Fentanyl is a synthetic opioid approximately 100 times more potent than morphine. This powerful analgesic is available for parenteral, transdermal, sublingual and buccal administration.

Sublingual and buccal routes are often preferred for the treatment of breakthrough pain as they provide rapid onset of action, avoid first-pass metabolism, and are convenient to administer. Three sublingual and buccal formulations of fentanyl are currently available for the treatment of breakthrough cancer pain, as shown in Table 1. It is important to note that these products are not interchangeable.

Table 1. Available strengths of sublingual and buccal fentanyl products

Abstral®

Sublingual Tablets

Actiq®

Lozenge

Fentora®

Orally Disintegrating Tablets

100µg

200µg

100µg

200µg

400µg

200µg

300µg

600µg

400µg

400µg

800µg

600µg

600µg

1200µg

800µg

800µg

1600µg

 

The above formulations offer rapid onset of effect. Compared to placebo, statistically significant improvement in pain intensity is achieved in 15 minutes. There is also data to suggest improvement occurs in as little as ten minutes for Abstral® and Fentora® .

Abstral® tablets are administered sublingually where they rapidly disintegrate and adhere to the oral mucosa. Actiq® lozenges are presented to the patient on an applicator that should be moved around the buccal mucosa throughout the 15-minute administration period. Fentora® tablets are administered to the buccal cavity between the cheek and gum; although they may also be administered sublingually. Fentora® tablets may take up to 25 minutes to dissolve.

Oral fentanyl is subject to extensive first-pass metabolism. Effective analgesia, therefore, relies upon limiting the amount of fentanyl that is swallowed. For this reason, tablets and lozenges must not be chewed, and patients must refrain from ingesting food or drink during the administration period.

These agents should not be used in opioid naïve patients due to the risk of life-threatening respiratory depression.

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References:

  1. Actiq® (fentanyl citrate) Australian approved product information. Macquarie Park: Teva Pharma Australia. Approved June 2016.
  2. Therapeutic Goods Administration. Australian public assessment report for fentanyl citrate: Abstral. Commonwealth of Australia. Woden, 2013.
  3. Therapeutic Goods Administration. Australian public assessment report for fentanyl citrate: Fentora. Commonwealth of Australia. Woden, 2015.

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