Bioavailability of Nasal Naloxone and Injected Naloxone Compared

Study Overview
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Brief Summary
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Opioid overdoses have in the last decade counted for about 230 untimely deaths annually in Norway. The government is currently implementing a strategy for combating this epidemic. Among the actions promoted in this strategy is the distribution of naloxone for intranasal administration. Such administration of naloxone is currently being implemented and tried out around the world, but very little has been done to pharmacologically study this new route of administration of this well known drug, and only 3 open label randomized controlled trials (RCTs) have been conducted. A recent guideline from the WHO on community management of opioid overdoses is a comprehensive review of many of the aspects the investigators cover in our research. Regarding both dosage, routes of administration of naloxone and care of these patients in the pre hospital setting. The WHO calls for nasal formulations with a higher concentration, as well as focuses on the current wide spread off label use of nasal naloxone as a problem and identifies several research questions of critical importance and very low evidence.The current study, together with our research group's previous and future studies, aims to provide data for the development of a medicinal product with marketing authorisation for use in pre-hospital overdoses. This to contribute to public health measures for opioid users and those around them.

Official Title
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Bioavailability of Nasal Naloxone and Injected Naloxone Compared. A Randomized, Open Label, 4-way Cross-over Study

Conditions
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Drug Overdose

Intervention / Treatment
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* Drug: Intranasal (IN) naloxone 1x
* Drug: Intranasal (IN) naloxone 2
* Drug: Intravenous (IV) naloxone
* Drug: Intramuscular (IM) naloxone


