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Sublingual administration
Sublingual administration
Sublingual administration
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Sublingual (abbreviated SL), from the Latin for "under the tongue", refers to the pharmacological route of administration by which substances diffuse into the blood through tissues under the tongue.[1]

Many drugs are absorbed through sublingual administration, including cardiovascular drugs, steroids, barbiturates, benzodiazepines,[2] opioid analgesics, THC, CBD, some proteins and increasingly, vitamins and minerals.

Principle

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When a chemical comes in contact with the mucous membrane beneath the tongue, it is absorbed. Because the connective tissue beneath the epithelium contains a profusion of capillaries, the substance then diffuses into them and enters the venous circulation.[1] In contrast, substances absorbed in the intestines are subject to first-pass metabolism in the liver before entering the general circulation.

Sublingual administration has certain advantages over oral administration. Being more direct, it is often faster onset of action, and it ensures that the substance will risk degradation only by salivary enzymes before entering the bloodstream, whereas orally administered drugs must survive passage through the hostile environment of the gastrointestinal tract, which risks degrading them, by either stomach acid or bile, or by enzymes such as monoamine oxidase (MAO). Furthermore, after absorption from the gastrointestinal tract, such drugs must pass to the liver, where they may be extensively altered; this is known as the first pass effect of drug metabolism. Due to the digestive activity of the stomach and intestines, the oral route is unsuitable for certain substances, such as salvinorin A.

Forms

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Pharmaceutical preparations for sublingual administration are manufactured in the form of:

  • Sublingual tablets—tablets which easily melt in the mouth, dissolve rapidly and with little or no residue. Nitroglycerine tablets are an example, the anti-emetic ondansetron is another.
  • Sublingual strips—similar to tablets in that they easily melt in the mouth and dissolve rapidly. Suboxone is an example of medication that comes in a sublingual strip.
  • Multi-purpose tablets—Soluble tablets for either oral or sublingual (or buccal) administration, often also suitable for preparation of injections, Hydrostat (hydromorphone) and a number of brands of morphine tablets and cubes.
  • Sublingual drops—a concentrated solution to be dropped under the tongue, as with some nicocodeine cough preparations,
  • Sublingual spray—spray for the tongue; certain human and veterinary drugs are dispensed as such.
  • Lozenge—effects a metred and patient-controlled-rate combination of sublingual, buccal, and oral administration, as with the Actiq fentanyl.
  • Effervescent buccal or sublingual tablets—this method drives the drug through the mucous membranes much faster (this is the case in the stomach with carbonated or effervescent liquids as well) and is used in the Fentora fentanyl buccal tablet.

Substance

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Almost any form of substance may be amenable to sublingual administration if it dissolves easily in saliva. Powders and aerosols may all take advantage of this method. However, a number of factors, such as pH, molecular weight, and lipid solubility, may determine whether the route is practical. Based on these properties, a suitably soluble drug may diffuse too slowly through the mucosa to be effective. However, many drugs are much more potent taken sublingually, and it is generally a safer alternative than administration via the nasal mucosa.[citation needed] This method is also extensively used by people administering certain psychoactive drugs. One drawback, however, is tooth discoloration and decay caused by long-term use of this method with acidic or otherwise caustic drugs and fillers.

Psychoactives

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In addition to salvinorin A, other psychoactives may also be applied sublingually. LSD, MDMA, morphine, alprazolam, clonazepam, diazepam, and many other substances including the psychedelic tryptamines and phenethylamines, and even recreational cannabis edibles (THC) are all viable candidates for administration via this route.[citation needed] Most often, the drug in question is powdered and placed in the mouth (often directly under the tongue). If held there long enough, the drug will diffuse into the blood stream, bypassing the GI tract. This may be a preferred method to simple oral administration, because MAO is known to oxidize many drugs (especially the tryptamines such as DMT) and because this route translates the chemical directly to the brain,[citation needed] where most psychoactives act. The method is limited by excessive salivation washing the chemical down the throat. Also, many alkaloids have an unpleasant taste which makes them difficult to hold in the mouth. Tablets of psychoactive pharmaceuticals usually include bitter chemicals such as denatonium in order to discourage abuse and also to discourage children from eating them.[citation needed]

Allergens

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Allergens may also be applied under the tongue as a part of allergen immunotherapy.

