Alternative routes of drug administration--advantages and disadvantages (subject review)

Abstract

To the Editor. I commend the Committee on Drugs on their review1; however, I must comment on three important omissions.When considering alternate routes of drug administration, these additional factors should be included in the decision-making process.In Reply. Dr. Zempsky raises several important issues. Rather than considering them omissions, I would ask that Dr. Zempsky consider that the purpose of the article was to point out the inherent risks and problems when administering drugs by routes of administration for which they were not designed and which have not been carefully studied. TAC is a perfect example of where efficacy was demonstrated when the drug was placed on a peripheral laceration but toxicity resulted when applied to mucous membrane. This was an example of the physicians' not appreciating the fact that there is a much more rapid uptake of drug through a mucosal surface than through the dermis. A similar thing could happen with lidocaine, epinephrine, and tetracaine if sufficient quantities were administered to the oral mucosa. The principles would be the same; toxicity could result. We are glad to see that LET is replacing TAC because of the better safety profile.Likewise, in describing the fentanyl Oralet, the purpose of using that as an example was that this was the first medication where the transoral mucosal route of administration was carefully studied. Dr Zempsky properly points out that the incidence of vomiting is about 30%, but what Dr Zempsky did not mention, however, is that the incidence of vomiting is the same whether the drug is given intravenously or transmucosally. If an opioid is indicated, the side effects of that opioid are going to be the same regardless of the route of administration. Condemning the route of administration really does not serve any purpose; it is the drug that causes the side effect not the route of administration. If an opioid is indicated for the treatment of pain, regardless of the side effects, the opioid is indicated. Fentanyl should not be administered for sedation but rather for the treatment of pain.Regarding iontophoresis, although not clearly evident, a reference to iontophoresis was provided14 regarding transdermal drug administration. Dr Zempsky is correct in pointing out that this method of drug administration offers great promise, but the premise put forth in our commentary is the same for iontophoresis as well; ie, because of the differences in skin thickness in children and differences in skin blood flow, we cannot just take research in adults and then apply it to children and expect the same results. One of the aspects Dr. Zempsky did not mention was the fact that frequently children do not like iontophoresis because it may be uncomfortable. However, as with all routes of drug administration, this one requires the same careful scientific investigation to assure safety and efficacy for all pediatric patients. We are glad that Dr. Zempsky has put so much thought into this.