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Sommerfeld-Klatta K, Jiers W, Łukasik-Głębocka M, Tezyk A, Dolińska-Kaczmarek K, Walter K, Świderski P, Rzepczyk S, Zielińska-Psuja B, Żaba C. Severe and Fatal Fentanyl Poisonings from Transdermal Systems after On-Skin and Ingestion Application. TOXICS 2023; 11:872. [PMID: 37888722 PMCID: PMC10610823 DOI: 10.3390/toxics11100872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/12/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023]
Abstract
In recent years, the administration of fentanyl (FNTL) implicitly in transdermal drug delivery systems (TDDS) has vastly increased in chronic pain treatment. Non-medical and uncontrolled use of FNTL in TFDS (transdermal fentanyl delivery systems) may reveal toxic effects by the route of exposure, dermal or alternative, by ingestion of patches, and drug release in the stomach. The purpose of this study was to present three different cases of FNTL poisonings, two of which resulted in death due to TFDS abuse. The first case is a 66-year-old woman treated for accidental FTNL poisoning resulting in acute respiratory distress syndrome. Two remaining cases are a 31-year-old woman and a 25-year-old man who died as a result of FNTL overdose after on-skin and ingestion application of the drug patches. During the hospitalization of the 66-year-old patient, in blood samples, FNTL was confirmed at a concentration of 10.0 ng/mL. Tests run on blood taken from the corpses of 25- and 31-year-old patients exhibited FNTL presence in concentrations of 29.1 ng/mL and 38.7 ng/mL, respectively. The various routes of administration and ultimately toxic effects are important to present because, in TDDS, fentanyl can be a reason for severe to fatal poisoning, as shown by the three cases above.
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Affiliation(s)
- Karina Sommerfeld-Klatta
- Department of Toxicology, Poznań University of Medical Sciences, 30 Dojazd Street, 60-631 Poznan, Poland
| | - Wiktoria Jiers
- Department of Toxicology, Poznań University of Medical Sciences, 30 Dojazd Street, 60-631 Poznan, Poland
| | - Magdalena Łukasik-Głębocka
- Department of Emergency Medicine, Poznań University of Medical Sciences, 7 Rokietnicka Street, 60-806 Poznan, Poland
| | - Artur Tezyk
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
| | - Klaudia Dolińska-Kaczmarek
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
| | - Kamil Walter
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
| | - Paweł Świderski
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
| | - Szymon Rzepczyk
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
| | - Barbara Zielińska-Psuja
- Department of Toxicology, Poznań University of Medical Sciences, 30 Dojazd Street, 60-631 Poznan, Poland
| | - Czesław Żaba
- Department of Forensic Medicine, Poznań University of Medical Sciences, 10 Rokietnicka Street, 60-806 Poznan, Poland
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Chiu SK, Hornsby‐Myers JL, Perio MA, Snawder JE, Wiegand DM, Trout D, Howard J. Health effects from unintentional occupational exposure to opioids among law enforcement officers: Two case investigations. Am J Ind Med 2019; 62:439-447. [PMID: 31016761 DOI: 10.1002/ajim.22967] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/28/2019] [Accepted: 02/19/2019] [Indexed: 12/23/2022]
Abstract
Recent increases in the rate of drug overdose-related deaths, the emergence of potent opioids such as carfentanil, and media reports of incidents have raised concerns about the potential for work-related exposure to a variety of illicit drugs among law enforcement officers (LEOs), other emergency responders, and other workers in the United States. To characterize the risk associated with unintentional occupational exposure to drugs, we retrospectively investigated two incidents that occurred in 2017 and 2018 where LEOs were exposed to opioid and stimulant drugs and experienced health effects. We interviewed five affected LEOs and others. We reviewed records, including emergency department documentation, incident reports, forensic laboratory results, and when available, body camera footage. Multiple drug types, including opioids and nonopioids, were present at each incident. Potential routes of exposure varied among LEOs and were difficult to characterize with certainty. Health effects were not consistent with severe, life-threatening opioid toxicity, but temporarily precluded affected LEOs from performing their essential job duties. While health risks from occupational exposure to drugs during law enforcement activities cannot currently be fully characterized with certainty, steps to prevent such exposures should be implemented now. The creation and implementation of appropriate controls plus education and training are both important to protecting first responders from these hazardous agents. To more fully characterize potential exposures, timely prospective toxicological evaluation of affected responders is recommended.
