# Sublingual ASPIRIN? Google isn't helping.



## mycrofft (Jan 30, 2013)

Closest I can get is an article in NIH about interaction between sublingual nitro combined with regular route ASA.

I have run across this three times in the last week, people claiming to have been told by a/their MD that a sublingual aspirin (acetylsalicylic acid gr. V) after having been chewed or crushed is ok to give buccally or sublingually instead of orally. In primary care I've seen people with buccal burns and dental erosion from doing it repeatedly, but in the emergency arena, is it among the meds that will profitably cross that barrier?
Citation PLEASE.


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## mycrofft (Jan 30, 2013)

*Have dug a little further. Still no authoritative dice.*

Many sites state the medications are rapidly absorbed and better because they "don't undergo first-pass metabolism". HOwever, these sites are all of the generic mold as "wikidiabetes" or "people's epilepsy" or some such. Wikipedia has an entry about sublingual administration 

http://en.wikipedia.org/wiki/Sublingual_administration

but of their (only) five footnotes, four are about sublingual immunizations and one is about the lack of efficacy of an opioid that route. None are about nitro much less aspirin.

I remember from my pharmacodynamic class (if I remember correctly) that the primary strength of effect from most sublinguals (mentioning nitro as an exception) is that they are eventually swallowed.

Any other input? Anyone have sublingual ASA as a protocol?


EDIT: A scholarly article about buccal admin of meds:

http://www.ualberta.ca/~csps/JPPS1(1)/A.Shojaei/buccalreview.htm


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## Veneficus (Jan 30, 2013)

I heard a couple of years ago Bayer was actually working on ASA spray.

I didn't follow up with how it was going.


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## FLdoc2011 (Jan 30, 2013)

Bayer did have a "quick release" ASA product in powder form that was discontinued in 2010 from what I could find.   It contained higher doses of ASA (~850mg) as well as caffeine.... so not the best thing to use as a substitute for ACS.


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## EpiEMS (Jan 30, 2013)

It looks like there are 40 relevant patents (per searching "sublingual aspirin" on Google Patents), though I haven't seen anything on the market. There are also some mentions of "sublingual aspirin" in journal articles (11 per searching "sublingual aspirin" on Google Scholar excluding patents, only 8 of which were actual journal articles; but no articles on PubMed). This is confusing.

If I read them correctly, all of the 8 relevant articles found via Google Scholar indicate that "sublingual aspirin" was used in the context of an acute chest pain presentation, and I think that they're serious. None give any detail as to preparation, or anything really useful.

Seems odd.


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## mycrofft (Jan 30, 2013)

You have more Googles on your Swiss Army Google than I.

And I don't know anyone who has buccal or sublingual ASA in their protocols.

I think this is one of those deals like sublingual sugar, seems to make sense, but just doesn't, and everyone at one time or another considers it.
(There has to be a name for that phenomenon).


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## PaddyWagon (Jan 30, 2013)

Medscape is barren of info on subQ aspirin as well.


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## Akulahawk (Jan 30, 2013)

I have heard of chewed/crushed ASA to be given orally, but sublingual or buccal route is new to me... Haven't heard of such a beast.


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## Veneficus (Jan 30, 2013)

PaddyWagon said:


> Medscape is barren of info on subQ aspirin as well.



Probably because injecting  *acetylsalicylic acid *sounds like a bad idea?


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## mycrofft (Jan 30, 2013)

Veneficus said:


> Probably because injecting  *acetylsalicylic acid *sounds like a bad idea?



Just dilute it enough.

I'd give "N" micrograms of IV potassium but not the same as SQ or IM in the same solution.

We just need to chew more willow cambium layer.

Besides, ASA helps in acute MI  more because it addresses inflammation more than "making blood slippery" right? And addresses the coronary plaque deal similarly?

When I was taking 500 to 1000mg naproxen daily, later warfarin, and now 81mg PO ASA daily, I can tell you that aspirin does NOT block anywhere near as much bleeding as either of the others.


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## Carlos Danger (Jan 30, 2013)

mycrofft said:


> I remember from my pharmacodynamic class (if I remember correctly) that the primary strength of effect from most sublinguals (mentioning nitro as an exception) is that they are eventually swallowed.



That isn't true. The whole point of SL administration is that they _aren't_ swallowed, and therefore avoid the extremely acidic environment of the GI tract as well as first-pass metabolism in the liver. Also, SL absorption is much quicker than GI absorption. SL administration can produce peak plasma levels nearly as fast as IV; must faster than PO.

I would imagine that SL administration would probably work as long as they are tablets that aren't enteric coated. But I've never heard of it.

Drugs meant to be swallowed are often much higher dosages or formulated differently (because of the very different pH's of blood and the GI tract) than those meant to be given IV or SL, so it's not necessarily safe to administer a drug SL that is meant to be given PO. 

Not saying it's unsafe or ineffective to give aspirin this way - I don't know if  it is or isn't - just saying that SL administration works completely differently than PO, and a drug that is safe/effective to give one way isn't necessarily safe/effective to give another way.


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## PaddyWagon (Jan 31, 2013)

Veneficus said:


> Probably because injecting  *acetylsalicylic acid *sounds like a bad idea?



Oh god, remind me never to read textbooks and forums at the same time :rofl:


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## mycrofft (Jan 31, 2013)

old school said:


> That isn't true. The whole point of SL administration is that they _aren't_ swallowed, and therefore avoid the extremely acidic environment of the GI tract as well as first-pass metabolism in the liver. Also, SL absorption is much quicker than GI absorption. SL administration can produce peak plasma levels nearly as fast as IV; must faster than PO.
> 
> I would imagine that SL administration would probably work as long as they are tablets that aren't enteric coated. But I've never heard of it.
> 
> ...




