limited by the potential for systemic toxicity. This study evaluated the efficacy of a slow‐release liposomal bupivacaine formulation on duration of wound analgesia.

Prolongation of epidural anesthesia using a lipid drug carrier with procaine, lidocaine, and tetracaine

This study evaluated the effect of a lipid drug carrier (iophendylate) on epidural anesthesia. The intensity and duration of motor blockade produced by aqueous and lipid preparations of local anesthetics were assessed in rabbits with long-term indwelling catheters in the epidural space. Motor blockades produced by procaine (1%, 2%, and 4%), lidocaine (1%, 2%, and 4%), and tetracaine (0.5%, 1%, and 2%) in normal saline solution were compared with the effects produced by equimolar amounts of the drug solutions in iophendylate. Procaine (4%) in aqueous solution produced motor blockade lasting 30 +/- 3.54 min (mean +/- SD) versus 84 +/- 4.18 min in lipid solution. Lidocaine (2% and 4%) in aqueous solution produced motor blockade lasting 41 +/- 4.18 and 65 +/- 6.12 min versus 39 +/- 4.18 and 118 +/- 10.1 min, respectively, in lipid solution. Aqueous tetracaine (0.5%, 1%, and 2%) produced motor blockade of 106 +/- 9.62, 189 +/- 6.52, and 273 +/- 26.8 min versus 284 +/- 14.7, 335 +/- 15.8, and 365 +/- 26.9 min, respectively, in their lipid counterparts. A control group of animals that received normal saline solution or iophendylate alone did not exhibit motor blockade. These results may be attributed to sustained release of local anesthetics from the lipid vehicle. Hence, lipid drug carriers may be effective in prolonging epidural anesthesia.

The partition coefficient as a predictor of local anesthetic potency for spinal anesthesia : evaluation of five local anesthetics in a mouse model

Local anesthetic partition coefficients correlate with drug potencies in vitro, but in vivo data have not always complimented in vitro results. Despite extensive studies on intrathecal anesthetic action, whether there is correlation between the partition coefficient and local anesthetic potency has not been addressed. Mice (n = 150) were randomly allocated into 15 groups. Intrathecal injections of etidocaine (E), tetracaine (T), bupivacaine (B), lidocaine (L), or procaine (P) were administered and analgetic effect was measured using tail-flick (TF) test. Concentration-response regressions were constructed for each drug; EC50 values were calculated and compared at 95% confidence intervals. The EC50 values between E (0.017%), T (0.019%), and B (0.012%) were not significantly variant. The EC50 of L (0.098%) and P (0.229%) were significantly different from each other and from E, T, and B. The EC50 values were converted to ED50 in nmols. Relative anesthetic potency, defined as the inverse value of ED50 of drug was 23:16:15:2.4:1 for B, E, T, L, and P, respectively. ED50 showed high correlation (R = 0.978) with partition coefficients of local anesthetics. This study implies that the partition coefficient is a predictor of intrathecal local anesthetic potency. We suggest that the mouse model is reliable for evaluation of intrathecal local anesthetic action.

Prolonged analgesia from Bupisome and Bupigel formulations: From design and fabrication to improved stability

There is a compelling need for an ultralong-acting local anesthetic. Previously, we demonstrated in mice and humans that encapsulation of bupivacaine into large multivesicular liposomes (Bupisome) prolongs drug residence time and analgesic duration at the injection site while reducing peak plasma concentration. However, we observed considerable leakage of bupivacaine from the liposomes during storage at 4 °C. This deficiency was overcome by modifying the lipid composition of Bupisome and by entrapping them in a Ca-alginate cross-linked hydrogel (Bupigel), forming stable, soft, injectable (3-5 mm) beads. Bupisome are not released from Bupigel, but their encapsulated bupivacaine is released into the bulk solution. Adding 0.5% to 2.0% free bupivacaine to the Bupigel prevented net loss of bupivacaine from the Bupisome after storage at 4 °C for 2 years, and at 37 °C enough bupivacaine was released to prolong analgesia. For injection subcutaneously into mice, the beads are drawn into a syringe, leaving the small amount of free bupivacaine behind. Both Bupisome and Bupigel formulations significantly prolonged analgesia in mice compared to standard bupivacaine, with Bupigel performing better than Bupisome.

Prolonged analgesia and decreased toxicity with liposomal morphine in a mouse model.

Inadequate control of postoperative pain remains a major clinical problem. A reliable method of providing long-lasting postoperative analgesia with a single dose would be very useful. We synthesized a liposomal morphine formulation and compared it to free morphine with regard to duration of analgesia in the mouse. Analgesia was assessed after intraperitoneal injection using the tail-flick test. The systemic toxicity after administration of liposomal and free morphine was compared. The release rate of morphine from liposomes in vitro was also evaluated. The lethal intraperitoneal dose of free morphine in 50% of mice (LD50) was 400 mg/kg. The maximum safe (non-lethal) dose of free morphine was 130 mg/kg. The highest dose of liposomal morphine administered (1650 mg/kg) did not cause death in any animal. Duration of analgesia was significantly prolonged with the highest dose of liposomal morphine (21.5 +/- 5.3 h) compared to the maximum safe dose of free morphine (3.7 +/- 0.75 h), P < 0.01. In vitro experiments showed a slow release rate of morphine from the liposome depot. Prolonged analgesia and decreased systemic toxicity for liposomal morphine are explained by sustained release of morphine from the liposomal depot. These results suggest that liposomal narcotic formulations may provide prolonged analgesia with single-dose administration.

A rat sciatic nerve model for independent assessment of sensory and motor block induced by local anesthetics.

The purpose of this study was to develop a reliable model to independently quantify motor and sensory block produced by local anesthetics. The sciatic nerve was blocked in 52 rats by injecting 0.2 mL of 0.125%, 0.25%, 0.5%, or 0.75% bupivacaine (n = 13 for each concentration). Accurate needle placement was achieved using a nerve stimulator at 0.2 mA and 1 Hz. Ten control rats received 0.9% saline (n = 5) or sham nerve stimulation (n = 5). Motor block was assessed by measuring hindpaw grip strength with a dynamometer. Sensory block was determined by measuring hindpaw withdrawal latency from radiant heat. The intensity of both motor and sensory block measured at 30-min intervals was plotted against time until full recovery to obtain the area under the curve. Intergroup comparisons using analysis of variance showed increasing area under the curve with increasing concentrations of bupivacaine for motor blocks (P < 0.05 for all intergroup comparisons except 0.5% vs 0.75%) and sensory blocks (P < 0.05 for all intergroup comparisons). Normal saline or sham nerve stimulation did not result in any motor or sensory block.