Therapeutic peptides and proteins

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A relatively new way of administration of therapeutic peptides and proteins (such as cytokines, domain antibodies, Fab fragments or single chain antibodies) is sublingual administration. Peptides and proteins are not stable in the gastro-intestinal tract, mainly due to degradation by enzymes and pH differences. As a consequence, most peptides (such as insulin, exenatide, vasopressin, etc.) or proteins (such as interferon, EPO and interleukins) have to be administered by injection. Recently, new technologies have allowed sublingual administration of such molecules. Increased efforts are underway to deliver macromolecules (peptides, proteins and immunotherapies) by sublingual route, by companies such as Novo Nordisk, Sanofi and BioLingus.[3] Sublingual delivery may be particularly effective for immuno-active medicines, due to the presence of immune-receptor cells close to the sublingual area.

Vaccines

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The sublingual route may also be used for vaccines against various infectious diseases. Thus, preclinical studies have found that sublingual vaccines can be highly immunogenic and may protect against influenza virus[4][5] and Helicobacter pylori,[6] but sublingual administration may also be used for vaccines against other infectious diseases.[citation needed]

Footnotes

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[edit]
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Sublingual administration

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from Grokipedia
Sublingual administration is a route of in which a is placed under the , where it dissolves in and is absorbed directly into the bloodstream through the highly vascularized sublingual mucosa. This method enables rapid onset of therapeutic effects by bypassing the and hepatic first-pass , which can degrade or inactivate many drugs. Sublingual delivery gained early prominence in the late with for relief and further expanded in the mid-20th century starting in the 1950s with the use of steroids such as methyltestosterone. Key advantages include enhanced for lipophilic, low-molecular-weight drugs, ease of administration without water, and suitability for patients with swallowing difficulties, such as children or the elderly. Absorption occurs primarily via passive across the thin epithelial layer, influenced by factors like drug in and . Common applications encompass emergency treatments and chronic conditions, with notable examples including for acute , for opioid dependence, and for severe pain, and for . While effective, limitations such as restricted surface area for dosing and potential taste or irritation issues constrain its use to potent, fast-acting medications rather than sustained-release therapies.

Overview

Definition and Principle

Sublingual administration is a route of in which a is placed under the , allowing it to be absorbed directly through the highly permeable into the systemic bloodstream. This method leverages the anatomical advantages of the sublingual region to achieve rapid onset of action without requiring swallowing. The underlying principle involves the dissolution of the drug in , followed by passive across the sublingual into the underlying capillaries. The sublingual veins drain directly into the , thereby circumventing the hepatic first-pass that occurs with traditional oral . This venous pathway ensures that the drug enters the systemic circulation more efficiently, avoiding significant degradation in the . Key anatomical features of the sublingual mucosa contribute to its suitability for absorption, including its high vascularity, which provides a rich network of blood vessels for rapid uptake. The is notably thin, with a thickness of 100–200 micrometers, enabling easier permeation by lipophilic or small-molecule drugs. Additionally, the neutral of the sublingual environment, ranging from approximately 6.2 to 7.4, supports drug stability and favorable for absorption.

Historical Development

The practice of sublingual administration traces its roots to ancient systems, where herbal remedies were placed under the tongue for rapid absorption and therapeutic effects. In , a Greco-Arabic system with origins dating back over 2,000 years, sublingual delivery was employed for managing acute conditions such as cardiac emergencies and through dissolvable tablets or pills held beneath the tongue. Similar approaches appear in broader ancient practices, including the placement of herbal substances in the oral cavity in Ayurvedic and to bypass digestive barriers and achieve swift systemic action, though documentation is often embedded in oral traditions rather than written records. The modern pharmaceutical adoption of sublingual administration began in the 19th century with the treatment of angina pectoris. In 1867, Scottish physician Thomas Lauder Brunton introduced amyl nitrite inhalation as a vasodilator to alleviate chest pain, marking an early recognition of the route's potential for rapid onset in acute cardiovascular conditions. This was followed in 1879 by English pharmacologist William Murrell, who popularized sublingual nitroglycerin—administered as drops under the tongue—for angina relief, demonstrating its efficacy in dilating coronary vessels and establishing it as a cornerstone of emergency therapy. Murrell's work, building on Brunton's, highlighted the route's ability to avoid first-pass metabolism, influencing subsequent developments in cardiovascular pharmacology. Key advancements in the early included the formulation of stable sublingual tablets, which improved dosing precision and portability compared to liquid forms, enabling widespread clinical use by the . Expansion into hormone therapies occurred in the mid-20th century, with sublingual progesterone tablets emerging in the and to enhance for gynecological applications, reflecting growing interest in mucosal routes for labile compounds. The 1970s saw become available worldwide as a sublingual , with approvals for opioid dependence following in the late 1990s (e.g., high-dose formulations in ) and 2002 in the , offering partial agonist effects with reduced abuse potential. Regulatory milestones in the 2000s advanced sublingual applications beyond small molecules, with the U.S. FDA approving the first sublingual tablets for allergens, such as grass pollen extracts in 2014, enabling disease-modifying treatment for through standardized mucosal delivery. By 2025, sublingual delivery has expanded to include generics and novel formulations for peptides and vaccines, building on earlier immunotherapy approvals. These developments underscore the route's evolution from empirical remedies to precision-engineered therapies.

