The Role of Fentanyl in Cancer-Related Pain

Intravenous bolus injection of fentanyl triggers an immediate central and upper airway obstructive apnea via activating vagal sensory afferents

Intravenous bolus (IVb) injection of fentanyl induces an immediate apnea, but the characteristics of the apnea and relevant mechanism remain unclear. Here, we tested whether IVb injection of fentanyl induced an immediate central and upper airway obstructive apnea associated with chest wall rigidity via activating vagal C-fibers (VCFs) and vagal afferent opioid receptors (ORs). Cardiorespiratory and electromyography of external and internal intercostal, thyroarytenoid, and superior pharyngeal constrictor muscles (EMGEI, EMGII, EMGTA, and EMGSPC) responses to IVb injection of fentanyl were recorded in anesthetized and spontaneously breathing rats with or without bilateral perivagal capsaicin treatment or intravagal microinjection of naloxone. An immunohistochemical approach was employed to define the presence of opioid mu-receptor (MOR) expression in vagal C-neurons, and a patch clamp technique was utilized to determine the evoked current responses of vagal C-neurons to fentanyl in vitro. Fentanyl induced an immediate apnea and subsequent respiratory depression. The apnea was characterized by cessation of EMGEI activity and augmentation of tonic discharges of EMGII, EMGTA, and EMGSPC, i.e., central expiratory apnea, laryngeal closure, and pharyngeal constriction/collapse accompanied with chest wall rigidity. The apneic response was abolished by blockade of VCF signal conduction and largely attenuated by antagonism of vagal afferent ORs. The latter significantly alleviated the initial (within 5-min postinjection), but not the latter, respiratory depression. Vagal C-neurons expressed MORs and were activated by fentanyl. We conclude that IVb injection of fentanyl causes a VCF- and vagal afferent OR-mediated immediate central apnea, upper airway obstruction, and chest wall rigidity.NEW & NOTEWORTHY Intravenous bolus injection of fentanyl triggers an immediate apnea, but the nature of apnea and relevant mechanisms remain unknown. Results in this study reveal that this fentanyl injection concurrently triggers an immediate central and upper airway obstructive apnea associated with chest wall rigidity via activating vagal sensory C-fibers.

Apneic response to fentanyl in adult rats: Role of laryngeal afferents

Intravenous (systemic) bolus injection of fentanyl (FNT) reportedly induces an immediate vagal-mediated apnea; however, the precise origin of vagal afferents responsible for this apnea remains unknown. We tested whether intralaryngeal (local) application of FNT would also trigger an apnea and whether the apneic response to both local and systemic administration of FNT was laryngeal afferent-mediated. Cardiorespiratory responses to FNT were recorded in anesthetized male adult rats with and without bilateral sectioning of the superior laryngeal nerve (SLNx) or peri-SLN capsaicin treatment (SLNcap) to block local C-fiber signal conduction. Opioid mu-receptor (MOR)-immunoreactivity was detected in laryngeal C- and myelinated neurons. We found that local and systemic administration of FNT elicited an immediate apnea. SLNx, rather than SLNcap, abolished the apneic response to local FNT application though MORs were abundantly expressed in both laryngeal C- and myelinated neurons. Importantly, SLNx failed to affect the apneic response to systemic FNT administration. These results lead to the conclusion that laryngeal afferents' MORs are responsible for the apneic response to local, but not systemic, administration of FNT.

Drug utilization study on immediate release Fentanyl in Spain. Prevalence, incidence, and indication

PURPOSE

We aimed to characterize the trends of immediate release fentanyl (IRF) use in Spain between 2012 and 2017 and indication for its use. IRF drugs are rapid-acting opioids approved to treat breakthrough cancer pain (BTCP) in patients already receiving maintenance opioid therapy for chronic cancer pain. A substantial increase in consumption of IRF has been observed with emerging cases of abuse and dependence, most of them in noncancer patients.

