LAIB Buvidal

On Cracking Addiction this week

Buvidal is a long acting injectable buprenorphine (LAIB) preparation manufactured by Camurus and uses "FluidCrystal" technology to provide for a sustained and prolonged delivery of buprenorphine into the systemic circulation after subcutaneous injection. Buvidal weekly contains the following excipients: soy phosphatidyl choline, glyceryl dioleate, anhydrous alcohol (< 100 mg). Buvidal monthly contains the following excipients: soy phosphatidyl choline glyceryl dioleate N-Methylpyrrolidone.

Dosing of LAIB

Buvidal has a wide range of doses available for both weekly and monthly administration.
Weekly doses: 8, 16, 24, 32 mg
Monthly dose: 64, 96, 128 mg

It is recommended that patient be commenced on seven or more days of continuous sublingual buprenorphine before transferring to Buvidal with doses of Buvidal administered according to a conversion table that is readily available from the manufacturer and most state based LAIB guidelines contain this table.

While not recommended as routine practice it is possible to induct from short acting opioids and opiates directly onto Buvidal Weekly or Monthly but it is recommended to seek guidance before doing this.

Buvidal is administered as a subcutaneous injection in either the buttocks, thigh, abdomen or upper arm.

Duration of action

Duration of action of buprenorphine is determined by the presence of the drug at levels above a threshold for effect which has been determined as being more than 1ng/ml to achieve relief from withdrawal symptoms. Compared with sublingual buprenorphine, LAIB provides for sustained and prolonged elevations of plasma buprenorphine over time.

Sublingual buprenorphine: Up to 72 hours – every third day dosing
Buvidal 8/16/24/32 mg: 1 week
Buvidal 64/96/128 mg: 1 month

Interactions

When considering drug-drug interactions and buprenorphine or LAIB, it is useful to conceptualise the interactions as either pharmacodynamic or pharmacokinetic.

Pharmacodynamic interactions depend on an interacting physiological drug effect (e.g. two antihypertensive drugs acting synergistically to lower blood pressure), whereas pharmacokinetic interactions depend on interacting kinetics causing altered drug concentration.

Pharmacodynamic interactions
Pharmacodynamic interactions that are relevant to buprenorphine include the following.

Precipitated withdrawal
Buprenorphine can displace other opioids from the mu receptor to cause a precipitated withdrawal in patients who are neuroadapted to opioids.

Sedation
The combination of buprenorphine with other hypnosedatives (e.g. other opioids, benzodiazepines, alcohol, gabapentinoids and sedating antidepressants) can contribute to an overall effect of respiratory depression and in severe cases death.

Serotonin syndrome
Buprenorphine, especially when combined with other serotonergic drugs (MAOIs / SSRIs / SNRIs) can trigger a serotonin syndrome.

Pharmacokinetic interactions

Buprenorphine is predominantly metabolised by CYP 3A4. Co-administration of Inhibitors of this enzyme will increase buprenorphine plasma levels. Examples of such enzyme inhibitors include macrolide antibiotics, azole-antifungal agents, and Protease inhibitors. Co-administration of inducers of this enzyme will decrease buprenorphine plasma levels. Examples of such enzymes inhibitors include rifampicin, and the AEDs carbamazepine phenytoin phenobarbital.

Contra-indications

The following are listed as contra-indications for Buvidal.

Child-Pugh C liver disease
Respiratory insufficiency
Hypersensitivity to either buprenorphine or excipients
Children less than 16 years of age
Acute alcoholism or delirium tremens
Pregnancy and lactation

Buvidal is one of the LAIB preparations in common clinical usage and has been helpful in assisting patients with opioid use disorder stabilise and remain in the opioid substation program.