1
|
Kwon MY, Lee MY, Han YJ, Lee SH, Kim EJ, Park S, Lee Y, Koo DH. Predicting tolerability of high-dose fentanyl buccal tablets in cancer patients. PLoS One 2023; 18:e0280212. [PMID: 36608031 PMCID: PMC9821425 DOI: 10.1371/journal.pone.0280212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND & AIMS Fentanyl buccal tablets (FBTs) are a rapid-onset opioid indicated for breakthrough cancer pain (BTcP) and FBT titration is needed to optimize BTcP management. We aimed to predict which patients could tolerate a high dose of FBT (400 μg or more at a time). METHODS A retrospective analysis was performed to assess the final FBT dose. The final FBT doses were compared according to the clinical features. The prediction accuracy of patients tolerant of 400 μg or higher FBT was compared using the area under the receiver operating characteristic (ROC) curves. A risk scoring model based on the odds ratio (OR) was developed from the final multivariable model, and patients were assigned into two groups: low tolerance (0-1 point) and high tolerance (2-3 points). RESULTS Among 131 patients, the most frequently effective dose of FBT was 200 μg (54%), followed by 100 μg (30%). The median value of morphine equivalent daily doses (MEDD) was 60 mg/day, and the most common daily use was 3-4 times/day. In multivariable analysis, male sex, younger age, and use of FBTs three or more times per day were independently associated with high-dose FBT. According to the risk scoring model, the patients with a final FBT of 400 μg or higher were significantly more in the high tolerance group (17%) compared to the low tolerance group (3%; p = 0.023). CONCLUSIONS According to the dose relationship between the final FBT dose and the clinical features, three factors (sex, age, daily use of FBT) were independently associated with the final dose of FBT. Our risk score model could help predict tolerance to high-dose FBT and guide the titration plan for BTcP.
Collapse
Affiliation(s)
- Mi-Young Kwon
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Mi-Yeon Lee
- Division of Biostatistics, Department of R&D Management, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Jae Han
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Sung Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eo Jin Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Songyi Park
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun‑Gyoo Lee
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Hoe Koo
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
| |
Collapse
|
2
|
Wirz S, Schenk M, Hofbauer H, Wartenberg HC, Cascella M, Kieselbach K. [Use of rapid-onset fentanyl preparations beyond indication : A random questionnaire survey among congress participants and pain physicians]. Schmerz 2020; 35:114-123. [PMID: 32975670 DOI: 10.1007/s00482-020-00503-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/18/2020] [Accepted: 08/19/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite publicised advice and warnings, there are only scant data on the non-indicated prescription of rapid-onset preparations of fentanyl (ROF) in non-cancer pain (NCP). Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation. OBJECTIVE Initiated by the Working Group Cancer Pain and supported by the German Pain Society, a random sample survey was conducted to assess the non-indicated use of ROF. METHODS The survey addressed attendees of pain conferences who were given the option to fill in the questionnaires outside the conference or online. Primary endpoints of the structured questionnaire were quantitative and qualitative items with regard to the prescription of ROF, while secondary endpoints were opioid-induced side effects. RESULTS Obtaining a response rate of 44% (132/300) and an additional 51 online questionnaires revealed that 165 (90%) respondents had knowledge of non-indicated prescriptions or were involved in these. Of these, 65% were clinicians and 17% worked in an outpatient capacity. In all, 22% were trained pain or palliative physicians. Approximately 1205 patients were assessed indirectly. The main causes for dispensing ROF included NCP entities such as back pain (44%), neuropathic pain (33%), head or facial pain (12%), and dyspnea (5%) in cancer pain or lack of break-through pain or basic medication (44%). Sedation (32%), nausea/vomiting (31%), constipation (16%) and insufficient analgesia (31%) were the mostly commonly reported adverse effects. CONCLUSION Despite the non-ambiguous indication for ROF, physicians often demonstrate inappropriate prescription behaviour. Iatrogenic misuse of ROF should be minimized. The rates of adverse effects of ROF seems to be in line with other opioids.
Collapse
Affiliation(s)
- Stefan Wirz
- Abteilung für Anästhesie, Intensivmedizin, Schmerzmedizin/Palliativmedizin - Zentrum für Schmerzmedizin, Weaningzentrum, CURA Krankenhaus, Betriebsstätte der GFO-Kliniken Bonn, Schülgenstr. 15, 53604, Bad Honnef, Deutschland.
| | - Michael Schenk
- Zentrum für Integrative Medizin, Franziskus-Krankenhaus Berlin, Budapester Str. 15-19, 10787, Berlin, Deutschland
| | - Hannes Hofbauer
- Sektion Schmerztherapie, Klinik für Anästhesiologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
| | - Hans-Christian Wartenberg
- Afdeling Anesthesiologie H1-115, Academisch Medisch Centrum, Universiteit van Amsterdam, Meibergdreef 9, NL-1105 AZ, Amsterdam, Niederlande
| | - Marco Cascella
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS. Fondazione G. Pascale, Via Mariano Semmola 52, 80131, Napoli, Italien
| | - Kristin Kieselbach
- Interdisziplinäres Schmerzzentrum ISZ, Universitätsklinikum Freiburg, Breisacherstr. 117, 79106, Freiburg, Deutschland
| |
Collapse
|
3
|
González-Bermejo D, Rayón-Iglesias P, Rodríguez-Pascual A, Álvarez-Gutiérrez A, Fernández-Dueñas A, Montero-Corominas D, Huerta-Álvarez C. Drug utilization study on immediate release Fentanyl in Spain. Prevalence, incidence, and indication. Pharmacoepidemiol Drug Saf 2020; 30:371-378. [PMID: 32929809 DOI: 10.1002/pds.5118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 08/15/2020] [Accepted: 08/25/2020] [Indexed: 11/06/2022]
Abstract
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.
Collapse
Affiliation(s)
- Diana González-Bermejo
- Pharmacoepidemiology and Pharmacovigilance Division. Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Pilar Rayón-Iglesias
- Pharmacoepidemiology and Pharmacovigilance Division. Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Alfonso Rodríguez-Pascual
- Pharmacoepidemiology and Pharmacovigilance Division. Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Arturo Álvarez-Gutiérrez
- Pharmacoepidemiology and Pharmacovigilance Division. Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Ana Fernández-Dueñas
- Pharmacoepidemiology and Pharmacovigilance Division. Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Dolores Montero-Corominas
- Pharmacoepidemiology and Pharmacovigilance Division. Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Consuelo Huerta-Álvarez
- Pharmacoepidemiology and Pharmacovigilance Division. Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| |
Collapse
|
4
|
Effects of age and gender in patients receiving doses of opioids for breakthrough pain proportional to background opioid doses. Support Care Cancer 2019; 28:3813-3818. [PMID: 31832823 DOI: 10.1007/s00520-019-05227-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
AIM To identify the role of age and gender in analgesic and adverse effects after administering fentanyl products for breakthrough pain (BT), given in doses proportional to opioid doses given for background pain. METHODS Data from nine studies, in which patients with BP were given fentanyl products in doses proportional to their basal opioid regimen, were analyzed. RESULTS A total 462 patients presenting 1905 episodes of BP were included in this analysis. In older patients, the decrease in pain intensity was more pronounced 15 min after administration of a BP medication. No gender differences were found. No significant differences in frequency and intensity of adverse effects for age and gender were found. CONCLUSION Fentanyl products given for BP in doses proportional to background opioid regimen were more effective in older patients without adding risks of adverse effects. Gender did not influence analgesia and adverse effects of fentanyl products.
