PecFent (fentanyl citrate) nasal spray - Important risk minimisation information for healthcare professionals
- 1. Name of the medicinal product
- 2. Qualitative and quantitative composition
- 3. Pharmaceutical form
- 4. Clinical particulars
- 4.1 Therapeutic indications
- 4.2 Posology and method of administration
- 4.3 Contraindications
- 4.4 Special warnings and precautions for use
- 4.5 Interaction with other medicinal products and other forms of interaction
- 4.6 Fertility, pregnancy and lactation
- 4.7 Effects on ability to drive and use machines
- 4.8 Undesirable effects
- 4.9 Overdose
- 5. Pharmacological properties
- 5.1 Pharmacodynamic properties
- 5.2 Pharmacokinetic properties
- 5.3 Preclinical safety data
- 6. Pharmaceutical particulars
- 6.1 List of excipients
- 6.2 Incompatibilities
- 6.3 Shelf life
- 6.4 Special precautions for storage
- 6.5 Nature and contents of container
- 6.6 Special precautions for disposal and other handling
- 7. Marketing authorisation holder
- 8. Marketing authorisation number(s)
- 9. Date of first authorisation/renewal of the authorisation
- 10. Date of revision of the text
Excipients with known effect:Each spray contains 0.02 mg propyl parahydroxybenzoate (E216).For the full list of excipients, see section 6.1.
PosologyPecFent should be titrated to an effective dose that provides adequate analgesia and minimises adverse reactions without causing undue (or intolerable) adverse reactions, for two consecutively treated episodes of BTP. The efficacy of a given dose should be assessed over the ensuing 30 minute period. Patients should be carefully monitored until an effective dose is reached.PectFent is available in two strengths: 100 micrograms/spray and 400 micrograms/spray.One dose of PecFent may include administration of 1 spray (100 microgram or 400 microgram doses) or 2 sprays (200 microgram or 800 microgram doses) of the same strength (either 100 microgram or 400 microgram strength). Patients should not use more than 4 doses per day. Patients should wait at least 4 hours after a dose before treating another BTP episode with PecFent.PecFent can deliver 100, 200, 400 and 800 microgram doses as follows:
|Dose required (micrograms)||Product strength (micrograms)||Amount|
|100||100||One spray administered into one nostril|
|200||100||One spray administered into each nostril|
|400||400||One spray administered into one nostril|
|800||400||One spray administered into each nostril|
Initial dose• The initial dose of PecFent to treat episodes of BTP is always 100 micrograms (one spray), even in patients switching from other fentanyl containing products for their BTP.• Patients must wait at least 4 hours before treating another episode of BTP with PecFent.
Method of titration• Patients should be prescribed an initial titration supply of one bottle (8 sprays) of PecFent 100 micrograms/spray.• Patients whose initial dose is 100 micrograms and who need to titrate to a higher dose due to a lack of effect can be instructed to use two 100 microgram sprays (one in each nostril) for their next BTP episode. If this dose is not successful, the patient may be prescribed a bottle of PecFent 400 micrograms/spray and instructed to change to one 400 microgram spray for their next episode of pain. If this dose is not successful, the patient may be instructed to increase to two 400 microgram sprays (one in each nostril).• From treatment initiation, patients should be closely followed and the dose titrated until an effective dose is reached and confirmed for two consecutively treated episodes of BTP.
Titration in patients switching between immediate-release fentanyl containing productsSubstantial differences may exist in the pharmacokinetic profile of immediate-release fentanyl medicinal products, which result in clinically important differences in the rate and extent of absorption of fentanyl. Therefore, when switching between fentanyl containing medicinal products indicated for treatment of breakthrough pain, including intranasal formulations, it is essential that patients are again titrated with the new medicinal product, and not switched on a dose-for-dose (microgram-for-microgram) basis.
Maintenance therapyOnce an effective dose has been established during titration, patients should continue to take this dose up to a maximum of 4 doses per day.
