Dr Chloe Webb Palliative Care Registrar Beaumont Hospital.
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Transcript of Dr Chloe Webb Palliative Care Registrar Beaumont Hospital.
Dr Chloe WebbPalliative Care Registrar
Beaumont Hospital
Drugs CoveredTarginPecfentEffentoraPalexiaOxynorm DispersaRelistor
Durogesic DtransBuprenorphine
TranstecButrans
Targin
Targin IndicationOpioid analgesicCombines oxycodone with opioid antagonist
naloxoneNaloxone is added to counteract opioid-
induced constipation- Blocks the action of oxycodone at opioid receptors locally in the gut.
Oral useTwice daily dose
Targin Recommended starting dose in opioid naïve
patients- 10 mg/5 mg oxycodone/naloxone BD
Max daily dose of Targin - 80 mg/40mg. If higher doses required – consider administration
of supplemental oxycodone hydrochloride prolonged-release at the same time.
Beneficial effect of naloxone hydrochloride on bowel function may be impaired with additional oxycodone
PecFentFentanyl Nasal Spray
IndicationManagement of breakthrough pain in adults
already receiving maintenance opioid therapy for chronic cancer pain
60mg PO morphine daily,25mcg/hr TD fentanyl,30mg PO oxycodone daily,8mg PO hydromorphone daily
PecFentNasal mucosa is highly vascularised with a
large surface area– Lipophilic drugs such as fentanyl are rapidly
and extensively absorbed
Avoids first pass metabolism and issues with oral pathologiese.g. nausea / vomiting or dry / ulcerated buccal
membrane
PecFentAvailable in two
strengths:Yellow pack –
100mcg/spray strength
Violet pack – 400mcg/spray strength
PecfentStarting dose of 100 mcg (one spray)
Titrated to an “effective dose” At least 4 hours before further dose of PecFent can be used.
Review background opioid treatment if >4 episodes of breakthrough pain/24hrs
Patient InstructionsBlow your nose if you
feel you need toSit down with head
uprightPut the nozzle a short
distance (about 1 cm) into your nostril
Close the other nostril with a finger from your other hand
Spray (listen for the click)
Stay sitting for at least 1 minute after using the nasal spray
Do not blow your nose straight after using the PecFent nasal spray
Effentora
EffentoraBuccal Fentanyl
IndicationTreatment of breakthrough pain in patients with
cancer already receiving maintenance opioid therapy for chronic cancer pain.
60mg PO morphine daily,25mcg/hr TD fentanyl,30mg PO oxycodone daily,8mg PO hydromorphone daily
EffentoraIndividually titrated to an
“effective”/maintenance doseThe effective dose of Effentora is not
predictable from the daily maintenance dose of opioid.
At least 4 hours between doses May require readjustment of
maintenance dose
Effentora - Titration100mcg initially
- If pain still present within 30mins - Give 2nd same strength Effentora tablet.
Increase dose to the next strength to treat the next episode of pain.
Multiple tablets may be used to treat a single episode of pain - up to four 100mcgs - up to four 200mcgs
Doses >800mcgs were not evaluated in clinical studies.
Effentora – How to use it!Blister pack (peel open)Place tablet above an upper rear molar
between cheek and the gum/sublingually
Dissolves/disintergrates in ~15-25minsShouldn’t be sucked or chewedIf any tablet remains after 30mins –
swallow with a glass of water
Palexia
PalexiaTapentadol
IndicationRelief of moderate to severe acute & chronic pain in
adults
µ-opioid receptor agonist & noradrenaline reuptake-inhibition
Nociceptive, neuropathic, visceral and inflammatory pain
Mainly evidence supports use in nociceptive pain conditions including postoperative orthopaedic & abdominal pain, also chronic pain due to osteoarthritis (hip/knee).
Palexia SRStarting dose - 50mg tapentadol BD (12hrs apart).
