Long-term efficacy and tolerability of intranasal fentanyl in the treatment of breakthrough cancer pain

Palliative patients who may benefit from intranasal delivery of symptomatic drugs: a two-center observational study evaluated the administration of morphine and dexamethasone in Polish hospices

INTRODUCTION

Patients receiving hospice care at the end of life often suffer from a variety of ailments. They may need medication to alleviate symptoms for the rest of their lives. The most common and recommended way to take opioids and steroids is orally. Less frequently, the subcutaneous or intravenous routes are used. The intranasal route is a relatively uncommon but interesting alternative for administering drugs.

AIM

The study aims to identify hospice patients who may benefit from changing the standard opioid and steroid administration route to intranasal delivery.

MATERIAL AND METHODS

The electronic medical records of all home and inpatient hospice patients (both rural and urban) were analyzed between February and April 2024. The study focused on the magnitude and type of problems associated with taking medications via standard routes and assessed the potential for changing to an intranasal route of administration.

RESULTS

Patients who were prescribed morphine, dexamethasone, or both during co-administration were included in the analysis. Of the 282 patients receiving hospice care over the study period, 95 met the inclusion criteria (33.7%). According to the researcher's original survey 87% of patients experienced issues with taking medications through the standard route. Among the problems related to oral medicines, consciousness disorders were the most significant at 66%. For subcutaneous administration, the main issues were reluctance to inject at 19% and lack of cooperation from caregivers at 20%.

CONCLUSION

The profile of a hospice patient who may benefit from intranasal administration of symptomatic drugs includes patients with impaired consciousness, aversion to subcutaneous injections, and reluctance to administer injections by caregivers.

Intranasal Therapy in Palliative Care

In recent years, the use of the intranasal route has been actively explored as a possible drug delivery method in the palliative patient population. There are reports demonstrating the effectiveness of nasally administered medications that are routinely used in patients at the end of life. The subject of this study is the intranasal drug administration among palliative patients. The aim is to summarize currently used intranasal therapies among palliative patients, determine the benefits and difficulties, and identify potential areas for future research. A review of available medical literature published between 2013 and 2023 was performed using online scientific databases. The following descriptors were used when searching for articles: "palliative", "intranasal", "nasal", "end-of-life care", "intranasal drug delivery" and "nasal drug delivery". Out of 774 articles, 55 directly related to the topic were finally selected and thoroughly analyzed. Based on the bibliographic analysis, it was shown that drugs administered intranasally may be a good, effective, and convenient form of treatment for patients receiving palliative care, in both children and adults. This topic requires further, high-quality clinical research.

Clinical and pharmacokinetics overview of intranasal administration of fentanyl

Due to the presence of large surfaces and high blood supply, drug delivery through the nasal route of administration is the appropriate route to administrate drugs with rapid onsets of action. Bypassing first-pass metabolism can increase drug bioavailability. The physicochemical properties of fentanyl led to a need to develop formulations for delivery by multiple routes. Several approved inter-nasal fentanyl products in Europe and the USA have been used in prehospital and emergency departments to treat chronic cancer pain and used to treat severe acute abdominal and flank pain. Analgesia durations and onsets were not significantly different between intranasal and intravenous fentanyl in patients with cancer breakthrough pain and were well-tolerated in the long term. Intranasal Fentanyl (INF) at a 50 μg/ml concentration decreased renal colic pain to the lowest level in 30 min. Possible adverse effects specific to INF are epistaxis, nasal wall ulcer, rhinorrhea, throat irritation, dysgeusia, nausea, and vomiting. However, there is limited available literature about the serious adverse effects of INF in adults and children. Intranasal Fentanyl Spray (INFS) results in significantly higher plasma concentrations and has a lower Tmax than oral transmucosal formulation, and the bioavailability of fentanyl in intranasal formulations is very high (89 %), particularly in pectin-containing formulations such as PecFent and Lazanda.