Methods and Forms

Administration Techniques

Sublingual administration begins with thorough to prevent , followed by moistening the with a sip of if the medication form requires it for easier dissolution. The patient should then place the —whether a tablet, , or spray—directly under the , as far back as possible without chewing, swallowing, or moving it, to allow contact with the mucosal surface. The should remain closed to avoid dislodging the dose. Patients are advised to sit upright or tilt the head slightly back during administration to minimize the risk of premature and enhance absorption by gravity. In emergency situations, such as an attack, the patient should sit down immediately upon feeling symptoms to prevent or fainting while placing the dose under the . This positioning helps maintain the medication in place and supports safe delivery, particularly when rapid onset is critical. The medication is typically held under the for 30 seconds to 5 minutes, depending on the specific product, until it fully dissolves; patients should avoid eating, drinking, or smoking for at least 5-10 minutes afterward to prevent interference with absorption. Proper administration may be indicated by a mild tingling or burning sensation under the , which is a normal sign of mucosal contact for some drugs like . Monitoring involves observing for complete dissolution and noting any immediate effects, with patients instructed to seek medical help if symptoms persist beyond the expected relief time. For pediatric patients, techniques may involve using flavored formulations to improve compliance, with caregivers assisting by gently holding the child's closed until dissolution; administration should be supervised to ensure the dose remains sublingual rather than swallowed. In elderly individuals, who may have reduced production or dexterity issues, moistening the beforehand and allowing extra time for dissolution can aid effectiveness, especially for those with difficulties. These adjustments prioritize ease and safety without altering the core procedure. Common errors include swallowing the medication prematurely, which reduces by routing it through the , or chewing it, which can lead to uneven absorption or . Moving the dose around the or talking during dissolution may also displace it, diminishing ; to avoid these, patients should be trained to keep the still and follow product-specific demonstrations provided by healthcare providers.

Available Dosage Forms

Sublingual drugs are commonly formulated as , which are compressed designed to disintegrate rapidly in the oral cavity for quick drug release. typically consist of the mixed with excipients such as or cellulose derivatives, compressed into small, flat shapes that dissolve under the within 1-5 minutes. For instance, tablets achieve in 1-3 minutes due to their fast disintegration. Lozenges, often flavored and shaped similarly, incorporate mucoadhesive polymers like Carbopol to promote adherence and controlled dissolution, though they may dissolve more slowly than tablets for sustained exposure. Films and strips represent another solid format, comprising thin, flexible sheets of water-soluble polymers such as hydroxypropyl methylcellulose (HPMC) that disintegrate in 30 seconds to 5 minutes. These forms allow for precise dosing through uniform drug distribution across the film surface, typically accommodating 1-30 mg of per strip. Their ease of administration without water or chewing makes them particularly advantageous for pediatric patients, reducing risks of and improving compliance. Liquid formulations include drops and sprays, delivered via droppers for adjustable volumes or metered spray devices for consistent . Drops are aqueous or alcohol-based solutions placed directly under the , while sprays use propellants like for fine mist dispersion, enabling rapid mucosal contact without the need for disintegration. These are frequently employed for allergens in sublingual , where small volumes of extract are administered daily. Powders and gels are less prevalent sublingual formats, with powders consisting of micronized particles often blended with mucoadhesives for better retention and controlled release upon contact with . Gels, as semi-solids, utilize viscous polymers like Carbopol 934 or to form structures that provide sustained , achieving near-complete release over 30 minutes while adhering to the mucosa. Key formulation factors across these dosage forms include excipients such as sweeteners (e.g., ) and buffers to improve , mask bitterness, and maintain stability for mucosal compatibility. Manufacturing emphasizes rapid disintegration, ideally under 30 seconds for optimal patient experience, achieved through techniques like lyophilization or superdisintegrants, ensuring the form disperses quickly in minimal .