METHODS

An ecological descriptive consumption study with aggregated data from drug dispensed by community pharmacies and reimbursed by the National Health System in which Defined Daily Doses per 10 000 inhabitants (DID) were calculated and a retrospective cohort study using data from the Spanish Database for Pharmacoepidemiological Research in Primary Care in which participants entered the cohort study after 1 year with the Primary Care Practitioners were performed. Annual prevalence and incidence rate of IRF use were estimated by sex and calendar year. Potential indication was also assessed.

RESULTS

IRF use in Spain increased from 2.1 DID in 2012 to 3.8 DID in 2017. The incidence rate and prevalence increased in 53% and 74%, respectively. Patients without previous cancer or BCTP diagnosis represented 27% of incident users, predominantly women. Half of patients with noncancer-related diagnosis had a musculoskeletal disorder linked to the first IRF prescription.

CONCLUSIONS

National consumption and new IRF users in Spain increased over the study period and one quarter of patients did not have a BTCP or cancer diagnosis registered in their clinical record.

Efficacy and Safety of Fentanyl Compared With Morphine among Adult Patients with Cancer: A Meta-Analysis

Background:

Cancer pain is experienced by numerous patients; thus, the main pain-relieving opioid analgesics, fentanyl and morphine, are of great importance. However, their analgesic efficacy and safety are different among individuals and are still controversial. The aim of this study was to compare the safety and efficacy of fentanyl and morphine among patients with cancer.

Methods:

We performed a meta-analysis by searching PubMed and the Cochrane Library up to 01 April 2019. The search terms were fentanyl, morphine, opioids and cancer pain. All randomised controlled trials comparing fentanyl and morphine were included in the analysis.

Results:

Overall, the initial search identified 2970 published studies; among them, 9 studies were included in the efficacy analysis and 8 studies were included in the safety analysis. The oral morphine versus oral transmucosal fentanyl subgroup analysis showed a mean difference(MD)=0.47[Confidence interval(CI):0.35-0.58] with an overall effect, Z=8.10, P<.00001. The outcome of the oral morphine versus nasal/transdermal fentanyl subgroup indicated a MD=0.20[CI:0.3-0.37] with an overall effect, Z=2.24 and P=.02.

For the oral morphine versus buccal/sublingual fentanyl subgroup, the analysis revealed a MD=1.80[CI:1.35-2.25] with an overall effect, Z=7.87 and P<.00001.

The oral morphine versus other forms of fentanyl subgroup showed a MD=0.70[95%CI:0.34-1.06] with the test for the overall effect, Z=3.81 and P=.0001.

Constipation, drowsiness, confusion and dry mouth were more common in the morphine group than in the fentanyl group, with a risk ratio=0.60[CI:0.37-0.97]; 0.93[CI:0.69-1.25]; 0.85[CI:0.23-3.13] and 0.54[CI:0.05-6.43], respectively.

Conclusions:

Compared with oral morphine, fentanyl is safer and more effective. Moreover, fentanyl presents fewer side effects than morphine, especially constipation, drowsiness, confusion and dry mouth.

Labour analgesia; Molecular pathway and the role of nanocarriers: a systematic review

Labour is considered to be one of the most painful procedures in human experience. The most effective technique for pain relief during labour is neuraxial labour analgesia which provides analgesia without maternal or fetal sedation. Genetic predisposition may be of importance for pain perception and women experience varying degrees of pain in labour. Genetic variations in opioid receptor (OPR) genes may influence the response to epidural opioid analgesia during labour. The single-nucleotide polymorphism, A118G of the mu opioid receptor gene (oprm1), has been associated with altered pain perception. Targeted drug delivery reduces toxic side effects. Liposomes, nano-particles, nanofibres hydrogel, have been suggested to deliver anaesthetic drugs.

[Fentanyl buccal tablets in the treatment of breakthrough cancer pain. German cohort of a pan-European multicentre study]

BACKGROUND

Patients with breakthrough cancer pain (BtCP) experience significant limitations in their physical, mental and social functions. Fentanyl buccal tablets (FBT), a rapid onset opioid, are specifically indicated for the treatment of BtCP.

