Evaluation of efficacy and safety of fentanyl transdermal patch (Durogesic D-TRANS) in chronic pain

Long-Lasting Analgesia With Transdermal Fentanyl: A New Approach in Rat Neonatal Research

Background: With advances in neonatal care, management of prolonged pain in newborns is a daily concern. In addition to ethical considerations, pain in early life would have long-term effects and consequences. However, its treatment remains inadequate. It was therefore important to develop an experimental model of long-lasting analgesia for neonatal research.

Materials and Methods: Experiments were performed in six groups of rats with transdermal fentanyl 0, 3, 12, 50, 100, or 200 μg/kg/h from second postnatal day (P2) until weaning. Assessment of analgesia was carried out at P21, with behavioral scores (ranging from 0 to 3) using a 4% formalin test. Plasma levels of fentanyl were determined by UPLC/TQD at P22. Growth rate was investigated.

Results: Fentanyl 100 and 200 μg/kg/h reduced scores of formalin-evoked behavioral pain. They increased time spent in pain score 0 (8 min 55 s and 6 min 34 s versus 23 s in controls) as in low pain scores 1 and 2, and decreased time in the most severe pain score 3 (19 min 56 s and 17 min 39 s versus 44 min 15 s). Fentanylemia increased in a dose-dependent manner from 50 μg/kg/h (2.36 ± 0.64 ng/ml) to 200 μg/kg/h (8.66 ± 1.80 ng/ml). Concerning growth, no difference was observed except weaker growth from P17 to P22 with 200 μg/kg/h. Clinically, we noticed no visible side effect from 3 to 100 μg/kg/h. Concomitantly, 200 μg/kg/h was responsible for ophthalmological side effects with appearance of corneal bilateral clouding in 90% pups. No difference was observed between male and female rats.

Conclusion: Altogether, results indicate that transdermal fentanyl 100 μg/kg/h is an efficient therapeutic for long-lasting analgesia in lactating pups. This new model provides a useful tool for protection and welfare, and future opportunity for studying long-term health consequences of sustainable neonatal analgesia.

Recent advances in polymeric transdermal drug delivery systems

Transdermal delivery has proven to be one of the most favorable methods among novel drug delivery systems. Since drugs administered by transdermal delivery systems avoid the gastrointestinal tract, and thus avoid conversion by the liver, the likelihood of liver dysfunction and gastrointestinal tract irritation as side effects is low. Drug delivery through the skin has other advantages, such as maintaining an effective rate of drug delivery over time, a steady rate of circulation, and the benefits of a passive delivery system and diffusion. Transdermal drug delivery is achieved using patches which consist of different and specific layers. In the last few decades, many types of patches have been approved worldwide, such as medical plasters, which have been generally applied to the skin for localized diseases. Such patches can be traced back to ancient China (around 2000 BCE) and are the early precursors of today's transdermal patches. With the help of effective design, materials, manufacturing, and evaluation, a large number of drugs can now be administered using this valuable advanced technology. This study reviews different types of polymer patches, their advantages and disadvantages, and different studies related to transdermal drug delivery methods, and the advantages and disadvantages of each method. Different mechanisms of transdermal drug delivery system with patches are also discussed.

Percutaneous Vertebroplasty versus Conservative Treatment Using a Transdermal Fentanyl Patch for Osteoporotic Vertebral Compression Fractures

Objective

Although surgical intervention, such as percutaneous vertebroplasty (PVP), is the standard treatment for osteoporotic vertebral compression fractures (OVCFs), its effectiveness and safety are unclear. Therefore, this study compared the safety and efficacy of conservative treatment with that of PVP for acute OVCFs.

