Fentanyl nasal spray in a patient with end-stage COPD and severe chronic breathlessness

Janssen, Daisy J.A.; Everdingen, M.H.J. van den Beuken-van; Verberkt, Cornelia A.; Creemers, Jacques; Wouters, Emiel F.M.

doi:10.1183/20734735.0183-2019

Cited by 7 publications

(6 citation statements)

References 19 publications

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“…24 Sublingual (or intranasal) fentanyl has been used for many years for incident and crisis management of pain, and more recently for dyspnea in COPD and congestive heart failure. 25,26 The oromucosal route allows medication to be rapidly absorbed via the vascular rich epithelium of the cheek. The buccal route is a simple method for small dose-small volume drug delivery, and patients or caregivers can easily learn to prefill syringes and administer medication into the cheek for rapid and effective relief of dyspnea.…”

Section: Discussionmentioning

confidence: 99%

Buccal Hydromorphone Syrup for Managing Dyspnea in Idiopathic Pulmonary Fibrosis

Fong

Richman‐Eisenstat

Kalluri

2020

Am J Hosp Palliat Care

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Context: Dyspnea is a highly distressing symptom that characterizes idiopathic pulmonary fibrosis (IPF), a common idiopathic interstitial lung disease (ILD) with a high symptom burden, poor quality of life, and early mortality. Though opioids are mentioned in guidelines for dyspnea management, guidance on how and when to initiate opioids is lacking. Different pharmacologic strategies are needed to address different types of dyspnea (baseline, incident, and crisis). Due to a longer onset of action, the oral route (swallowed) may be less effective for prevention of incident dyspnea or for rapid relief of crisis dyspnea, prompting the use of alternative drug delivery strategies for self-management. We inadvertently discovered the efficacy of buccal administration of low dose, low volume hydromorphone oral syrup for dyspnea management in ILD, which has not been previously reported in the literature. Case Series: We describe our approach to dyspnea assessment and management in IPF, including use of the Multidimensional Dyspnea Scale (MDDS), a novel instrument yet to be validated that we developed to better identify and categorize dyspnea into the types experienced by a patient with IPF over the course of a day. We then describe how buccal hydromorphone oral syrup is initiated and titrated for dyspnea management in 3 patients at different points in their disease trajectory. Conclusion: Buccal hydromorphone oral syrup is effective for dyspnea management across the spectrum of IPF. When integrated into a patient-centered algorithm for symptom assessment and management, it allows for rapid and easy self-management of dyspnea by patients and their caregivers.

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Section: Discussionmentioning

confidence: 99%

Buccal Hydromorphone Syrup for Managing Dyspnea in Idiopathic Pulmonary Fibrosis

Fong

Richman‐Eisenstat

Kalluri

2020

Am J Hosp Palliat Care

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“…Fentanyl by applying an aqueous solution to the mucous membrane surface, a new pectin-based delivery technique known as pectin nasal spray causes a regulated absorption of fentanyl. Nasal spray fentanyl pectin quickly relieves pain and has a duration of action [40].…”

Section: Pectin As a Transport For The Delivery Of Medicinesmentioning

confidence: 99%

Overview of the Pharmacological Use of Pectins and Pectin-Containing Substances: Recent Achievements and Prospects

Maslova¹,

Mishvelov²,

Nasrulaeva³

et al. 2023

Pharmacophore

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Biomedical and pharmaceutical properties of pectinThis paper is an overview on the Pectins which are a group of polysaccharides from plant cells. Structural diversity makes functionality of the pectins versatile with a variety of biological, technofunctional, biomedical, and pharmaceutical properties. Nearly all the plants contain pectin, however, the majority of it is used commercially and is derived from citrus fruits, specifically oranges, lemons, grapefruit, and apples. Commercial production is judged on new features and applications in addition to economics. Recently, there has been an effort to find new sources of pectin, such as using the leftovers from the processing of pulp from sugar beet, mango, and sunflower. Pectin substances can affect the human body as follows: prebiotic effect, cholesterol reduction, anti-inflammatory and antimicrobial effect, antitumor effect, biosorbent, transportation of drugs. This article's goal is to discuss pectin application techniques and pectin-containing products. The prospects of further development and use of these biopolymers are also considered.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non commercially, as long as the author is credited and the new creations are licensed under the identical terms.

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“…The only published data relate to a case report of abuse of transmucosal fentanyl for breathlessness (a patient with COPD who had been prescribed up to 4 doses of 50 micrograms daily for the past 3 years, who presented using 40 doses each day) with withdrawal during rationalisation of regimen. 49 The misuse potential of transmucosal fentanyl should be systematically investigated prospectively before this approach is used routine in clinical practice.…”

Section: Trials Of Opioids and Exertional Breathlessnessmentioning

confidence: 99%

“…55 Since this review there have been two further case reports: one in a patient with COPD taking background sustained release morphine and concomitant immediate release morphine presenting with respiratory depression following a large immediate release dose, 56 the other was of the COPD patient with transmucosal fentanyl discussed above. 49 The largest longer term studies have been conducted as observational consecutive cohort studies looking at outcomes after opioids are started. At doses of 30mg of morphine equivalent per 24 hours or less, Ekström's large consecutive COPD and long term oxygen cohort with 4 years' follow up showed no increase in hospital admissions nor in mortality when opioids were commenced at a morphine equivalent daily dose of ≤30mg.…”

Section: Safetymentioning

confidence: 99%

Opioids for breathlessness: a narrative review

Johnson

Currow

2020

BMJ Support Palliat Care

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Chronic breathlessness is a disabling and distressing condition for which there is a growing evidence base for a range of interventions. Non-pharmacological interventions are the mainstay of management and should be optimised prior to use of opioid medication. Opioids are being implemented variably in practice for chronic breathlessness. This narrative review summarises the evidence defining current opioids for breathlessness best practice and identifies remaining research gaps. There is level 1a evidence to support the use of opioids for breathlessness. The best evidence is for 10–30 mg daily de novo low-dose oral sustained-release morphine in opioid-naïve patients. This should be considered the current standard of care following independent, regulatory scrutiny by one of the world’s therapeutics regulatory bodies. Optimal benefits are seen in steady state; however, there are few published data about longer term benefits or harms. Morphine-related adverse events are common but mostly mild and self-limiting on withdrawal of drug. Early and meticulous management of constipation, nausea and vomiting is needed particularly in the first week of administration. Serious adverse events are no more common than placebo in clinical studies. Observational studies in severe chronic lung disease do not show excess mortality or hospital admission in those taking opioids. We have no long-term data on immune or endocrine function. There are promising data regarding prophylaxis for exertion-related breathlessness, but given the risks associated with transmucosal fentanyl, caution is needed with regard to clinical use pending longer term, robust safety data.

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Fentanyl nasal spray in a patient with end-stage COPD and severe chronic breathlessness

Cited by 7 publications

References 19 publications

Buccal Hydromorphone Syrup for Managing Dyspnea in Idiopathic Pulmonary Fibrosis

Buccal Hydromorphone Syrup for Managing Dyspnea in Idiopathic Pulmonary Fibrosis

Overview of the Pharmacological Use of Pectins and Pectin-Containing Substances: Recent Achievements and Prospects

Opioids for breathlessness: a narrative review

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