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Nalbuphine, sold under the brand names Nubain among others, is an opioid analgesic which is used in the treatment of pain. It is given by injection into a vein, muscle, or fat.
of nalbuphine include sedation, sweatiness, , nausea, vomiting, dizziness, vertigo, dry mouth, and headache. Unlike other opioids, it has little to no capacity to cause euphoria or respiratory depression. There is also little to no incidence of dysphoria, dissociative, , and related side effects at typical therapeutic doses. Nalbuphine is a mixed agonist/antagonist opioid modulator. Specifically, it acts as a moderate-efficacy partial agonist or antagonist of the μ-opioid receptor (MOR) and as a high-efficacy partial agonist of the κ-opioid receptor (KOR), whereas it has relatively low affinity for the δ-opioid receptor (DOR) and .
Nalbuphine was patented in 1963US Patent 3393197 - Nusubstituted-14-hydroxydihydronormorphines and was introduced for medical use in the United States in 1979. It is marketed in many countries throughout the world.
In addition to relieving pain, nalbuphine has been shown to reduce morphine-induced pruritus (itching). Pruritus is a common side effect of morphine and other pure μ-opioid receptor (MOR) agonists. A systematic review of clinical trials concluded that nalbuphine is effective in counteracting morphine-induced pruritus, likely through central nervous system mechanisms.
Evidence suggests that κ-opioid receptor (KOR) activation can counteract MOR-mediated effects in the brain. This interaction may have broader implications for central nervous system disorders, including potential applications in treating Parkinson's disease, where KOR agonism and MOR antagonism have been shown to reduce levodopa-induced dyskinesia and normalize striatal function.
Morphine-induced pruritus may also result from histamine release by in the skin. Both MORs and KORs are expressed in skin nerves and keratinocytes, indicating potential peripheral mechanisms for opioid-induced pruritus. Histamine-mediated responses such as increased capillary permeability and vasodilation have been observed following intradermal administration of some opioids. However, nalbuphine does not elicit either a wheal or flare response, suggesting it does not promote histamine release from mast cells.
An investigational extended-release oral formulation is under development by Trevi Therapeutics.
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Nalbuphine is a semisynthetic mixed agonist/antagonist opioid modulator of the phenanthrene or morphinan series. It is structurally related to the widely used opioid antagonists naloxone and naltrexone, and to the potent opioid analgesic oxymorphone. Nalbuphine binds with high affinity to the MOR and KOR, and has relatively low affinity for the DOR. It behaves as a moderate-efficacy partial agonist (or mixed agonist/antagonist) of the MOR and as a high-efficacy partial agonist of the KOR. Nalbuphine has weak or no affinity for the sigma receptor (e.g., Ki > 100,000 nM).
Nalbuphine is said to be more morphine-like at lower doses. However at higher doses, it produces more sedation, drunkenness, dysphoria, and dissociative. As such, its effects are dose-dependent. Such effects include sedation (21–36%), dizziness or vertigo (5%), lightheadedness (1%), anxiety (<1%), dysphoria (<1%), euphoria (<1%), mental confusion (<1%), (<1%), depersonalization (1%), unusual (<1%), and derealization (<1%).
Nalbuphine is a potent analgesic. Its analgesic potency is essentially equivalent to that of morphine on a milligram basis, which is based on relative potency studies using intramuscular administration (Beaver et al. 1978). Oral administered nalbuphine is reported to be three times more potent than codeine (Okun et al. 1982). Clinical trials studied single dose experimental oral immediate release nalbuphine tablets for analgesic efficacy over a four- to six-hour time period following administration. Nalbuphine in the 15 to 60 mg range had similar analgesic effects to immediate release codeine in the 30 to 60 mg range (Kantor et al. 1984; Sunshine et al. 1983). Schmidt et al. (1985) reviewed the preclinical pharmacology of nalbuphine and reported comparative data relative to other types of opioid compounds. The authors point out that the nalbuphine moiety is approximately ten times more pharmacologically potent than the mixed opioid agonist/antagonist butorphanol on an "antagonist index" scale which quantitates the drug's ability to act both as an analgesic (via opioid KOR agonism) as well as a MOR antagonist. The opioid antagonist activity of nalbuphine is one-fourth as potent as nalorphine and 10 times that of pentazocine.
In the search for opioid analgesics with less abuse potential than pure MOR agonist opioids, a number of semisynthetic opioids were developed. These substances are referred to as mixed agonist–antagonists analgesics. Nalbuphine belongs to this group of substances. The mixed agonists-antagonists drug class exerts their analgesic actions by agonistic activity at the KOR. While all drugs in this class possess MOR antagonistic activity leading to less abuse potential, nalbuphine is the only approved drug in the mixed agonist–antagonist class listed in terms of its pharmacological actions and selectivities on opioid receptors as a MOR partial agonist or antagonist as well as a KOR agonist (Gustein et al. 2001).
Nubain was approved for marketing in the United States in 1978 and remains as the only opioid analgesic of this type (marketed in the U.S.) not controlled under the Controlled Substances Act (CSA). When the Controlled Substances Act (CSA) was enacted in 1971, nalbuphine was placed in schedule II. Endo Laboratories, Inc. subsequently petitioned the DEA to exclude nalbuphine from all schedules of the CSA in 1973. After receiving a medical and scientific review and a scheduling recommendation from the Department of Health, Education and Welfare, forerunner to the Department of Health and Human Services, nalbuphine was removed from schedule II of the CSA in 1976. Presently, nalbuphine is not a controlled substance under the CSA.
Nalbuphine HCL is currently available only as an injectable in the US and the European Union. Nubain, the Astra USA brand name for injectable nalbuphine HCL, was discontinued from being marketed in 2008 in the United States for commercial reasons (Federal Register 2008); however, other commercial suppliers now provide generic injection formulation nalbuphine for the market.
In cats nalbuphine has been shown to provide an equal sedative effect to butorphanol when adminsistered with acepromazine and an equal sedative and analgesic effect when combined with dexmedetomidine and tiltamine-zolazepam respectively.
In horses evidence is mixed. One study found that nalbuphine combined with xylazine was more effective than xylazine by itself as an analgesic and anaesthetic, but another study found no difference between xylazine itself and xylazine with nalbuphine.
Evidence in livestock is limited. One study in Holstein cattle calves following castration found nalbuphine to provide inadequate analgesia and sedation. In goats one study found that nalbuphine combined with ketamine provided better post-operative analgesia than ketamine by itself at a higher dose.
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