Collapse
|
5
|
Kaplan S, Bergamasco A, Sergerie M, Castilloux AM, Moride Y. Effectiveness of Risk Minimization Measures for Fentanyl Buccal Tablet (FENTORA) in Canada: A Mixed-Methods Evaluation Using Surveys, Medical Chart Records and Web Surveillance. Drug Saf 2019; 43:163-177. [PMID: 31691255 DOI: 10.1007/s40264-019-00882-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fentanyl buccal tablet (FBT), a potent opioid, was approved in Canada in 2013 for breakthrough pain in opioid-tolerant adult cancer patients. Additional risk minimization measures (aRMMs), consisting of communications to patients and healthcare providers (HCPs), were implemented from November 2014 through September 2015. OBJECTIVES The aim of this study was to assess the effectiveness of FBT aRMMs as measured by prescriber knowledge, understanding, and behavior regarding key safety concerns (off-label use, use in non-opioid-tolerant patients, misuse/abuse/diversion, and drug-drug interaction) and to evaluate illicit FBT use. METHODS The study included three components: (1) a knowledge and understanding (KAU) survey of FBT prescribers conducted in two waves: November 2016-February 2017 and April-September 2018; (2) a retrospective prescription study of medical records of patients treated with FBT by a subgroup of prescribers from the KAU survey; and (3) Web surveillance of illicit FBT use in Canada using the search term FENTORA (May 2014-September 2018). The aRMMs were considered effective if the lower bound of the 95% confidence interval indicated that at least 65% of respondents met or partly met the knowledge objective for each key safety concern. RESULTS KAU survey: Of 46 eligible HCPs, 97.8% met or partly met the knowledge objective on use in breakthrough pain cancer patients, 97.8% on use in opioid-tolerant patients, 89.1% on dose and titration, 100% on abuse/addiction, and 58.7% on drug-drug interaction. Retrospective prescription study: Of 22 FBT-treated patients identified from 14 HCPs, 45.5% had cancer, 50.0% recorded a breakthrough pain indication, and 36.4% reported opioid tolerance; however, only 13.6% of patients were prescribed FBT according to the approved indication. Web surveillance: Of 932 FBT posts in Canada, only 40 (4.3%) mentioned illicit use. CONCLUSIONS The aRMMs as measured by the prescriber KAU were effective for most key safety messages; however, not all key messages of the aRMMs were stringently followed in routine practice.
Collapse
Affiliation(s)
- Sigal Kaplan
- Teva Pharmaceutical Industries Ltd, Netanya, Israel.
| | | | | | | | - Yola Moride
- YOLARX Consultants, Montreal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| |
Collapse
|
6
|
Kwon MY, Cho HN, Koo DH, Lee YG, Oh S, Lee SS. Initial titration with 200 μg fentanyl buccal tablets: a retrospective safety analysis in Korean cancer patients. Korean J Intern Med 2018; 33:577-584. [PMID: 28111431 PMCID: PMC5943645 DOI: 10.3904/kjim.2016.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND/AIMS Managing breakthrough pain (BTP) is important for many cancer patients because of the rapid onset and unpredictable nature of the pain episodes. Fentanyl buccal tablets (FBTs) are a rapid-onset opioid indicated for BTP management. However, FBT titration is needed to optimize BTP management. In this study, we aimed to evaluate the safety and efficacy of initiating 200 μg FBTs in Korean cancer patients. METHODS A retrospective analysis of medical records was performed on all advanced cancer patients treated with FBTs for BTP between October 2014 and July 2015. Patients who received initial doses of 200 μg FBTs for at least 3 days and cases in which FBT was available at doses of 200, 400, and 800 μg were included. RESULTS A total of 56 patients with a median age of 62 years (range, 32 to 80) were analyzed, 61% of whom were male. The median and mean values of morphine equivalent daily doses were 60 mg/day (range, 15 to 540) and 114.8 ± 124.8 mg/day, respectively. The most frequent effective doses of FBT were 200 μg (41 patients, 74%) and 400 μg (12 patients, 21%). Three patients (5%) could not tolerate 200 μg of FBT and discontinued treatment. Nausea, vomiting, somnolence, and dizziness were the most frequent treatment-related adverse events (AEs), and all AEs were grade 1 (mild) or 2 (moderate). CONCLUSIONS FBT at the initial 200 μg dosage was well-tolerated and effective as a BTP management strategy in Korean cancer patients. Further prospective studies are needed to determine appropriate initiating doses of FBT in Korean patients with opioid tolerance.
Collapse
Affiliation(s)
- Mi-Young Kwon
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Ha-Na Cho
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Dong-Hoe Koo
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- Correspondence to Dong-Hoe Koo, M.D. Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 03181, Korea Tel: +82-2-2001-8330 Fax: +82-2-2001-8360 E-mail:
| | - Yun-Gyoo Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sukjoong Oh
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Sei Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
7
|
Oh TK, Eom W, Yim J, Kim N, Kwon K, Kim SE, Kim DH. The Effect of Chronic Opioid Use on End-Tidal Concentration of Sevoflurane Necessary to Maintain a Bispectral Index Below 50: A Prospective, Single-Blind Study. Anesth Analg 2017; 125:156-161. [PMID: 28614132 DOI: 10.1213/ane.0000000000001791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Opioid analgesics decrease the minimum alveolar concentration of inhalation agents during the acute phase response. However, the effect of chronic opioid exposure on minimum alveolar concentration of inhalation agents remains unknown. This study aimed to determine the concentration of sevoflurane necessary to maintain a bispectral index (BIS) <50 (SEVOBIS50) in patients with chronic opioid use compared with those naïve to opioid use. METHODS We included chronic opioid users who received a stable dose of oral morphine of at least 60 mg/d according to the morphine equivalent daily dose for at least 4 weeks and opioid-naïve patients. General anesthesia that included thiopental, vecuronium, and sevoflurane in oxygen was administered to all patients. Anesthesia was maintained using predetermined end-tidal sevoflurane concentrations. Fifteen minutes after achieving the determined end-tidal sevoflurane concentration through closed circuit anesthesia, BIS was measured for 1 minute in both groups. SEVOBIS50 was determined using Dixon's up-down method and probit analysis. RESULTS Nineteen and 18 patients from the chronic opioid and control groups, respectively, were included in the final analysis. SEVOBIS50values for the chronic opioid and control patients were 0.84 (95% confidence interval, 0.58-1.11) and 1.18 (95% confidence interval, 0.96-1.40), respectively (P = .0346). CONCLUSIONS Our results suggest that the end-tidal concentration of sevoflurane necessary to maintain a BIS <50 is lower for chronic opioid users than for opioid-naïve patients.