Dose readjustmentGenerally, the maintenance dose of PecFent should be increased only where the current dose fails to adequately treat the BTP for several consecutive episodes.A review of the dose of the background opioid therapy may be required if patients consistently present with more than four BTP episodes per 24 hours.If adverse reactions are intolerable or persistent, the dose should be reduced or treatment with PecFent replaced by another analgesic.
Discontinuation of therapyPecFent should be discontinued immediately if the patient no longer experiences breakthrough pain episodes. The treatment for persistent backgound pain should be kept as prescribed.If discontinuation of all opioid therapy is required, the patient must be closely followed by the doctor as gradual downward opioid titration therapy is necessary in order to avoid the possibility of abrupt withdrawal effects.
Elderly (older than 65 years)In the PecFent clinical trial programme, 104 (26.1%) of patients were over 60 years of age, 67 (16.8%) over 65 years and 15 (3.8%) over 75 years. There was no indication that older patients tended to titrate to lower doses or experience more adverse reactions. Nevertheless, in view of the importance of renal and hepatic function in the metabolism and clearance of fentanyl, additional care should be exercised in the use of PecFent in the elderly. No data on the pharmacokinetics of PecFent in elderly patients are available.
Hepatic or renal impairmentPecFent should be administered with caution to patients with moderate or severe hepatic or renal impairment (see section 4.4).
Paediatric populationThe safety and efficacy of PecFent in children and adolescents aged below 18 years have not yet been established. No data are available.
Method of administrationPecFent is for nasal use only.The bottle should be removed from the child resistant container immediately prior to use and the protective cap removed. The bottle must be primed before first use by holding upright and simply pressing and releasing the finger grips either side of the nozzle until a green bar appears in the counting window (should occur after four sprays). If the product has not been used for 5 days, it should be re-primed by spraying once. The patient should be advised to write the date of first use in the space provided on the label of the child resistant container. To administer PecFent the nozzle is placed a short distance (about 1 cm) into the nostril and pointed slightly towards the bridge of the nose. A spray is then administered by pressing and releasing the finger grips either side of the nozzle. An audible click will be heard and the number displayed on the counter will advance by one. Patients must be advised that they may not feel the spray being administered, and that they should, therefore, rely on the audible click and the number on the counter advancing to confirm that a spray has been delivered. The PecFent spray droplets form a gel in the nose. Patients should be advised not to blow their nose immediately after PecFent administration. The protective cap should be replaced after each use and the bottle returned to the child resistant container for safe storage.
Respiratory depressionThere is a risk of clinically significant respiratory depression associated with the use of fentanyl. Patients with pain who receive chronic opioid therapy develop tolerance to respiratory depression and hence the risk of respiratory depression in these patients is reduced. The use of concomitant central nervous system depressants may increase the risk of respiratory depression (see section 4.5).
Chronic pulmonary diseaseIn patients with chronic obstructive pulmonary diseases, fentanyl may cause more serious adverse reactions. In these patients, opioids may decrease respiratory drive and increase airway resistance.
Increased intracranial pressurePecFent should only be administered with extreme caution in patients who may be particularly susceptible to the intracranial effects of CO2 retention, such as those with evidence of increased intracranial pressure or impaired consciousness. Opioids may obscure the clinical course of patients with a head injury and should be used only if clinically warranted.
Cardiac diseaseFentanyl may produce bradycardia. PecFent should, therefore, be used with caution in patients with previous or pre-existing bradyarrhythmias.
Impaired hepatic or renal functionIn addition, PecFent should be administered with caution to patients with hepatic or renal impairment. The influence of hepatic and renal impairment on the pharmacokinetics of the medicinal product has not been evaluated; however, when administered intravenously the clearance of fentanyl has been shown to be altered in hepatic and renal impairment due to alterations in metabolic clearance and plasma proteins. Therefore, special care should be taken during the titration process in patients with moderate or severe hepatic or renal impairment.Careful consideration should be given to patients with hypovolaemia and hypotension.
