Long-term safety of oral transmucosal fentanyl citrate for breakthrough cancer pain

Peripherally acting opioid analgesics and peripherally-induced analgesia

The management of pain, particularly chronic pain, is still an area of medical need. In this context, opioids remain a gold standard for the treatment of pain. However, significant side effects, mainly of central origin, limit their clinical use. Here, we review recent progress to improve the therapeutic and safety profiles of opioids for pain management. Characterization of peripheral opioid-mediated pain mechanisms have been a key component of this process. Several studies identified peripheral µ, δ, and κ opioid receptors (MOR, DOR, and KOR, respectively) and nociceptin/orphanin FQ (NOP) receptors as significant players of opioid-mediated antinociception, able to achieve clinically significant effects independently of any central action. Following this, particularly from a medicinal chemistry point of view, main efforts have been directed towards the peripheralization of opioid receptor agonists with the objective of optimizing receptor activity and minimizing central exposure and the associated undesired effects. These activities have allowed the characterization of a great variety of compounds and investigational drugs that show low central nervous system (CNS) penetration (and therefore a reduced side effect profile) yet maintaining the desired opioid-related peripheral antinociceptive activity. These include highly hydrophilic/amphiphilic and massive molecules unable to easily cross lipid membranes, substrates of glycoprotein P (a extrusion pump that avoids CNS penetration), nanocarriers that release the analgesic agent at the site of inflammation and pain, and pH-sensitive opioid agonists that selectively activate at those sites (and represent a new pharmacodynamic paradigm). Hopefully, patients with pain will benefit soon from the incorporation of these new entities.

Improvement of Pain Relief of Fentanyl Citrate Drug Encapsulated in Nanostructured Lipid Carrier: Drug Formulation, Parameter Optimization, in vitro and in vivo Studies

Introduction

In this study, the encapsulation of fentanyl citrate as an opioid drug with hydrophobic nature in the nanostructured lipid carrier (NLC) is performed.

Methods

For encapsulation of fentanyl citrate drug, hot homogenization method is used. The pharmacokinetics of encapsulated fentanyl citrate for pain relief of rats are investigated. The influence of important variables such as the ratio of liquid lipid to the total amount of lipids, surfactant type and concentration on the particle size is investigated using response surface method.

Results

Results show that the optimal NLC size is about 90 nm with PDI value around 0.2 and zeta potential of -25±4.01 mV. Characterization analysis of optimal nanostructure shows successful encapsulation of the drug in nanostructure with a spherical morphology of the NLC structure. Results of drug release from commercial fentanyl citrate ampoule and NLC form indicate a control drug release from the NLC within 72 hours in comparison to the commercial ampoule. In vivo studies show that fentanyl citrate-loaded NLC not only has the potential to relieve pain in doses equal to commercial drug but also it can reduce the dose of the drug about 50%.

Conclusion

In conclusion, NLC form of fentanyl citrate can increase the efficacy of the drug by appropriate drug distribution in the body and can reduce the risks of overdose.

Nanotechnology application for pain therapy

Prolonged delivery of analgesic drugs at target sites remains a critical issue for efficient pain management. The use of nano-carriers has been reported to facilitate applicable delivery of these agents to target sites with a reduced level of systemic toxicity. Different analgesics have been loaded onto various nano carriers, including those that are natural, synthetic and copolymer, for various medical applications. In this review, we will discuss the concept of nano-formulated carriers for analgesic drugs and their impacts on the field of pain management.

Rapid acting fentanyl formulations in breakthrough pain in cancer. Drug selection by means of the System of Objectified Judgement Analysis

Drug selection of rapid acting fentanyl formulations in the treatment of breakthrough pain in patients with cancer is performed by the System of Objectified Judgement Analysis method. All seven available formulations were included in the analysis. The following selection criteria were used: number of available strengths, variability in the rate of absorption, interactions, clinical efficacy, side effects, ease of administration and documentation. No direct double-blind comparative studies between two or more formulations were identified and the clinical documentation of all formulations is limited. The most distinguishing criterion was ease of use. This led to slightly higher scores for Abstral, Instanyl and PecFent than for the other formulations. The pros and cons of each formulation should be discussed with the patient, and the most suitable formulation selected for each individual patient.

Chronic opioid therapy in long-term cancer survivors

PURPOSE

Long-term cancer survivors develop special health issues and specific needs. Chronic pain, whether the consequence of their cancer or as a side effect of treatment, is one of their most prevalent concerns.

METHODS

We conducted a review of the English-language literature on long-term cancer survivorship and chronic opioid therapy, with the objective of determining the efficacy, safety and tolerability in this group of patients. Practical management recommendations are made on the basis of this review.

RESULTS

Pain syndromes encountered in the long-term cancer survivors are diverse. Opioid receptor pathways possess complex and pleiotropic functions and continuous over-activation may lead to de novo endocrinopathies, immunosuppression, neurocognitive impairment, or cell cycle disturbances with potential clinical connotations. However, there are insufficient data to support evidence-based decision making with respect to patient selection, doses, administration, monitoring and follow-up. Data about long-term treatment effectiveness and safety are limited and often aggravated by the overlapping of several diseases prevalent among long-term cancer survivors, as well as chronic opiate-induced toxicity.

CONCLUSIONS

Chronic opioid therapy is frequent in long-term cancer survivors, and may negatively affect the immune system, and produce health problems such as endocrinopathies, osteoporosis, neurological or cardiopulmonary effects, alterations of cell cycle kinetics, abuse and addiction. This review highlights the need for specialized teams to treat chronic pain in long-term cancer survivors from an integrative perspective.

Prospective Observational Study of Patient-Controlled Intrathecal Analgesia: Impact on Cancer-Associated Symptoms, Breakthrough Pain Control, and Patient Satisfaction

BACKGROUND AND OBJECTIVES

Although data exist for the efficacy of intrathecal therapy (ITT), there are no prospective data on patient-controlled intrathecal analgesia (PCIA) in refractory cancer pain. This study examines the effect of PCIA on cancer symptom scores, patient satisfaction, and analgesic efficacy with an emphasis on breakthrough pain (BTP).