METHOD

The results of the German cohort of a pan-European study are presented. This included cancer pain patients from 32 German centers. Patients were on continuous opioid medication and had at least 4 BtCP episodes per day. After randomization to 2 groups, 66 patients started the titration of FBT with 100 μg (group A) and 200 μg (group B), respectively. All patients were titrated to their individual EAD, which could be a maximum of 800 μg FBT per episode, regardless of the initial dose. Subsequently, up to 8 BtCP episodes were treated with this EAD. At baseline and after treatment, patients assessed the effects of BtCP on their functional status using the modified BPI-7S and answered questions about the efficacy, simplicity, and ease-of-use of the treatment.

RESULTS AND CONCLUSIONS

Successful titration was achieved by 49 patients (74.2%). There was no statistically significant difference between group A and group B. The global score of the modified BPI-7S increased by 8.5 (± 12.8) points (from 34.7 ± 13.6 at the beginning to 26.2 ± 15.8 at the end of treatment), from which a statistically significant improvement in the quality of life of patients can be derived. Global patient contentment improved, most notably the rapid onset of 2.4 points to 3.4 points at the end of the study. 76.9% of patients found taking FBT simple or very simple.

Efficacy, safety, and tolerability of fentanyl pectin nasal spray in patients with breakthrough cancer pain

Objective

Assessment of analgesic effectiveness, safety, and tolerability of fentanyl pectin nasal spray (FPNS) in the treatment of breakthrough cancer pain (BTcP) in routine clinical practice.

Methods

A prospective, open-label, noninterventional study (4-week observation period, 3 month follow-up) of opioid-tolerant adults with BTcP in 41 pain and palliative care centers in Germany. Standardized BTcP questionnaires and patient diaries were used. Evaluation was made of patient-reported outcomes with respect to “time to first effect”, “time to maximum effect”, BTcP relief, as well as changes in BTcP-related impairment of daily life activities, quality-of-life restrictions, and health care resource utilization.

Results

A total of 235 patients were recruited of whom 220 completed all questionnaires and reported on 1,569 BTcP episodes. Patients reported a significant reduction of maximum BTcP intensity (11-stage numerical rating scale [0= no pain, 10= worst pain conceivable]) with FPNS (mean ± standard deviation = 2.8±2.3) compared with either that reported at baseline (8.5±1.5), experienced immediately before FPNS application (7.4±1.7), or that achieved with previous BTcP medication (6.0±2.0; P<0.001 for each comparison). In 12.3% of BTcP episodes, onset of pain relief occurred ≤2 minutes and in 48.4% ≤5 minutes; maximum effects were reported within 10 minutes for 37.9% and within 15 minutes for 79.4%. By the end of the study, there had been significant improvements versus baseline in BTcP-related daily life activities (28.3±16.9 vs 53.1±11.9), physical (35.9±8.4 vs 26.8±6.5), and mental quality of life (38.7±8.5 vs 29.9±7.9) (P<0.001 for each comparison vs baseline); in addition, health care resource utilization requirements directly related to BTcP were reduced by 67.5%. FPNS was well tolerated; seven patients (3.2%) experienced eight treatment-emergent adverse events of which none was serious. There were no indicators of misuse or abuse.

Conclusion

FPNS provided rapid and highly effective BTcP relief in opioid-tolerant cancer patients with substantial improvements in daily functioning and quality of life. FPNS was well tolerated and associated with significant reductions in health care resource utilization and nursing assistance.

Fentanyl sublingual spray for breakthrough cancer pain in patients receiving transdermal fentanyl

AIM

To investigate the relationship between effective fentanyl sublingual spray (FSS) doses for breakthrough cancer pain (BTCP) and around-the-clock (ATC) transdermal fentanyl patch (TFP).