Abuse potential and toleranceTolerance and physical and/or psychological dependence may develop upon repeated administration of opioids such as fentanyl. However, iatrogenic addiction following therapeutic use of opioids is rare.Athletes should be informed that treatment with fentanyl could lead to positive doping tests.
Serotonin SyndromeCaution is advised when PecFent is coadministered with medicinal products that affect the serotoninergic neurotransmitter systems.The development of a potentially life-threatening serotonin syndrome may occur with the concomitant use of serotonergic medicinal products such as Selective Serotonin Re-uptake Inhibitors (SSRIs) and Serotonin Norepinephrine Re-uptake Inhibitors (SNRIs), and with medicinal products which impair metabolism of serotonin (including Monoamine Oxidase Inhibitors [MAOIs]). This may occur within the recommended dose (see section 4.5).Serotonin syndrome may include mental-status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular abnormalities (e.g., hyperreflexia, incoordination, rigidity), and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhoea).If serotonin syndrome is suspected, treatment with PecFent should be discontinued.
Route of administrationPecFent is only intended for nasal use, and must not be administered by any other route. Due to physico-chemical properties of excipients included in the formulation, intravenous or intra-arterial injection must be avoided in particular.
Nasal conditionsIf the patient experiences recurrent episodes of epistaxis or nasal discomfort while taking PecFent, an alternative method of administration for treatment of breakthrough pain should be considered.
PecFent excipientsPecFent contains propyl parahydroxybenzoate (E216). Propyl parahydroxybenzoate may cause allergic reactions (possibly delayed) and, exceptionally, bronchospasm (if the medicinal product is not correctly administered).
Serotoninergic medicinal products:Coadministration of fentanyl with a serotoninergic medicinal product, such as a Selective Serotonin Re-uptake Inhibitor (SSRI) or a Serotonin Norepinephrine Re-uptake Inhibitor (SNRI) or a Monoamine Oxidase Inhibitor (MAOI), may increase the risk of serotonin syndrome, a potentially life-threatening condition.PecFent is not recommended for use in patients who have received monoamine oxidase (MAO) inhibitors within the previous 14 days because severe and unpredictable potentiation by MAO inhibitors has been reported with opioid analgesics.The concomitant use of partial opioid agonists/antagonists (e.g. buprenorphine, nalbuphine, pentazocine) is not recommended. They have high affinity to opioid receptors with relatively low intrinsic activity and, therefore, partially antagonise the analgesic effect of fentanyl and may induce withdrawal symptoms in opioid dependent patients.Concomitant use of nasally administered oxymetazoline has been shown to decrease the absorption of PecFent (see section 5.2). The concomitant use of nasally administered vasoconstrictive decongestants during titration is, therefore, not recommended as this may lead to patients titrating to a dose that is higher than required. PecFent maintenance treatment may also be less effective in patients with rhinitis when administered concomitantly with a nasal vasoconstrictive decongestant. If this occurs, patients should be advised to discontinue their decongestant.Concomitant use of PecFent and other medicinal products (other than oxymetazoline) administered via the nose has not been evaluated in the clinical trials. Other nasally administered treatments should be avoided within 15 minutes of dosing with PecFent.
PregnancyThere are no adequate data from the use of fentanyl in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown. PecFent should not be used during pregnancy unless clearly necessary.Following long-term treatment, fentanyl may cause withdrawal in the new-born infant. It is advised not to use fentanyl during labour and delivery (including caesarean section) because fentanyl passes through the placenta and may cause respiratory depression in the foetus. If PecFent is administered, an antidote for the child should be readily available.
BreastfeedingFentanyl passes into breast milk and may cause sedation and respiratory depression in the breast-fed child. Fentanyl should not be used by breastfeeding women and breast-feeding should not be restarted until at least 5 days after the last administration of fentanyl.
