Fentanyl

Indications
 Oral
Breakthrough cancer pain
Adult: For patients who are already receiving and tolerant to opioid treatment: As a loz: Initially, 200 mcg over 15 minutes for an episode of breakthrough pain; may repeat once after 15 minutes if needed. Titrate subsequent doses based on response up to 1.6 mg per dose. Once the effective dose has been identified, no more than 4 unit doses should be taken daily.
Elderly: and debilitated patients: Dose reduction may be needed.
Intravenous
Adjunct to general anaesthesia
Adult: For patients with spontaneous respiration: Initially, 50-200 mcg followed by supplements of 50 mcg. To be injected over 3-5 minutes. Possible increased risk of resp depression following doses >200 mcg. For patients with assisted ventilation: Initially, 300-3,500 mcg (up to 50 mcg/kg) followed by supplements of 100-200 mcg depending on the patient's response. To be injected over 3-5 minutes.
Child: For patients with spontaneous respiration: >2 yr: 3-5 mcg/kg IV, supplements of 1 mcg/kg may be given. For patients with assisted ventilation: >2 yr: Initially, 15 mcg/kg with supplements of 1-3 mcg/kg.
Elderly: and debilitated patients: Dose reduction may be needed.
Transdermal
Intractable chronic pain
Adult: Patches deliver fentanyl in doses that range from 12-100 mcg/hr. Doses should be individually titrated based on previous use of opioids. For opioid-naive patients: Initiate with patches that deliver not more than 25 mcg/hr of fentanyl. Recommended for opioid-naive patients to start with low doses of short-acting opioids before starting on fentanyl patches. For patients who have been receiving a strong opioid, the initial dose should be based on the previous 24-hr opioid requirement. During transfer to fentanyl patches, previous opioid treatment should be phased out gradually. If patient requires doses >100 mcg/hr, >1 patch may be used; consider alternative or additional therapy if doses >300 mcg/hr are required. Replace patch every 72 hr and apply the new patch to a different site; avoid using the same area of skin for a few days.
Elderly: and debilitated patients: Dose reduction may be needed.
Intramuscular
Premedication before anaesthesia
Adult: 50-100 mcg, to be given 30-60 minutes before induction of anaesthesia.
Elderly: and debilitated patients: Dose reduction may be needed.

Special Populations: Reduce dose in elderly and debilitated patients.

Incompatibility: Thiopental sodium and methohexital sodium.
Contraindications
 Hypersensitivity.
Warnings / Precautions
 Myasthaenia gravis. Head injury; increased intracranial pressure; intracranial lesions; renal or hepatic impairment; neonates; opioid-nontolerant patients. Increased risk of respiratory depression in elderly, debilitated patients, patient with hypoxia or hypercapnia. Hypothyroidism, prostatic hyperplasia, inflammatory bowel disorders, bradycardia or bradyarrhythmias. Rapid IV infusion may cause skeletal muscle and chest wall rigidity, impaired ventilation or respiratory distress/arrest. Prolonged use may cause tolerance, psychological and physical dependence. Abrupt withdrawal after prolonged admin may lead to withdrawal symptoms. Lactation. Pregnancy (avoid high doses or prolonged usage).
Adverse Reactions
 Nausea, vomiting; bradycardia, oedema, CNS depression, confusion, dizziness,drowsiness, headache, sedation, transient hypotension, peripheral vasodilation; increased intracranial pressure. High IV dose may cause chest wall rigidity. Transdermal: Rash, erythema and itching.
Potentially Fatal: Respiratory depression, trunk rigidity, laryngospasm, bronchoconstriction.
Drug Interactions
 Depressant effects may be enhanced by other CNS depressants e.g. alcohol, anaesthetics, anxiolytics, hypnotics, TCAs and antipsychotics. Ammonium chloride may increase excretion of fentanyl. Phenothiazines may increase hypotensive effect of opioid analgesics. Serum levels may be increased by CYP3A4 inhibitors (e.g. azole antifungals, clarithromycin, diclofenac, doxycycline, erythromycin, imatinib, isoniazid, nefazodone, nicardipine, propofol, protease inhibitors, quinidine, telithromycin and verapamil). May reduce the efficacy of pegvisomant. Serum levels may be reduced by rifamycin derivatives. May increase serotonergic effect of SSRIs and sibutramine.
See Below for More fentanyl Drug Interactions
Food Interactions
 Avoid valerian, kava-kava and gotu kola. Serum levels may be reduced by St John's wort.
Mechanism of Actions
 Fentanyl is a potent opioid analgesic that increases pain threshold, alters pain reception and inhibits ascending pain pathways by binding to stereospecific receptors within the CNS.
Onset: Rapid.
Duration: Short.
Distribution: Rapidly into tissues; appears in the CSF, crosses the placenta and small amounts enter the breast milk. Protein-binding: 80%
Metabolism: Hepatic via N-dealkylation and hydroxylation.
Excretion: Urine (as metabolites and unchanged drug); 4 hrs (elimination half-life).
Storage Conditions
 Intramuscular: Store between 20-25°C. Intravenous: Store between 20-25°C. Oral: Store between 20-25°C. Transdermal: Store between 20-25°C.
ATC Classification
 N01AH01 - fentanyl ; Belongs to the class of opioid anesthetics. Used as general anesthetics.
N02AB03 - fentanyl ; Belongs to the class of phenylpiperidine derivative opioids. Used to relieve pain.
Storage
 Intramuscular: Store between 20-25°C. Intravenous: Store between 20-25°C. Oral: Store between 20-25°C. Transdermal: Store between 20-25°C.
Available As
  • Fentanyl 100 mcg
  • Fentanyl 12 mcg
  • Fentanyl 25 mcg
  • Fentanyl 50 mcg
  • Fentanyl Citrate 50 mcg

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