Methods

Patients with single-level OVCFs who were treated conservatively with a transdermal fentanyl patch (TFP) or with PVP between March 2013 and December 2017 and followed-up for more than 1 year were retrospectively evaluated. Patients with pathologic fractures, fractures of more than two columns, or a history of PVP were excluded. Clinical outcomes (visual analog scale [VAS] scores) and radiographic factors were evaluated, including changes in the compression rate of the corresponding vertebral body at onset and after 12 months, sagittal Cobb angle at onset and after 6 and 12 months, and the incidence of adjacent compression fractures.

Results

Of the 131 patients evaluated, 75 were treated conservatively using TFPs and 56 underwent PVP. We divided the patients into TFP and PVP groups. Their baseline characteristics (including sex, level of fracture, and bone mineral density T-scores) were similar, but the TFP group was significantly younger. The overall VAS score for pain showed a greater decrease during the first month (1 week after PVP) in the PVP group but remained similar in the two groups thereafter. The compression rate after 12 months increased in the TFP group but decreased in the PVP group. Five patients in the PVP group, but none in the TFP group, experienced adjacent compression fractures within 12 months.

Conclusion

We compared clinical and radiological outcomes between the TFP and PVP groups. The immediate pain reduction effect was superior in the PVP group, but the final clinical outcome was similar. Although the PVP group had a better-preserved compression rate than the TFP group for 1 year, the development of adjacent fractures was significantly higher. Although TFPs seemed to be beneficial in reducing the failure rate of conservative treatment, the possibility of side effects (22.6%, 17 out of 75 patients, in this study) should be carefully monitored.

Gabapentin versus Transdermal Fentanyl Matrix for the Alleviation of Chronic Neuropathic Pain of Radicular Origin: A Randomized Blind Multicentered Parallel-Group Noninferiority Trial

A number of studies have been published proposing various approaches to the treatment of neuropathic pain; however, to our knowledge, no attempts have been made to compare gabapentin and fentanyl in patients with lumbar radiculopathy. We evaluated the relative efficacy and safety of fentanyl matrix and gabapentin for the treatment of chronic neuropathic pain of radicular origin. The study was designed as a randomized blind multicentered parallel-group noninferiority trial. A total of 108 patients with moderate-to-severe pain (≥4 intensity on an 11-point numeric rating scale) were randomly prescribed either fentanyl matrix or gabapentin over a period of 56 days. In the primary analysis, the noninferiority of fentanyl matrix treatment was evaluated in relation to the efficacy of gabapentin based on the pain intensity difference (PID) at 56 days after the first dose of the drugs. Secondary endpoints included pain relief, improvement in functional status (the Korean-Oswestry Disability Index (K-ODI)), improvement in depressive symptoms (Korean-Beck Depression Index (K-BDI)) between the 28th and 56th day, and adverse events (AEs). Analysis of the primary efficacy endpoint established the noninferiority of fentanyl matrix compared with gabapentin, with no statistically significant difference observed in the PID after 56 days for the two treatment groups. Similarly, analysis of pain relief revealed no significant differences between the groups on days 28 and 56. There was no difference in the K-ODI and K-BDI between the groups during the study period. The overall incidence of at least one AE was similar for fentanyl matrix (67.3%) and gabapentin (69.6%). The most commonly reported AEs for patients treated with fentanyl matrix and gabapentin included dizziness (30.8% vs. 44.6%, respectively), somnolence (26.9% vs. 35.7%), and constipation (15.4% vs. 17.9%). This study demonstrated that the analgesic effect of fentanyl matrix is noninferior in comparison with gabapentin and supports the use of fentanyl matrix as an effective and safe treatment for moderate-to-severe chronic neuropathic pain. This trial is registered with NCT01127100.

Use of Fentanyl Patch and Intravenous Morphine for Treatment of Leg Bone Fracture: Treatment Profile, and Clinical Effectiveness

BACKGROUND:

Severe pain is one of the major problems in patients with leg bone fracture. Various methods have been proposed to relieve pain. Opioids are one of the most important available medications to control these types of pain. Among the opioids available, fentanyl can be applied for its unique properties as transdermal patches.