METHODS

Ninety-eight patients with refractory cancer pain prospectively completed questionnaires including the MD Anderson Symptom Inventory and a BTP survey before and after the implantation of an intrathecal pump.

RESULTS

Fifty-eight patients were included in the study group. Average "worst" pain scores decreased from 8.32 (SD, 1.73) pre-ITT to 4.98 (SD, 2.92) post-ITT, P < 0.001. Severe pain (numerical rating score ≥7) decreased from 84.2% to 35.2% (P < 0.001). Mean daily morphine equivalent dosing decreased from 805.3 mg/d to 128.2 mg/d, with 65.5% of patients discontinuing all nonintrathecal opioids. The mean MD Anderson Symptom Inventory symptom severity score decreased from 4.98 to 3.72 (P < 0.0001), and the symptom interference score from 6.53 to 4.37 (P < 0.001). Pain reduction was 46.8% with pre-ITT breakthrough medications and 65.2% with PCIA (P < 0.001). Median time to onset was 30 minutes with pre-ITT breakthrough medications and 10 minutes with PCIA (P < 0.001). Patient-controlled intrathecal analgesia, compared with conventional BTP medications, was "a lot better" in 60.7% and "a little better" in 28.6%. Overall pain control satisfaction was also improved, with 78.2% "a lot better" and 10.9% "I have no pain."

CONCLUSIONS

In patients with poorly controlled cancer pain, PCIA is associated with improved pain control, improved cancer-related symptoms, and high satisfaction. Compared with conventional BTP regimens, PCIA provides superior analgesia and a 3-fold faster onset of action.

Long-term safety of fentanyl sublingual spray in opioid-tolerant patients with breakthrough cancer pain

PURPOSE

The current study assessed the long-term safety of fentanyl sublingual spray for managing breakthrough cancer pain (BTCP).

METHODS

This open-label, multicenter study enrolled both de novo and rollover patients who completed a double-blind, efficacy trial. Eligible patients were ≥18 years of age and experiencing pain that was being managed with an around-the-clock opioid yet were experiencing ≤4 BTCP episodes daily and were opioid-tolerant (i.e., receiving ≥60 mg/day oral morphine or an equivalent dose of another opioid for ≥1 week). De novo patients initially entered a 21-day titration period to identify an effective dose of fentanyl sublingual spray (100-1600 μg), then entered a 90-day maintenance period. The incidence of adverse events (AEs), results of laboratory tests, vital sign assessments, and treatment satisfaction were assessed.

RESULTS

Of the 269 patients (de novo, 179; rollover, 90) who entered the maintenance period, 163 (60.6 %) completed the study; the primary reason for discontinuation was an AE (22.3 %). Eighty percent of patients identified an effective dose of fentanyl sublingual spray (median dose, 600 μg). The most common AEs differed from the titration period (nausea (13 %), vomiting (12 %), and somnolence (10 %)) to the maintenance period (malignant neoplasm progression (24 %), vomiting (16 %), and peripheral edema (12 %)). Few changes in laboratory parameters and vital sign assessments were observed. Patients generally reported being more satisfied with fentanyl sublingual spray than with their previous BTCP treatment.

CONCLUSIONS

This long-term maintenance study demonstrated that fentanyl sublingual spray was generally safe and well tolerated for managing BTCP over a 90-day period.

Diagnosis and management of breakthrough cancer pain: Have all the questions been resolved? A Delphi-based consensus assessment (DOIRON)

OBJECTIVE

To ascertain the level of agreement and achieve a consensus among cancer pain specialists in Spain with regard to the optimal definition, diagnosis, and management of breakthrough cancer pain (BTcP).

DESIGN

Two-round Delphi methodology survey (February-May 2013) using seven-point Likert scales (ranging from 1 "strongly disagree" to 7 "strongly agree") was carried out. Mean scores >5 or <3 indicated, respectively, agreement or disagreement. Scores from 3 to 5 indicated no consensus.

RESULTS

A total of 126 experienced specialists were surveyed. Response rates were 68 % in round 1 and 90 % in round 2. Agreement (mean Likert score) was strongest for the proposed BTcP definition (6.6), the use of oral (6.1), and intranasal (6.0) transmucosal fentanyl, the need for early assessment after BTcP treatment initiation, and the need to improve staff knowledge of BTcP. Broad agreement was also reached regarding the need to systematically screen all cancer patients for BTcP (5.9). Most respondents (82 %) considered strong opioids to be appropriate treatment. In contrast, no consensus was reached regarding strong opioid treatment for baseline pain as a prerequisite for BTcP diagnosis.

CONCLUSIONS

Consensus was strong for most treatment, and diagnostic aspects were evaluated in the study. However, several important issues remain unresolved, particularly whether the diagnostic criteria must include strong opioids for background pain. Nurses' awareness and understanding of BTcP was considered insufficient, and more training is needed in this area. Overall, agreement among specialists was good, but more work is needed to better define the optimal diagnostic features and treatments for this condition.

Fentanyl for the treatment of tumor-related breakthrough pain

BACKGROUND

Breakthrough cancer pain (BTCP) is common among cancer patients and markedly lowers their quality of life. The treatment for BTCP episodes that is recommended in current guidelines involves extended-release formulations in combination with rapid-onset and short-acting opioids. In the past few years, several new preparations of fentanyl, an opioid with a very rapid onset, have been approved for this indication. Treating physicians need to be aware of the clinical differences between the newer fentanyl preparations and immediate-release opioids.

METHODS

We searched the PubMed and Embase databases for randomized controlled trials (RCTs) of fentanyl for buccal, sublingual or intranasal administration in comparison with other opioids or a different fentanyl preparation for the treatment of BTCP.

RESULTS

In 6 trials of buccal, sublingual or intranasal fentanyl versus oral immediate-release opioids for the treatment of BTCP episodes, the use of fentanyl was associated with significantly less intense pain. In particular, fentanyl more often lowered the intensity of pain by at least 33% (range between studies: 13% to 57%) or by at least 50% (range between studies: 9% to 38%) within 15 minutes. Please change to "versus" if you agree.] Dose titration should begin at the lowest dose. When one fentanyl preparation is exchanged for another, the effective dose will probably differ.

