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Table 1 Advantages and limitations of benzodiazepines delivery routes in dogs

From: First-line management of canine status epilepticus at home and in hospital-opportunities and limitations of the various administration routes of benzodiazepines

Administration route Advantages Limitations
Intravenous Likely effective (clinical evidence)
Likely rapid onset of action (clinical evidence)
Precise control of the administered dose
Avoidance of first-pass hepatic metabolism
Subject to blood-brain barrier
Requirement for hospitalisation
Requirement for medically-trained staff
Hard to establish during seizures
Not for at-home use
Intramuscular Likely favourable pharmacokinetics
Avoidance of first-pass hepatic metabolism
Subject to blood-brain barrier
Requirement for training or medical staff
Needle/syringe misuse by non-trained caregivers
Less suitable for at-home use
Soft tissue or nerve damage risk
Infection risk
Painful
Transdermal Painless
Easy to use
Suitable for home
No requirement for medical training
Avoidance of first-pass hepatic metabolism
Subject to blood-brain barrier
Slow release not suitable for emergency
Buccal Painless
Ease to administer
Suitable for home
No requirement for medical training
Avoidance of first-pass hepatic metabolism
Subject to blood-brain barrier
Potentially unfavourable pharmacokinetics
Delivery of limited drug amount
If swallowed, functions as oral
Dog’s compliance is needed
Incorrect administration during seizures
Sublingual Similar to buccal Similar to buccal
Oral Painless
Easy to use
No requirement for medical training
Suitable for home
Subject to blood-brain barrier
Potentially unfavourable pharmacokinetics
Slow absorption not suitable for emergency
Potential for gastrointestinal degradation
Subject to first-pass hepatic metabolism
Dog’s compliance is needed
Rectal Minimal pain/discomfort
Relatively easy to use
No requirement for medical training
Suitable for home
Subject to blood-brain barrier
Variability in effectiveness (clinical evidence)
Variability in pharmacokinetics
Partially subject to first-pass hepatic metabolism
Likely slow onset of action
Socially unacceptable
Intranasal Likely effective (clinical evidence)
Likely rapid onset of action (clinical evidence)
Likely favourable pharmacokinetics
Avoidance of first-pass hepatic metabolism
Avoidance of blood-brain barrier
No requirement for medical training
Relatively easy to use
Painless
Suitable for home
Need for high concentration drug
Potentially affected by mucosal factors
Potentially affected by drug formulation
Need for a veterinary nasal device