Increase in increments of 50 mg tapentadol SR twice daily every 3 days
Titrate dose to provide adequate analgesia with minimal undesirable effects
PalexiaNon-Opioid Dose
Independent
Tramadol PO (mg/d)
< 400mg 400 – 600mg 600mg
Oxycodone PO (mg/d)
< 40mg 40 – 60mg 60 – 80mg
Morphine PO (mg/d)
< 80mg 80 – 120mg 120 – 160mg
Hydromorphone PO (mg/d)
< 12mg 12 – 16mg 16 – 20mg
Fentanyl TD (µg/h)
< 37.5µg 37.5 – 50µg 50 – 75µg
Buprenorphine TD (µg/h)
< 35µg 35 – 52.5µg 52.5 – 70µg
Palexia SR 50mg BD 100mg BD 150mg BD
Oxynorm DispersaOrodispersible oxycodone
Indication Treatment of severe pain/breakthrough pain
Oral useTaken every 4-6hours as neededDissolves on tongue
RelistorMethylnaltrexone
bromideSubcutaneous injection
IndicationTreatment of opioid-
induced constipation in palliative care patients when response to usual laxative therapy has not been sufficient
Given on top of usual laxatives
Relistor DoseRecommended dose
- 8 mg (0.4 ml) for patients weighing 38-61 kg - 12 mg (0.6 ml) for patients weighing 62-114 kg- Patients whose weight falls outside these ranges should be dosed at 0.15 mg/kg.
Induces prompt bowel motionSingle dose alternate days. Doses may also be given with longer intervals,
as per clinical need.Rotate injection sites (upper arms & legs,
abdomen)
RelistorUse with caution in patients with known or
suspected GI lesions. - Increased risk of GI perforation
Advise patients to discontinue and consult their doctor if they develop severe, persistent, and/or worsening abdominal symptoms (GI perforation).
Note concomitant medications [e.g. bevacizumab (AVASTIN), NSAIDs and steroids]
Durogesic
Durogesic Transdermal fentanyl patch
IndicationManagement of chronic intractable pain in
patients requiring opioid analgesia
Reapplied every 72hoursInitial dose - based on the patient's current
opioid use. Recommended that Durogesic DTrans be used
in opioid tolerant patients
Durogesic DTransOpioid-tolerant patients
Use Equianalgesic potency conversion chart to convert from PO/parenteral opioids to Durogesic Dtrans.
Dose may be titrated up or down- increments of 12/25 µg/h - achieve the lowest appropriate dose of Durogesic Dtrans- depends on response and supplementary analgesic requirements.
Oral 24hr Morphine (mg/day)
Durogesic Dtrans Dose (µg/h)
4 hourly PO morphine (mg) breakthrough
< 44 12 < 7.5
45-89 25 10-15
90-134 37 15-20
135-189 50 25-30
190-224 62 35
225-314 75 40-50
315-404 100 55-65
405-494 125 70-80
495-584 150 85-95
585-674 175 100-110
675-764 200 115-125
765-854 225 130-140
855-944 250 145-155
945-1034 275 160-170
1035-1124 300 175-185
Durogesic DTransOpioid-naïve patientsThe normal initial Durogesic DTrans dosage should not
exceed 25 µg/h. Recommended that patients be titrated with low doses
of immediate-release opioids (e.g., morphine, oxycodone) to attain equianalgesic dose relative to Durogesic 12/25 µg/h
TD fentanyl is licensed for use as a 1st line strong opioid severe dysphagia, renal failure high risk of diversion and tablet misuse.
Durogesic – Patient InstructionApply to upper arm or chest areaDon’t apply patch in same place twice in a rowClean and dry skinTakes 18-24hr to become therapeutic intially
1.Open the pouch – tear off edge of pouch2.Mind not to tear patch3.Peel off backing – try not to touch sticky side4.Press onto skin firmly (hold for 30secs)5.Wash your hands
Butrans & TranstecTransdermal Buprenorphine
IndicationPain of moderate to severe intensityAlternative to both weak opioids and morphineNot suitable for the treatment of acute pain
Take into account previous opioid historyOpioid naive pts – prescribe lowest strength
(5mcg/h)
BuprenorphineButrans Transtec7 day patch
Doses available 5, 10 and 20mcg/h
Onset of action18–24h
Peak plasma concentration3 days
4 day patch
Doses available35, 52.5, 70mcg/h
Onset of action21h for 35mcg/h patch;11h for 70mcg/h patch
Peak plasma concentration60 hrs
Butrans vs MorphineBuprenorphine Morphine
5µg/hr 10mg/24hrs
10µg/hr 20mg/24hrs
20µg/hr 30mg/24hrs
35µg/hr 40mg/24hrs
52.5µg/hr 80mg/24hrs
70µg/hr 100mg/24hrs
ReferencesPalliative Care Formulary 3 - Robert Twycross
and Andrew Wilcockwww.palliativedrugs.comwww.medicines.ieArchimedes PharmaCephalonJanssenCilag GrunenthalMundipharmaWyeth