Pharmacology

Absorption and Bioavailability

Sublingual absorption primarily occurs through passive across the of the sublingual , where drugs partition into and permeate the non-keratinized mucosal membrane driven by concentration gradients. This process favors lipophilic molecules that can traverse the transcellular route, with optimal permeability achieved for compounds exhibiting moderate (logP values of 1-3) and low molecular weight (ideally <500 Da), as higher molecular weights hinder through the tight junctions or aqueous pores. Hydrophilic drugs may utilize paracellular pathways, though this is less efficient due to the 's thickness (100-200 μm). Bioavailability (F) following sublingual administration is quantified as F = (AUC_sublingual / AUC_IV) × 100%, where AUC represents the area under the plasma concentration-time curve for sublingual and intravenous routes, respectively, typically ranging from 30-90% for suitable candidates compared to <20% for some drugs via the oral route due to first-pass avoidance. This enhanced systemic exposure results from direct entry into the venous drainage of the sublingual mucosa, which feeds into the and , bypassing hepatic . Several physiological factors influence sublingual absorption efficiency. Salivary flow rate, normally 0.3-0.4 mL/min unstimulated, can increase to 1-2 mL/min or higher with mechanical or gustatory , promoting dissolution and contact time with the mucosa. The salivary (typically 6.2-7.6) favors absorption of the unionized form, as this neutral to slightly alkaline environment minimizes ionization for weak bases and acids, enhancing solubility. Variations in sublingual flow, which is rich due to high (up to 1 mL/min/g tissue), further accelerate uptake but can be altered by vasoconstrictors or disease states. The pharmacokinetic profile of sublingual administration features rapid onset, with peak plasma concentrations often reached in 5-15 minutes, attributed to the thin epithelium and direct systemic access. This leads to a shorter effective duration compared to oral routes, as drugs exhibit quicker distribution and potential for faster elimination without enterohepatic recirculation. Drug suitability for sublingual delivery requires low doses (<10 mg) to fit the limited mucosal surface area (~26 cm²) and chemical stability in saliva to prevent degradation by enzymes like amylase.

Advantages and Limitations

Sublingual administration offers several key advantages, particularly for drugs requiring rapid systemic effects. The route enables quick due to the thin (100–200 μm) and rich vascular supply of the sublingual mucosa, allowing drugs like to provide relief within 2–5 minutes. It also bypasses hepatic first-pass , resulting in higher for drugs prone to liver clearance, such as or , compared to oral . As a non-invasive method, it serves as an alternative to injections, enhancing patient compliance, especially in where needle aversion is common, and in individuals with difficulties. Despite these benefits, sublingual administration has notable limitations. The small mucosal surface area (approximately 26 cm²) restricts it to low-dose formulations, typically up to 10 mg, making it unsuitable for high-dose or large-molecule drugs like peptides and proteins. Bitter or unpleasant tastes from many formulations can cause patient discomfort and reduce adherence, while absorption variability arises from factors such as salivary flow, changes, food intake, or mucosal conditions. Additionally, it is ineffective for irritant substances or hydrophilic compounds due to poor permeability across the mucosal barrier. The safety profile of sublingual administration is generally favorable, with low risk of overdose owing to controlled absorption rates, though potential for local irritation or allergic reactions exists, particularly in patients with oral ulcers or . Contraindications include active mucosal lesions, where absorption could exacerbate irritation. Compared to other routes, sublingual delivery provides faster effects than by avoiding gastrointestinal degradation and first-pass effects, yet it is slower and less precise than intravenous delivery while remaining non-invasive. Versus the buccal route, sublingual offers quicker venous drainage to the due to its thinner tissue, leading to more rapid systemic . Recent advancements as of 2025 have addressed some limitations through taste-masking technologies in fast-dissolving films and the use of permeation enhancers like nanoparticles and mucoadhesive polymers, which improve retention, stability, and bioavailability for challenging drugs.