Localized Drug Delivery Systems: An Update on Treatment Options for Head and Neck Squamous Cell Carcinomas

Head and neck squamous cell carcinoma (HNSCC) is one of the most common cancers in the world, with surgery, radiotherapy, chemotherapy, and immunotherapy being the primary treatment modalities. The treatment for HNSCC has evolved over time, due to which the prognosis has improved drastically. Despite the varied treatment options, major challenges persist. HNSCC chemotherapeutic and immunotherapeutic drugs are usually administered systemically, which could affect the patient's quality of life due to the associated side effects. Moreover, the systemic administration of salivary stimulating agents for the treatment of radiation-induced xerostomia is associated with toxicities. Localized drug delivery systems (LDDS) are gaining importance, as they have the potential to provide non-invasive, patient-friendly alternatives to cancer therapy with reduced dose-limiting toxicities. LDDSs involve directly delivering a drug to the tissue or organ affected by the disease. Some of the common localized routes of administration include the transdermal and transmucosal drug delivery system (DDSs). This review will attempt to explore the different treatment options using LDDSs for the treatment of HNSCC and radiotherapy-induced damage and their potential to provide a better experience for patients, as well as the obstacles that need to be addressed to render them successful.

Cannabinoid Formulations and Delivery Systems: Current and Future Options to Treat Pain

The field of Cannabis sativa L. research for medical purposes has been rapidly advancing in recent decades and a growing body of evidence suggests that phytocannabinoids are beneficial for a range of conditions. At the same time impressing development has been observed for formulations and delivery systems expanding the potential use of cannabinoids as an effective medical therapy. The objective of this review is to present the most recent results from pharmaceutical companies and research groups investigating methods to improve cannabinoid bioavailability and to clearly establish its therapeutic efficacy, dose ranges, safety and also improve the patient compliance. Particular focus is the application of cannabinoids in pain treatment, describing the principal cannabinoids employed, the most promising delivery systems for each administration routes and updating the clinical evaluations. To offer the reader a wider view, this review discusses the formulation starting from galenic preparation up to nanotechnology approaches, showing advantages, limits, requirements needed. Furthermore, the most recent clinical data and meta-analysis for cannabinoids used in different pain management are summarized, evaluating their real effectiveness, in order also to spare opioids and improve patients' quality of life. Promising evidence for pain treatments and for other important pathologies are also reviewed as likely future directions for cannabinoids formulations.

Transmucosal drug administration as an alternative route in palliative and end-of-life care during the COVID-19 pandemic

The Coronavirus disease 2019 (COVID-19) pandemic has led to a surge in need for alternative routes of administration of drugs for end of life and palliative care, particularly in community settings. Transmucosal routes include intranasal, buccal, sublingual and rectal. They are non-invasive routes for systemic drug delivery with the possibility of self-administration, or administration by family caregivers. In addition, their ability to offer rapid onset of action with reduced first-pass metabolism make them suitable for use in palliative and end-of-life care to provide fast relief of symptoms. This is particularly important in COVID-19, as patients can deteriorate rapidly. Despite the advantages, these routes of administration face challenges including a relatively small surface area for effective drug absorption, small volume of fluid for drug dissolution and the presence of a mucus barrier, thereby limiting the number of drugs that are suitable to be delivered through the transmucosal route. In this review, the merits, challenges and limitations of each of these transmucosal routes are discussed. The goals are to provide insights into using transmucosal drug delivery to bring about the best possible symptom management for patients at the end of life, and to inspire scientists to develop new delivery systems to provide effective symptom management for this group of patients.

Video Education Reduces Pain and Anxiety Levels in Cancer Patients Who First Use Fentanyl Transdermal Patch: A Randomized Controlled Trial

Objective

We sought to evaluate the efficacy of using a quick response (QR) code within video education to guide proper use of fentanyl transdermal patches and control pain, depression, and anxiety levels in cancer patients.