CONCLUSION

The newer fentanyl preparations extend the treatment options for BTCP. They relieve pain within a short time better than conventional, immediate-release oral opioids do and may therefore be very helpful for patients with suddenly arising, intense, and short-lasting BTCP episodes. Further comparative trials are urgently needed.

Fentanyl (transmucosal)

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

A comprehensive review of rapid-onset opioids for breakthrough pain

Breakthrough pain (BTP) is a transitory pain (reaching maximum severity in ~15 minutes and lasting ~60 minutes in patients with cancer) that occurs despite the management of chronic pain with long-term around-the-clock analgesia. BTP occurs in 33-65% of patients with chronic cancer pain and in ~70% of patients with chronic noncancer pain. BTP has historically been managed with short-acting opioids; however, these medications have a pharmacokinetic profile that does not correlate with the sudden onset and short time to maximum severity of BTP. Interest in rapid-onset opioids to relieve BTP has therefore been growing. This comprehensive review aims to summarize the currently available clinical data for the approved rapid-onset opioids, which comprise different formulations of fentanyl, a μ-opioid receptor agonist with anaesthetic and analgesic properties. Administration routes for fentanyl in the management of BTP currently include the transmucosal and intranasal routes; an intrapulmonary formulation is also in development. The findings of this review suggest that the efficacy and safety of the approved rapid-onset opioids are comparable.

Efficacy and safety of fentanyl sublingual spray for the treatment of breakthrough cancer pain: a randomized, double-blind, placebo-controlled study

BACKGROUND AND OBJECTIVES

A number of transmucosal fentanyl formulations have been developed for the management of breakthrough cancer pain (BTCP). Sublingual delivery of fentanyl, formulated as fentanyl sublingual spray, offers the potential for more rapid and greater absorption of fentanyl and associated onset of analgesic effect compared with other formulations. The objective of this study was to assess the efficacy and safety of fentanyl sublingual spray for the treatment of BTCP.

RESEARCH DESIGN AND METHODS

This was a randomized, double-blind, placebo-controlled phase III trial conducted in opioid-tolerant patients with BTCP. An open-label titration period was followed by a double-blind treatment period during which patients received fentanyl sublingual spray (100-1600 mcg) or placebo.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT00538850.

MAIN OUTCOME MEASURES

The primary efficacy measure was summed pain intensity difference at 30 minutes (SPID(30)). Secondary efficacy measures included total pain relief at 30 minutes (TOTPAR(30)) and patient global evaluation of study medication at 30 minutes. Efficacy measures were also assessed at various time points from 5-60 minutes postdose. Adverse events were monitored throughout the study.

RESULTS

A total of 130 patients were treated during the titration period, of whom 98 (75.4%) entered the double-blind period. Relative to placebo, fentanyl sublingual spray significantly improved mean SPID scores from 5 minutes (p = 0.0219) through 60 minutes (p < 0.0001), including the primary endpoint at 30 minutes (p < 0.0001). Fentanyl sublingual spray produced significantly greater pain relief (expressed in terms of TOTPAR) from 5 through 60 minutes (p < 0.0001), and significantly greater global evaluation of treatment effectiveness (p < 0.0001), compared with placebo. During double-blind treatment, the most frequently reported adverse events were nausea (7.1%), hyperhidrosis (5.1%), and peripheral edema (5.1%). Serious adverse events occurred in seven patients (5.4%) during titration and six (6.1%) during double-blind treatment; none were considered related to treatment.

CONCLUSIONS

These findings indicate that treatment with fentanyl sublingual spray results in effective relief of BTCP, with a rapid onset of action, and is well tolerated.

Oral trasmucosal fentanyl citrate for breakthrough pain treatment in cancer patients

INTRODUCTION

Breakthrough cancer pain has been defined as a transitory increase in pain intensity that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. The availability of supplemental doses of oral opioids, in addition to the continuous analgesic medication, is the main treatment suggested to manage pain flares.

AREAS COVERED

Oral transmucosal fentanyl citrate (OTFC) is the first product of a new generation of delivery systems, named rapid-onset opioids (ROOs), characterized by rapidity of effect and the short duration of analgesia. Controlled studies and long-term experience have shown that OTFC is an effective treatment for breakthrough pain management and its use should be considered in any patient experiencing breakthrough pain related to cancer.

EXPERT OPINION

The onset of action of OTFC - demonstrated to start within 15 min - and the short time to maximum concentration make it a useful indication for breakthrough pain; dose titration is commonly recommended. However, it is likely that patients receiving high doses of opioids for background analgesia will not be candidates for titration with minimal initial doses of OTFC, as they are opioid tolerant and the process would be time consuming.

[Cancer breakthrough pain. Indications for rapidly effective opioids]

The pharmacotherapy of tumor pain has two main aims: to deliver an adequate basic analgesia using long-term retarded opioid medication and an effective treatment of tumor breakthrough pain using rapidly effective non-retarded opioids. Breakthrough pain is characterized by a sudden onset and rapid increase in the pain level and should be treated with correspondingly rapidly effective opioids. The pharmacological characteristics of previously available and routinely prescribed non-retarded opioids do not always correspond in oral galenics to the demands resulting from the definition of tumor breakthrough pain. As alternatives to these substances five different rapidly effective fentanyl preparations are now available for transmucosal administration.

Patient-controlled intrathecal analgesia for the management of breakthrough cancer pain: a retrospective review and commentary

OBJECTIVE

  Intrathecal therapy (ITT) via an implanted pump has become an accepted practice for the treatment of refractory cancer pain by infusing opioids and adjuncts directly to the neuraxis. Until recently, only a programmed basal rate of infusion could be delivered, and therefore, breakthrough pain required ongoing use of oral or transmucosal opioids. Recently, an implanted pump manufacturer has introduced a handheld device to bolus additional medication for breakthrough pain. We hypothesize that patient-controlled intrathecal analgesia (PCIA) for the treatment of breakthrough cancer pain reduces the need for breakthrough opioids and improves the patient perception of pain.

METHODS

  A retrospective chart review was done on all patients who underwent ITT for cancer pain between January 2009 and February 2011. Clinical outcomes of interest were reduction in nonintrathecal opioid use and reduction in numerical rating score (NRS) for pain. The data was collected prior to ITT and at a 4-6 week postimplant visit.