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Affiliation(s)
- Sophia K. Chiu
- National Institute for Occupational Safety and Health, Division of Surveillance, Hazard Evaluations and Field StudiesCincinnati Ohio
| | - Jennifer L. Hornsby‐Myers
- National Institute for Occupational Safety and Health, Office of the Director, Emergency Preparedness and Response OfficeMorgantown West Virginia
| | - Marie A. Perio
- National Institute for Occupational Safety and Health, Division of Surveillance, Hazard Evaluations and Field StudiesCincinnati Ohio
| | - John E. Snawder
- National Institute for Occupational Safety and Health, Division of Applied Research and TechnologyCincinnati Ohio
| | - Douglas M. Wiegand
- National Institute for Occupational Safety and Health, Division of Surveillance, Hazard Evaluations and Field StudiesCincinnati Ohio
| | - Douglas Trout
- National Institute for Occupational Safety and Health, Division of Surveillance, Hazard Evaluations and Field StudiesCincinnati Ohio
| | - John Howard
- National Institute for Occupational Safety and Health, Office of the DirectorWashington District of Columbia
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Janknegt R, van den Beuken M, Schiere S, Überall M, Knaggs R, Hanley J, Thronaes M. Rapid acting fentanyl formulations in breakthrough pain in cancer. Drug selection by means of the System of Objectified Judgement Analysis. Eur J Hosp Pharm 2017; 25:e2. [PMID: 29732145 PMCID: PMC5931243 DOI: 10.1136/ejhpharm-2016-001127] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/17/2016] [Accepted: 11/28/2016] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Robert Janknegt
- Department of Clinical Pharmacy and Toxicology, Zuyderland Medical Centre, Sittard, The Netherlands
| | | | | | - Michael Überall
- IFNAP Institute for Neurosciences, Algesiology and Paediatrics, Nürnberg, Germany
| | - Roger Knaggs
- University of Nottingham, Nottingham, UK.,Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Morten Thronaes
- Faculty of Medicine, Department of Cancer Research and Molecular Medicine, European Palliative Care Research Centre (PRC), Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Chang A, Roeland EJ, Atayee RS, Revta C, Ma JD. Transmucosal Immediate-Release Fentanyl for Breakthrough Cancer Pain: Opportunities and Challenges for Use in Palliative Care. J Pain Palliat Care Pharmacother 2015; 29:247-60. [PMID: 26368648 DOI: 10.3109/15360288.2015.1063560] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Opioids are used to treat breakthrough cancer pain (BTCP) and can be classified by relative duration and onset of action. Regulatory approvals of numerous transmucosal immediate-release fentanyl (TIRF) formulations provide alternative options to palliative care-trained providers in the management of BTCP. TIRFs have been formulated as a sublingual tablet, sublingual spray, intranasal spray, pectin-based nasal spray, buccal tablet, and buccal soluble film. Differences exist between TIRFs regarding formulation design and dosing to treat BTCP. Opportunities for use include palliation of BTCP in head and neck cancer and/or radiation-induced mucositis. The purpose of this review is to discuss TIRF formulation and dosing, pharmacokinetics, clinical efficacy, patient acceptability, and safety/tolerability. In addition, barriers to TIRF utilization will be discussed.
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Mercadante S. Fentanyl buccal tablet for the treatment of cancer-related breakthrough pain. Expert Rev Clin Pharmacol 2014; 8:9-13. [DOI: 10.1586/17512433.2015.977254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Darwish M, Messina J. Clinical pharmacology of fentanyl buccal tablet for the treatment of breakthrough pain. Expert Rev Clin Pharmacol 2014; 1:39-47. [PMID: 24410508 DOI: 10.1586/17512433.1.1.39] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fentanyl buccal tablet (FBT) is a new formulation of fentanyl providing rapid-onset analgesia for the treatment of breakthrough pain. FBT has been approved for the management of breakthrough pain in patients with cancer who are already receiving and who are tolerant to opioid therapy for underlying persistent pain. FBT has demonstrated a favorable pharmacokinetic profile, which is closely aligned to the rapid onset and duration of an episode of breakthrough pain, and is generally safe and well tolerated.