METHODS

Adults tolerating ATC opioids received open-label FSS for 26 days, followed by a 26-day double-blind phase for patients achieving an effective dose (100-1600 µg).

RESULTS

Out of 50 patients on ATC TFP at baseline, 32 (64%) achieved an effective dose. FSS effective dose moderately correlated with mean TFP dose (r = 0.4; p = 0.03). Patient satisfaction increased during the study. Common adverse event included nausea (9%) and peripheral edema (9%).

CONCLUSION

FSS can be safely titrated to an effective dose for BTCP in patients receiving ATC TFP as chronic cancer pain medication. ClinicalTrials.gov identifier: NCT00538850.

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.

Effective Dose Titration of Fentanyl Sublingual Spray in Patients With Breakthrough Cancer Pain

OBJECTIVE

To further describe effective dose titration of fentanyl sublingual spray to treat breakthrough cancer pain (BTCP) during the 26-day open-label titration phase of a phase 3, randomized, double-blind, placebo-controlled study.

METHODS

Opioid-tolerant patients with 1 to 4 episodes of BTCP per day were enrolled. For randomization into double-blind treatment, patients must have titrated to a dose (100 to 1,600 mcg) providing effective analgesia for 2 consecutive BTCP episodes. The Treatment Satisfaction Questionnaire for Medication was administered at baseline and at titration end and included a Global Satisfaction domain.

RESULTS

Of 130 patients undergoing titration, 98 (75%) achieved pain relief (median dose = 800 mcg). The most common doses that allowed for adequate pain relief were 800 mcg (24.5%) and 1,200 mcg (20.4%). Of 32 (25%) patients who withdrew from the study, only 3 (2.3%) did not achieve an effective dose. In patients attaining an effective dose, mean Global Satisfaction increased from 54.9 ± 2.1 at baseline to 75.3 ± 1.7 at the end of the titration phase. Seventy-eight patients (60%) reported ≥ 1 adverse event (AE). Thirty-three AEs (25.4%) were considered probably related to treatment, with nausea (6.2%) and somnolence (4.6%) most commonly reported.

CONCLUSIONS

In patients with BTCP, fentanyl sublingual spray can be rapidly and safely titrated to an effective dose, resulting in greater satisfaction with fentanyl sublingual spray than previous BTCP medications.

Comparing the effectiveness of intranasal fentanyl spray with oral transmucosal fentanyl citrate in breakthrough pain

BACKGROUND

Breakthrough cancer pain (BTCP) is complex and severe, affecting quality of life and increasing hospitalisation. BTCP has a rapid onset that requires fast acting medication with minimal side effects.

AIM

This article compares the effectiveness of intranasal fentanyl spray (INFS) and oral transmucosal fentanyl citrate (OTFC) and their alleviation of BTCP within 10 minutes of administration.

METHOD

The article considers pharmacokinetic and bioavailability studies demonstrating the efficacy of the route of administration, time-based effects of pain relief as well as patient preference.

CONCLUSION

The data collected indicates that INFS is more effective than OTFC for BTCP.

The efficacy of low-dose transdermal fentanyl in opioid-naïve cancer patients with moderate-to-severe pain

BACKGROUND/AIMS

Little is known about the efficacy of low-dose transdermal fentanyl (TDF) patches in opioid-naïve patients with moderate-to-severe cancer pain.

METHODS

This study had an open-label, prospective design, and was conducted between April 2007 and February 2009 in seven tertiary cancer hospitals; 98 patients were enrolled. TDF was started using a low-dose formulation (12.5 µg/hr), and the dose was adjusted according to the clinical situation of individual patients. Pain intensity, the TDF doses used, and adverse events (AEs) were monitored over 4 weeks. Data were analyzed using the intent-to-treat and per-protocol principles.