RESULTS

  After initiation of ITT with PCIA, 50% of patients had discontinued all nonintrathecal opioids at follow-up, and 46% of the patients on breakthrough medications no longer required their use. At follow-up, there was a significant reduction in total nonintrathecal opioid use, with an average of 796 mg pre-ITT vs 64 mg post-ITT of daily oral morphine equivalent dosing (P = <0.001). There was a significant difference between mean NRS pain score at follow-up-6.5 vs 3.1 pre-ITT (P<0.001). 65% of patients reported their pain as severe (NRS of 7 or greater) prior to ITT; this decreased to 3% at follow-up.

CONCLUSIONS

  In patients with refractory cancer pain, intrathecal drug therapy with PCIA is associated with improved pain reporting, reduced nonintrathecal around-the-clock, and breakthrough opioid requirements.

The efficacy and safety of fentanyl buccal tablet compared with immediate-release oxycodone for the management of breakthrough pain in opioid-tolerant patients with chronic pain

BACKGROUND

Current clinical guidelines have identified the need for studies comparing the effect of different short-acting or rapid-onset opioids for the treatment of breakthrough pain (BTP). In this study we evaluated the efficacy and safety of treatment with fentanyl buccal tablet (FBT) in comparison with immediate-release oxycodone in alleviating BTP in opioid-tolerant patients with chronic pain.

METHODS

In this cross-over design study, opioid-tolerant patients were randomized to open-label titration with FBT (200, 400, 600, 800 μg) followed by oxycodone (15, 30, 45, 60 mg) or vice versa for the management of BTP. After titration to a successful dose of both study drugs, patients were rerandomized to double-blind treatment for 10 BTP episodes with 1 of the already identified successful doses of study drug followed by cross-over to double-blind treatment for 10 BTP episodes with the other study drug. The primary efficacy measure was the difference in pain intensity (based on an 11-point numerical scale) 15 minutes after administration of study drug (PID(15)). Other efficacy measures included PID at other time points postdose (5 through 60 minutes), the sum of pain intensity differences (SPID) at 30 and 60 minutes postdose, pain relief (5 through 60 minutes), proportion of BTP episodes for which patients experienced meaningful reduction in pain intensity, and patient preference for BTP medication. Adverse events were also recorded.

RESULTS

Of the 323 patients enrolled, 203 achieved a successful dose of both study drugs, 191 completed the titration phase, and 180 completed the double-blind phase. PID(15) was significantly greater after FBT versus oxycodone (mean [SD], 0.82 [1.12] vs. 0.60 [0.88]; 95% confidence interval [CI] = 0.18, 0.29; P < 0.0001). Secondary efficacy measures favored FBT and showed differences versus oxycodone from 5 minutes postdose for PID and 10 minutes postdose for pain relief. SPID(30) and SPID(60) were greater with FBT than with oxycodone (P < 0.0001 for both measures). A ≥33% improvement in pain intensity occurred in a larger proportion of FBT-treated episodes versus oxycodone beginning 15 through 45 minutes postdose (P < 0.05). FBT was preferred by 52% of patients, oxycodone by 33%. Adverse events with both study drugs were generally typical of opioids, and the majority occurred during titration. Two serious adverse events (pneumonia) were reported in 1 patient; both occurrences were considered unrelated to study drug.

CONCLUSION

FBT resulted in more rapid onset of analgesia and was generally well tolerated in comparison with oxycodone for the treatment of BTP in opioid-tolerant patients.

Breakthrough pain in cancer patients

Breakthrough pain is a transient exacerbation of pain that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. A typical episode of breakthrough pain has a fast onset and short duration, yet despite the self-limiting nature of each breakthrough pain, the repeated episodes can have a significant effect on patients' quality of life. Normal-release oral opioids have been the mainstay pharmacological approach for patients who are receiving an around the clock opioid regimen, but the onset and duration of action of oral opioids such as morphine may not be suitable for treating many breakthrough pains. Efforts to provide non-parenteral opioid formulations that could provide more rapid, and more effective, relief of breakthrough pain have led to the development of transmucosal opioid formulations.

Treatment of breakthrough pain with fentanyl buccal tablet in opioid-tolerant patients with chronic pain: appropriate patient selection and management

BACKGROUND

Opioids can be a safe and effective option for carefully selected patients with a structured treatment program that includes consistent monitoring. However, the benefits and risks of opioid therapy for patients with chronic pain, and society as a whole, have been sharply debated. A key component of this debate has involved the administration of rapid-onset opioids for the management of breakthrough pain.

OBJECTIVE

Review key aspects of breakthrough pain management with fentanyl buccal tablet, with a focus on minimizing risk to optimize therapeutic outcomes. Recommendations that apply broadly to all rapid-onset opioids are also discussed.

DESIGN

Available fentanyl buccal tablet clinical and post-marketing data were reviewed.

RESULTS

Like other schedule II controlled substances, and because fentanyl buccal tablet is a highly potent opioid, its use is associated with risk of overdose, misuse, and diversion. As with all rapid-onset opioids, particular attention to patient selection and risk assessment is warranted. The inclusion and exclusion criteria in fentanyl buccal tablet clinical studies represent patient selection standards that should be translated to clinical practice, most importantly, that patients are opioid-tolerant before fentanyl buccal tablet initiation. Titration of fentanyl buccal tablet from a low starting dose to a successful dose allows the safe identification of a dose that provides the greatest pain relief without unacceptable adverse events. After initiating fentanyl buccal tablet therapy, all patients should continue to be regularly monitored for response, including analgesia, functioning, tolerability, and aberrant behavior.

CONCLUSIONS

Fentanyl buccal tablet can be an effective and generally safe treatment for breakthrough pain when appropriate patient selection, administration, dosing, and monitoring are applied.