FertilityThere are no clinical data on the effects of fentanyl on fertility.
Summary of the safety profileTypical opioid adverse reactions are to be expected with PecFent. Frequently, these will cease or decrease in intensity with continued use of the medicinal product, as the patient is titrated to the most appropriate dose. However, the most serious adverse reactions are respiratory depression (potentially leading to apnoea or respiratory arrest), circulatory depression, hypotension and shock and all patients should be monitored for these.The clinical studies of PecFent were designed to evaluate safety and efficacy in treating BTP and all patients were also on background opioid therapies, such as sustained-release morphine or transdermal fentanyl, for their persistent pain. Therefore it is not possible to definitively separate the effects of PecFent alone.
Tabulated list of adverse reactionsThe following adverse reactions have been reported with PecFent and/or other fentanyl-containing compounds during clinical studies and post marketing experience (frequencies defined as very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); unknown (cannot be estimated from available data)).
|Infections and infestations||Pneumonia Nasopharyngitis Pharyngitis Rhinitis|
|Blood and lymphatic system disorders||Neutropenia|
|Immune system disorders||Hypersensitivity|
|Metabolism and nutrition disorders||Dehydration Hyperglycaemia Decreased appetite Increased appetite|
|Psychiatric disorders||Disorientation||Drug abuse Delirium Hallucination Confusional state Depression Attention deficit/hyperactivity disorder Anxiety Euphoric mood Nervousness||Insomnia|
|Nervous system disorders||Dysgeusia Dizziness Somnolence Headache||Loss of consciousness Depressed level of consciousness Convulsion Ageusia Anosmia Memory impairment Parosmia Speech disorder Sedation Lethargy Tremor|
|Ear and labyrinth disorders||Vertigo|
|Vascular disorders||Cardiovascular insufficiency Lymphoedema Hypotension Hot flush||Flushing|
|Respiratory, thoracic and mediastinal disorders||Epistaxis Rhinorrhoea Nasal discomfort||Upper airway obstruction Pharyngolaryngeal pain Rhinalgia Nasal mucosal disorder Cough Dyspnoea Sneezing Upper respiratory tract congestion Nasal congestion Intranasal hypoaesthesia Throat irritiation Postnasal drip Nasal dryness||Respiratory depression|
|Gastrointestinal disorders||Vomiting Nausea Constipation||Intestinal perforation Peritonitis Oral hypoaesthesia Oral paraesthesia Diarrhoea Retching Abdominal pain Tongue disorder Mouth ulceration Dyspepsia Dry mouth|
|Skin and subcutaneous tissue disorders||Pruritus||Hyperhydrosis Urticaria|
|Musculoskeletal and connective tissue disorders||Arthralgia Muscle twitching|
|Renal and urinary disorders||Anuria Dysuria Proteinuria Urinary hesitation|
|Reproductive system and breast disorders||Vaginal haemorrhage|
|General disorders and administration site conditions||Non-cardiac chest pain Asthenia Chills Face oedema Peripheral oedema Gait disturbance Pyrexia Fatigue Malaise Thirst||Withdrawal syndrome*|
|Investigations||Platelet count decreased Weight increased|
|Injury, poisoning and procedural complications||Fall Intentional drug misuse Medication error|
Description of selected adverse reactionsOpioid withdrawal symptoms such as nausea, vomiting, diarrhoea, anxiety, chills, tremor, and sweating have been observed with transmucosal fentanyl.
Reporting of suspected adverse reactionsReporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard .
Mechanism of actionFentanyl is an opioid analgesic, interacting predominantly with the opioid µ-receptor. Its primary therapeutic actions are analgesia and sedation. Secondary pharmacological effects are respiratory depression, bradycardia, hypothermia, constipation, miosis, physical dependence and euphoria.