Collapse
Affiliation(s)
- Tak Kyu Oh
- From the *Department of Anesthesiology and Pain Medicine, National Cancer Center, Gyeonggi-do, Republic of Korea; †Department of Anesthesiology and Pain Medicine, Moonsan Central General Hospital, Gyeonggi-do, Republic of Korea; and ‡Department of Biostatistics, Korea University College of Medicine, Seongbuk-gu, Republic of Korea
| | | | | | | | | | | | | |
Collapse
|
8
|
Hansen J. Opiates for Chronic Pain. Pain Pract 2017; 17:147-148. [DOI: 10.1111/papr.12500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- John Hansen
- Sanford Clinic Pain Center; Sanford School of Medicine; University of South Dakota; Sioux Falls South Dakota U.S.A
| |
Collapse
|
9
|
Katz NP, Gajria KL, Shillington AC, Stephenson JJ, Harshaw Q. Impact of breakthrough pain on community-dwelling cancer patients: results from the National Breakthrough Pain Study. Postgrad Med 2016; 129:32-39. [DOI: 10.1080/00325481.2017.1261606] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Nathaniel P. Katz
- Tufts University School of Medicine, Boston, MA, USA
- Analgesic Solutions, Natick, MA, USA
| | | | | | | | | |
Collapse
|
10
|
|
11
|
Mercadante S, Adile C, Cuomo A, Aielli F, Cortegiani A, Casuccio A, Porzio G. Fentanyl Buccal Tablet vs. Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Randomized, Crossover, Comparison Study. J Pain Symptom Manage 2015; 50:579-86. [PMID: 26303188 DOI: 10.1016/j.jpainsymman.2015.05.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/28/2015] [Accepted: 05/31/2015] [Indexed: 11/16/2022]
Abstract
CONTEXT Fentanyl products have shown superiority to oral opioids for the management of breakthrough cancer pain (BTcP). However, these studies did not use appropriate patient selection, and drugs have been compared by using different rationales. OBJECTIVES The aim of this randomized, crossover, controlled study was to compare efficacy and safety of fentanyl buccal tablets (FBTs) and oral morphine (OM), given in doses proportional to opioid daily doses. METHODS Cancer patients with pain receiving ≥60 mg or more of oral morphine equivalents per day and presenting with ≤3 episodes of BTcP per day were included. In a randomized, crossover manner, patients received FBT or OM at doses proportional to the daily opioid regimen in four consecutive episodes of BTcP. Pain intensity was measured before (T0) and 15 (T15) and 30 minutes (T30), after study drugs. RESULTS In total, 263 episodes of BTcP were treated. A statistical difference in changes in pain intensity-decrease of ≥33% and ≥50%-between the two groups was observed at T15 and T30 (P < 0.0005). No severe adverse effects after study drug administration were observed. CONCLUSION When used in doses proportional to the basal opioid regimen, FBT showed a clear superiority and was well tolerated when compared with OM during the first 30 minutes, which is the approximate target for a timely intervention required for a BTcP medication.
Collapse
Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Arturo Cuomo
- Anesthesia and Pain Therapy, National Cancer Institute Pascale, Naples, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Andrea Cortegiani
- Section of Anesthesia, Analgesia, Intensive Care and Emergency, Department of Biopathology, Medical and Forensic Biotechnologies, Policlinico P. Giaccone, University of Palermo, Palermo, Italy
| | - Alessandra Casuccio
- Department of Experimental Biomedicine and Clinical Neuroscience, University of Palermo, Palermo, Italy
| | - Giampiero Porzio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| |
Collapse
|
12
|
Rauck R, Bull J, Parikh N, Dillaha L, Stearns L. Effective Dose Titration of Fentanyl Sublingual Spray in Patients With Breakthrough Cancer Pain. Pain Pract 2015; 16:1012-1018. [PMID: 26509361 DOI: 10.1111/papr.12360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/20/2015] [Indexed: 11/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- Richard Rauck
- Carolinas Pain Institute and The Center for Clinical Research, Winston Salem, North Carolina, U.S.A
| | - Janet Bull
- Four Seasons Hospice and Palliative Care, Flat Rock, North Carolina, U.S.A
| | - Neha Parikh
- Insys Therapeutics, Inc., Chandler, Arizona, U.S.A
| | | | - Lisa Stearns
- The Center for Pain and Supportive Care, Scottsdale, Arizona, U.S.A
| |
Collapse
|
13
|
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.