AIM:

Therefore, the current study aimed to investigate the effect of intravenous morphine and fentanyl skin patch in patients with a lower leg fracture.

METHODS:

We entered 60 patients in this randomised, one-blind randomised clinical trial among patients referring to the emergency department of Vali-e-Asr Hospital in Arak with a fracture of the leg. Demographic and clinical data were recorded for patients. The case group (n = 30) received the fentanyl patch in the same area. Patients in the control group (30) received 0.1mcg/kg of morphine intravenously. In both groups, the severity of pain was measured every 20 minutes within two hours after onset of treatment based on VAS criteria and subsequently recorded in the checklist. Data were analysed by SPSS v.22 software package.

RESULTS:

The results of the present study demonstrated that the mean visual analogue scale (VAS) pain score at minutes 20, 40, 60 and 80 were statistically lower in intervention group when compared with the control group (p = 0.000).

CONCLUSION:

Our results indicated a considerable risk-benefit profile for the treatment of pain in patients suffering from dysphagia, nausea and vomiting, or resistance to other opioids. The use of fentanyl patch is also suitable for patients who are not able to take their medication at their scheduled time.

The Efficacy of Fentanyl Transdermal Patch as the First-Line Medicine for the Conservative Treatment of Osteoporotic Compression Fracture

Objective

There are no strong guidelines on how long or how we should undertake conservative treatment during the acute period of an osteoporotic vertebral compression fracture (VCF).

Methods

We treated 202 patients with conservative treatment on VCF from March 2012 to August 2015. On inclusion criteria, 75 patients (22 males and 53 females) were included in the final analysis. After admission, a transdermal fentanyl patch with low dose (12.5 µg) application was attempted in all patients. In an unresponsive patient, the fentanyl patch was increased by 25 µg. After identifying the tolerable toilet ambulation of the patient without any assistance, hospital discharge was recommended. We classified two patient groups into one favorable group and one unfavorable group and compared several clinical and radiological factors.

Results

Among 75 patients, the clinical outcome of 57 patients (76%) was favorable, but that of 18 patients (24%) was unfavorable. In clinical outcomes, the numeric rating scale at 6 and 12 months and Odom's criteria at 12 months was significantly different between the favorable and the unfavorable groups. The dose of the patches used showed statistically significant differences between the two groups (p=0.001).

Conclusion

The only statistically significant affecting factor for an unfavorable outcome was the use of a higher dose fentanyl patch. Our data inferred that the unresponsiveness to a low-dose fentanyl patch could be helpful to select patients necessary for percutaneous vertebroplasty or kyphoplasty.

Fentanyl for neuropathic pain in adults

BACKGROUND

Opioid drugs, including fentanyl, are commonly used to treat neuropathic pain, and are considered effective by some professionals. Most reviews have examined all opioids together. This review sought evidence specifically for fentanyl, at any dose, and by any route of administration. Other opioids are considered in separate reviews.

OBJECTIVES

To assess the analgesic efficacy of fentanyl for chronic neuropathic pain in adults, and the adverse events associated with its use in clinical trials.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase from inception to June 2016, together with the reference lists of retrieved articles, and two online study registries.

SELECTION CRITERIA

We included randomised, double-blind studies of two weeks' duration or longer, comparing fentanyl (in any dose, administered by any route, and in any formulation) with placebo or another active treatment in chronic neuropathic pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched for studies, extracted efficacy and adverse event data, and examined issues of study quality and potential bias. We did not carry out any pooled analyses. We assessed the quality of the evidence using GRADE.