RESULTS

Of the 98 patients enrolled, 64 (65%) completed the study. The median pain intensity decreased from 6.0 to 3.0 (p < 0.001) at the follow-up visit. The efficacy of low-dose TDF on pain relief was consistent across groups separated according to gender (p < 0.001), age (p < 0.001), metastasis (p < 0.001), previous treatment (p < 0.001), and baseline pain intensity (p < 0.001). The decrease in pain intensity was significantly greater in the severe group compared with the moderate group (mean ± SD, 5.10 ± 2.48 vs. 2.48 ± 1.56; p < 0.001). TDF dose (27.8 µg/hr vs. 24.8 µg/hr, p = 0.423) and the mean treatment time (7.5 days vs. 7.9 days, p = 0.740) required for pain control were not different between the two pain-intensity groups. Patients had AEs of only mild or moderate intensity; among these, nausea (38%) was the most common, followed by vomiting (22%) and somnolence (22%).

CONCLUSIONS

Low-dose TDF was an effective treatment for patients with cancer pain of moderate-to-severe intensity. Further randomized trials assessing the efficacy of TDF for severe pain and/or optimal starting doses are warranted.

Adverse drug reactions monitoring: prospects and impending challenges for pharmacovigilance

Pharmacovigilance plays a consequential role in the surveillance of adverse drug reactions, which is provoked by the drugs used to cure diseases. Adverse drug reactions (ADRs) produce detrimental or undesirable effects to the body after administration of drugs. It has been reported that the number of patients dying because of contrary effects of drugs per year increased upto 2.6-fold. Moreover, rates of hospitalization of patients are increasing owing to adverse effects of drugs. Thus, it becomes challengeable for physician, health care providers, WHO and pharmaceutical industries to resolve the associated problem of ADRs. During the clinical trial of a novel drug, it is prominent to explore the dependability of drug. In this review, we documented the details required to identify the ADRs in patients along with reported banned drugs.

Patient Satisfaction with Fentanyl Sublingual Spray in Opioid-Tolerant Patients with Breakthrough Cancer Pain

OBJECTIVES

Breakthrough cancer pain (BTCP) is associated with decreased satisfaction with around-the-clock opioid therapy. This analysis examined patient satisfaction with fentanyl sublingual spray for BTCP during the open-label titration period of a randomized, placebo-controlled study.

METHODS

Opioid-tolerant patients with 1 to 4 daily BTCP episodes were included. During a 26-day, open-label titration phase, a successful dose (100 to 1600 mcg) of fentanyl sublingual spray was established that provided effective analgesia for 2 consecutive BTCP episodes with tolerable side effects. The Treatment Satisfaction Questionnaire for Medication (TSQM) was administered at baseline to assess satisfaction with previous BTCP medication and at the end of the titration to assess satisfaction with fentanyl sublingual spray.

RESULTS

Of 130 enrolled patients, 115 (88.5%) had a TSQM measure at baseline and at the end of their titration period. Scores on all 4 TSQM domains increased from baseline to end of the titration, with mean (standard error [SE]) improvements of 22.3 (2.3) for effectiveness, 7.7 (3.2) for side effects, 6.8 (2.2) for convenience, and 12.9 (2.8) for global satisfaction (P < 0.05 for all). Satisfaction with symptom relief (26.1% to 77.4%) and onset of action (21.7% to 82.6%) also improved from baseline to end of titration. At least one adverse event (AE) was reported by 78 patients (60.0%). The most common AEs considered possibly or probably related to study medication were dizziness, somnolence, and nausea (n = 10 [7.7%] each).

DISCUSSION

These data indicate markedly improved satisfaction among patients receiving fentanyl sublingual spray relative to previous BTCP medications.

Efficacy and safety of a six-hour continuous overlap method for converting intravenous to transdermal fentanyl in cancer pain

CONTEXT

Managing cancer pain often requires opioid medications, such as fentanyl, which is frequently initiated parenterally, and then converted to transdermal form. Little evidence exists to guide this conversion.

OBJECTIVES

To observe the efficacy and safety of a six-hour continuous overlap method for converting intravenous fentanyl (IVF) to transdermal fentanyl (TF) in patients with cancer pain.