Methods

Patients using a fentanyl transdermal patch for the first time were enrolled in the study and then given an information leaflet as well as an informed consent form. We asked them to complete the first questionnaire (Q1) prior to first use of the fentanyl transdermal patch, and then used a random number table to randomize those who completed it into two groups. Participants in group A received a QR code (to make it easier for them to obtain additional video information) and a traditional information leaflet, whereas those in group B (control group) only received a traditional information leaflet. Thereafter, we requested all participants to complete standard questionnaires, which comprised a Numeric Rating Scale (NRS), a Spielberger State-Trait Anxiety Inventory (STAI), as well as a Hospital Anxiety and Depression Scale (HADS). The resulting continuous (with a normal distribution) and categorical data were analyzed using Student’s t- and chi-square tests, respectively. We also recorded parameters such as NRS, STAI, and HADS, as well as the frequency of rescue medication in both groups.

Results

A total of 154 cancer patients who first used a fentanyl transdermal patch were recruited during the study period, from April to May 2020. Among these, 138 completed follow-up, with 70 and 68 in group A and B, respectively. Participants in both groups had similar baseline and clinical characteristics, whereas significant differences were observed between the groups with regard to the other parameters. Specifically, participants in group A recorded a lower STAI state (38.2 vs 38.9, P=0.027) and HADS (3.9 vs 4.2, P=0.001) anxiety scores, as well as NRS (2.1 vs 2.4, P=0.025) and frequency of rescue medication (0.4 vs 1.4, P<0.001) than those in group B, following 14 days of using a fentanyl transdermal patch.

Conclusion

Our results indicated that incorporating a QR code within additional video education leads to proper use of a fentanyl transdermal patch and relieves pain and anxiety levels in patients with cancer. Based on this, we recommend a new style of education during care of cancer patients who first use a fentanyl transdermal patch.

Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.

The Intranasal Route as an Alternative Method of Medication Administration

Intranasal drug administration is a less invasive method of drug delivery that is easily accessible for adult and pediatric patients. Medications administered by the intranasal route have efficacy comparable to intravenous administration and typically have superior efficacy to subcutaneous or intramuscular routes. The intranasal route is beneficial in emergent situations when the intravenous route is not available. The intranasal route is safe and effective in various indications, and therapeutic systemic concentrations of medication can be attained via this route. As the evidence for and comfort with intranasal administration continue to grow, guidance on correct technique, medications, and dosing is vital for appropriate use. This article reviews the process and practices of appropriate intranasal medication administration.

The Use of Intranasal Fentanyl for the Palliation of Incident Dyspnea in Advanced Congestive Heart Failure: A Pilot Study

Background:

Dyspnea is distressing in palliative patients with end-stage heart failure and many are hospitalized to optimize this symptom. We hoped to conduct a pilot study to determine whether the administration of intranasal fentanyl would decrease activity-induced dyspnea in this patient population.

Methods:

Patients performed two 6-minute walk tests with and without the administration of 50 μg of intranasal fentanyl. Vital signs were recorded before and after each walk, as were participant reported dyspnea and adverse events scores.

Results:

Twenty-four patients were screened, 13 were deemed eligible, and 6 completed the study. Dyspnea scores changed from a mean of 6.00 immediately after the walk without fentanyl to a mean of 3.83 after the walk with fentanyl ( P = .048). Mean respiratory rate decreased from 21.0 to 18.7 ( P = .034) breaths per minute and was considered a favorable outcome by the participants. Distance walked did not significantly increase with the fentanyl pretreatment (136.0-144.2 m; P = .283), although the participants reported feeling better while walking a similar distance.

Conclusions:

In this pilot study, the preadministration of intranasal fentanyl prior to activity in palliative, end-stage hospitalized heart failure patients, safely reduced tachypnea, and the feeling of shortness of breath. This approach may help palliate advanced heart failure patients by alleviating symptoms brought on by exertional activities.

Breakthrough Cancer Pain: A Systematic Review of Pharmacologic Management

BACKGROUND

Breakthrough cancer pain (BtCP), defined as a transient exacerbation of pain that occurs in conjunction with well-controlled background pain, is a common and burdensome problem in patients with cancer.
.

OBJECTIVES

The aim of this systematic review is to identify evidence-based pharmacologic modalities for adequate management of BtCP. 
.

METHODS

PubMed and CINAHL® databases were searched to identify literature regarding pharmacologic strategies for BtCP published from January 2006 to June 2016. These studies were then synthesized by the Oncology Nursing Society Putting Evidence Into Practice pain team. 
.