Collapse
|
14
|
Zeppetella G, Davies AN. WITHDRAWN: Opioids for the management of breakthrough pain in cancer patients. Cochrane Database Syst Rev 2015; 2015:CD004311. [PMID: 26275024 PMCID: PMC10671027 DOI: 10.1002/14651858.cd004311.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
At August 2015, this review has been withdrawn. It is correct at the date of publication, and previous versions can be accessed in the ‘Other versions’ tab on the Cochrane Library. The Cochrane Editorial Unit (CEU) agreed with the authors of the feedback that the review was misleading, and because the original author team was unavailable to update the review, the CEU advised that it should be withdrawn. See below for full details. PaPaS is seeking a new author team to develop a new review which will serve to update the original. Feedback 1, received 15 February 2015 Dr Vicente Ruiz Garcia
vicenteruizgarcia@gmail.com With colleagues Xavier Bonfill Cosp, Eduardo Lopez Briz, Rafa Carbonell, Jose Luis Gonzalvez Perales, Sylvia Bort Martí, and Marta Roque Figuls. Comment: Dear editor: We have read the update of Zeppetella and Davies about management of breakthrough pain in cancer patients (1). We think that this review is very important to help clinicians and patients to decide whether the new treatments for the breakthrough pain in cancer could be a useful alternative to morphine. In this update, some comments that we made to the previous review (the letter was not published) (2) were considered by the authors; in particular, not pooling the results obtained for oral transmucosal fentanyl citrate (OTFC) versus placebo, with those of OTFC versus morphine, and those of two trials that were titration of doses of fentanyl. However, we do not agree with the authors’ results when they state: “When compared with placebo or oral morphine, participants gave lower pain intensity and higher pain relief scores for transmucosal fentanyl formulations at all time points”. First, the outcomes at 15 min (the most important to obtain a quick relief of pain), Pain intensity Difference (Comparison 2. Transmucosal opioid versus oral morphine) and Comparison 4. OTFC versus intravenous morphine), failed to show statistically significant differences with oral morphine (mean difference 0.37 CI 95% 0.00‐0.73) and with morphine iv (mean difference 0.80 CI 95% 0.00‐1,60). In any case the results had no clinical relevance. Moreover the authors state “at all time points”, whereas they do not provide any data for longer times (i.e. 30, 45, 60 min). In addition, authors state “transmucosal fentanyl citrate are safe (..) (compared with both placebo and morphine) in relieving breakthrough pain”. Surprisingly no analysis of adverse events have been done that were only described in each study. Seven out 15 were crossover trials and it was impossible to draw conclusions about it. As reviewers we know that multiple comparisons could be made, but the most clinical interesting comparison is the gold standard, morphine. The review only shows in SOF, comparisons of fentanyl with placebo and concludes, that it is effective. Surprisingly, there is no mention of morphine comparison, which we consider a key point, because no patient will take placebo if he has a breakthrough pain, but morphine for obvious reasons. In our opinion, traversing the authors’ conclusions, this review did not show that the use of oral and nasal transmucosal fentanyl is an effective alternative to morphine for patients with breakthrough cancer pain. Reply The authors of the review were contacted but chose not to provide a response to the feedback. Contributors Kate Seers, PaPaS Feedback Editor, and Anna Hobson, PaPaS Managing Editor. Additional feedback 2, received May 2015 On 15 February 2015, Dr Vicente Ruiz Garcia (University Hospital La Fe, Spain), and his colleagues Xavier Bonfill Cosp, Eduardo Lopez Briz, Rafa Carbonell, Jose Luis Gonzalvez Perales, Sylvia Bort Martí, and Marta Roque Figuls submitted feedback via the Cochrane Library. The main complaint is available above. On 23 February, 16 March and 15 April, Kate Seers (Feedback Editor, PaPaS) contacted the authors and invited them to respond. On 21 March, John Zeppetella (lead author) declined to provide a formal response. No response was received from Andrew Davies (second author). On 31 March, PaPaS sought advice from the Cochrane Editorial Unit (CEU) on how to manage the issue; advised to publish without a response, depending on nature of feedback. On 11 May 2015, review re‐published with feedback incorporated. On 20 May 2015, Marta Roqué Figuls (Statistician, Iberoamerican Cochrane Centre) wrote to the CEU repeating the initial claim. They did not agree with the approach decided upon by the Co‐Ed, which was supported by the EiC. They stated “The CCIb assessment is that the review presents methodological shortcomings, and the conclusions are skewed in favor of fentanyl. Consequently, we support Vicente and colleagues’ petition to re‐assess the publication status of the review.” Reply On 9 June, Christopher Eccleston (Co‐ordinating Editor, PaPaS) advised that the review remain unchanged until it was ready for updating in September 2015. On 25 June 2015 David Tovey (Editor in Chief, Cochrane) responded to say “We have now had a chance to appraise this review and also obtain a report from our screening team… In summary we agree with almost all of the criticisms made of the review, and are concerned that the flaws may mean that the findings are misleading as currently presented. We note that the authors have declined to respond to the useful comments provided by Vicente. Having considered this and discussed it internally, we agree with our colleagues at the IbCC that the review should be withdrawn temporarily until the errors have been fixed and the review updated. We would like to re‐screen the review before any update or amendment is published.” On 2 July and 23 July, Anna Hobson (Managing Editor, PaPaS) again invited the authors to respond to the initial feedback and subsequent reviews by 23 July. No response was forthcoming. At August 2015, the review was withdrawn. Contributors Kate Seers (Feedback Editor, PaPaS), Cochrane Editorial Unit (CEU), Christopher Eccleston (Co‐ordinating Editor, PaPaS), David Tovey (Editor in Chief, Cochrane), Anna Hobson (Managing Editor, PaPaS). The editorial group responsible for this previously published document have withdrawn it from publication.
Collapse
Affiliation(s)
| | - Andrew N Davies
- Royal Surrey County HospitalDepartment of Palliative MedicineGuildfordUK
| | | |
Collapse
|
15
|
Park JH, Lee C, Shin Y, An JH, Ban JS, Lee JH. Comparison of oxycodone and fentanyl for postoperative patient-controlled analgesia after laparoscopic gynecological surgery. Korean J Anesthesiol 2015; 68:153-8. [PMID: 25844134 PMCID: PMC4384403 DOI: 10.4097/kjae.2015.68.2.153] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 10/17/2014] [Accepted: 10/21/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Opioids are widely used in boluses and patient-controlled analgesia (PCA) for postoperative pain control. In this study, we compared the effects of oxycodone and fentanyl on postoperative pain in patients with intravenous patient-controlled analgesia (IV-PCA) after laparoscopic gynecological surgery. METHODS Seventy-four patients undergoing elective total laparoscopic hysterectomy or laparoscopic myomectomy were randomly assigned to the administration of either fentanyl or oxycodone using IV-PCA (potency ratio 1 : 60). The cumulative dose administered in the patient-controlled mode during the initial 48 hours after the operation was measured. Patients were also assessed for postoperative pain severity, adverse effects, and patient satisfaction. RESULTS No significant differences were observed in patient satisfaction with the analgesia during the postoperative period. Patients in the oxycodone group experienced significantly more dizziness compared to the fentanyl group. Patients in the oxycodone group showed significantly lower consumption of opioid in the patient-controlled mode (10.1 ± 8.5 ml vs. 16.6 ± 12.0 ml, P = 0.013). CONCLUSIONS Our data suggest that oxycodone and fentanyl demonstrated similar effects, and therefore oxycodone may be a good alternative to fentanyl in postoperative pain management. Further studies in various clinical settings will be needed to determine the adequate potency ratio.