METHODS

We switched from IVF to TF using a 1:1 (IVF:TF) conversion ratio and overlapped a continuous, nontapered dose of IVF until six hours after TF placement. Pain intensity by Numeric Rating Scale, number of rescue analgesic doses, and presence and severity of opioid-related adverse events were recorded immediately before TF placement, and at six, 12, 18, and 24 hours thereafter.

RESULTS

A total of 17 consecutive patients with cancer pain controlled on IVF were converted to TF. Median age was 65 years, 10 were female, and all had Stage IV cancer. Pain intensity at six and 24 hours remained stable; a slight but statistically significant increase in Numeric Rating Scale was noted at 12 and 18 hours (P=0.01 and 0.02, respectively); however, there was no significant increase in number of rescue doses throughout the observation period. Only one patient experienced opioid-related adverse events.

CONCLUSION

A continuous six-hour overlap method is a safe and effective strategy when converting from IVF to TF in patients with cancer pain. A slight increase in pain intensity may occur, but does not lead to increased rescue doses.

Case report of severe bradycardia due to transdermal fentanyl

BACKGROUND

This case report describes a patient who developed severe bradycardia due to transdermal fentanyl. There have been no prior case reports of this occurring in palliative care, but the frequency of association of fentanyl with bradycardia in the anesthesia setting suggests it may be more common than realized. Palliative care settings often have a policy of not routinely checking vital signs, and symptoms of bradycardia could be misinterpreted as the dying process.

CASE PRESENTATION

A patient with recurrent ovarian cancer was admitted with nausea and abdominal pain due to bowel obstruction and fever from a urinary tract infection. A switch from injectable hydromorphone to transdermal fentanyl resulted in symptomatic severe bradycardia within 36 h, without any other signs of opioid toxicity and with good analgesic effect.

CASE MANAGEMENT

The fentanyl patch was removed. Atropine was not required.

CASE OUTCOME

The patient made an uneventful recovery. Transdermal buprenorphine was subsequently used satisfactorily for long-term background pain control, with additional hydromorphone when needed.

CONCLUSIONS

The delayed absorption of fentanyl via the transdermal route makes early identification of fentanyl-induced bradycardia key to prompt reversal. Patients with resting or relative bradycardia may be at higher than average risk.

Single-dose pharmacokinetics of fentanyl sublingual spray and oral transmucosal fentanyl citrate in healthy volunteers: a randomized crossover study

BACKGROUND

Fentanyl sublingual spray (FSS) is a novel fentanyl formulation recently developed for the treatment of breakthrough cancer pain, which is characterized by a fast onset and a relatively short duration.

OBJECTIVE

To compare rate of absorption and systemic bioavailability between FSS and oral transmucosal fentanyl citrate (OTFC) in healthy volunteers.

METHODS

This randomized 3-way crossover study involved 29 healthy volunteers (25 men and 4 women; mean age, 35 years) who received single doses of FSS (400 μg), OTFC (400 μg), and intravenous fentanyl citrate (100 μg) separated by washout periods of ≥7 days. Oral naltrexone was given to minimize potential adverse effects of fentanyl. Plasma fentanyl concentrations were measured for 36 hours after each dose for the calculation of pharmacokinetic parameters.

RESULTS

Mean Cmax values of fentanyl were higher with FSS versus OTFC (0.81 ng/mL vs 0.61 ng/mL) and were attained more quickly; the median Tmax was 1.5 hours with FSS and 2.0 hours with OTFC (P < 0.05). Furthermore, potentially effective fentanyl concentrations were achieved more quickly with FSS than with OTFC. Five and 10 minutes after administration, mean plasma concentrations were 19.0% and 53.7% of Cmax with FSS, respectively, compared with levels below the lower limit of assay quantification and 6.1%, respectively, with OTFC. Plasma concentrations of fentanyl at 10 minutes with FSS were equivalent to those with OTFC at 60 minutes. The Cmax and AUCs were approximately 33% to 36% greater with FSS than with OTFC, and the 90% CIs of the geometric mean ratios for each parameter fell outside the bioequivalence range of 80% to 125%. Systemic bioavailability was also greater with FSS than with OTFC (approximately 76% vs 51%). All 3 fentanyl treatments were well tolerated. All reported adverse events were mild and consistent with those previously reported in healthy volunteers receiving transmucosal fentanyl with naltrexone, and none occurred in >2 participants during any treatment period.