MAIN RESULTS

Only one study met our inclusion criteria. Participants were men and women (mean age 67 years), with postherpetic neuralgia, complex regional pain syndrome, or chronic postoperative pain. They were experiencing inadequate relief from non-opioid analgesics, and had not previously taken opioids for their neuropathic pain. The study used an enriched enrolment randomised withdrawal design. It was adequately blinded, but we judged it at unclear risk of bias for other criteria.Transdermal fentanyl (one-day fentanyl patch) was titrated over 10 to 29 days to establish the maximum tolerated and effective dose (12.5 to 50 µg/h). Participants who achieved a prespecified good level of pain relief with a stable dose of fentanyl, without excessive use of rescue medication or intolerable adverse events ('responders'), were randomised to continue with fentanyl or switch to placebo for 12 weeks, under double-blind conditions. Our prespecified primary outcomes were not appropriate for this study design, but the measures reported do give an indication of the efficacy of fentanyl in this condition.In the titration phase, 1 in 3 participants withdrew because of adverse events or inadequate pain relief, and almost 90% experienced adverse events. Of 258 participants who underwent open-label titration, 163 were 'responders' and entered the randomised withdrawal phase. The number of participants completing the study (and therefore continuing on treatment) without an increase of pain by more than 15/100 was 47/84 (56%) with fentanyl and 28/79 (35%) with placebo. Because only 63% responded sufficiently to enter the randomised withdrawal phase, this implies that only a maximum of 35% of participants entering the study would have had useful pain relief and tolerability with transdermal fentanyl, compared with 22% with placebo. Almost 60% of participants taking fentanyl were 'satisfied' and 'very satisfied' with their treatment at the end of the study, compared with about 40% with placebo. This outcome approximates to our primary outcome of moderate benefit using the Patient Global Impression of Change scale, but the group was enriched for responders and the method of analysis was not clear. The most common adverse events were constipation, nausea, somnolence, and dizziness.There was no information about other types of neuropathic pain, other routes of administration, or comparisons with other treatments.We downgraded the quality of the evidence to very low because there was only one study, with few participants and events, and there was no information about how data from people who withdrew were analysed.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support or refute the suggestion that fentanyl works in any neuropathic pain condition.

The Incidence of Severe Diarrhea with Transdermal Fentanyl Patch: An Uncommon Event

Cancer pain is a major problem for the health care providers. One of the most important aspects of cancer pain is palliative care management. Recently, different research finding shows the efficacy of opioid analgesics such as fentanyl transdermal patch in chronic pain management. Transdermal Fentanyl patches may cause side effects such as drowsiness, dizziness, itching, life-threatening or serious breathing difficulties and diarrhea, mainly during the first 72 h of patient's treatment initiation and any time when the drug's dose is increased. We report three case reports of severe diarrhea without most common side effects associated with Fentanyl patches during first 72 h of patient's treatment.

A case of overdose via tattoo

Transdermal fentanyl patches are used frequently for the management of both acute and chronic pain. Adverse events with their use, in particular overdose, are not uncommon. We describe a case of fentanyl overdose from transdermal patch placed over a five-day old tattoo. The report will review the pharmacology of transdermal fentanyl and the physiology of tattooing, as well as the potential link between the two, which may have lead to the overdose.

Efficacy of fentanyl transdermal patch in the treatment of chronic soft tissue cancer pain

Background:

Cancer pain may be a major problem for health care providers worldwide. According to different studies reporting the pain severity, one-third of patients reported to have moderate to severe pain. Management of cancer pain is one of the most important goals of palliative care. Recently, different research results on the efficacy of opioid analgesics in chronic pain management have played a role to implement standards in pain control by government agencies worldwide.

Objectives:

This study aimed to investigate the efficacy of fentanyl transdermal patch in the treatment of chronic soft tissue cancer pain.

Patients and Methods:

In a prospective descriptive study, we evaluated 86 patients with soft tissue tumors with chronic pain referred to cancer institute of Imam Khomeini Hospital, Tehran, Iran, during 2006-2007. For all patients, transdermal fentanyl patch (25 μg/h) was administered. The appearance of patches was the same. Pain severity was measured by Visual Analogue Scale (VAS) initially and 24, 48 and 72 hours after the initiation of treatment.

