Transcript New Drugs in Palliative Care

Dr Chloe Webb
Palliative Care Registrar
Beaumont Hospital
Drugs Covered
 Targin
 Durogesic Dtrans
 Pecfent
 Buprenorphine
 Transtec
 Butrans
 Effentora
 Palexia
 Oxynorm Dispersa
 Relistor
Targin
Targin
Indication
 Opioid analgesic
 Combines oxycodone with opioid antagonist
naloxone
 Naloxone is added to counteract opioid-induced
constipation
- Blocks the action of oxycodone at opioid receptors
locally in the gut.
 Oral use
 Twice 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 prolongedrelease at the same time.
 Beneficial effect of naloxone hydrochloride on bowel
function may be impaired with additional oxycodone
PecFent
Fentanyl Nasal Spray
Indication
 Management 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
PecFent
 Nasal 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
pathologies
 e.g. nausea / vomiting or dry / ulcerated buccal
membrane
PecFent
 Available in two
strengths:
 Yellow pack –
100mcg/spray
strength
 Violet pack –
400mcg/spray
strength
Pecfent
 Starting 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 Instructions
 Blow your nose if you
feel you need to
 Spray (listen for the
click)
 Sit down with head
 Stay sitting for at least 1
upright
 Put the nozzle a short
distance (about 1 cm)
into your nostril
 Close the other nostril
with a finger from your
other hand
minute after using the
nasal spray
 Do not blow your nose
straight after using the
PecFent nasal spray
Effentora
Effentora
 Buccal Fentanyl
Indication
 Treatment 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
Effentora
 Individually titrated to an
“effective”/maintenance dose
 The 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 - Titration
 100mcg initially
 Multiple tablets may be
- If pain still present
within 30mins
- Give 2nd same strength
Effentora tablet.
used to treat a single
episode of pain
- up to four 100mcgs
- up to four 200mcgs
 Increase dose to the next
 Doses >800mcgs were
strength to treat the next
episode of pain.
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 ~15-25mins
 Shouldn’t be sucked or chewed
 If any tablet remains after 30mins – swallow
with a glass of water
Palexia
Palexia
 Tapentadol
Indication
 Relief 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 SR
 Starting 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
Palexia
Non-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 Dispersa
 Orodispersible oxycodone
Indication
 Treatment of severe pain/breakthrough pain
 Oral use
 Taken every 4-6hours as needed
 Dissolves on tongue
Relistor
 Methylnaltrexone bromide
 Subcutaneous injection
Indication
 Treatment of opioidinduced constipation in
palliative care patients
when response to usual
laxative therapy has not
been sufficient
 Given on top of usual
laxatives
Relistor Dose
 Recommended 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 motion
Single dose alternate days.
Doses may also be given with longer intervals, as per
clinical need.
Rotate injection sites (upper arms & legs, abdomen)
Relistor
 Use 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
Indication
 Management of chronic intractable pain in patients
requiring opioid analgesia
 Reapplied every 72hours
 Initial dose - based on the patient's current opioid use.
 Recommended that Durogesic DTrans be used in
opioid tolerant patients
Durogesic DTrans
Opioid-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 DTrans
Opioid-naïve patients
 The 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 Instruction




Apply to upper arm or chest area
Don’t apply patch in same place twice in a row
Clean and dry skin
Takes 18-24hr to become therapeutic intially
1.
2.
3.
4.
5.
Open the pouch – tear off edge of pouch
Mind not to tear patch
Peel off backing – try not to touch sticky side
Press onto skin firmly (hold for 30secs)
Wash your hands
Butrans & Transtec
 Transdermal Buprenorphine
Indication
 Pain of moderate to severe intensity
 Alternative to both weak opioids and morphine
 Not suitable for the treatment of acute pain
 Take into account previous opioid history
 Opioid naive pts – prescribe lowest strength (5mcg/h)
Buprenorphine
Butrans
Transtec
 7 day patch
 4 day patch
 Doses available
 5, 10 and 20mcg/h
 Doses available
 35, 52.5, 70mcg/h
 Onset of action
 18–24h
 Onset of action
 21h for 35mcg/h patch;
 11h for 70mcg/h patch
 Peak plasma concentration
 60 hrs
 Peak plasma concentration
 3 days
Butrans vs Morphine
Buprenorphine
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
References
 Palliative Care Formulary 3 - Robert Twycross and
Andrew Wilcock
 www.palliativedrugs.com
 www.medicines.ie
 Archimedes Pharma
 Cephalon
 JanssenCilag
 Grunenthal
 Mundipharma
 Wyeth