Breakthrough pain in patients receiving opioid therapy
for chronic cancer pain
▶BY BUCCAL ADMINISTRATION USING LOZENGES
▶Child 16–17 years:Initially 200 micrograms, dose to be
given over 15 minutes, then 200 micrograms after
15 minutes if required, no more than 2 dose units for
each pain episode; if adequate pain relief not achieved
with 1 dose unit for consecutive breakthrough pain
episodes, increase the strength of the dose unit until
adequate pain relief achieved with 4 lozenges or less
daily, if more than 4 episodes of breakthrough pain
each day, adjust background analgesia
DOSE EQUIVALENCE AND CONVERSION
▶Fentanylfilms arenot bioequivalentto other fentanyl
preparations.
▶Fentanyl preparations for the treatment of
breakthrough pain are not interchangeable; if patients
are switched from another fentanyl-containing
preparation, a new dose titration is required.
DOSESATEXTREMESOFBODY-WEIGHT
▶To avoid excessive dosage in obese patients, weight-
based doses may need to be calculated on the basis of
ideal bodyweight.lUNLICENSED USE
▶With intravenous useNot licensed for use in children under
2 years; infusion not licensed for use in children under
12 years.
lCAUTIONSCerebral tumour.diabetes mellitus (with
Actiq®lozenges).impaired consciousness
CAUTIONS, FURTHER INFORMATION
▶With transdermal useTransdermal fentanyl patches are not
suitable for acute pain or in those patients whose analgesic
requirements are changing rapidly because the long time
to steady state prevents rapid titration of the dose. Risk of
fatal respiratory depression, particularly in patients not
previously treated with a strong opioid analgesic;
manufacturer recommends use only in opioid tolerant
patients.
▶With intravenous useRepeated intra-operative doses should
be given with care since the resulting respiratory
depression can persist postoperatively and occasionally it
may become apparent for thefirst time postoperatively
when monitoring of the patient might be less intensive.
lINTERACTIONS→Appendix 1 : opioids
lSIDE-EFFECTS
▶Common or very common
▶With parenteral useAllergic dermatitis.apnoea.arrhythmia
.hypertension.movement disorders.muscle rigidity.
respiratory disorders.vascular disorders
▶With transdermal useAnxiety.appetite decreased.asthenia
.depression.diarrhoea.dyspnoea.gastrointestinal
discomfort.hypertension.insomnia.malaise.muscle
complaints.peripheral oedema.sensation abnormal.skin
reactions.temperature sensation altered.tremor
▶Uncommon
▶With parenteral useAirway complication of anaesthesia.
chills.hiccups.hypothermia
▶With transdermal useConsciousness impaired.cyanosis.
disorientation.fever.gastrointestinal disorders.influenza
like illness.memory loss.respiratory disorders.seizures.
sexual dysfunction.vision blurred
▶Rare or very rare
▶With transdermal useApnoea
▶Frequency not known
▶With buccal or oral useAdrenal insufficiency (long term use)
.androgen deficiency.anxiety.appetite decreased.
asthenia.circulatory depression.coma.depersonalisation
.depression.diarrhoea.dyspnoea.emotional lability.
fever.gait abnormal.gastrointestinal discomfort.
gastrointestinal disorders.gingival haemorrhage.gingivitis.hypotension exacerbated.injury.loss of
consciousness.malaise.movement disorders.oral
disorders.peripheral oedema.seizure.sensation
abnormal.shock.sleep disorders.speech slurred.taste
altered.thinking abnormal.throat oedema.ulcer.
vasodilation.vision disorders.weight decreased
▶With parenteral useBiliary spasm.cardiac arrest.cough.
hyperalgesia.loss of consciousness.seizure
▶With transdermal useMyoclonus
SIDE-EFFECTS, FURTHER INFORMATION
Muscle rigidityIntravenous administration of fentanyl
can cause muscle rigidity, which may involve the thoracic
muscles. Manufacturer advises administration by slow
intravenous injection to avoid; higher doses may require
premedication with benzodiazepines and muscle
relaxants.
Transdermal useMonitor patients using patches for
increased side-effects if fever is present (increased
absorption possible); avoid exposing application site to
external heat, for example a hot bath or sauna (may also
increase absorption).
lBREAST FEEDING
▶With buccal useManufacturer advises avoid during
treatment and for 5 days after last administration—present
in milk.
▶With intravenous useManufacturer advises avoid during
treatment and for 24 hours after last administration—
present in milk.
▶With transdermal useManufacturer advises avoid during
treatment and for 72 hours after removal of patch—present
in milk.
lRENAL IMPAIRMENTAvoid use or reduce dose; opioid
effects increased and prolonged and increased cerebral
sensitivity occurs.
lDIRECTIONS FOR ADMINISTRATION
▶With transdermal useForpatches, apply to dry, non-
irritated, non-irradiated, non-hairy skin on torso or upper
arm, removing after 72 hours and siting replacement patch
on a different area (avoid using the same area for several
days).
▶With intravenous useForintravenous infusion, injection
solution may be diluted in Glucose 5 % or Sodium Chloride
0. 9 %.
▶With buccal usePatients should be advised to place the
lozenge in the mouth against the cheek and move it
around the mouth using the applicator; each lozenge
should be sucked over a 15 minute period. In patients with
a dry mouth, water may be used to moisten the buccal
mucosa. Patients with diabetes should be advised each
lozenge contains approximately 2 g glucose.
lPRESCRIBING AND DISPENSING INFORMATION
▶With transdermal usePrescriptions for fentanyl patches can
be written to show the strength in terms of the release rate
and it is acceptable to write’Fentanyl 25 patches‘to
prescribe patches that release fentanyl 25 micrograms per
hour. The dosage should be expressed in terms of the
interval between applying a patch and replacing it with a
new one, e.g.’one patch to be applied every 72 hours’. The
total quantity of patches to be supplied should be written
in words andfigures.
lPATIENT AND CARER ADVICE
▶With transdermal usePatients and carers should be
informed about safe use, including correct administration
and disposal, strict adherence to dosage instructions, and
the symptoms and signs of opioid overdosage. Patches
should be removed immediately in case of breathing
difficulties, marked drowsiness, confusion, dizziness, or
impaired speech, and patients and carers should seek
prompt medical attention.
Medicines for Children leaflet: Fentanyl lozenges for pain
http://www.medicinesforchildren.org.uk/fentanyl-lozenges-for-pain280 Pain BNFC 2018 – 2019
Nervous system4