Results:

Patients' characteristics and VAS score before the treatment were not significantly different (P > 0.05). According to our findings, the pain severity was significantly reduced after the treatment (P = 0.001). The incidence of adverse events in patients was significantly high (72%). The most common adverse events were sleepiness, nausea and vomiting in 30.2% and 18.6%, respectively.

Conclusions:

Transdermal fentanyl patch was an effective and safe method to reduce pain in patients with soft tissue tumors. Moreover, it could improve the quality of life in these patients, but adverse events occurred in approximately 72% of patients.

Opioid-induced bowel dysfunction: pathophysiology and management

Opioids are the most commonly prescribed medications to treat severe pain in the Western world. It has been estimated that up to 90% of American patients presenting to specialized pain centres are treated with opioids. Along with their analgesic properties, opioids have the potential to produce substantial side effects, such as nausea, cognitive impairment, addiction and urinary retention. In the gut, opioids exert their action on the enteric nervous system, where they bind to the myenteric and submucosal plexuses, causing dysmotility, decreased fluid secretion and sphincter dysfunction, which all leads to opioid-induced bowel dysfunction (OIBD). In the clinic, this is reported as nausea, vomiting, gastro-oesophageal reflux-related symptoms, constipation, etc. One of the most severe symptoms is constipation, which can be assessed using different scales for subjective assessment. Objective methods such as radiography and colonic transit time can also be used, together with manometry and evaluation of anorectal function to explore the pathophysiology. Dose-limiting adverse symptoms of OIBD can lead to insufficient pain treatment. Even though several treatment strategies are available, the side effects are still a major challenge. Traditional laxatives are normally prescribed but they are often insufficient to alleviate symptoms, especially those from the upper gastrointestinal tract. Newer prokinetics, such as prucalopride and lubiprostone, may be more effective in alleviating OIBD. Another treatment approach is co-administration of opioid antagonists, which either cannot cross the blood-brain barrier or selectively target opioid receptors in the gastrointestinal tract. However, although these new agents have proved to be more efficacious than placebo, clinical trials still need to prove their superiority to standard co-prescribed laxative regimes.

The Pain and Sleep Questionnaire three-item index (PSQ-3): a reliable and valid measure of the impact of pain on sleep in chronic nonmalignant pain of various etiologies

BACKGROUND

Sleep disturbance is among the more common complaints reported by chronic pain patients. Because pain-related sleep disturbance may serve as a marker for the assessment of responses to treatment for chronic pain, inclusion of a measure designed to assess the impact of pain on sleep in clinical trial protocols is important, if not necessary. Measures typically used for this purpose lack scales specifically designed for the assessment of the impact of pain on sleep or are based on a single item. Single-item scales lack reliability and, therefore, validity.

OBJECTIVES

To investigate the psychometric properties of the five-item Pain and Sleep Questionnaire (PSQ) Index, which is embedded in the eight-item inventory, by applying an accepted methodology using retrospective analyses in controlled clinical trials in which the measure had been administered among patients with chronic nonmalignant pain.

METHODS

Data were pooled from nine independent, single-site, double-blind, randomized placebo-controlled clinical trials conducted over a period of approximately 10 years, the majority of which were cross-over designs. A cross-validation approach was adopted with exploratory and confirmatory factor analyses conducted to evaluate the underlying structure and dimensionality of the measure. Internal consistency reliability was evaluated using Cronbach's alpha coefficient. Mean score differences were used to assess the ability of the index to detect important treatment changes. Correlation coefficients were calculated between index scores and scores from other health-related outcome measures to evaluate the criterion validity of the index. Finally, predictive validity was assessed using multiple regression analyses.