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Affiliation(s)
- Mona Darwish
- Cephalon, Inc., 41 Moores Road, PO Box 4011, Frazer, PA 19355, USA.
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Shankaran H, Adeshina F, Teeguarden JG. Physiologically-based pharmacokinetic model for Fentanyl in support of the development of Provisional Advisory Levels. Toxicol Appl Pharmacol 2013; 273:464-76. [DOI: 10.1016/j.taap.2013.05.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 04/23/2013] [Accepted: 05/11/2013] [Indexed: 01/01/2023]
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8
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Saunders DL, Messina J, Darwish M, Xie F, Leary KJ, Cantilena LR. Assessment of the Relative Potency of Fentanyl Buccal Tablet to Intravenous Morphine in Healthy Volunteers Using a Thermally Induced Hyperalgesia Pain Model. J Clin Pharmacol 2013; 52:870-9. [DOI: 10.1177/0091270011407496] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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9
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Suzuki J, Broeyer F, Cohen A, Takebe M, Burggraaf J, Mizushima Y. Pharmacokinetics of PC-SOD, a Lecithinized Recombinant Superoxide Dismutase, After Single- and Multiple-Dose Administration to Healthy Japanese and Caucasian Volunteers. J Clin Pharmacol 2013; 48:184-92. [DOI: 10.1177/0091270007309705] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Moore N, Darwish M, Amores X, Schneid H. A review of the pharmacokinetic profile of transmucosal fentanyl formulations. Curr Med Res Opin 2012; 28:1781-90. [PMID: 23020252 DOI: 10.1185/03007995.2012.735227] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Breakthrough pain (BTP) is a transitory flare of moderate-to-severe pain that occurs in patients with stable, controlled persistent pain. Management of BTP episodes is difficult because frequency, time-to-peak intensity, and duration of episodes vary both within and between individuals. Formulations of fentanyl that use a buccal, sublingual, or nasal transmucosal route of administration have been developed for the treatment of BTP in opioid-tolerant patients with cancer. These formulations allow rapid passage into the bloodstream and avoid first-pass metabolism and, therefore, are more likely to match the time-course of BTP episodes than are oral formulations. The purposes of this analysis were to identify and review published data describing the pharmacokinetic properties of rapid-onset fentanyl formulations and to evaluate these properties in view of the temporal dynamic characteristics of BTP in order to help guide medical practice. METHODS Relevant publications were searched in the PubMed database from 1998. The plasma drug concentration-time profile of each formulation obtained from the identified studies was adjusted to a consistent scale for comparison. RESULTS The data revealed that the various transmucosal formulations resulted in three typical plasma fentanyl concentration profiles: (1) type 1: a very rapid rise and short duration; (2) type 2: a rapid increase and sustained intensity; and (3) type 3: a slower onset and longer duration. CONCLUSIONS Given the substantial variability of BTP episodes experienced by patients, these pharmacokinetic differences may provide useful information for a physician who is selecting a rapid-onset opioid medication for a patient.
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Affiliation(s)
- Nicholas Moore
- Department of Pharmacology, Bordeaux 2 University, 33076 Bordeaux, France.
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Abstract
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).
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12
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A review of transbuccal fentanyl use in the emergency department. PAIN RESEARCH AND TREATMENT 2012; 2012:768796. [PMID: 22550580 PMCID: PMC3324937 DOI: 10.1155/2012/768796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 01/03/2012] [Indexed: 11/29/2022]
Abstract
Patients with severe, painful injuries and illnesses treated in the emergency department are commonly administered opioid medications. Intravenous administration provides the most rapid onset of pain relief and is readily titrated. Fentanyl, administered intravenously, is well documented as an effective medication for pain management in the emergency department. It is preferred in many settings due to its minimal hemodynamic effects, as compared to other commonly used opioids. However, not all patients require intravenous access. These patients are given orally administered pain medications. The oral route is effective at minimizing pain but has a much slower onset of action when compared to the intravenous route. As an alternative to the slower onset of action seen with oral opioids, this paper discusses the use of fentanyl buccal tablet for pain management in the emergency department. Fentanyl buccal tablets are readily absorbed, with a bioavailability of approximately 65%, and have a more rapid onset of action than achieved with traditional oral opioids used in the emergency department.
