The pharmacokinetics of the traditional oral opioids do not match the time course of breakthrough cancer pain, a common and distinct component of cancer pain which has a negative impact on quality of life for the patient.
Fentanyl and alfentanil are potent, lipophilic, fast acting opioids with short durations of action and consequently more appropriate for the treatment of breakthrough cancer pain. These agents are ideal for oral transmucosal or nasal transmucosal administration.
There are now four licensed preparations of fentanyl in the UK for the treatment of cancer breakthrough pain; lozenge, buccal tablet, sublingual tablet and nasal spray. They are not interchangeable and all require titration using the lowest dose.
Alfentanil is available as a buccal or nasal spray. It is an unlicensed product and is available as a special order from Torbay Pharmacy Manufacturing Unit.
There is a paucity of comparator studies for these new modes of administration.
Further innovative delivery systems of fentanyl are on the horizon.
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References
1.
ZepettellaGRiberioMDCOpioids for the management of breakthrough (episodic) pain in cancer patientsCDSR2006 Jan 25; (1) CD004311.
2.
DaviesANDickmanAReidCStevensAMZepettellaG. The management of cancer-related breakthrough pain: recommendations of the task group of the science committee of the association of palliative medicine of Great Britain and Ireland. European Journal of Pain2009;13:331–8.
3.
DaviesEuropean survey of oncology patient's experience of breakthrough cancer pain: UK, Sweden and Denmark results. Poster presented at EFIC September 2009.
4.
TwycrossRWilcockAPalliative Care Formulary third edition, May 2007http://www.palliativedrugs.com updated June 2008 [Accessed 1 May 2010].
WillensJSMyslinskiNRPharmacodynamics, pharmacokinetics and clinical uses of Fentanyl. Sufentanil and Alfentanil Heart and Lung1993;22:239–251.
7.
ScholzJSteinfathMSchultzMClinical pharmacokinetics of alfentanil, fentanyl and sufentanil. An update. Clinical Pharmacokinetics1996;31 (4) 275–292.
8.
HallTHardyJThe lipophilic opioids: Fentanyl, Alfentanil, Sufentanil and Remifentanil In: DavisM (eds) Opioids in cancer pain2005. Oxford University Press, Oxford.
9.
LarijaniGGoldbergM. Alfentanil hydrochloride: a new short acting narcotic analgesic for surgical proceduresClinical Pharmacy1987;6: 275–282.
BredenbergSDubergMLennernasBIn vitro and in vivo evaluation of a new sublingual tablet system for rapid oromucosal absorption using fentanyl citrate as the active substanceEuropean Journal of Pharmaceutical Sciences2003;20 (3) 327–334.
MercandanteSRadbruchLDaviesAA comparison of intransal fentanyl spray with oral transmucosal fentanyl citrate for the treatment of breakthrough cancer pain: an open-label, randomised, crossover trialCurrent Medical Research and Opinion2009;25: 11: 2805–15.
20.
FarrarJTClearyJRauckROral transmucosal fentanyl citrate: randomised, double-blinded, placebo-controlled trial for breakthrough pain in cancer patientsJournal of the National Cancer Institute1998;90: (8) 611–616.
21.
StamWBLenreMNolteTEfficacy of intranasal fentanyl spray versus oral transmucosal fentanyl citrate, fentanyl buccal tablet and oral morphine for breakthrough pain in cancer: a meta-analysis of randomised controlled trials. Poster presentation. Presented at ISPOR 11th Annual European Congress. Athens, Greece. 8–11 November 2008.
WallaceMTaylorDRauckRGalanVBurtonAPortenoyRFentanyl pectin nasal spray (FPNS) with PecSys®: Efficacy, tolerability, and onset of action in the treatment of breakthrough cancer pain (BTCP)The Journal of Pain, 2009;10: 4: S36.
RauckRNorthJGeverLNTagarroLFinnALFentanyl buccal soluble film for breakthrough pain in patients with cancer: a randomised, double-blind, placebo-controlled studyAnnals of Oncology, published online 25 November 2009 http://annonc.oxfordjournals.org/cgi/reprint/mdp541v1 Accessed 1 May 2010.
ClarkA.Rossiter-RooneyM.Valle-LeutriF. Aerosolized liposome-encapsulated fentanyl (AeroLEF) via pulmonary administration allows patients with moderate to severe post-surgical acute pain to self-titrate to effective analgesiaThe Journal of Pain, 2008, 9, (4) 42–42.