Clinical Applications

Psychoactive Substances

Sublingual administration is employed for several psychoactive substances, particularly in the management of opioid dependence and emerging psychiatric therapies, due to its ability to provide rapid onset and improved bioavailability compared to oral routes. Buprenorphine, a partial opioid agonist, is commonly delivered sublingually via films like Suboxone for treating opioid use disorder, with bioavailability ranging from 30% to 50%, allowing effective dosing while minimizing diversion risks through the inclusion of naloxone. Other opioids, such as sufentanil sublingual tablets, are used for acute severe pain requiring opioid treatment when other pain relievers are ineffective. In therapeutic psychiatry, sublingual delivery of psychedelics such as LSD in blotter form and psilocybin (typically oral, with emerging sublingual psilocin formulations) microdoses facilitates controlled absorption for conditions like anxiety and depression, with studies demonstrating pharmacokinetic profiles that support microdosing regimens without full hallucinogenic effects. The mechanism underlying sublingual psychoactive delivery involves direct absorption through the into the systemic circulation via the , bypassing hepatic first-pass and enabling quicker crossing of the blood-brain barrier for rapid effects. This route avoids extensive liver , which can reduce required doses by up to 50% for certain lipophilic psychoactives like , where oral drops below 10%. Consequently, onset of effects occurs within minutes, contrasting with the delayed absorption of swallowed formulations. In clinical applications, sublingual serves as an effective alternative to for addiction , offering flexible office-based prescribing and reduced clinic visit requirements while maintaining comparable retention rates in . For mood disorders, sublingual lozenges are under investigation in trials for and anxiety, with onset of antidepressant effects reported in 5 to 10 minutes due to mucosal absorption, providing faster than traditional oral antidepressants. These uses highlight sublingual routes' role in both for substance use disorders and acute interventions in psychiatric care. Challenges in sublingual psychoactive administration include taste aversion, which can lead to non-adherence during long-term use of formulations like films, prompting patients to swallow rather than dissolve them properly. Regulatory hurdles persist for psychedelics, with MDMA-assisted therapy receiving FDA breakthrough designation in 2017 for , though a 2024 rejection of its necessitated additional phase 3 trials, delaying widespread adoption of sublingual or oral analogs. Efficacy studies indicate higher adherence with sublingual opioids compared to oral forms, with retention rates in treatment reaching 70% to 90% at six months, attributed to the faster onset of therapeutic effects that enhances patient satisfaction in supervised settings, though this can also increase misuse potential due to quicker .

Allergens and Immunotherapy

Sublingual (SLIT) utilizes standardized extracts of common environmental allergens, such as grass pollen and house dust mites, to desensitize patients with or through daily sublingual administration. Certain allergy immunotherapy extracts are available as sublingual drops or tablets for this purpose. This approach gradually builds over a typical treatment duration of 3-5 years, allowing patients to sustained symptom even after discontinuation. The mechanism of SLIT involves a localized in the , where exposure promotes the induction of regulatory T-cells (Tregs) that secrete immunosuppressive cytokines like IL-10, thereby suppressing Th2-driven and reducing IgE-mediated reactions. Meta-analyses confirm SLIT's , demonstrating significant reductions in symptom scores and use, with response rates achieving up to 70% symptom improvement in patients across multiple trials. Standard SLIT protocols begin with low initial doses, often 100-300 index of reactivity (IR) units, followed by a gradual escalation over days to weeks to reach a maintenance dose, which is then administered daily for the full treatment course. Available forms include liquid drops or dissolvable tablets; for instance, Grazax, a grass pollen SLIT tablet containing 75000 SQ-T Timothy grass extract, was approved in Europe in 2006 for treating grass pollen-induced allergic rhinoconjunctivitis. Key benefits of SLIT include the convenience of home administration, which minimizes clinic visits compared to subcutaneous alternatives, and a substantially lower of severe adverse events, with extremely rare in SLIT (fewer than 1 case per 100 million doses) versus higher rates of systemic reactions (up to 0.8%, including rare ) in subcutaneous . Recent developments as of 2025 include expanded pediatric approvals for SLIT products, such as the FDA extension of Odactra ( SLIT tablet) to children aged 5-11 years (approved February 2025), enabling earlier intervention from around age 5; ongoing trials are also exploring multi-allergen SLIT formulations to address polysensitization, though efficacy for combined extracts remains under evaluation due to mucosal absorption limits.