Collapse
Affiliation(s)
- Joong-Ho Park
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Chiu Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Youngmin Shin
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Ji-Hyun An
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jong-Seouk Ban
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Ji-Hyang Lee
- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, Korea
| |
Collapse
|
16
|
Takigawa C, Goto F, Tanda S, Shima Y, Yomiya K, Matoba M, Adachi I, Yoshimoto T, Eguchi K. Breakthrough pain management using fentanyl buccal tablet (FBT) in combination with around-the-clock (ATC) opioids based on the efficacy and safety of FBT, and its relationship with ATC opioids: results from an open-label, multi-center study in Japanese cancer patients with detailed evaluation. Jpn J Clin Oncol 2014; 45:67-74. [PMID: 25381384 PMCID: PMC4277255 DOI: 10.1093/jjco/hyu167] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective Rapid analgesic onset opioids, particularly fentanyl buccal tablet, is preferable for managing breakthrough pain. The efficacy and safety of fentanyl buccal tablet and its association with around-the-clock opioids needs to be explored with an option of dose adjustments, more closely reflecting administration in clinical practice. The aim of the study was to assess the safety and efficacy of fentanyl buccal tablet in breakthrough pain management in combination with around-the-clock opioids with the dose adjustment option, and explore the dose adjustment's influence on breakthrough pain management using detailed evaluation. Methods The 12-week open-label, multi-center study was conducted throughout Japan. Cancer patients aged 20 years or older, experiencing persistent pain controlled with around-the-clock opioids and breakthrough pain with supplemental medications were enrolled. Fentanyl buccal tablet and around-the-clock opioid doses could be adjusted under protocol-specified conditions. Efficacy variables were assessed at each fentanyl buccal tablet administration. Safety was assessed mainly by adverse events. Results All efficacy variables showed sustained analgesic effect. Nearly half the patients stayed on the same dose; most fentanyl buccal tablet administrations did not require additional supplemental medications. Dose increase of fentanyl buccal tablet and around-the-clock opioids seemed to improve breakthrough pain intensity and frequency, respectively. Fentanyl buccal tablet and around-the-clock opioid doses were not strongly associated. Treatment-related adverse events were all common with opioid treatment and did not increase over time. Conclusions Fentanyl buccal tablet can stably and safely manage breakthrough pain in cancer patients with independent dose adjustment based on detailed evaluation of each patient's condition. Breakthrough pain management using fentanyl buccal tablet with around-the-clock opioids at optimal doses may be an important factor in palliative care for cancer patients with breakthrough pain.
Collapse
Affiliation(s)
- Chizuko Takigawa
- Department of Palliative Medicine, KKR Sapporo Medical Center, Sapporo
| | - Fumio Goto
- International University of Health and Welfare Hospital, Nasushiobara
| | - Shigeru Tanda
- Department of Medical Oncology, Tohoku Rosai Hospital, Sendai
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba
| | - Kinomi Yomiya
- Department of Palliative Care, Saitama Cancer Center, Kitaadachi-gun
| | - Motohiro Matoba
- Department of Palliative Medicine, Aomori Prefectural Central Hospital, Aomori
| | - Isamu Adachi
- Division of Palliative Medicine, Shizuoka Cancer Center, Sunto-gun
| | | | - Kenji Eguchi
- Department of Internal Medicine and Medical Oncology, Teikyo University School of Medicine, Itabashi-ku, Japan
| |
Collapse
|
17
|
Gibbs NM, Weightman WM. An Audit of the Statistical Validity of Conclusions of Clinical Superiority in Anaesthesia Journals. Anaesth Intensive Care 2014; 42:599-607. [DOI: 10.1177/0310057x1404200509] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Making a statistically valid conclusion of the superiority of a clinical intervention in a clinical trial requires not only a statistically significant P value, but also adequate a priori power and an observed effect size larger than the clinically important value specified in the sample size calculation. We scrutinised the five most highly cited clinical trials reporting one or more conclusions of clinical superiority published in Anesthesiology, the British Journal of Anaesthesia, Anaesthesia, Anesthesia and Analgesia and Anaesthesia and Intensive Care in 2011 or 2012 to determine how many met all three requisite criteria. In the 25 articles, there were a total of 36 unconditional conclusions of the superiority of a clinical intervention. All were supported by a statistically significant P value. However, only 15 (41.6%) met all three requisite statistical criteria to support clinical superiority. The remainder included secondary outcomes without specific reference to their observational nature, and primary outcomes whose observed effect size was smaller than the clinically important value specified in the sample size calculation. These findings indicate that clinicians should closely scrutinise conclusions of clinical superiority in anaesthesia journals. Many will be ‘hypothesis-generating observations’ without adequate statistical support for a conclusion of clinical superiority in their own right.
Collapse
Affiliation(s)
- N. M. Gibbs
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia
| | - W. M. Weightman
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia
| |
Collapse
|
18
|
Abstract
OBJECTIVE The present review was performed to identify possible differences observed between adults and elderly patients and between males and females in randomized clinical trials of breakthrough pain (BTP). METHODS A systematic search of the existing literature from 1998 to September 2013 was performed. Randomized clinical trials reporting data on older patients were selected. RESULTS Sixteen comparative studies were selected. The age range of inclusion criteria patients was mainly between 18-80 or ≥18 years. In some cases this data was unreported. The mean age of patients was 48-64 years, but information regarding the number of elderly patients was present in three studies only. Gender distribution was more or less 50%:50%. No subgroup analysis of efficacy or adverse effects of BTP medications for age and gender was reported. CONCLUSION There is a need for more information regarding the use of opioids for BTP according to age and gender.
Collapse
|
19
|
Scharnagel R, Kaiser U, Schütze A, Heineck R, Gossrau G, Sabatowski R. [Chronic non-cancer-related pain. Long-term treatment with rapid-release and short-acting opioids in the context of misuse and dependency]. Schmerz 2014; 27:7-19. [PMID: 23340881 DOI: 10.1007/s00482-012-1278-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Annually published data show a continual increase in the volume of opioid prescriptions in Germany, thus indicating an intensification of opioid therapy. The majority of opioids are prescribed to treat chronic non-cancer-related pain. On the basis of current guidelines, as well as in terms of the lack of data regarding long-term use of opioids and their effectiveness beyond a period of 3 months, this development must be viewed critically. With reference to four case reports, we discuss and evaluate opioid therapy in relation to medication misuse and the development of drug dependency. Particular emphasis is placed on the administration of rapid-release and short-acting opioid preparations, which we consider to be particularly problematic.
