How to Use Midazolam Nasal Spray
Midazolam nasal spray should be administered by directing the spray away from the nasal septum using the contralateral hand technique to reduce the risk of epistaxis, with careful monitoring for respiratory depression especially when combined with other sedative medications. 1, 2
Administration Technique
- Prime the bottle before first use to ensure proper medication delivery 1
- Shake the bottle prior to spraying to decrease the viscosity of the drug suspension, allowing creation of fine mist needed for appropriate nasal deposition 1
- Blow the nose prior to using the spray to clear nasal passages 1
- Keep the head in an upright position during administration 1
- Hold the spray in the opposite hand in relation to the nostril in which the spray should be applied (contralateral technique) to direct spray away from the septum 1
- Breathe in gently or slowly during spraying 1
- Do not close the opposite nostril to prevent pushing the septum to the side of the spray 1
Dosing Guidelines
- For seizures in patients 12 years and older: 5 mg dose (FDA-approved for intermittent, stereotypic episodes of frequent seizure activity) 3, 4
- Onset of action is rapid with intranasal administration (tmax 9.0-21.5 minutes) 2
- Peak psychomotor impairment occurs approximately 17-120 minutes after administration 2
- Return to baseline alertness and psychomotor function typically occurs within 240 minutes (4 hours) after administration 2, 5
Monitoring and Safety Precautions
- Monitor oxygen saturation and respiratory effort during and after administration 1
- Be prepared to provide respiratory support as there is an increased risk of respiratory depression, especially when combined with other sedative agents 1
- Respiratory depression is more likely in patients with underlying respiratory disease 1
- Flumazenil may be administered to reverse life-threatening respiratory depression caused by midazolam, but be aware it will also reverse any anticonvulsant effects and may precipitate seizures 1
Special Population Considerations
- Dose reduction is required in elderly patients (typically 20% or more) due to reduced clearance 1
- Use caution in patients with hepatic or renal dysfunction as midazolam clearance may be prolonged 6
- Avoid coadministration with moderate or strong CYP3A4 inhibitors as these may result in prolonged midazolam effects due to decreased plasma clearance 2
- Use with caution when coadministered with mild CYP3A4 inhibitors 2
Advantages of Nasal Administration
- Allows for outpatient treatment by caregivers and non-healthcare professionals 5
- Bypasses first-pass metabolism, reducing potential for drug-drug interactions compared to oral dosing 2
- Particularly beneficial for patients where other routes of administration are unsuitable 5
- Provides rapid absorption and distribution to the central nervous system 2
Remember that proper technique is essential for efficacy and to minimize side effects. Teaching patients and caregivers the correct administration method significantly improves treatment outcomes and reduces adverse effects 1.