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Abstract
The purpose of this article is to systematically review the use of fentanyl as an analgesic for breakthrough pain. This article found that the oral transmucosal fentanyl (OTFC) had a quicker onset to analgesia than oral immediate-release opioids. Intranasal fentanyl (INFS) had a quicker onset to analgesia than buccal tablets, which in turn had a quicker onset to analgesia than OTFC. Patient acceptance and global rating of efficacy were greater for INFS than for buccal fentanyl. OTFC and INFS have been used effectively to reduce acute pain in children who are opioid-naive. Abuse and addiction to OTFC, fentanyl buccal tablets and INFS was low, owing to patient selection.
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Affiliation(s)
- Mellar P Davis
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, The Harry R Horvitz Center for Palliative Medicine, Cleveland, OH 44195, USA.
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Abstract
Fentanyl buccal tablet (FBT) is indicated for the treatment of breakthrough pain in patients who are already receiving and are tolerant to opioid therapy for underlying, persistent cancer pain. FBT is designed to enhance the rate and efficiency of absorption of fentanyl through the buccal mucosa. FBT was shown to be dose proportional from 100 to 1,300 μg. This analysis provides an overview of the pharmacokinetic profile of FBT based on pooled data from nine pharmacokinetic studies. In all, 365 healthy non-opioid-tolerant adults receiving naltrexone were included in the analysis. Single-dose (100 to 1,300 μg) pharmacokinetic parameters were dose normalized to 100 μg. Pharmacokinetic measures included maximum observed plasma drug concentration (C(max)), plasma drug concentration versus time curve from time zero to infinity (AUC(0-∞)), time to reach C(max) (T(max)), apparent plasma terminal elimination rate constant, and elimination half-life. After FBT administration, fentanyl was rapidly absorbed, with T(max) ranging from 20 minutes to 4 hours postdose. Mean AUC(0-∞) was 1.49 ng•hour/mL, and mean C(max) was 0.237 ng/mL. However, plasma fentanyl concentration reached 80% of C(max) within 25 minutes and was maintained through 2 hours after administration. Based on the individual studies, bioequivalence was shown for sublingual and buccal tablet placement, and no significant effect of dwell time (duration of FBT presence in the oral cavity) was observed. The pharmacokinetic profile of FBT was characterized by rapid absorption, which is consistent with the rapid-onset efficacy profile of FBT observed in clinical studies.
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Affiliation(s)
- Mona Darwish
- Clinical Research, Cephalon, Inc., Frazer, Pennsylvania 19355, USA.
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Lister N, Warrington S, Boyce M, Eriksson C, Tamaoka M, Kilborn J. Pharmacokinetics, safety, and tolerability of ascending doses of sublingual fentanyl, with and without naltrexone, in Japanese subjects. J Clin Pharmacol 2011; 51:1195-204. [PMID: 21209242 DOI: 10.1177/0091270010379410] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This open-label, nonrandomized study assessed single and repeat ascending doses of a new sublingual fentanyl (SLF) formulation in 48 healthy Japanese opiate-naïve subjects (47 completed). Subjects received single-dose SLF 100, 200, 400, or 800 µg followed by 13 doses 6 hourly, at their dose level. Subjects taking repeat-dose 400 and 800 µg were pretreated with naltrexone in order to block opiate-receptor-mediated effects on respiration, monitored by pulse oximetry and transcutaneous pco(2). Sublingual fentanyl was rapidly and consistently absorbed. After single doses, median t(first) was 0.08 to 0.25 hours and t(max) 0.50 to 1.00 hours. After repeat dosing, median t(max) (t(max,ss)) was 0.50 to 2.00 hours. Plasma concentrations were dose proportional both after single and repeat dosing, and naltrexone appeared to have no effect on SLF pharmacokinetics. Plasma fentanyl reached steady state within the 72-hour dosing period and accumulation was approximately 2-fold. After single doses, effects on respiratory variables were evident after the 400-µg and 800-µg doses. Transcutaneous pco(2) was not helpful in detecting respiratory depression. Thus, SLF yielded rapid absorption of fentanyl and dose-proportional plasma concentrations that, for 400 µg and 800 µg, were within the typical analgesic range. Respiratory depression in these opioid-naïve volunteers was manageable with simple clinical measures.
