fentanyl

fentanyl

(fen' ta nil)

Actiq; Duragesic 25, 50, 75, 100; Sublimaze

Pregnancy Category C

Controlled Substance C-II

Drug class

Opioid agonist analgesic

Therapeutic actions

Acts at specific opioid receptors, causing analgesia, respiratory depression, physical depression, euphoria.

Indications

·        Analgesic action of short duration during anesthesia and immediate postoperative period

·        Analgesic supplement in general or regional anesthesia

·        Administration with a neuroleptic as an anesthetic premedication, for induction of anesthesia, and as an adjunct in maintenance of general and regional anesthesia

·        For use as an anesthetic agent with oxygen in selected high-risk patients

·        Transdermal system: Management of chronic pain in patients requiring opioid analgesia over an extended period of time who cannot be managed by other means and who are already receiving opioid therapy

·        Actiq: Treatment of breakthrough pain in cancer patients being treated with and tolerant to opioids

Contraindications and cautions

·        Contraindicated with hypersensitivity to opioids, diarrhea caused by poisoning, acute bronchial asthma, upper airway obstruction, pregnancy.

·        Use cautiously with bradycardia, history of seizures, lactation, renal dysfunction; history of drug addiction.

Available forms

Lozenge on a stick (Actiq)—200, 400, 600, 800, 1,200, 1,600 mcg; transdermal—12.5, 25, 50, 75, 100 mcg/hr; injection—50 mcg/mL

Dosages

Individualize dosage; monitor vital signs.

ADULTS

Parenteral

·        Premedication: 50–100 mcg IM 30–60 min before surgery.

·        Adjunct to general anesthesia: Total dosage is 2 mcg/kg. Maintenance dose, 2–20 mcg IV or IM when changes in vital signs indicate surgical stress or lightening of analgesia.

·        With oxygen for anesthesia: Total high dose is 20–50 mcg/kg IV.

·        Adjunct to regional anesthesia: 500–100 mcg IM or slowly IV over 1–2 min.

·        Postoperatively: 50–100 mcg IM for the control of pain, tachypnea, or emergence delirium; repeat in 1–2 hr if needed.

Transdermal

Initiate therapy with 25 mcg/hr system; adjust dose as needed and tolerated. Apply to nonirritated and nonirradiated skin on a flat surface of the upper torso; may require replacement in 72 hr if pain has not subsided; do not use torn or damaged systems, serious overdose can occur.

Lozenges

Place Actiq unit in mouth between cheek and lower gum. Start with initial dose of 200 mcg. Until appropriate dose is reached, an additional dose can be used to treat an episode of breakthrough pain. Redosing may start 15 min after the previous lozenge has been completed. No more than two lozenges should be used for each breakthrough pain episode. Can consider increasing dose if requiring more than one lozenge for treatment of several consecutive breakthrough pain episodes. If more than four lozenges are needed daily, increase the dosage of long-acting opioid. Actiq should be sucked slowly over 15 min.

PEDIATRIC PATIENTS 2–12 YR

Parenteral

2–3 mcg/kg IV as vital signs indicate.

Transdermal

Do not exceed 15 mcg/kg.

Lozenges

5–15 mcg/kg transmucosal.

Pharmacokinetics

Route	Onset	Duration
IV	1–2 min	0.5–1 hr
IM	7–8 min	1–2 hr
Transdermal	Gradual	72 hr
Transmucosal	15 min	1 hr

Metabolism: Liver; T_1/2: 1.5–6 hr

Distribution: Crosses placenta; may enter breast milk

Excretion: Unknown

IV facts

Preparation: May be used undiluted or diluted with 250 mL of D₅W. Protect vials from light.

Infusion: Administer slowly by direct injection, each milliliter over at least 1 min, or into running IV tubing.

Incompatibilities: Do not mix with methohexital, pentobarbital, thiopental.