Formulations of fentanyl for the management of pain

Fentanyl is an opioid initially developed for parenteral administration. While oral administration is not an option due to a high first-pass metabolism, its high potency and lipophilicity have made a number of new routes of administration feasible. The transdermal therapeutic system offers an excellent option for long-term treatment of cancer and chronic pain, achieving stable plasma concentrations over the treatment period. The recent change from reservoir to matrix systems has made these systems more convenient to wear and safer to use, while being bioequivalent. In contrast, the patient-controlled iontophoretic transdermal system has been developed to enable on-demand delivery of transdermal bolus doses of fentanyl to treat postoperative pain. It offers a needle-free system to provide patient-controlled analgesia otherwise offered by intravenous pumps. However, due to technical difficulties the system is currently not clinically available. Oral transmucosal fentanyl utilizes the rapid uptake through the buccal mucosa to achieve high plasma concentrations rapidly and is indicated to treat breakthrough pain in patients who are not opioid-naive. The recently introduced fentanyl buccal tablets offer slightly better pharmacokinetics for the same indication. The intranasal route is another option to achieve rapid uptake of fentanyl, and is currently being investigated to provide acute and breakthrough pain relief. Transpulmonary administration of fentanyl remains experimental and this route of administration is not yet in clinical use. Overall, the specific pharmacological and physicochemical properties of fentanyl have made this compound highly suitable for novel routes of administration in a range of clinical indications.

Oral Transmucosal Fentanyl Citrate: Overview of Pharmacological and Clinical Characteristics

Oral transmucosal fentanyl citrate (OTFC; brand name Actiq, Cephalon, UT) is a new opioid formulation that incorporates fentanyl into a lozenge and allows drug delivery through the buccal mucosa. This kind of absorption avoids first-pass metabolism, yielding a bioavailability substantially greater than oral administration. OTFC has a rapid onset of action and a short duration of effect. These characteristics, which resemble the course of a typical breakthrough pain episode, resulted in making OTFC the first opioid analgesic formulation specifically developed and approved for control of breakthrough pain in cancer patients. Apart from that, OTFC has been used in a variety of clinical situations of noncancer pain. This review article presents the synthesis; clinical pharmacology; pharmacokinetic and pharmacodynamic properties, toxicity, and clinical efficacy of this novel agent.

[Oral transmucosal fentanyl citrate for the treatment of breakthrough pain. Results of a non-interventional study (NIS)]

BACKGROUND

In a non-interventional study the efficacy and tolerability of oral transmucosal fentanyl citrate (OTFC) was studied in patients with opioid-treated cancer pain suffering from breakthrough pain.

PATIENTS AND METHODS

The prospective multicenter observational trial included 406 patients. For 3-4 months, efficacy of OTFC treatment for breakthrough pain was documented using a numerical analog pain intensity scale (NAS). Further, OTFC therapy was rated and adverse events were recorded.

RESULTS

With application of oral transmucosal fentanyl citrate median pain intensity fell from NAS 8 points at the beginning to NAS 2 points at the end of the study. The median effective dosage was 400 g. Tolerability was rated as good or very good by 87.5% of the patients.

CONCLUSION

Oral transmucosal fentanyl citrate is a safe and effective treatment for breakthrough pain in chronic cancer-related pain.

The use of oral transmucosal fentanyl citrate during high-dose-rate gynecologic brachytherapy

Gynecologic brachytherapy is a form of cancer treatment in which radioactive sources are placed into the pelvic organs via specialized applicators. Traditional low-dose-rate (LDR) brachytherapy has been performed over several days in a hospital setting. Since the 1990s, high-dose-rate (HDR) brachytherapy has been used increasingly because of its decreased treatment time, outpatient administration, and equal or superior efficacy compared with LDR treatment. However, the management of procedural pain in the radiation oncology setting has not been studied extensively. The purpose of this article is to discuss the use of oral transmucosal fentanyl citrate (OTFC) for the management of pain during gynecologic HDR brachytherapy. OTFC provides noninvasive, rapid analgesia with a low incidence of side effects and may be appropriate for other forms of procedure-related cancer pain.

Oral transmucosal fentanyl citrate in cancer pain management: a practical application of nanotechnology

Pain is experienced by most cancer patients and represents an important issue in the clinical setting. Breakthrough pain is a transitory flare of pain that occurs in most cancer patients on a background of otherwise controlled persistent pain. Treatment of breakthrough pain is a challenging phenomenon. Oral transmucosal fentanyl citrate (OTFC; Actiq, Cephalon, UK), a new opioid formulation with a unique delivery system, utilizing the advantages that nanotechnology offers, reflects the characteristics of breakthrough pain (rapid onset of action and short duration), which makes it an effective treatment to cancer patients who are already receiving opioids and continue to experience such flares of pain. Oral transmucosal fentanyl citrate is specifically developed and approved for the management of breakthrough pain in cancer patients and it has the potential to be a useful tool for clinicians.

Fentanyl buccal tablet for the relief of breakthrough pain in opioid-tolerant adult patients with chronic neuropathic pain: a multicenter, randomized, double-blind, placebo-controlled study

BACKGROUND

Patients with chronic noncancer pain, including neuropathic pain, may have transitory exacerbations of pain (median duration, 60 minutes), termed breakthrough pain (BTP), that may reach peak intensity within minutes. Typical short-acting oral opioids may not provide sufficiently rapid relief (30- to 60-minute onset of analgesia). The fentanyl buccal tablet (FBT) provides a rapid onset of analgesia (10-15 minutes) by enhancing fentanyl absorption across the buccal mucosa.

OBJECTIVE

This study evaluated the efficacy and tolerability of FBT in opioid-tolerant patients with BTP associated with chronic noncancer neuropathic pain.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled study in men and women aged 18 to 80 years who were opioid tolerant; had a >/= 3-month history of chronic persistent neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia, traumatic injury, or complex regional pain syndrome; and reported having episodes of BTP. After an open-label titration period to identify an effective FBT dose (the dose at which the patient reported receiving adequate pain relief within 30 minutes after administration of a single tablet of that dose during at least 2 of 3 BTP episodes), patients were randomly assigned to treat 9 consecutive episodes of BTP over the next 21 days with 1 of 3 double-blind dose sequences of FBT and placebo tablets. Pain intensity (PI) (rated on an 11-point pain scale, from 0 = no pain to 10 = worst pain) and other outcomes were assessed before dosing and for 2 hours after dosing. The primary efficacy measure was the sum of PI differences (PIDs) for the first 60 minutes (SPID(60)). Secondary efficacy measures included the proportion of BTP episodes with >/= 33% and >/= 50% improvement in PI from baseline; PID at other time points (5, 10, 15, 30, 45, 60, 90, and 120 minutes after dosing); pain relief (PR) at the same time points (rated on a 5-point Likert scale from 0 = none to 4 = complete); proportion of BTP episodes with meaningful PR; time to meaningful PR; and proportion of BTP episodes in which supplemental medication was required after administration of study drug. Adverse events (AEs) spontaneously reported by the patient or elicited by the investigator were recorded throughout the study.