FINDINGS

Forty-four studies provide evidence for the use of opioids for the management of BtCP. Transmucosal immediate-release fentanyl (TIRF) was found to have the most evidence for BtCP. Five studies and guidelines also suggest that oral opioids (not including TIRF products) be dosed proportionally to baseline opioids at 10%-20% of the 24-hour, around-the-clock dose.

[Transmucosal fentanyl administration: sublingual, buccal, nasal - all the same? Treatment of breakthrough cancer pain]

BACKGROUND

Transient exacerbation of pain in cancer patients (breakthrough cancer pain, BTCP) despite adequately controlled background pain should be regarded as an independent disease and receive targeted treatment. The opioid of choice is fentanyl, a rapid onset and highly potent WHO category III analgesic. Fentanyl has a strong first pass effect when administered orally and resorbed enterally, however it is well suited for transmucosal administration, e.g. on the oral or nasal mucosa. Seven different preparations of rapid onset fentanyl for transmucosal administration via various administration pathways are currently available in Germany.

SCIENTIFIC PROBLEM AND METHOD

The aim of this review article was to determine which patient can benefit most from which forms of administration. Since there are hardly any direct comparisons of administration forms among each other, meta-analyses and reviews were included in the assessment.

RESULTS AND CONCLUSION

Tablets with an applicator (lozenge), sublingual and buccal tablets, as well as a buccal film are available for the oral transmucosal administration of fentanyl; there is an aqueous fentanyl nasal spray and a pectin-rich nasal spray for nasal transmucosal administration. The individual preparations differ considerably with regard to their pharmacological (e.g. bioavailability, c_max and t_max) and patient-relevant parameters (e.g. onset of action, potency and duration of effect). Fentanyl nasal spray is superior to the other forms of administration in terms of rapid onset of action and clinically relevant pain reduction and can thus be recommended as a treatment option for rapidly evolving and/or spontaneously occurring breakthrough cancer pain.

Assessment and treatment of breakthrough cancer pain: from theory to clinical practice

Breakthrough cancer pain (BTcP) is a common condition in oncological patients. However, its management is still suboptimal. Improved knowledge of BTcP and its management in clinical practice may have immediate importance for all physicians involved in the supportive care of cancer patients. This review critically discusses the most important concepts for the correct diagnosis of BTcP and presents some intriguing cases of the management of this condition in clinical practice. Overall, the most appropriate therapeutic choice appears to be a rapid-onset opioid (ROO), and in particular, the nasal route of administration is the quickest and most convenient mode of administration for the management of BTcP, especially when the patient needs rapid resolution of pain. To this end, intranasal fentanyl spray may have a particular relevance in clinical practice. Future research should focus on accepted definitions of BTcP to investigate the optimal management of this highly heterogeneous pain condition. Therapeutic decision-making of patients, clinicians, and payers will likely be driven from results of well-designed clinical trials of ROOs.

Transdermal buprenorphine and fentanyl patches in cancer pain: a network systematic review

Treatment of cancer pain is generally based on the three-step World Health Organization (WHO) pain relief ladder, which utilizes a sequential approach with drugs of increasing potency. Goals of pain management include optimization of analgesia, optimization of activities of daily living, minimization of adverse effects, and avoidance of aberrant drug taking. In addition, it is recommended that analgesic regimens are individualized and simplified to help ensure patient compliance and should provide the least invasive, easiest, and safest route of opioid administration to ensure adequate analgesia. Buprenorphine and fentanyl are two opioids available for the relief of moderate-to-severe cancer pain. Available clinical data regarding the transdermal (TD) formulations of these opioids and the extent to which they fulfill the recommendations mentioned earlier are systematically reviewed, with the aim of providing additional information for oncologists and pain specialists regarding their comparative use. Due to lack of studies directly comparing TD buprenorphine with TD fentanyl, data comparing these with other step-3 opioids are also evaluated in a network fashion.

Endogenous Opiates and Behavior: 2015

This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.