Fentanyl

Aka: Fentanyl, Transdermal Fentanyl, Fentanyl Patch, Duragesic, Sublimaze

1. Class
   1. Short acting Narcotic (except Transdermal Fentanyl)
2. Indication
   1. Chronic Pain (especially Cancer Pain Management)
   2. Short-acting Labor Analgesia
   3. Procedural Sedation and Analgesia (PSAA)
3. Contraindications
   1. Mild pain, acute pain or postoperative pain due to risk of respiratory depression (FDA Black Box warning)
4. Dosing: Procedural Sedation and Analgesia (PSAA)
   1. Nasal: 2 mcg/kg intranasal (1/2 in each nostril)
   2. Nebulized: 4 mcg/kg in breath activated neb
   3. IV (onset in 3-5 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)
5. Dosing: Adult
   1. Transdermal Fentanyl (Duragesic)
      1. Available strengths: 25, 50, 75, 100 mcg/hour
      2. Onset of full effect only after 24 hours (steady state may not be reached for 1 week)
      3. 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
      4. Conversions from prior morphine (total per 24 hours)
         1. Fentanyl 25 mcg/h: MS 37.5 mg PO or 12.5 mg IV
         2. Fentanyl 50 mcg/h: MS 75 mg PO or 25 mg IV
         3. Fentanyl 75 mcg/h: MS 112 mg PO or 37.5 mg IV
         4. Fentanyl 100 mcg/h: MS 150 mg PO or 50 mg IV
   2. Transmucosal Lozenge (Actiq)
      1. Available strengths: 200, 400, 800, 1200, 1600 ug
      2. Maximum: 4 lozenges per day
6. Pharmacokinetics
   1. Intramuscular
      1. Onset: 7 to 15 minutes
      2. Peak: 15 minutes
      3. Duration: 1 to 2 hours
   2. Intravenous
      1. Onset: minutes
      2. Peak: minutes
      3. Duration: 30 to 60 minutes
7. Precautions
   1. Respiratory Depression (FDA Black Box Warning)
   2. Oversedation
      1. Antagonist: Naloxone (Narcan)
8. Efficacy: Non-Cancer Chronic Pain
   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
9. References
   1. Miner (2012) APLS Lecture, HCMC, Minneapolis
   2. Hamilton (2012) Tarascon Pharmacopeia, Jones and Bartlett, Burlington
   3. Rispoli (2002) Tarascon Pocket Orthopedics, Loma Linda, p. 115
   4. University Minnesota Childrens - Pediatric Emergency Drug Card
   5. Becker (2012) Anesth Prog 59:28-42
   6. Brown (2005) Am Fam Physician 71:85-90
   7. Singh in Blaivas (2012) Emergency Medicine - an International Perspective, p. 199-208