RESULTS

Of 102 patients in the open-label titration period, 80 identified an effective dose of FBT and 79 entered the double-blind phase. Of these 79 patients, 77 (97%) completed the study and 75 (95%) were evaluable for efficacy. Of the 79 patients who entered the double-blind phase, 63% were women and 92% were white; their mean (SD) age was 48.3 (10.42) years, and their mean weight was 96.8 (33.42) kg. Baseline demographic and pain characteristics were similar between the overall population and the double-blind population. SPID(60) was significantly greater for BTP episodes treated with FBT compared with those in which placebo was administered (mean [SE], 9.63 [0.75] vs 5.73 [0.72], respectively; P < 0.001). Significant differences between FBT and placebo were seen beginning at 10 minutes for PID (mean, 0.740 [0.149] vs 0.427 [0.081]; P < 0.047) and PR (mean, 0.561 [0.087] vs 0.324 [0.056]; P < 0.001). A >/= 33% improvement in PI from baseline was seen in a greater proportion of BTP episodes treated with FBT compared with placebo from 10 minutes (9% vs 3%; P = 0.008) through 2 hours (66% vs 37%; P < 0.001). Patients were almost 4 times less likely to require supplemental opioids when BTP episodes were treated with FBT compared with placebo (odds ratio = 0.28; 95% Cl, 0.18-0.42). AEs were reported by 64 (63%) of 102 patients. The most commonly reported AEs were those typical of opioids (nausea [13%], dizziness [13%], somnolence [10%], and vomiting [5%]) and occurred more often during the dose-titration phase (55/102 [54%]) than during the double-blind phase (22/79 [28%]).

CONCLUSION

In these opioid-tolerant patients with chronic neuropathic pain who identified an effective FBT dose, FBT had a rapid onset of action and was effective and well tolerated in the treatment of BTP.

Breakthrough pain in children with cancer

The aims of this prospective study were to determine the prevalence, characteristics, and impact of breakthrough pain in children with cancer. Twenty-seven pediatric inpatients with cancer (aged 7-18 years) who had severe pain requiring treatment with opioids and who received care in the Oncology Unit at the Children's Hospital at Westmead, Sydney, Australia participated in this study. The children responded to a structured interview (Breakthrough Pain Questionnaire for Children), designed to characterize breakthrough pain in children. Measures of pain, anxiety, and depressed mood were completed. Fifty-seven percent of the children experienced one or more episodes of breakthrough pain during the preceding 24 hours, each episode lasting seconds to minutes, occurring 3-4 times/d, and most commonly characterized as "sharp" and "shooting" by the children. Younger children (7-12 years) had a significantly higher risk of experiencing breakthrough pain compared to teenagers. No statistical difference could be shown between children with and without breakthrough pain in regard to anxiety and depression. The most effective treatment of an episode of breakthrough pain was a patient-controlled analgesia opioid bolus dose. Further studies of breakthrough pain in children and more effective treatment strategies in this age group are necessary.

Actiq: an effective oral treatment for cancer-related breakthrough pain

As a result of improved survival in cancer and the transfer of care from hospital to primary care, community nurses are taking increasing responsibility for the management of patients at all stages of the disease. Persistent or background pain is common, but between 40% and 80% of patients with advanced cancer also experience breakthrough pain (BTP), a sudden, rapidly escalating flare of pain occurring against a background of otherwise well-controlled persistent pain. While background pain can be successfully managed in most patients, BTP presents a particular challenge to community nurses, because short-acting, 'normal release' oral opioid drugs are absorbed too slowly to treat the typical episode. As this article explains, Actiq is an effective strong opioid with a rapid onset and short duration of action that closely matches the characteristics of an episode of BTP.

Treating cancer-related breakthrough pain: the oral transmucosal route

Between 40 and 80% of patients with advanced cancer experience breakthrough pain (BTP), a sudden, rapidly escalating flare of pain occurring against a background of otherwise well-controlled persistent pain. Patients often have up to four episodes of BTP each day, with a typical episode reaching its peak intensity in three to five minutes and lasting about 30 minutes in total. It is essential to provide fast and effective relief since BTP reduces the quality of life of patients and their families, and increases health care costs. The usual approach is to treat BTP with a short-acting, 'normal release' oral opioid, but this is absorbed too slowly to treat the typical episode of BTP. As this article explains, oral transmucosal fentanyl citrate (Actiq) is an effective strong opioid that has a rapid onset and short duration of action that closely matches the characteristics of an episode of BTP.

Pharmacological strategies for the management of cancer pain in developing countries

Pain associated with cancer is often under treated especially in the developing countries where there are problems of poor economy, poor purchasing power of the citizens, absence of effective national health insurance schemes, poor manpower, fake adulterated and expired drugs, poor drug storage conditions; adverse temperature conditions combined with poor power supply which may affect drug efficacy. There is also poor understanding of the physiopharmacology of cancer pain management by health care providers. Assessment of the severity of the pain by location, oncological type, as well as psychosocial, emotional and environmental factors are necessary. The pain often occurs from malignancy, from procedures done to diagnose, stage and treat the malignancy, and from the toxicities of therapy used in treating the cancer. The first priority of treatment is to control pain rapidly and completely, as judged by the patient. The second priority is to prevent recurrence of pain. Analgesic drugs are given 'by the ladder,' 'by the clock' and 'by the appropriate route' using the analgesic ladder guideline proposed by the World Health Organization (WHO). The pharmacological aspects of various drugs used in the management of cancer pain are discussed.