CONCLUSIONS

Absorption of fentanyl in this study was faster and bioavailability was greater with FSS than with OTFC. The pharmacokinetic profile of the sublingual spray closely matches the duration of onset to pain intensity in a breakthrough cancer pain episode. These findings suggest that FSS is appropriate for the treatment of breakthrough cancer pain. ClinicalTrials.gov identifier: NCT01780233.

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.

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.

[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.

Reporting characteristics of cancer pain: a systematic review and quantitative analysis of research publications in palliative care journals

Objective:

A common disorder requiring symptom palliation in palliative and end-of-life care is cancer. Cancer pain is recognized as a global health burden. This paper sought to systematically examine the extent to which there is an adequate scientific research base on cancer pain and its reporting characteristics in the palliative care journal literature.

Materials and Methods:

Search conducted in MEDLINE and CINAHL sought to locate all studies published in 19 palliative/ hospice/ supportive/ end-of-life care journals from 2009 to 2010. The journals included were: American Journal of Hospice and Palliative Care, BMC Palliative Care, Current Opinion in Supportive and Palliative Care, End of Life Care Journal, European Journal of Palliative Care, Hospice Management Advisor, Indian Journal of Palliative Care, International Journal of Palliative Nursing, Internet Journal of Pain Symptom Control and Palliative Care, Journal of Pain and Palliative Care Pharmacotherapy, Journal of Palliative Care, Journal of Palliative Medicine, Journal of Social Work in End-of-life and Palliative Care, Journal of Supportive Oncology, Palliative Medicine, Palliative and Supportive Care, and Supportive Care in Cancer. Journal contents were searched to identify studies that included cancer pain in abstract.

Results:

During the years 2009 and 2010, of the selected 1,569 articles published in the journals reviewed, only 5.86% (92 articles) were on cancer pain.

Conclusion:

While researchers in the field of palliative care have studied cancer pain, the total percentage for studies is still a low 5.86%. To move the field of palliative care forward so that appropriate guidelines for cancer pain management can be developed, it is critical that more research be reported upon which to base cancer pain therapy in an evidence-based palliative care model.

[Neuropathic and tumour-induced headache: Therapeutic options]

Cancer pain in the field of otolaryngology can be effectively alleviated. Only very few questions regarding the patient's history of pain are required to understand the type of pain being dealt with and to be able to make the correct selection of analgetic agents. It is particularly important to treat tumor breakthrough pain appropriately, for which a sufficient number of therapeutic agents are available. The present article comments on the various possibilities of specific drugs and interventional therapeutic approaches, as well as their specific characteristics within the field of otolaryngology, supplemented with various tricks for their practical application. Using these basic rules, most problems can be identified and specific treatments optimized. The progression of cancer pain may show wide dynamic ranges, and the therapeutic approach should always be adjusted to the current situation. Palliative care of a cancer patient may be particularly challenging in that, not only the treatment of pain, but also the treatment of respiratory distress is of key importance.

Transdermal opioids for cancer pain

PURPOSE OF REVIEW

Cancer patients with moderate-to-severe pain require opioids for analgesia. Whereas early guidelines recommend oral morphine as the 'drug of choice', newer synthetic opioids can be given by a reliable and effective nonoral transdermal route. We examine the mode of action of transdermal patches and we review the evidence on two drugs, which are currently available in this formulation - buprenorphine and fentanyl - covering physicochemical characteristics and pharmacokinetics of the patches, clinical efficacy data and adverse effects.