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Shear ML, Adler JN, Shewakramani S, Ilgen J, Soremekun OA, Nelson S, Thomas SH. Transbuccal fentanyl for rapid relief of orthopedic pain in the ED. Am J Emerg Med 2010; 28:847-52. [DOI: 10.1016/j.ajem.2009.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 04/11/2009] [Accepted: 04/14/2009] [Indexed: 11/26/2022] Open
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Darwish M, Hamed E, Messina J. Fentanyl buccal tablet for the treatment of breakthrough pain: pharmacokinetics of buccal mucosa delivery and clinical efficacy. PERSPECTIVES IN MEDICINAL CHEMISTRY 2010; 4:11-21. [PMID: 20634985 PMCID: PMC2901636 DOI: 10.4137/pmc.s3928] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The treatment of breakthrough pain (BTP), a transitory exacerbation of pain that occurs on a background of otherwise-controlled, persistent pain, requires an opioid formulation and/or method of administration that can provide rapid and extensive systemic exposure. Fentanyl buccal tablet (FBT; FENTORA®, Cephalon, Inc.) employs OraVescent® drug delivery technology, which enhances the rate and extent of fentanyl absorption. OraVescent technology enhances the oral dissolution and buccal absorption of fentanyl, which facilitates rapid uptake of fentanyl into the bloodstream, reducing gastrointestinal absorption and minimizing extensive first-pass metabolism. The resulting pharmacokinetic profile of FBT is characterized by greater bioavailability and a higher early systemic exposure compared with the earlier oral transmucosal fentanyl citrate formulation. In clinical studies of opioid-tolerant patients with cancer-related and noncancer-related BTP, FBT has provided consistent and clinically relevant improvements in pain intensity and pain relief relative to placebo, with a safety and tolerability profile that is generally typical of that observed with other potent opioids. The pharmacokinetic properties of FBT allow for meaningful clinical efficacy, with an onset of action that closely matches the onset of BTP.
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Abstract
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.
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Affiliation(s)
- Sina Grape
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
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Affiliation(s)
- Eric Prommer
- Department of Hematology/Oncology/Palliative Care, Mayo Clinic Arizona, Phoenix, Arizona
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Christrup LL, Lundorff L, Werner M. Novel formulations and routes of administration for opioids in the treatment of breakthrough pain. ACTA ACUST UNITED AC 2009. [DOI: 10.2217/thy.09.51] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
This paper is the thirtieth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2007 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; alcohol and drugs of abuse; 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.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, 65-30 Kissena Blvd.,Flushing, NY 11367, United States.
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Darwish M, Tempero K, Jiang JG, Simonson PG. Relative Bioavailability of Fentanyl Following Various Dosing Regimens of Fentanyl Buccal Tablet in Healthy Japanese Volunteers. ARCHIVES OF DRUG INFORMATION 2008; 1:56-62. [PMID: 19915709 PMCID: PMC2773523 DOI: 10.1111/j.1753-5174.2008.00009.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Fentanyl buccal tablet (FBT; FENTORA®, Cephalon, Inc., Frazer, PA, USA) is indicated in the US for breakthrough pain in patients with cancer who are already receiving and are tolerant to around-the-clock opioid therapy for underlying persistent cancer pain. For each individual patient, FBT should be titrated to the effective dose. Objective The primary objective was to characterize the pharmacokinetic parameters of FBT 400 µg administered as a single 400 µg tablet (regimen A) or as two 200 µg tablets given simultaneously (regimen B) and determine whether these are bioequivalent in healthy Japanese volunteers. Regimen C (two 200 µg tablets 30 minutes apart) was also compared as a secondary objective. Methods Healthy Japanese adults received regimens A, B, and C in a crossover fashion. Naltrexone was given to minimize the opioid effects of fentanyl. Serum fentanyl concentrations were determined in venous blood collected through 36 hours post dose. Regimens were declared bioequivalent with respect to bioavailability (as reflected by AUC0–∞, AUC0–last, and Cmax) if the 90% confidence interval (CI) of the regimens' ratio fell within 0.80–1.25 (80%–125%). Results Twenty-nine volunteers (13 men, 16 women) were enrolled; 24 completed the study. Regimens A and B had bioequivalent systemic exposure parameters (B/A [90% CI]: AUC0–∞108.4 [103.4, 113.7], AUC0–last 106.1 [100.7, 111.7], and Cmax 92.3 [83.2, 102.4]). Regimen C was bioequivalent to both A and B for AUCs, but only to B for Cmax. Median time to Cmax was 45 minutes for regimen A and 60 minutes for regimens B and C. The most frequent AEs were dizziness, application-site erythema, headache, somnolence, nausea, and vomiting. All AEs were mild or moderate. Conclusions Bioavailability of fentanyl after FBT 400 µg administered as a single tablet was bioequivalent to that after 2 simultaneously administered 200 µg tablets in healthy Japanese volunteers. AEs were mild or moderate.