"Not true": in the sense that many people who try sublingual drugs do so without benefit of accurate medical direction, it is true. An example: transbuccal glucose. Just a squirt of Glutose between the cheek and gums does not significantly increase blood glucose elves, but the salivatin and swallowing certainly does, and to the layperson that connotes success...which, in a way, it is, but not due to a fairly long molecule being absorbed through that tissue.
http://www.ncbi.nlm.nih.gov/pubmed/691147
How about "sometimes true"? I'll go with that, and agree totally that pharmacodynamically medicine does different things if it doesn't have to pass through stomach and colon before absorption. (That's why I like IM penicillin versus oral, as long as it isn't me).

"Not saying it's unsafe or ineffective to give aspirin this way" paragraph: money shot. There is the gist of it. I *totally* agree.

I did run across one article about transbuccal absorption which indicated that certain types of substances pass through better than others, including some fatty ones (surprise) and some substances were suggested as "carriers" to bring them across. ANd buccal tissues are pretty much like sublingual ones except you can't se all the blood vessels like you can under the tongue. The the absorption will probably occur at the invisible vascular level, not the big blue one the junkies shoot into.

But ASA looks like a bust.

On the other hand, I've read a few empiric statements that generically state sublingual or transbuccal benzos are good for seizure abatement. My understanding is, excepting Lorazepam, Oxazepam and Temazepam,  that they need a pass through the lever to form active metabolites. I would think they would then have the same delays that IM or IV would have, only the dose is being taken on board much more slowly.


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## Carlos Danger (Jan 31, 2013)

mycrofft said:


> "Not true": in the sense that many people who try sublingual drugs do so without benefit of accurate medical direction, it is true. An example: transbuccal glucose. Just a squirt of Glutose between the cheek and gums does not significantly increase blood glucose elves, but the salivatin and swallowing certainly does, and to the layperson that connotes success...which, in a way, it is, but not due to a fairly long molecule being absorbed through that tissue.
> http://www.ncbi.nlm.nih.gov/pubmed/691147
> How about "sometimes true"? I'll go with that, and agree totally that pharmacodynamically medicine does different things if it doesn't have to pass through stomach and colon before absorption. (That's why I like IM penicillin versus oral, as long as it isn't me).



I think you missed the context of my "not true" statement.

I was replying to this specific statement: "the primary strength of effect from most sublinguals (mentioning nitro as an exception) is that they are eventually swallowed."

It is, in fact, quite untrue that *most* sublinguals are swallowed. Thus, most sublinguals don't exert their "primary strength of effect" from being "eventually swallowed".

Many if not most sublinguals won't even work properly if swallowed. There's usually a good reason they are formulated to be given SL in the first place. Usually it's because in order to exert it's desired effect, the medication has to reach a certain plasma level quicker than GI absorption will allow. Or because the chemical characteristics of the medication are such that it would be changed or otherwise rendered inactive by the low gastric pH or enzymes. 

The glucose example that you use isn't really a SL medication. It's an oral medication that can be placed in the buccal cavity to stimulate swallowing.

At any rate, I never said "never". I'm sure there are a few exceptions but it's definitely not true that "most" SL drugs exert their effect by eventually being swallowed.


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## mycrofft (Jan 31, 2013)

OK, got it.

I didn't get the context of sublinguals limited to/as "medicines which are designed and ordered for sublingual admin", I was thinking of meds including those which are not designed for it but just get stuck there like a pinch of Skoal by responders and laypersons alike.

Still, I agree.


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## NomadicMedic (Jan 31, 2013)

Closest I could find was "quick dissolve ASA granules". This was a product developed by Bayer. http://www.packworld.com/package-component/closures/aspirin-sachet-wins-competition


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## mycrofft (Jan 31, 2013)

BUt still, no protocols. Thanks.


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## systemet (Feb 2, 2013)

mycrofft said:


> On the other hand, I've read a few empiric statements that generically state sublingual or transbuccal benzos are good for seizure abatement. My understanding is, excepting Lorazepam, Oxazepam and Temazepam,  that they need a pass through the lever to form active metabolites. I would think they would then have the same delays that IM or IV would have, only the dose is being taken on board much more slowly.



I have the option of buccal midazolam in seizing kids.  I've never used it -- I've gone IM instead.  But the buccal dose is pretty high -- 0.5mg/kg.

Here's a relevant article that I found:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1873675/pdf/bcp0046-0203.pdf


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## mycrofft (Feb 3, 2013)

systemet said:


> I have the option of buccal midazolam in seizing kids.  I've never used it -- I've gone IM instead.  But the buccal dose is pretty high -- 0.5mg/kg.
> 
> Here's a relevant article that I found:
> 
> http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1873675/pdf/bcp0046-0203.pdf



Thanks, the study report was daunting but had some good stuff.

Interestingly, they significantly cited self-report of anesthetization by the volunteers as an indicator. The reporter's reason was that effect does not necessarily correspond to dosage; to me, the *whole* study should have been about serum level due to buccal admin. I also lost track of placebo versus active agent volunteers. The study size was eight.

(How to they keep from swallowing it?)


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## Bullets (Feb 3, 2013)

The NJ BLS protocol directs EMTs to give up to 325mg of ASA by having the patient chew the tabs even if it is not a "chewable" aspirin. 

It also tells you to apply 100% O2 on a NRB so take it for what its worth


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## mycrofft (Feb 3, 2013)

Yeah, chewing the ASA makes it dissolve faster, especially the ones with enteric coating (pass through stomach to the bowel before dissolving, theoretically).


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