dr chloe webb palliative care registrar beaumont hospital
TRANSCRIPT
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Dr Chloe WebbPalliative Care Registrar
Beaumont Hospital
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Drugs CoveredTarginPecfentEffentoraPalexiaOxynorm DispersaRelistor
Durogesic DtransBuprenorphine
TranstecButrans
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Targin
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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
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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
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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
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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
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PecFentAvailable in two
strengths:Yellow pack –
100mcg/spray strength
Violet pack – 400mcg/spray strength
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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
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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
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Effentora
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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
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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
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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.
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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
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Palexia
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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).
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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
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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
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Oxynorm DispersaOrodispersible oxycodone
Indication Treatment of severe pain/breakthrough pain
Oral useTaken every 4-6hours as neededDissolves on tongue
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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
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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)
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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]
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Durogesic
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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
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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.
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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
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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.
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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
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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)
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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
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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
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ReferencesPalliative Care Formulary 3 - Robert Twycross
and Andrew Wilcockwww.palliativedrugs.comwww.medicines.ieArchimedes PharmaCephalonJanssenCilag GrunenthalMundipharmaWyeth