Therapeutic Peptides and Proteins

Therapeutic peptides and proteins, typically exceeding 1000 Da in molecular weight, face substantial barriers to sublingual administration due to their large size, hydrophilicity, and susceptibility to enzymatic degradation by salivary proteases. These properties hinder passive across the sublingual and necessitate formulation strategies like permeation enhancers, like , which improve mucoadhesion and transiently open tight junctions to enhance paracellular transport. A representative example is , a synthetic analog used in , available as a sublingual lyophilisate with an absolute of approximately 0.25%, outperforming traditional oral tablets (0.08-0.16%) but remaining lower than intranasal routes (3-10%). Experimental sublingual insulin formulations, such as nanoparticle-loaded films with enhancers like , have demonstrated pharmacological availability exceeding 100% and over 80% in preclinical models, though human clinical data remain limited. Advances in engineering, including cyclization to reduce enzymatic cleavage at termini and to shield hydrophilic regions and prolong mucosal residence, have bolstered stability for sublingual delivery. For instance, ongoing developments for GLP-1 receptor agonists like include sublingual thin films and formulations in early clinical stages, aiming for phase II evaluation by 2026, with preclinical data showing 6-7% in human volunteers for similar peptide systems. Small peptides delivered sublingually exhibit comparable to subcutaneous injection, often within 15-30 minutes, while larger proteins lag due to slower absorption kinetics. Patient adherence favors these non-injectable options for chronic conditions, reducing needle and injection-site reactions. Despite these progresses, sublingual and protein therapeutics remain an emerging field with less than 5% compared to injectable biologics, primarily due to inconsistent (often <10%) and the need for optimized dosing to account for inter-subject variability in mucosal permeability.

Vaccines and Other Uses

Sublingual vaccines target infectious diseases by inducing mucosal immunity through antigen uptake primarily by M-cells in the , which facilitate transport to underlying lymphoid tissues for immune activation. This process stimulates the production of secretory IgA antibodies at mucosal sites, providing localized protection against pathogens entering via respiratory or gastrointestinal routes, while also eliciting systemic responses including IgG and T-cell immunity. Adjuvants such as the B subunit enhance uptake and by promoting maturation and release, improving overall efficacy without significant toxicity in preclinical models. Promising candidates include sublingual formulations for , where plant-based or recombinant subunit have demonstrated robust mucosal IgA responses and protection in murine challenge models, though human trials remain preclinical. For , phase I and II trials of inactivated or live-attenuated sublingual , such as quadrivalent formulations with novel adjuvants like ND002, have shown safety and , with rates of approximately 60-70% for hemagglutinin-specific antibodies in healthy adults, comparable to intramuscular routes but with added mucosal benefits; as of , phase II trials continue to evaluate efficacy. These trials highlight sublingual delivery's potential for annual prophylaxis, inducing both local IgA in respiratory mucosa and systemic neutralizing antibodies. Recent advancements include sublingual boosters evaluated in 2023-2025 studies, such as protein-based formulations with receptor-binding domain and poly(I:C) adjuvant, which elicited strong secretory IgA in and serum IgG in non-human , supporting mucosal barrier enhancement against variants. For pediatric applications, oral rotavirus vaccines administered as drops have shown high efficacy in preventing severe , with two-dose regimens achieving over 85% protection in infants starting at 6 weeks of age. Overall, sublingual vaccines demonstrate efficacy comparable to oral routes in mucosal protection but often yield superior systemic responses due to direct lymphatic drainage, though multi-dose regimens face adherence challenges in outpatient settings. Beyond vaccines, sublingual administration is utilized for various therapeutic applications, including antiemetics like , which is delivered via orally disintegrating tablets to rapidly alleviate and associated with , , or , achieving peak plasma levels within 30 minutes for quick onset. In hormone replacement therapy, sublingual effectively manages menopausal symptoms such as hot flashes and vaginal by providing bioidentical with high , bypassing first-pass to maintain steady levels and reduce vasomotor symptoms in postmenopausal women. Additionally, vitamin B12 supplements are administered sublingually to treat deficiency in patients who do not absorb the vitamin adequately from food or oral sources, improving nervous system health and red blood cell production.

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