Adverse effects

·        CNS: Sedation, clamminess, sweating, headache, vertigo, floating feeling, dizziness, lethargy, confusion, light-headedness, nervousness, unusual dreams, agitation, euphoria, hallucinations, delirium, insomnia, anxiety, fear, disorientation, impaired mental and physical performance, coma, mood changes, weakness, headache, tremor, seizures

·        CV: Palpitation, increase or decrease in BP, circulatory depression, cardiac arrest, shock, tachycardia, bradycardia, arrhythmia, palpitations

·        Dermatologic: Rash, hives, pruritus, flushing, warmth, sensitivity to cold

·        EENT: Diplopia, blurred vision

·        GI: Nausea, vomiting, dry mouth, anorexia, constipation, biliary tract spasm

·        GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or hesitancy, oliguria, antidiuretic effect, reduced libido or potency

·        Local: Phlebitis following IV injection, pain at injection site; tissue irritation and induration (subcutaneous injection)

·        Respiratory: Slow, shallow respiration, apnea, suppression of cough reflex, laryngospasm, bronchospasm

·        Other: Physical tolerance and dependence, psychological dependence; local skin irritation with transdermal system

Interactions

Drug-drug

·        Potentiation of effects when given with other CNS acting drugs or barbiturate anesthetics; decrease dose of fentanyl when coadministering

·        Potentiation of effects may occur when given with macrolide antibiotics, ketoconazole, itraconazole, and protease inhibitors

·        Do not administer an MAOI within 14 days of fentanyl (increased CNS effects)

·        Increased risk of adverse effects and toxicity if combined with alcohol

Drug-food

·        Decreased metabolism and risk of toxic effects if taken with grapefruit juice; avoid this combination

Drug-lab test

·        Elevated biliary tract pressure may cause increases in plasma amylase, lipase; determinations of these levels may be unreliable for 24 hr after administration of opioids

Nursing considerations

CLINICAL ALERT!

Name confusion has occurred between fentanyl and sufentanil; use extreme caution.

Assessment

·        History: Hypersensitivity to fentanyl or opioids, physical dependence on an opioid analgesic, pregnancy, labor, lactation, COPD, respiratory depression, anoxia, increased intracranial pressure, acute MI, ventricular failure, coronary insufficiency, hypertension, biliary tract surgery, renal or hepatic dysfunction

·        Physical: Orientation, reflexes, bilateral grip strength, affect; pupil size, vision; P, auscultation, BP; R, adventitious sounds; bowel sounds, normal output; LFTs, renal function tests

Interventions

·        Administer to women who are nursing a baby 4–6 hr before the next scheduled feeding to minimize the amount in milk.

·        WARNING: Keep opioid antagonist and facilities for assisted or controlled respiration readily available during parenteral administration.

·        Prepare site for transdermal form by clipping (not shaving) hair at site; do not use soap, oils, lotions, alcohol; allow skin to dry completely before application. Apply immediately after removal from the sealed package; firmly press the transdermal system in place with the palm of the hand for 10–20 sec, making sure the contact is complete. Must be worn continually for 72 hr. Do not use any system that has been torn or damaged. Remove old patch before applying a new one.

·        Note that the patch does not work quickly. It may take up to 12 hr to get the full therapeutic effect. Breakthrough medications need to be used.

·        Do not use Actiq in patients who never received opioids before; should be used only in opioid tolerant patients.

·        Use caution with Actiq form to keep this drug out of the reach of children (it looks like a lollipop) and follow the distribution restrictions in place with this drug very carefully.

Teaching points

·        Do not drink grapefruit juice while using this drug.

·        You may experience these side effects: Dizziness, sedation, drowsiness, impaired visual acuity (ask for assistance if you need to move); nausea, loss of appetite (lie quietly, eat frequent small meals); constipation (a laxative may help).

·        Report severe nausea, vomiting, palpitations, shortness of breath, or difficulty breathing.

Adverse effects in Italic are most common; those in Bold are life-threatening.