TRANSMUCOSAL FENTANYL PREPARATIONS
Seek specialist palliative care advice before prescribing immediate release fentanyl preparations.
Various transmucosal fentanyl preparations are available8 with similar onset of action and alternative routes of delivery:-
• buccal tablets
• intranasal spray
• sublingual tablets
• transmucosal lozenges
The most appropriate route of administration will depend on the patient’s preference, their manual dexterity and other clinical circumstances. These medications all require careful individual dose titration according to the product literature and patient response.
Transmucosal fentanyl preparations are licensed for breakthrough pain in patients receiving opioid therapy for chronic cancer pain. Such patients should already be receiving a strong opioid for background pain and should have been receiving oral morphine for at least 60mg /24hours (or equivalent dose of an alternative strong opioid) for the previous week before being commenced on an immediate release fentanyl preparation.
Transmucosal fentanyl preparations:
Abstral® sublingual tablets:
100, 200, 300, 400, 600 and 800 microgram tablets
Actiq® lozenges with applicator:
200, 400, 600, 800, 1200, 1600 micrograms lozenges
Effentora® buccal tablets:
100, 200, 400, 600 and 800 microgram tablets
Instanyl® nasal spray:
50, 100, 200 microgram metered sprays
PecFent® nasal spray:
100 , 400 microgram metered sprays
Abstral® (Summary of Product Characteristics – SPC)
• Sublingual tablets should be placed under the tongue at the deepest part and dissolved without chewing or sucking
• Patients should not eat or drink until tablet has dissolved but can moisten mouth with water before having Abstral®
• Absorption takes 30 minutes and pain should be relieved in 15 – 30 minutes
• If pain is not relieved a second tablet can be used after 15-30 minutes
• No more than 2 tablets for each episode of pain (maximum dose
800 micrograms per pain episode)
• A compressed lozenge unit containing fentanyl and integral oro- mucosal applicator
• Dose range starts at 200 micrograms.
• Unit is placed against buccal mucosa and consumed over a 15 minute period
• The unit needs to be constantly rotated against the buccal mucosa for successful absorption and should not be sucked and swallowed
• Buccal tablets should be held between the cheek and gum near a molar tooth
• The tablet will effervesce and should be absorbed in 14-25 minutes.
• Effentora® can also be dissolved under the tongue
• Adequate analgesia should occur within 30 minutes, a second dose can be used after 30 minutes but no more than 2 doses per episode of pain (maximum 800 micrograms per pain episode) and leave at least 4 hours between treatments of pain during titration
• A pump action nasal spray used in one nostril, if pain is not relieved a second dose can be used after 10 minutes, however patient must wait 4 hours before a further dose
• A pump action nasal spray
• Initial dose is one spray (100 micrograms)
• Patient must wait another 4 hours at least before treating a further pain episode with PecFent®