Orofacial pain in cancer: part II--clinical perspectives and management

Cancer-associated pain is extremely common and is associated with significant physical and psychological suffering. Unfortunately, pain associated with cancer or its treatment is frequently under-treated, probably due to several factors, including phobia of opioids, under-reporting by patients, and under-diagnosis by healthcare workers. The most common etiology of cancer pain is local tumor invasion (primary or metastatic), involving inflammatory and neuropathic mechanisms; these have been reviewed in Part I. As malignant disease advances, pain usually becomes more frequent and more intense. Additional expressions of orofacial cancer pain include distant tumor effects, involving paraneoplastic mechanisms. Pain secondary to cancer therapy varies with the treatment modalities used: Chemo-radiotherapy protocols are typically associated with painful mucositis and neurotoxicity. Surgical therapies often result in nerve and tissue damage, leading, in the long term, to myofascial and neuropathic pain syndromes. In the present article, we review the clinical presentation of cancer-associated orofacial pain at various stages: initial diagnosis, during therapy (chemo-, radiotherapy, surgery), and in the post-therapy period. As a presenting symptom of orofacial cancer, pain is often of low intensity and diagnostically unreliable. Diagnosis, treatment, and prevention of pain in cancer require knowledge of the presenting characteristics, factors, and mechanisms involved.

The rationale for a multimodal approach in the management of breakthrough cancer pain: a review

Breakthrough pain has been described differently in various countries, and not surprisingly, recommendations for its management vary according to the institution. Usually when breakthrough pain occurs, the patient's pain has already been managed according to the World Health Organization 3-step ladder for cancer pain. After this point, the treatment choice is usually based on clinical judgment, the physician's personal experience with interventional procedures, and local resources available. Opioids remain the mainstay of the management of breakthrough cancer pain. However, the combination of radio-oncology, adjuvant drugs, and interventional pain procedures can improve pain relief. This review addresses those questions and proposes a multimodal approach to manage breakthrough cancer pain.

Cancer pain: an update of pharmacological approaches in pain therapy

PURPOSE OF REVIEW

This review discusses clinically oriented data on advances in pharmacological research of cancer pain therapy carried out during the last year. The aim is to ascertain whether well known guidelines for cancer pain prove to be adequate or require modification.

RECENT FINDINGS

There are alternatives to morphine, which is the standard drug, including oxycodone or methadone, with the problem of equivalence doses in the case of opioid rotation. Depending on the underlying pathophysiological mechanisms, adjuvant drugs are recommended, such as antidepressants and anticonvulsants for neuropathic pain, or bisphosphonates for metastasis bone pain. Current and future research will offer receptor-specific acting new drugs or old drugs under new indications.

SUMMARY

The recommendations of the World Health Organization ladder remain the mainstay of cancer pain management. These recommendations, however, are based more on expert opinions than on evidence-based data.

Fentanyl buccal tablet (FBT) for relief of breakthrough pain in opioid-treated patients with chronic low back pain: a randomized, placebo-controlled study

BACKGROUND

Short-acting opioids are commonly used to treat breakthrough pain (BTP) and rapid-onset formulations are being developed to improve the effectiveness of this approach. Fentanyl buccal tablet (FBT) is a new formulation of fentanyl that enhances transbuccal drug delivery via an effervescent reaction and may provide relatively rapid-onset analgesia. FBT was evaluated for BTP in opioid-treated patients with chronic low back pain--the first such study in a population with chronic non-cancer pain.

DESIGN

Randomized, double-blind, placebo-controlled.

PATIENTS AND SETTING

Patients with chronic low back pain receiving long-term opioid therapy at 16 pain treatment centers in the United States.

PROCEDURES

Following open-label titration to identify an effective FBT dose, patients were randomly assigned to one of three double-blind dose sequences (six doses of FBT, three placebo) to treat nine BTP episodes. Pain intensity (PI), measured on an 11-point scale (0 = no pain; 10 = worst pain), and other outcomes were assessed for 2 h after dosing.

DATA ANALYSIS

The primary efficacy measure was the sum of pain intensity differences (PIDs) for the first 60 min (SPID60); secondary efficacy measures included PIDs at other time points, pain relief (PR), meaningful PR, time to meaningful PR, use of supplementary BTP medication, and self/investigator-reported adverse events.

RESULTS

Of the 124 patients screened, 105 patients were enrolled, 84 identified an effective FBT dose, and 77 entered the double-blind phase. SPID60 significantly favored FBT (p < 0.0001). All secondary measures also favored FBT, with PIDs and PR showing significant differences versus placebo as early as 10 and 15 min, respectively. An improvement in PI score of > or = 33% occurred in a significantly larger proportion of FBT-treated episodes versus placebo from 15 min (20% vs. 11%, p < 0.01) through 2 h (65% vs. 28%, p < 0.0001). Patients were approximately four times more likely to require supplemental opioids for BTP episodes following administration of placebo compared with episodes treated with FBT. AEs were typical for opioids, and were mostly reported during dose titration. Limitations of this study may be related to its open-label dose-titration phase (which has the potential to compromise blinding) and the recruitment of patients from pain clinics, which could potentially yield a study population that is not representative of the general population with BTP.

CONCLUSIONS

FBT was efficacious and well tolerated in the treatment of BTP in opioid-treated patients with chronic low back pain.

Oral transmucosal fentanyl citrate for cancer breakthrough pain: a review

PURPOSE/OBJECTIVES

To review the dose titration, efficacy, and safety of oral transmucosal fentanyl citrate (OTFC).

DATA SOURCES

Phase I and II clinical trial abstracts and evidence-based review articles.

DATA SYNTHESIS

OTFC has an onset, peak, and duration of action similar to that of an IV dose of an opioid and has been demonstrated to be effective and well tolerated for the management of breakthrough pain in patients with cancer.

CONCLUSIONS

Studies of OTFC demonstrate that it is easy to use,noninvasive, effective, safe, and acceptable to patients, caregivers, and healthcare providers. However, OTFC is expensive and approved for use only in opioid-tolerant patients with cancer.

IMPLICATIONS FOR NURSING

Breakthrough pain in patients with cancer is a common problem with characteristics that make it difficult to treat. Oncology nurses should familiarize themselves with OTFC's unique characteristics to be able to best help patients manage their therapy.