Collapse
Affiliation(s)
- R Scharnagel
- UniversitätsSchmerzCentrum, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | | | | | | | | | | |
Collapse
|
20
|
Abstract
BACKGROUND This review is an update of a previously published review in the Cochrane Database of Systematic Reviews (Issue 1, 2006). Breakthrough pain is a transient exacerbation of pain that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger despite relative stable and adequately controlled background pain. Breakthrough pain usually related to background pain and is typically of rapid onset, severe in intensity and generally self limiting with a mean duration of 30 minutes. Breakthrough pain has traditionally been managed by the administration of supplemental oral analgesia (rescue medication) at a dose proportional to the total around-the-clock (ATC) opioid dose. OBJECTIVES To determine the efficacy of opioid analgesics given by any route, used for the management of breakthrough pain in patients with cancer, and to identify and quantify, if data permitted, any adverse effects of this treatment. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registries in January 2005 for the original review, and again on 6 February 2013 for this update. SELECTION CRITERIA We included randomised controlled trials (RCTs) of opioids used as rescue medication against active or placebo comparator in patients with cancer pain. Outcome measures sought were reduction in pain intensity measured by an appropriate scale, adverse effects, attrition, patient satisfaction and quality of life. We applied no language restrictions. DATA COLLECTION AND ANALYSIS Two review authors independently selected and examined eligible studies. We retrieved full text if any uncertainty about eligibility remained. We screened non-English texts. We conducted quality assessment and data extraction using standardised data forms. We compared drug and placebo dose, titration, route and formulation and recorded details of all outcome measures (if available). MAIN RESULTS The original review included four studies (393 participants), all concerned with the use of oral transmucosal fentanyl citrate (OTFC) in the management of breakthrough pain. Two studies examined the titration of OTFC, one study compared OTFC versus normal-release morphine and one study compared OTFC versus placebo.Fifteen studies (1699 participants) met the inclusion criteria for this update. All studies reported on the utility of seven different transmucosal fentanyl formulations, five of which were administered orally and two nasally. Eight studies compared the transmucosal fentanyl formulations versus placebo, four studies compared them with another opioid, one study was a comparison of different doses of the same formulation and two were randomised titration studies. Oral and nasal transmucosal fentanyl formulations were an effective treatment for breakthrough pain. When compared with placebo or oral morphine, participants gave lower pain intensity and higher pain relief scores for transmucosal fentanyl formulations at all time points. Global assessment scores also favoured transmucosal fentanyl preparations. One study compared intravenous with the transmucosal route and both were effective. AUTHORS' CONCLUSIONS Oral and nasal transmucosal fentanyl is an effective treatment in the management of breakthrough pain. The RCT literature for the management of breakthrough pain is relatively small. Given the importance of this subject, more trials, including head-to-head comparisons of the available transmucosal fentanyl formulations are required.
Collapse
|
21
|
Michna E, Cheng WY, Korves C, Birnbaum H, Andrews R, Zhou Z, Joshi AV, Schaaf D, Mardekian J, Sheng M. Systematic literature review and meta-analysis of the efficacy and safety of prescription opioids, including abuse-deterrent formulations, in non-cancer pain management. PAIN MEDICINE 2013; 15:79-92. [PMID: 24112715 DOI: 10.1111/pme.12233] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study was conducted to compare safety and efficacy outcomes between opioids formulated with technologies designed to deter or resist tampering (i.e., abuse-deterrent formulations [ADFs]) and non-ADFs for commonly prescribed opioids for treatment of non-cancer pain in adults. METHODS PubMed and Cochrane Library databases were searched for opioid publications between September 1, 2001 and August 31, 2011, and pivotal clinical trials from all years; abstracts from key pain conferences (2010-2011) were also reviewed. One hundred and ninety-one publications were initially identified, 68 of which met eligibility criteria and were systematically reviewed; a subset of 16 involved a placebo group (13 non-ADFs vs placebo, 3 ADFs vs placebo) and reported both efficacy and safety outcomes, and were included for a meta-analysis. Summary estimates of standardized difference in mean change of pain intensity (DMCPI), standardized difference in sum of pain intensity difference (DSPID), and odds ratios (ORs) of each adverse event (AE) were computed through random-effects estimates for ADFs (and non-ADFs) vs placebo. Indirect treatment comparisons were conducted to compare ADFs and non-ADFs. RESULTS Summary estimates for standardized DMCPI and for standardized DSPID indicated that ADFs and non-ADFs showed significantly greater efficacy than placebo in reducing pain intensity. Indirect analyses assessing the efficacy outcomes between ADFs and non-ADFs indicated that they were not significantly different (standardized DMCPI [0.39 {95% confidence interval (CI) 0.00-0.76}]; standardized DSPID [-0.22 {95% CI -0.74 to 0.30}]). ADFs and non-ADFs both were associated with higher odds of AEs than placebo. Odds ratios from indirect analyses comparing AEs for ADFs vs non-ADFs were not significant (nausea, 0.87 [0.24-3.12]; vomiting, 1.54 [0.40-5.97]; dizziness/vertigo, 0.61 [0.21-1.76]; headache, 1.42 [0.57-3.53]; somnolence/drowsiness, 0.47 [0.09-2.58]; constipation, 0.64 [0.28-1.49]; pruritus 0.41 [0.05-3.51]). CONCLUSION ADFs and non-ADFs had comparable efficacy and safety profiles, while both were more efficacious than placebo in reducing pain intensity.
