Analgesic

Fentanyl

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Fentanyl, Transdermal Fentanyl, Fentanyl Patch, Duragesic, Sublimaze, Sublingual Fentanyl, Submucosal Fentanyl, Intranasal Fentanyl, Buccal Fentanyl, Abstral, Subsys, Lazanda, Buccal Tablets, Fentora, Actiq

  • See Also
  1. Opioid
  • Class
  1. Short acting Opioid (except Transdermal Fentanyl)
  • Indications
  1. Intravenous
    1. Acute ParenteralOpioid analgesia (short acting, preferred in Renal Insufficiency)
      1. Less cardiovascular depression (e.g. Hypotension) than with Morphine or Hydromorphone
    2. Short-acting Labor Analgesia
    3. Procedural Sedation and Analgesia (PSAA)
  2. Transdermal
    1. Chronic Pain (especially Cancer Pain Management)
  • Contraindications
  • Fentanyl Patch
  1. Mild pain, acute pain or postoperative pain due to risk of respiratory depression (FDA Black Box warning)
  2. Limit use to Opioid tolerant patients (Morphine Sulfate >60 mg/day for at least one week)
  • Precautions
  • Transdermal and Transmucosal Fentanyl
  1. Fentanyl Patches are only indicated for Chronic Pain in patients that are Opioid tolerant
    1. Up to half of Fentanyl Patch prescriptions are written for acute pain despite contraindication and risk
    2. Serious respiratory depression and death has occurred with Fentanyl Patches
    3. Only use in patients on at least equivalent of 60 mg Morphine per day (see below)
    4. (2018) Presc Lett 25(4)
  2. Risk Evaluation and Mitigation Strategies (REMS)
    1. Document Opioid tolerant (to >=60 mg Morphine/day) on each Fentanyl prescription (transmucosal, transdermal)
  1. Nasal: 2 mcg/kg intranasal (1/2 in each nostril)
  2. Nebulized: 4 mcg/kg in breath activated neb
  3. IV (onset in 1-3 min, lasting 30-60 min)
    1. Adult: 50 mcg/dose every 3 minutes, titrating to effect
    2. Child: 1 mcg/kg/dose IV every 3 minutes, titrating to effect
      1. Age 1-3 years old: 2-3 mcg/kg/dose every 30-60 minutes as needed
      2. Age 3-12 years old: 1-2 mcg/kg/dose every 30-60 minutes as needed
      3. Age >12 years old: 0.5-1 mcg/kg/dose every 30-60 minutes as needed
  4. Reversal: Naloxone
  5. Often administered in combination with Midazolam (Procedural Sedation and Analgesia)
    1. Use lower doses in combination with Midazolam (Versed)
  1. Transdermal Fentanyl (Duragesic)
    1. Generic strengths: 25, 50, 75, 100 mcg/hour
    2. Trade name strengths: 37.5, 62.5, 87.5 mcg/hour (released in 2015 at 3x the cost of generic)
    3. Onset of full effect only after 24 hours (steady state may not be reached for 1 week)
    4. Change patch ever 72 hours
      1. In atypical cases may need to be changed every 48 hours for end-of-dose pain
      2. Should not be changed more often than every 48 hours
    5. Conversions from prior Morphine (total per 24 hours)
      1. Start with 25 mcg/h Fentanyl Patch for those on Morphine Sulfate 60-134 mg/day
        1. Slowly titrate doses at no more often than every 3 days
      2. Fentanyl 25 mcg/h: MS 37.5 mg PO or 12.5 mg IV
      3. Fentanyl 50 mcg/h: MS 75 mg PO or 25 mg IV
      4. Fentanyl 75 mcg/h: MS 112 mg PO or 37.5 mg IV
      5. Fentanyl 100 mcg/h: MS 150 mg PO or 50 mg IV
  2. Transmucosal Fentanyl
    1. Sublingual tab (Abstral) 100 mcg
    2. Sublingual spray (Subsys) 100 mcg
    3. Nasal spray (Lazanda) 100 mcg
    4. Buccal Tablets (Fentora)
    5. Transmucosal Lozenge (Actiq)
      1. Available strengths: 200, 400, 800, 1200, 1600 ug
      2. Maximum: 4 lozenges per day
  • Pharmacokinetics
  1. Intramuscular
    1. Onset: 7 to 15 minutes
    2. Peak: 15 minutes
    3. Duration: 1 to 2 hours
  2. Intravenous
    1. Duration: 30 to 60 minutes
    2. Onset <1 minute
    3. Peaks 2 to 5 minutes
  1. Less Histamine release than with Morphine
  2. Chest wall rigidity (with high doses)
  3. Respiratory depression
    1. Supplemental Oxygen, Jaw Thrust maneuver, bag-valve mask
    2. Use lower doses in combination with Midazolam (Versed)
  1. Respiratory Depression (FDA Black Box Warning)
    1. Limit transdermal use to Opioid tolerant patients (>60 mg Morphine Sulfate per day for at least one week)
    2. Start at low dose
  2. Oversedation
    1. Antagonist: Naloxone (Narcan)
  1. Transdermal Fentanyl preferred over oral Morphine
    1. Better pain relief
    2. Improved quality of life
  2. Reference
    1. Allan (2001) BMJ 322:1154-8 [PubMed]
  • Resources
  1. Fentanyl Injection (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c5d40297-b769-48cc-9f84-f98b7a333507
  2. Fentanyl Patch (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2a2238e9-4b5d-c56d-8663-dd354ff9ae0c
  3. Fentanyl Lozenge (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=78221eab-66fd-4cd8-9c81-af52eb83671c
  • References
  1. Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
  2. (2015) Presc Lett 22(7): 42
  3. (2021) Presc Lett 28(3): 15-6
  4. Miner (2012) APLS Lecture, HCMC, Minneapolis
  5. Hamilton (2012) Tarascon Pharmacopeia, Jones and Bartlett, Burlington
  6. Rispoli (2002) Tarascon Pocket Orthopedics, Loma Linda, p. 115
  7. Singh in Blaivas (2012) Emergency Medicine - an International Perspective, p. 199-208
  8. University Minnesota Childrens - Pediatric Emergency Drug Card
  9. Velasco and Kiel (2023) Crit Dec Emerg Med 37(1): 4-9
  10. Becker (2012) Anesth Prog 59:28-42 [PubMed]
  11. Brown (2005) Am Fam Physician 71:85-90 [PubMed]