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: In order to participate in this study the subjects must meet all of the following inclusion criteria: Provision of a signed written informed consent ECG without any pathological abnormalities Have a BMI range of 18.5- 26.0 kg/m Female subject with child bearing potential must use high efficacy contraception. For the purpose of this study acceptable contraception is defined as sterilization, oral contraceptives, patch, implants, vaginal ring, hormonal IUD or copper IUD through out the study until the last visit. Laboratory values within reference values for the following haematology and biochemistry tests: Haemoglobin Creatinine ASAT ALAT Gamma GT Exclusion Criteria: In order to participate in the study subjects must not meet any of the following exclusion criteria: using medication on a regular basis, including regular use of nasal spray of any form. History of prior drug allergy local nasal disease or nasal surgery for the last 2 months Pregnant or breast feeding women. A serum HCG below 3 U/L must be demonstrated in females of child-bearing potential at Screening Visit. Current drug or alcohol abuse, which in the opinion of the Investigator should preclude participation in the study. Having received another new medical chemical entity (defined as a compound which has not been approved for marketing) or having participated in any other clinical study that included drug treatment within 3 months of the administration of investigational product in this study. Hypersensitivity to naloxone or any of its excipients. Investigator considers subject unlikely to comply with study procedures, restrictions and/or other requirements.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 40 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Basic Science
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intranasal naloxone 1x<br>Each subject will receive one dose of IN naloxone 1.4 mg, IN naloxone 2 x 1.4 mg, IV naloxone 0.4 mg and IM naloxone 0.8 mg in a randomized order. The four doses will be given at four different visits with a washout period of at least 72 hours between. One follow-up visit will be conducted within one month after the last exposure. | Drug: Intranasal (IN) naloxone 1x<br>* Administered as 100 μl 14.0 mg/ml (1.4 mg naloxone) by Aptar Unitdose device as one puff in one nostril<br>Drug: Intranasal (IN) naloxone 2<br>* Administered as 2x 100 μl 14 mg/ml (2.8 mg naloxone) by Aptar Unitdose device as two puffs within the same nostril with 3 minutes interval<br>Drug: Intravenous (IV) naloxone<br>* Administered as 1 ml Naloxon B Braun 0.4 mg/ml (0.4 mg naloxone), in an intravenous cannula in the opposite arm of which the blood samples are drawn from. IV bolus will be given rapidly (in less than 5 seconds)<br>Drug: Intramuscular (IM) naloxone<br>* Naloxone administered as 2 ml Naloxon B Braun 0.4 mg/ml (0.8 mg naloxone) in a Braun Omnifix 2.5 ml syringe using a BD Microlance 3 21G (green) 0.8x40 mm needle in the deltoid muscle of the non-dominant arm<br>|
| Active Comparator: Intranasal naloxone 2x<br>Each subject will receive one dose of IN naloxone 1.4 mg, IN naloxone 2 x 1.4 mg, IV naloxone 0.4 mg and IM naloxone 0.8 mg in a randomized order. The four doses will be given at four different visits with a washout period of at least 72 hours between. One follow-up visit will be conducted within one month after the last exposure. | Drug: Intranasal (IN) naloxone 1x<br>* Administered as 100 μl 14.0 mg/ml (1.4 mg naloxone) by Aptar Unitdose device as one puff in one nostril<br>Drug: Intranasal (IN) naloxone 2<br>* Administered as 2x 100 μl 14 mg/ml (2.8 mg naloxone) by Aptar Unitdose device as two puffs within the same nostril with 3 minutes interval<br>Drug: Intravenous (IV) naloxone<br>* Administered as 1 ml Naloxon B Braun 0.4 mg/ml (0.4 mg naloxone), in an intravenous cannula in the opposite arm of which the blood samples are drawn from. IV bolus will be given rapidly (in less than 5 seconds)<br>Drug: Intramuscular (IM) naloxone<br>* Naloxone administered as 2 ml Naloxon B Braun 0.4 mg/ml (0.8 mg naloxone) in a Braun Omnifix 2.5 ml syringe using a BD Microlance 3 21G (green) 0.8x40 mm needle in the deltoid muscle of the non-dominant arm<br>|
| Active Comparator: Intravenous naloxone<br>Each subject will receive one dose of IN naloxone 1.4 mg, IN naloxone 2 x 1.4 mg, IV naloxone 0.4 mg and IM naloxone 0.8 mg in a randomized order. The four doses will be given at four different visits with a washout period of at least 72 hours between. One follow-up visit will be conducted within one month after the last exposure. | Drug: Intranasal (IN) naloxone 1x<br>* Administered as 100 μl 14.0 mg/ml (1.4 mg naloxone) by Aptar Unitdose device as one puff in one nostril<br>Drug: Intranasal (IN) naloxone 2<br>* Administered as 2x 100 μl 14 mg/ml (2.8 mg naloxone) by Aptar Unitdose device as two puffs within the same nostril with 3 minutes interval<br>Drug: Intravenous (IV) naloxone<br>* Administered as 1 ml Naloxon B Braun 0.4 mg/ml (0.4 mg naloxone), in an intravenous cannula in the opposite arm of which the blood samples are drawn from. IV bolus will be given rapidly (in less than 5 seconds)<br>Drug: Intramuscular (IM) naloxone<br>* Naloxone administered as 2 ml Naloxon B Braun 0.4 mg/ml (0.8 mg naloxone) in a Braun Omnifix 2.5 ml syringe using a BD Microlance 3 21G (green) 0.8x40 mm needle in the deltoid muscle of the non-dominant arm<br>|
| Active Comparator: Intramuscular naloxone<br>Each subject will receive one dose of IN naloxone 1.4 mg, IN naloxone 2 x 1.4 mg, IV naloxone 0.4 mg and IM naloxone 0.8 mg in a randomized order. The four doses will be given at four different visits with a washout period of at least 72 hours between. One follow-up visit will be conducted within one month after the last exposure. | Drug: Intranasal (IN) naloxone 1x<br>* Administered as 100 μl 14.0 mg/ml (1.4 mg naloxone) by Aptar Unitdose device as one puff in one nostril<br>Drug: Intranasal (IN) naloxone 2<br>* Administered as 2x 100 μl 14 mg/ml (2.8 mg naloxone) by Aptar Unitdose device as two puffs within the same nostril with 3 minutes interval<br>Drug: Intravenous (IV) naloxone<br>* Administered as 1 ml Naloxon B Braun 0.4 mg/ml (0.4 mg naloxone), in an intravenous cannula in the opposite arm of which the blood samples are drawn from. IV bolus will be given rapidly (in less than 5 seconds)<br>Drug: Intramuscular (IM) naloxone<br>* Naloxone administered as 2 ml Naloxon B Braun 0.4 mg/ml (0.8 mg naloxone) in a Braun Omnifix 2.5 ml syringe using a BD Microlance 3 21G (green) 0.8x40 mm needle in the deltoid muscle of the non-dominant arm<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Difference in Peak plasma concentration (Cmax) | Cmax will be compared for single dose IN, IM and IV naloxone | 4 days | 
| Difference in systemic exposure: Area under the plasma concentration versus time curve (AUC-0last) | AUC 0-last will be compared for single dose IN, IM and IV naloxone | 4 days | 
| Difference in dose adjusted systemic exposure: Area under the plasma concentration versus time curve (AUC-0inf) | AUC0-inf will be compared for single dose IN, IM and IV naloxone | 4 days | 
| Difference in time at which the Cmax is observed (Tmax) | Tmax will be compared for single dose IN, IM and IV naloxone | 4 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Dose proportionality | assessed by comparing systemic exposure (AUC0-last) following one and two doses of 1.4 mg of IN naloxone in the same nostril. | 4 days | 
| Absolute bioavailability | assessed by comparing dose adjusted systemic exposure (AUC0-last) of IN and IV naloxone | 4 days | 
| Relative bioavailability | assessed by comparing dose adjusted systemic exposure (AUC0-last) of IN and IM naloxone | 4 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Emergency Treatment, Morphine Derivates, Heroin, Antidotes, Administration, Intravenous, Pharmacology, Naloxone, Healthy volunteers, Administration, intramuscular, Administration, intranasal