A Randomized, Placebo-controlled Study of Fentanyl Buccal Tablet for Breakthrough Pain in Opioid-treated Patients With Cancer

OBJECTIVES

Cancer-related breakthrough pain (BTP) is typically managed with a short-acting oral opioid, taken as needed during a fixed-schedule opioid regimen. The conventional approach may not provide the onset of analgesia required for BTP for many patients, because the onset of analgesia with short-acting opioids lags behind the time course of the majority of episodes of BTP. The fentanyl buccal tablet (FBT) employs a novel delivery system that enhances the rate and extent of absorption of fentanyl through the buccal mucosa. This double-blind, randomized, placebo-controlled study evaluated the efficacy, safety, and tolerability of FBT in opioid-treated patients with cancer-related BTP.

METHODS

After an open-label titration (N=123) to identify an effective FBT dose to treat BTP episodes, 77 patients were randomly assigned to 1 of 18 prespecified dose sequences of 10 tablets (7 FBT and 3 placebo). Pain intensity, pain relief (PR), and global performance of the medication were recorded at regular time intervals between 15 and 60 minutes. Pain intensity differences (PID), the summed PID (SPID), and summed total PR were calculated. The SPID at 30 minutes (SPID30) was the primary efficacy variable. Adverse events were reported.

RESULTS

Sixty-five percent (80/123) of patients were titrated to an effective dose. The mean (SE) SPID30 for FBT was 3.0+/-0.12 versus 1.8+/-0.18 for placebo (P<0.0001). Measures of PR, PID, SPID, summed total PR, and patient ratings of global performance of medication significantly favored FBT over placebo at all time points. Adverse events were typical of opioid drugs. Poor oral tolerability was noted in 2 patients.

CONCLUSIONS

FBT is efficacious and safe in the treatment of cancer-related BTP.

Opioids in pain management of blood-related malignancies

Opioids are basic analgesics used in the treatment of moderate to severe pain in patients affected by blood-related malignancies. They should be sequentially administered according to the World Health Organisation scale for cancer pain. Initial treatment and titration with opioids should be based on immediate-release preparations, to be administered at appropriate intervals in order to relieve pain and to satisfy the individual opioid requirement. Once a relatively good pain control has been achieved, a slow release formulation at equivalent doses can be given. Most patients can be adequately managed using oral formulation opioids. However, a small group, such as those presenting severe mucositis or requiring a rapid pain relief, should be managed by intravenous continuous infusion and/or by a patient-controlled analgesia system; while for patients in the community, there are distinct advantages to using the subcutaneous route. Other available routes of administration for opioids, can be used in selected circumstances, including rectal, transdermal, epidural, intrathecal and intramuscular. The invasive neuraxial route has a very limited role in patients with haematological malignancies, given the high risk of infection and bleeding. Through a close observation and a careful management, opioid-related side effects can be effectively prevented and treated. This article reviews the principles of opioid therapy and how opioids can be adapted for patients with pain due to haematological malignancies.

Palliative Care and Pediatrics

This article reviews the unique challenges of pediatric palliative medicine. These challenges originate from the specific epidemiology of pediatric diseases for which palliative care is indicated and the necessity to provide child-focused, family-oriented, relationship-centered medical care. The emphasis of the ultimate aims of pediatric palliative care is to care for the body, mind, and spirit, to enhance quality of life, and to minimize suffering.

Evidence-Based Oral Transmucosal Fentanyl Citrate (OTFC®) Dosing Guidelines

OBJECTIVE

To review the evidence for dosing and efficacy of oral transmucosal fentanyl citrate in the management of pain and produce dosing guidelines.

DESIGN

The scientific literature pertaining to oral transmucosal fentanyl citrate was reviewed, focusing upon its pharmacology and clinical experience with use in cancer and noncancer pain. Emphasis was upon published, peer-reviewed English language articles.

RESULTS

Information was crucially examined and synthesized into guidelines for use and dosing of oral transmucosal fentanyl citrate in cancer and noncancer pain.

CONCLUSIONS

Oral transmucosal fentanyl citrate is a potent opioid delivery system, which, when used appropriately, is an effective treatment option for pain. Adherence to guidelines should promote its safe and efficacious use in a variety of clinical pain management settings.

Oral transmucosal fentanyl citrate for the treatment of breakthrough pain in cancer patients: an overview of its pharmacological and clinical characteristics

Breakthrough pain is a transitory flare of pain occurring in most cancer patients against a background of otherwise controlled persistent pain. Treatment of breakthrough pain is a challenging phenomenon. Oral transmucosal fentanyl citrate (Actiq, Cephalon, Inc, West Chester, PA), a new opioid formulation with a unique delivery system, reflects the characteristics of breakthrough pain (rapid onset of action and short duration), making it an effective treatment for cancer patients who already receive opioids and experience flares of pain. This review article aims to present the role of oral transmucosal fentanyl citrate in the management of breakthrough pain in cancer patients. In particular, it is going to discuss the synthesis, clinical pharmacology, pharmacokinetic and pharmacodynamic properties, toxicity, and clinical efficacy of this novel agent.

[Safety and efficacy of oral trans-mucosal fentanyl citrate in the long-term treatment of breakthrough pain in oncology patients: the ECODIR study]

INTRODUCTION

Oral trans-mucosal fentanyl citrate (OTFC) is the one drug specifically developed for the management of breakthrough pain. This study assesses the long-term safety and efficacy of OTFC standard clinical conditions. Patients and methods. Six-month observational study performed on cancer patients with episodes of breakthrough pain. Safety was assessed by recording the advent of adverse events and efficacy by the evaluating the intensity of breakthrough pain.

RESULTS

174 cancer patients were recruited into the study. All adverse reactions reported were mild or moderate. OTFC was significantly faster (time to the commencement of pain relief: 12.7 +/- 11.4 vs 32.7 +/- 18.4 minutes; p < 0.001) and potent (post-treatment pain intensity: 3.4 +/- 1.5 vs 4.3 +/- 1.5; p < 0.001) than the previously-used drugs.

CONCLUSIONS

This observational study confirms the good safety profile of OTFC as well as its effectiveness over long-term period treatment of breakthrough pain.