RECENT FINDINGS

Both buprenorphine and fentanyl possess ideal characteristics for transdermal delivery, being small molecules with high lipophilicity. Studies of buprenorphine patches show benefits but there is poor randomized controlled trial evidence comparing them with oral opioids. Fentanyl patches have been used for longer and have a larger body of evidence supporting their use, with data to suggest improved pain relief and reduced opioid side effects compared with sustained release oral morphine. Patients who have used both oral morphine and transdermal fentanyl express a preference for the patch drug.

SUMMARY

Transdermal buprenorphine and fentanyl are now established for moderate-to-severe cancer pain. There is still a need for further comparative studies with other opioids, especially for buprenorphine.

Fentanyl pectin nasal spray: in breakthrough pain in opioid-tolerant adults with cancer

Fentanyl pectin nasal spray (PecFent®) uses a novel pectin-based delivery system that turns from an aqueous solution into a gel when applied to mucosal surfaces. Fentanyl is absorbed in a controlled manner from the pectin gel formed in the nasal cavity, and has a rapid onset of pain relief and duration of action that matches the time course of a typical episode of breakthrough pain in cancer (BTPc). Relative to administration as oral transmucosal fentanyl, fentanyl administered as fentanyl pectin nasal spray is more rapidly absorbed, reaches higher maximum plasma concentrations and has greater bioavailability. In the treatment of BTPc in two randomized, double-blind, crossover trials in opioid-tolerant adults, fentanyl pectin nasal spray (100-800 μg titrated doses) was significantly more effective than placebo in reducing pain intensity and provided a significantly faster onset of pain relief than oral immediate-release morphine. During long-term treatment of BTPc episodes, fentanyl pectin nasal spray consistently provided effective pain relief in an open-label, 16-week trial. Most patients were satisfied or very satisfied with the ease of use and convenience of the nasal spray. Fentanyl pectin nasal spray 100-800 μg was generally well tolerated and was not associated with nasal tolerability problems.

Intranasal fentanyl for pain control: current status with a focus on patient considerations

Of several newer delivery systems under development and investigation for the administration of opioids, the intranasal route has received a substantial amount of attention. Intranasal administration is a convenient form of delivery that is applicable to several opioids. It has the potential for self-administration, combined with a rapid onset of action, allowing for patient-controlled analgesia. In clinical practice, intranasal administration has been found to be a reliable drug delivery method that is familiar to patients. Intranasal opioids have proven to be useful in both in-hospital and out-of-hospital pain management settings. Fentanyl, a highly lipophilic step 3 opioid, has been evaluated for intranasal administration. The purpose of this review is to examine the role of the nasal route of opioid administration and examine the evidence base for the use of fentanyl intranasally.

Role of intranasal fentanyl in breakthrough pain management in cancer patients

Fentanyl is a strong opioid analgesic, which is commonly used in the form of a transdermal patch for the treatment of chronic cancer pain. An intranasal route of fentanyl administration is a novel treatment for breakthrough cancer pain (BTCP). The prevalence, assessment, and management of BTCP is outlined in this paper, and basic pharmacodynamic and pharmacokinetic properties, dosing guidelines, and clinical experience with the use of intranasal fentanyl in this indication are discussed. Intranasal fentanyl is an attractive and convenient mode of BTCP treatment in opioid-tolerant patients due to its quick onset and short duration of action, noninvasive administration route, high bioavailability, and avoidance of a hepatic first-pass effect. Until now, few clinical trials have been conducted with intranasal fentanyl, but all have confirmed its usefulness and acceptability in BTCP treatment. Intranasal fentanyl may be used in opioid-tolerant patients without nasal pathologies. The dose should be titrated in each patient regardless of the regular opioid dose administered. Future studies should compare intranasal fentanyl with other fentanyl formulations used for BTCP management, and with analgesia, adverse effects, and quality of life taken into consideration.