RESULTS

Pooling the data resulted in a sample of 605 patients (65.5% female; mean age 55.7 years). Findings suggested a revised three-item PSQ Index (PSQ-3). The PSQ-3 demonstrated high internal consistency across samples (ranging from 0.82 to 0.93) and was sensitive to detecting meaningful treatment effects within different chronic pain categories. Moderate to strong correlations (r>0.40) between the PSQ-3 and other health-related outcome measures provided preliminary evidence for criterion-related validity. Results of multiple regression analyses demonstrated that the PSQ-3 accounted for between 29% and 40% of the variance in scores from other health-related outcome measures.

CONCLUSIONS

Results support the scoring of a revised three-item index for the assessment of the impact of pain on sleep. The revised index demonstrated acceptable levels of internal consistency and preliminary support for the structural, criterion-related and predictive validity of the index was achieved.

Transdermal opioid patches for pain treatment in ancient Greece

Pain treatment in ancient Greece, and through the middle ages in Europe, was to a great extent based on the expertise of the Greek physician Galen (c. 129-200 A.D.). Galen makes particular reference to "Olympic Victor's Dark Ointment" (OVDO), which is listed with a number of collyria. Galen states that OVDO can be useful for treating extreme pain and swellings, forming one of the best eye salves. Olympic Victor's Dark Ointment, an opium-based treatment, forms a "patch" when applied externally as an ointment, because it quickly dries to cover a localized region but still retains its elastic properties. This study has recreated OVDO and applied the ointment to abdominal mouse skin, in vitro. To assess the efficacy of OVDO, the transdermal transfer of morphine was measured when given as OVDO and compared to morphine administered in the form of a solution of Opium + PBS (ringer). Olympic Victor's Dark Ointment showed a transdermal transfer of morphine over time comparable to 25% of the most efficient modern transdermal opioid patches, while hardly any morphine was able to penetrate the skin when applied mixed in PBS. We conclude that OVDO is very efficient in its composition and may carry some forgotten abilities in terms of drug delivery, which could be transferred to modern medicine. Indeed, this may lead to a better choice of morphine use and controlled management in individual patient cases, taking both pain relief and anti-inflammatory aspects into account.

Effect of transdermal opioids in experimentally induced superficial, deep and hyperalgesic pain

BACKGROUND AND PURPOSE

Chronic pain and hyperalgesia can be difficult to treat with classical opioids acting predominately at the µ-opioid receptor. Buprenorphine and its active metabolite are believed to act through µ-, κ- and δ-receptors and may therefore possess different analgesic and anti-hyperalgesic effects compared with pure µ-receptor agonists, for example, fentanyl. Here, we have compared the analgesic and anti-hyperalgesic effects of buprenorphine and fentanyl.

EXPERIMENTAL APPROACH

Twenty-two healthy volunteers were randomized to treatment with transdermal buprenorphine (20 µg·h(-1), 144 h), fentanyl (25 µg·h(-1), 72 h) or placebo patches in a double-blind, cross-over experimental pain study. The experimental pain tests (phasic pain, sensitization) involved pressure at the tibial bone, cutaneous electrical and thermal stimulation, intramuscular nerve growth factor, UVB light burn injury model and intradermal capsaicin-induced hyperalgesia. Pain testing was carried out at baseline, 24, 48, 72 and 144 h after application of the drugs.

KEY RESULTS

Compared with placebo, buprenorphine, but not fentanyl, significantly attenuated pressure at the tibial bone as well as pressure pain in the primary hyperalgesic area induced by UVB light The two drugs were equipotent and better than placebo against cutaneous thermal pain stimulation), but failed to show significant analgesic effect to cutaneous electrical stimulation, nerve growth factor-induced muscle soreness and to capsaicin-induced hyperalgesia.

CONCLUSIONS AND IMPLICATIONS

Buprenorphine, but not fentanyl, showed analgesic effects against experimentally induced, bone-associated pain and primary hyperalgesia compared with placebo. These tissue- and modality-differentiated properties may reflect the variable effects of opioid drugs observed in individual patients.