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Darwish M, Tempero K, Jiang JG, Thompson J, Simonson PG. Dose Proportionality of Fentanyl Buccal Tablet in Healthy Japanese Volunteers. ARCHIVES OF DRUG INFORMATION 2008; 1:43-49. [PMID: 19915713 PMCID: PMC2773537 DOI: 10.1111/j.1753-5174.2008.00007.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE: This study was conducted to assess the dose proportionality, safety, and tolerability of fentanyl buccal tablet (FBT) in Japanese volunteers. METHODS: Healthy, opioid-naive Japanese adults received single-dose FBT 100, 200, 400, and 800 microg in a randomized, open-label, crossover fashion. Naltrexone was given to minimize the opioid effects of fentanyl. Peak serum fentanyl concentration (C(max)), time to C(max) (t(max)), area under the serum fentanyl concentration-time curve (AUC) from time 0 to infinity (AUC(0-infinity)), and AUC from 0 to the last quantifiable concentration (AUC(0-last)) were summarized using descriptive statistics. Dose proportionality was claimed if the ln-ln plots of C(max), AUC(0-infinity), and AUC(0-last) vs. dose were linear and the 90% confidence intervals (CI) of the slopes were within 0.8927 and 1.1073. The safety population comprised volunteers who received >/=1 FBT. RESULTS: Twenty-five volunteers were enrolled, 23 were included in the safety population (mean age 35.3 years), and 19 completed the study. The assessment of dose proportionality did not meet the statistical criteria (slope [90% CI]: 0.9118 [0.8601, 0.9635] for C(max), 1.0756 [1.0377, 1.1136] for AUC(0-infinity), and 1.0992 [1.0677, 1.1307] for AUC(0-last)). However, the increase in systemic exposure with dose appeared linear, and a post hoc analysis of partial AUCs from time 0 to 8, 12, 18, and 24 hours supported dose proportionality. Median t(max) of 90 minutes (range 30-180 minutes) was independent of dose. Adverse events (AEs) were mild or moderate. The most frequent AEs were nausea (N = 9), dizziness (N = 8), headache (N = 6), somnolence (N = 6), dyspepsia (N = 5), and vomiting (N = 3). No application-site or serious AEs were reported. CONCLUSIONS: Systemic exposure to FBT was approximately dose proportional across the range 100 microg to 800 microg in healthy Japanese adults. Adverse events were mild or moderate.
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Darwish M, Tempero K, Jiang JG, Simonson PG. Extent of Fentanyl Accumulation Following Multiple Doses of Fentanyl Buccal Tablet 400 microg in Healthy Japanese Volunteers. ARCHIVES OF DRUG INFORMATION 2008; 1:50-55. [PMID: 19915714 PMCID: PMC2773539 DOI: 10.1111/j.1753-5174.2008.00008.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective This study was conducted to characterize the pharmacokinetics, including extent of accumulation, and safety and tolerability of fentanyl following multiple doses of fentanyl buccal tablet (FBT) in healthy Japanese volunteers. Methods Healthy Japanese adults received 10 successive doses of open-label FBT 400 µg at 6-hour intervals. Naltrexone was given to minimize the opioid effects of fentanyl. FBT was placed above a molar tooth between the gum and cheek. Peak serum fentanyl concentration (Cmax), time to Cmax (tmax), and area under the serum fentanyl concentration-time curve from 0 to 6 hours (AUC0–6) were summarized using descriptive statistics. Accumulation ratio was calculated as Cmax for dose 10/Cmax for dose 1, and was calculated similarly for AUC0–6. Results Fourteen volunteers (mean age 33 years) were enrolled, and 13 completed the study. After doses 1 and 10, respectively, mean (SD) Cmax was 1.70 (0.49) ng/mL and 1.97 (0.42) ng/mL, AUC0–6 was 4.46 (1.14) ng·h/mL and 6.81 (0.90) ng·h/mL, and median (range) tmax was 50 (30–110) minutes and 30 (15–120) minutes. Following 10 successive doses, systemic exposure (AUC0–6) was 55% higher than after dose 1, and Cmax was 23% higher. Steady state was achieved within 3 days of dosing at 6-hour intervals, i.e., prior to dose 10. The most frequent adverse events (AEs) were somnolence (N = 9), decreased oxygen saturation (N = 4), headache (N = 3), application-site pain (N = 8), application-site erythema (N = 6), and application-site reaction (N = 5). All AEs were mild or moderate. Conclusions Following administration of FBT at 6-hour intervals to healthy Japanese volunteers, at steady state, fentanyl exposure was higher by 55% (AUC0–6) and 23% (Cmax) than after a single dose of FBT. Adverse events were mild or moderate.