Collapse
Affiliation(s)
- Edward Michna
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Webster LR, Slevin KA, Narayana A, Earl CQ, Yang R. Fentanyl Buccal Tablet Compared with Immediate-Release Oxycodone for the Management of Breakthrough Pain in Opioid-Tolerant Patients with Chronic Cancer and Noncancer Pain: A Randomized, Double-Blind, Crossover Study Followed by a 12-Week Open-Label Phase to Evaluate Patient Outcomes. PAIN MEDICINE 2013; 14:1332-45. [DOI: 10.1111/pme.12184] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
23
|
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 3, 2006, which included 23 trials. The use of opioids for neuropathic pain remains controversial. Studies have been small, have yielded equivocal results, and have not established the long-term profile of benefits and risks for people with neuropathic pain. OBJECTIVES To reassess the efficacy and safety of opioid agonists for the treatment of neuropathic pain. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (to 24th October 2012), MEDLINE (1966 to 24th October 2012 ), and EMBASE (1980 to 24th October 2012) for articles in any language, and reference lists of reviews and retrieved articles. SELECTION CRITERIA We included randomized controlled trials (RCTs) in which opioid agonists were given to treat central or peripheral neuropathic pain of any etiology. Pain was assessed using validated instruments, and adverse events were reported. We excluded studies in which drugs other than opioid agonists were combined with opioids or opioids were administered epidurally or intrathecally. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and included demographic variables, diagnoses, interventions, efficacy, and adverse effects. MAIN RESULTS Thirty-one trials met our inclusion criteria, studying 10 different opioids: 23 studies from the original 2006 review and eight additional studies from this updated review.Seventeen studies (392 participants with neuropathic pain, average 22 participants per study) provided efficacy data for acute exposure to opioids over less than 24 hours. Sixteen reported pain outcomes, with contradictory results; 8/16 reported less pain with opioids than placebo, 2/16 reported that some but not all participants benefited, 5/16 reported no difference, and 1/16 reported equivocal results. Six studies with about 170 participants indicated that mean pain scores with opioid were about 15/100 points less than placebo.Fourteen studies (845 participants, average 60 participants per study) were of intermediate duration lasting 12 weeks or less; most studies lasted less than six weeks. Most studies used imputation methods for participant withdrawal known to be associated with considerable bias; none used a method known not to be associated with bias. The evidence, therefore, derives from studies predominantly with features likely to overestimate treatment effects, i.e. small size, short duration, and potentially inadequate handling of dropouts. All demonstrated opioid efficacy for spontaneous neuropathic pain. Meta-analysis demonstrated at least 33% pain relief in 57% of participants receiving an opioid versus 34% of those receiving placebo. The overall point estimate of risk difference was 0.25 (95% confidence interval (CI) 0.13 to 0.37, P < 0.0001), translating to a number needed to treat for an additional beneficial outcome (NNTB) of 4.0 (95% CI 2.7 to 7.7). When the number of participants achieving at least 50% pain relief was analyzed, the overall point estimate of risk difference between opioids (47%) and placebo (30%) was 0.17 (95% CI 0.02 to 0.33, P = 0.03), translating to an NNTB of 5.9 (3.0 to 50.0). In the updated review, opioids did not demonstrate improvement in many aspects of emotional or physical functioning, as measured by various validated questionnaires. Constipation was the most common adverse event (34% opioid versus 9% placebo: number needed to treat for an additional harmful outcome (NNTH) 4.0; 95% CI 3.0 to 5.6), followed by drowsiness (29% opioid versus 14% placebo: NNTH 7.1; 95% CI 4.0 to 33.3), nausea (27% opioid versus 9% placebo: NNTH 6.3; 95% CI 4.0 to 12.5), dizziness (22% opioid versus 8% placebo: NNTH 7.1; 95% CI 5.6 to 10.0), and vomiting (12% opioid versus 4% placebo: NNTH 12.5; 95% CI 6.7 to 100.0). More participants withdrew from opioid treatment due to adverse events (13%) than from placebo (4%) (NNTH 12.5; 95% CI 8.3 to 25.0). Conversely, more participants receiving placebo withdrew due to lack of efficacy (12%) versus (2%) receiving opioids (NNTH -11.1; 95% CI -20.0 to -8.3). AUTHORS' CONCLUSIONS Since the last version of this review, new studies were found providing additional information. Data were reanalyzed but the results did not alter any of our previously published conclusions. Short-term studies provide only equivocal evidence regarding the efficacy of opioids in reducing the intensity of neuropathic pain. Intermediate-term studies demonstrated significant efficacy of opioids over placebo, but these results are likely to be subject to significant bias because of small size, short duration, and potentially inadequate handling of dropouts. Analgesic efficacy of opioids in chronic neuropathic pain is subject to considerable uncertainty. Reported adverse events of opioids were common but not life-threatening. Further randomized controlled trials are needed to establish unbiased estimates of long-term efficacy, safety (including addiction potential), and effects on quality of life.
Collapse
Affiliation(s)
- Ewan D McNicol
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonMassachusettsUSA
| | - Ayelet Midbari
- Institute of Pain MedicinePain Research UnitRambam Health Care Campus and the Technion‐Israel Institute of TechnologyHaifaIsrael
| | - Elon Eisenberg
- Rambam Health Care Campus and the Technion‐Israel Institute of TechnologyPain Research UnitHaifaIsrael
| | | |
Collapse
|
24
|
Osborne V, Layton D, Fogg C, Al-Shukri M, Shakir S. Utilization of fentanyl buccal tablets in England: Exploring off-label use reported in a cohort study. Eur J Pain 2013; 18:506-12. [DOI: 10.1002/j.1532-2149.2013.00389.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2013] [Indexed: 11/10/2022]
Affiliation(s)
- V. Osborne
- Drug Safety Research Unit; Southampton UK
- School of Pharmacy and Biomedical Science; University of Portsmouth; UK
| | - D. Layton
- Drug Safety Research Unit; Southampton UK
- School of Pharmacy and Biomedical Science; University of Portsmouth; UK
| | - C. Fogg
- Drug Safety Research Unit; Southampton UK
- School of Pharmacy and Biomedical Science; University of Portsmouth; UK
| | | | - S.A.W. Shakir
- Drug Safety Research Unit; Southampton UK
- School of Pharmacy and Biomedical Science; University of Portsmouth; UK
| |
Collapse
|
25
|
Affiliation(s)
- W Meissner
- Klinik für Anästhesiologie und Intensivtherapie, Sektion Schmerztherapie und Abteilung für Palliativmedizin, Klinikum für Innere Medizin II, Universitätsklinikum Jena, Erlanger Allee 101, 07747 Jena, Deutschland,
| | | |
Collapse
|
26
|
Beutlhauser T, Oeltjenbruns J, Schäfer M. Durchbruchschmerzen und kurz wirksame Opioide. Anaesthesist 2013; 62:431-9. [DOI: 10.1007/s00101-013-2193-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
27
|
Bornemann-Cimenti H, Wejbora M, Szilagyi IS, Sandner-Kiesling A. Fentanyl for the treatment of tumor-related breakthrough pain. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:271-7. [PMID: 23671467 DOI: 10.3238/arztebl.2013.0271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 12/17/2012] [Indexed: 11/27/2022]
Abstract
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.
Collapse
|
28
|
Smith HS. Considerations in selecting rapid-onset opioids for the management of breakthrough pain. J Pain Res 2013; 6:189-200. [PMID: 23503653 PMCID: PMC3594916 DOI: 10.2147/jpr.s40745] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Breakthrough pain (BTP) is a transitory pain that occurs despite the use of long-term, around-the-clock analgesia. It is highly prevalent in certain populations and places a significant burden on patients, their families, caregivers, and health-care systems. Despite its prevalence and impact, BTP is sometimes unrecognized and often undertreated. Various formulations of fentanyl – a rapid-onset opioid with short duration of action – are available for the management of BTP. The efficacy of formulations using transmucosal, transbuccal, sublingual, and intranasal administration routes has been demonstrated for BTP treatment in clinical trials. However, a lack of head-to-head trials evaluating their relative efficacy makes it challenging for physicians to reach informed decisions on the most efficacious intervention for individual patients. In the absence of clear data on the relative efficacy of fentanyl formulations, prescribing decisions need to be based on physician understanding and experience and product cost and availability, taking into account the individual patient’s needs, the ability of the patient or caregivers to administer medication, and the patient’s wishes. This review evaluates current pharmacologic methods of alleviating BTP and discusses factors that should be considered when selecting the most appropriate formulation for individual patients. With the range of fentanyl formulations available, it is now possible to successfully address BTP in the majority of patients.
