October 25, 2019

Raffi M. Asadorian
Chief Financial Officer
ACELRX PHARMACEUTICALS INC
351 Galveston Drive
Redwood City, CA 94063

       Re: ACELRX PHARMACEUTICALS INC
           Form 10-K for the Fiscal Year Ended December 31, 2018
           Filed March 7, 2019
           File No. 001-35068

Dear Mr. Asadorian:

       We have reviewed your filing and have the following comments. In some of
our
comments, we may ask you to provide us with information so we may better
understand your
disclosure.

       Please respond to these comments within ten business days by providing
the requested
information or advise us as soon as possible when you will respond. If you do
not believe our
comments apply to your facts and circumstances, please tell us why in your
response.

       After reviewing your response to these comments, we may have additional
comments.

Form 10-K for the Fiscal Year Ended December 31, 2018

Business
Clinical Trials, page 8

1.     Please address the following regarding your disclosure of certain
serious adverse events
       (SAEs) experienced by patients in the clinical trials of certain product
candidates:

           You disclose in a risk factor on page 34 that in the phase 3
active-comparator clinical
           trial (IAP309), double-blind, placebo-controlled, orthopedic surgery
trial (IAP311)
           and phase 3 multi-center, open-label study (IAP312), patients
experienced serious
           adverse events (SAEs) that were assessed as "possibly or probably
related to the
           study drug." Please provide us proposed disclosure to be provided in
future filings
           identifying each treatment-related SAE "possibly or probably"
related to Zalviso.

           Further on page 9, you disclose that in the IAP312 study "A total of
5 patients
           experienced serious adverse events, but all were considered
unrelated to study drug
 Raffi M. Asadorian
ACELRX PHARMACEUTICALS INC
October 25, 2019
Page 2
              by investigators." This disclosure appears to contradict your
disclosure on page 34.
              Please clarify for us whether the SAEs in the IAP312 study were
related or unrelated
              to Zalviso. Revise such disclosure in future filings to reconcile
the apparent
              contradiction.

        We remind you that the company and its management are responsible for
the accuracy
and adequacy of their disclosures, notwithstanding any review, comments, action
or absence of
action by the staff.

       You may contact Sasha Parikh at 202-551-3627 or Kevin Vaughn at
202-551-3494 if you
have any questions.



FirstName LastNameRaffi M. Asadorian                          Sincerely,
Comapany NameACELRX PHARMACEUTICALS INC
                                                              Division of
Corporation Finance
October 25, 2019 Page 2                                       Office of Life
Sciences
FirstName LastName