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Taylor DR. Fentanyl buccal tablet: rapid relief from breakthrough pain. Expert Opin Pharmacother 2007; 8:3043-51. [DOI: 10.1517/14656566.8.17.3043] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Darwish M, Kirby M, Jiang JG. Effect of buccal dwell time on the pharmacokinetic profile of fentanyl buccal tablet. Expert Opin Pharmacother 2007; 8:2011-6. [PMID: 17714055 DOI: 10.1517/14656566.8.13.2011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The time fentanyl buccal tablet (FBT) takes to completely dissolve after placement on the buccal mucosa (i.e., 'dwell time') could exceed the time to onset of analgesia. OBJECTIVE To examine the relationship between FBT dwell time and fentanyl pharmacokinetic parameters. RESEARCH DESIGN AND METHODS This was a post hoc exploratory analysis of data from two randomized, open-label, crossover, pharmaco-kinetic studies that were designed to assess dose proportionality within the anticipated therapeutic dose range. Healthy adults received single FBT doses of 200-1080 microg in Study 1 (n = 28) and 270-1300 microg in Study 2 (n = 42). MAIN OUTCOME MEASURES Assessments included buccal dwell time, defined as the duration of FBT presence in the oral cavity, and the following pharmacokinetic measures: maximum serum concentration (C(max)), time to C(max) (T(max)) and area under the concentration-time curve (AUC; exposure) from 0 minutes to median T(max) adjusted for the dose (T(max')) (AUC(0 T(max'))). Spontaneously reported adverse events were recorded. RESULTS Mean buccal dwell time for FBT across the dose range varied from 14 to 25 minutes (range 3 - 62 minutes). There was no evidence of an association between FBT dwell time and values for T(max) (medians 45 - 60 minutes), dose-normalized C(max) (means 0.42-0.66 pg/ml/200 microg) or dose-normalized AUC(0 T(max')) (means 0.24-0.38 pg x h/ml/200 microg) over the range of FBT doses delivered. All adverse events reported were mild to moderate; none were unexpected or serious. CONCLUSION The pharmacokinetic parameters of FBT did not appear to be related to its buccal dwell time.
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Affiliation(s)
- M Darwish
- Clinical Pharmacology, Cephalon, Inc., Frazer, PA 19355, USA.
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Abstract
Breakthrough pain (BTP) is an unmet clinical need that is still poorly diagnosed, evaluated and inadequately treated. The prevalence of BTP has been estimated to affect at least 64% of cancer patients. Two pain-relief strategies were proposed: preventive and active ('rescue'). Oral short-acting opioid seems to be the most popular approach for BTP treatment, however, it is likely to be inadequate for a substantial proportion of patients as a result of the slow-onset of most available opioid preparations. Fentanyl buccal tablet (FBT) is a novel delivery system for fentanyl citrate. FBT utilizes OraVescent technology to improve bioavailability and speed of drug delivery. Recent studies have demonstrated superior pharmacokinetic profiles when compared with other available transmucosal opioids (OTFC), however, pharmacodynamic data are still somewhat limited.
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Affiliation(s)
- Remigiusz Lecybyl
- King's College London, Pain Clinical Research Hub, King's College Hospital, Denmark Hill Campus, London, SE5 9RS, UK.
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