Collapse
Affiliation(s)
- Howard S Smith
- Departments of Anesthesiology, Medicine, and Physical Medicine and Rehabilitation Albany Medical College, Albany, NY, USA
| |
Collapse
|
29
|
Optimal management of breakthrough cancer pain (BCP). Clin Transl Oncol 2012; 15:526-34. [DOI: 10.1007/s12094-012-0981-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 11/21/2012] [Indexed: 11/26/2022]
|
30
|
Abstract
This paper is the thirty-fourth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2011 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 (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration (Section 16); and immunological responses (Section 17).
Collapse
Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
| |
Collapse
|
31
|
Küçük M, Uğur B, Oğurlu M. Comparing the administration of fentanyl 1 µg kg⁻¹ and fentanyl 0.5 µg kg⁻¹ in dilation and curettage procedures. Gynecol Endocrinol 2012; 28:736-9. [PMID: 22316334 DOI: 10.3109/09513590.2011.652248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This study was carried out to compare fentanyl 0.5 µg kg⁻¹ -propofol as opposed to fentanyl 1 µg kg⁻¹ -propofol in terms of providing adequate analgesia, and a comparable recovery profile in dilation and curettage (D&C) procedures. METHODS Verbal Pain Scale (VPS) scores, modified Aldrete scores, and hemodynamic parameters were recorded during and after the surgical procedure. In addition, a record was also kept of adverse events, and patients and surgeons were questioned about their satisfaction with the anesthesia. RESULTS No difference was found between the two groups in terms of hemodynamic parameters, the VPS scores, or patient and surgeon satisfaction. The fentanyl 0.5 µg group displayed significantly higher modified Aldrete scores at both 5- and 10-min postoperative. Adverse events in both groups were considerably few. The incidence of postoperative nausea and vomiting (PONV) in the fentanyl 0.5 µg group was lower eventhough it did not reach the statistically significance level. In addition, faster recovery times were recorded with the administration of fentanyl 0.5 µg kg⁻¹ . CONCLUSION Fentanyl 0.5 µg kg⁻¹ appears to be as reliable as that of fentanyl 1 µg kg⁻¹ with faster recovery times when used in D&C procedures.
Collapse
Affiliation(s)
- Mert Küçük
- Department of Obstetrics and Gynecology, Faculty of Medicine, Adnan Menderes University, Aydın, Turkey
| | | | | |
Collapse
|
32
|
Davis MP. Are there cost benefits to fentanyl for breakthrough pain? J Pain Symptom Manage 2012; 44:e1-2. [PMID: 22939453 DOI: 10.1016/j.jpainsymman.2012.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 06/30/2012] [Indexed: 10/27/2022]
|
33
|
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).
Collapse
|
34
|
Abstract
Breakthrough pain (BTP) is a transitory pain (reaching maximum severity in ~15 minutes and lasting ~60 minutes in patients with cancer) that occurs despite the management of chronic pain with long-term around-the-clock analgesia. BTP occurs in 33-65% of patients with chronic cancer pain and in ~70% of patients with chronic noncancer pain. BTP has historically been managed with short-acting opioids; however, these medications have a pharmacokinetic profile that does not correlate with the sudden onset and short time to maximum severity of BTP. Interest in rapid-onset opioids to relieve BTP has therefore been growing. This comprehensive review aims to summarize the currently available clinical data for the approved rapid-onset opioids, which comprise different formulations of fentanyl, a μ-opioid receptor agonist with anaesthetic and analgesic properties. Administration routes for fentanyl in the management of BTP currently include the transmucosal and intranasal routes; an intrapulmonary formulation is also in development. The findings of this review suggest that the efficacy and safety of the approved rapid-onset opioids are comparable.
Collapse
Affiliation(s)
- Howard Smith
- Departments of Anesthesiology, Medicine, and Physical Medicine & Rehabilitation, Albany Medical College, Albany, NY 12208, USA.
| |
Collapse
|
35
|
|
36
|
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.
Collapse
|
37
|
Seed SM, Dunican KC, Lynch AM, Desilets AR. An update in options for the treatment of pain: a review of new opioid formulations. Hosp Pract (1995) 2012; 40:166-75. [PMID: 22406892 DOI: 10.3810/hp.2012.02.957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the past 2 decades, there has been a significant increase in the use of opioids for the management of chronic nonmalignant pain. This increase in usage has led to concerns of misuse and abuse of opioids. Also, many of the available opioid options were previously only available as oral tablets or capsules, further limiting treatment options for health care providers. Several new opioid formulations have been developed to address and prevent the misuse and abuse of opioids via tampering in the United States. In addition, alternative delivery systems have been developed to provide physicians with more options to provide adequate pain management for those with chronic pain. This article reviews new opioid options for the treatment of pain management and requirements of the Risk Evaluation and Mitigation Strategies program.
Collapse
Affiliation(s)
- Sheila M Seed
- Associate Professor of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA 01608, USA.
| | | | | | | |
Collapse
|
38
|
|
39
|
Mercadante S. Fentanyl buccal tablets for the treatment of breakthrough pain. Pain Manag 2011; 1:533-8. [DOI: 10.2217/pmt.11.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Fentanyl buccal tablets (FBT) have been designed to treat breakthrough pain (BTP) in patients who are already receiving, and who are tolerant to, opioid therapy for their underlying persistent pain. FBT are a formulation that uses an effervescent drug delivery system to enhance penetration across the buccal mucosa. OraVescent technology provides an effervescent reaction that liberates carbon dioxide in the buccal cavity. This reaction causes an initial decrease in pH, which facilitates solubilization, thus driving fentanyl into solution. Subsequently, carbon dioxide increases the local pH, which facilitates permeation of unionised fentanyl across the buccal mucosa. In clinical studies of opioid-tolerant patients with cancer and noncancer-related BTP, FBT have provided consistent and clinically relevant improvements in pain intensity and pain relief relative to placebo and oral opioids like oxycodone. The safety and tolerability profile is generally typical of that observed with other opioids. The pharmacokinetic properties of FBT allow for a meaningful clinical efficacy, with an onset of action that closely matches the onset of BTP. FBT, as with any other transmucosal preparations of fentanyl, should not be used in patients who are not opioid-tolerant.
Collapse
Affiliation(s)
- Sebastiano Mercadante
- Pain Relief & Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90146 Palermo, Italy
| |
Collapse
|
40
|
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.
Collapse
Affiliation(s)
- Mona Darwish
- Clinical Research, Cephalon, Inc., Frazer, Pennsylvania 19355, USA.
| | | |
Collapse
|