Indications And Dose
Chronic intractable pain not currently treated with a strong opioid analgesic ▶BY TRANSDERMAL APPLICATION ▶Child 16–17 years: Initially 12 micrograms/hour every 72 hours, alternatively initially 25 micrograms/hour every 72 hours, when starting, evaluation of the analgesic effect should not be made before the system has been worn for 24 hours (to allow for the gradual increase in plasma-fentanyl concentration)—previous analgesic therapy should be phased out gradually from time of first patch application, dose should be adjusted at 48–72 hour intervals in steps of 12–25 micrograms/hour if necessary, more than one patch may be used at a time (but applied at the same time to avoid confusion)—consider additional or alternative analgesic therapy if dose required exceeds 300 micrograms/hour (important: it takes 17 hours or more for the plasma-fentanyl concentration to decrease by 50%— replacement opioid therapy should be initiated at a low dose and increased gradually) ▶Adult: Initially 12 micrograms/hour every 72 hours, alternatively initially 25 micrograms/hour every 72 hours, when starting, evaluation of the analgesic effect should not be made before the system has been worn for 24 hours (to allow for the gradual increase in plasma-fentanyl concentration)—previous analgesic therapy should be phased out gradually from time of first patch application, dose should be adjusted at 48–72 hour intervals in steps of 12–25 micrograms/hour if necessary, more than one patch may be used at a time (but applied at the same time to avoid confusion)—consider additional or alternative analgesic therapy if dose required exceeds 300 micrograms/hour (important: it takes 17 hours or more for the plasma-fentanyl concentration to decrease by 50%— replacement opioid therapy should be initiated at a low dose and increased gradually) Chronic intractable pain currently treated with a strong opioid analgesic ▶BY TRANSDERMAL APPLICATION ▶Child 2–17 years: Initial dose based on previous 24-hour opioid requirement (consult product literature), for evaluating analgesic efficacy and dose increments, see under Chronic intractable pain not currently treated with a strong opioid analgesic, for conversion from long term oral morphine to transdermal fentanyl, see Pain management with opioids under Prescribing in palliative care p. 28. ▶Adult: Initial dose based on previous 24-hour opioid requirement (consult product literature), for evaluating analgesic efficacy and dose increments, see under Chronic intractable pain not currently treated with a strong opioid analgesic, for conversion from long term oral morphine to transdermal fentanyl, see Pain management with opioids under Prescribing in palliative care p. 28. Spontaneous respiration: analgesia and enhancement of anaesthesia, during operation ▶BY SLOW INTRAVENOUS INJECTION Nervous system ▶Adult: Initially 50–100 micrograms (max. per dose 200 micrograms), dose maximum on specialist advice, then 25–50 micrograms as required ▶BY INTRAVENOUS INFUSION ▶Adult: 3–4.8 micrograms/kg/hour, adjusted according to response Assisted ventilation: analgesia and enhancement of anaesthesia during operation ▶BY SLOW INTRAVENOUS INJECTION ▶Adult: Initially 300–3500 micrograms, then 100–200 micrograms as required ▶BY INTRAVENOUS INFUSION ▶Adult: Initially 10 micrograms/kg, dose to be given over 10 minutes, then 6 micrograms/kg/hour, adjusted according to response, may require up to 180 micrograms/kg/hour during cardiac surgery Assisted ventilation: analgesia and respiratory depression in intensive care ▶BY SLOW INTRAVENOUS INJECTION ▶Adult: Initially 300–3500 micrograms, then 100–200 micrograms as required ▶BY INTRAVENOUS INFUSION ▶Adult: Initially 10 micrograms/kg, dose to be given over 10 minutes, then 6 micrograms/kg/hour, adjusted according to response, may require up to 180 micrograms/kg/hour during cardiac surgery Breakthrough pain in patients receiving opioid therapy for chronic cancer pain ▶BY BUCCAL ADMINISTRATION USING LOZENGES ▶Child 16–17 years: Initially 200 micrograms, dose to be given over 15 minutes, then 200 micrograms after 15 minutes if required, no more than 2 dose units for each pain episode; if adequate pain relief not achieved with 1 dose unit for consecutive breakthrough pain episodes, increase the strength of the dose unit until adequate pain relief achieved with 4 lozenges or less daily, if more than 4 episodes of breakthrough pain each day, adjust background analgesia ▶Adult: Initially 200 micrograms, dose to be given over 15 minutes, then 200 micrograms after 15 minutes if required, no more than 2 dose units for each pain episode; if adequate pain relief not achieved with 1 dose unit for consecutive breakthrough pain episodes, increase the strength of the dose unit until adequate pain relief achieved with 4 lozenges or less daily, if more than 4 episodes of breakthrough pain each day, adjust background analgesia ▶BY BUCCAL ADMINISTRATION USING BUCCAL FILMS ▶Adult: Initially 200 micrograms, adjusted according to response, consult product literature for information on dose adjustments, maximum 1.2 mg per episode of breakthrough pain; leave at least 4 hours between treatment of episodes of breakthrough pain, if more than 4 episodes of breakthrough pain each day occur on more than 4 consecutive days, adjust background analgesia DOSE EQUIVALENCE AND CONVERSION ▶Fentanyl films are not bioequivalent to other fentanyl preparations. ▶Fentanyl preparations for the treatment of breakthrough pain are not interchangeable; if patients are switched from another fentanyl-containing preparation, a new dose titration is required. continued → DOSES AT EXTREMES OF BODY-WEIGHT ▶To avoid excessive dosage in obese patients, weight- based doses may need to be calculated on the basis of ideal bodyweight. ABSTRAL ® Breakthrough pain in patients receiving opioid therapy Nervous system for chronic cancer pain ▶BY MOUTH USING SUBLINGUAL TABLETS ▶Adult: Initially 100 micrograms, then 100 micrograms after 15–30 minutes if required, dose to be adjusted according to response—consult product literature, no more than 2 dose units 15–30 minutes apart, for each pain episode; max. 800 micrograms per episode of breakthrough pain; leave at least 2 hours between treatment of episodes of breakthrough pain, if more than 4 episodes of breakthrough pain each day, adjust background analgesia EFFENTORA ® Breakthrough pain in patients receiving opioid therapy for chronic cancer pain ▶BY MOUTH USING BUCCAL TABLET ▶Adult: Initially 100 micrograms, then 100 micrograms after 30 minutes if required, dose to be adjusted according to response—consult product literature, no more than 2 dose units for each pain episode; max. 800 micrograms per episode of breakthrough pain; leave at least 4 hours between treatment of episodes of breakthrough pain during titration INSTANYL ® Breakthrough pain in patients receiving opioid therapy for chronic cancer pain ▶BY INTRANASAL ADMINISTRATION ▶Adult: Initially 50 micrograms, dose to be administered into one nostril, then 50 micrograms after 10 minutes if required, dose to be adjusted according to response, maximum 2 sprays for each pain episode and minimum 4 hours between treatment of each pain episode, if more than 4 breakthrough pain episodes daily, adjust background analgesia PECFENT ® Breakthrough pain in patients receiving opioid therapy for chronic cancer pain ▶BY INTRANASAL ADMINISTRATION ▶Adult: Initially 100 micrograms, adjusted according to response, dose to be administered into one nostril only, maximum 2 sprays for each pain episode and minimum 4 hours between treatment of each pain episode, if more than 4 breakthrough pain episodes daily, adjust background analgesia
Source pages 501, 502