Pharmacodynamic effectsA double-blind, randomised, placebo-controlled crossover study has been conducted in which 114 patients who experienced on average 1 to 4 episodes of break through pain (BTP) per day while taking maintenance opioid therapy were entered into an initial open-label titration phase in order to identify an effective dose of PecFent (Study CP043). The patients entering the double-blind phase treated up to 10 episodes of BTP with either PecFent (7 episodes) or placebo (3 episodes) in a random order.Of the patients entering the titration phase, only 7 (6.1 %) were unable to be titrated to an effective dose due to lack of efficacy and 6 (5.3 %) withdrew due to adverse events.The primary endpoint was the comparison between the summed pain intensity difference at 30 minutes after dosing (SPID30), which was 6.57 in the PecFent-treated episodes compared to 4.45 for placebo (p<0.0001 ). The SPID for PecFent-treated episodes was also significantly different to placebo at 10 15, 45 and 60 minutes after administration.The mean pain intensity scores (73 patients) for all PecFent-treated episodes (459 episodes) compared to those treated with placebo (200 episodes) were significantly lower at 5, 10, 15, 30, 45 and 60 minutes following administration (see Figure 1).Figure 1: Mean (± SE) Pain Intensity Scores at Each Time Point (mITT Population)The superior efficacy of PecFent over placebo was supported by data from secondary endpoints including the number of BTP episodes with clinically meaningful pain relief, defined as a reduction in pain intensity score of at least 2 (Figure 2). Figure 2: Clinically Meaningful Pain Relief PecFent vs placebo: % Patients' Episodes With ≥2 Point Reduction in Pain IntensityIn a double-blind, randomized comparator-controlled study (Study 044) of similar design to Study 043 conducted in opioid-tolerant patients with breakthrough cancer pain on stable doses of regularly scheduled opioids, PecFent was shown to be superior to immediate-release morphine sulfate (IRMS). Superiority was demonstrated by the primary endpoint, Pain Intensity Difference within 15 minutes, which was 3.02 in patients treated with PecFent compared to 2.69 in patients treated with IRMS (p=0.0396).In a long-term, open-label, safety study (Study 045), 355 patients entered the 16-week treatment phase, during which 42,227 episodes of breakthrough cancer pain (BTP) were treated with PecFent. One hundred of these patients continued treatment for up to 26 months in an extension phase. Of the 355 patients treated in the open-label treatment phase, 90 % required no increase in dose. In the randomised, placebo-controlled study (CP043) 9.4% of 459 PecFent-treated BTP episodes in 73 patients required use of any further (rescue) medicinal products within 60 minutes of dosing. During the longer-term, open-label study (CP045) this was 6.0 % of 42,227 episodes in 355 patients treated with PecFent during up to 159 days of treatment.
General introductionFentanyl is highly lipophilic and can be absorbed very rapidly through the nasal mucosa and more slowly by the gastrointestinal route. It is subject to first pass hepatic and intestinal metabolism and the metabolites do not contribute to fentanyl's therapeutic effects.PecFent utilises the PecSys nasal drug delivery system to modulate the delivery and absorption of fentanyl. The PecSys system allows the product to be sprayed into the front area of the nasal cavity as a fine mist of droplets, which gel on contact with the calcium ions present in the nasal mucosa. Fentanyl diffuses from the gel and is absorbed through the nasal mucosa; this gel-modulated absorption of fentanyl restrains the peak in plasma concentration (Cmax) whilst allowing the attainment of an early time to that peak (Tmax).
AbsorptionIn a pharmacokinetic study comparing PecFent (100, 200, 400 and 800 micrograms) with oral transmucosal fentanyl citrate (OTFC, 200 micrograms), fentanyl was shown to be rapidly absorbed following single dose intranasal administration of PecFent, with median Tmax ranging from 15 to 21 minutes (Tmax for OTFC was approximately 90 minutes). The variability of the pharmacokinetics of fentanyl was considerable following treatment with both PecFent and OTFC. Relative bioavailability of fentanyl from the PecFent treatment compared to the 200 microgram OTFC was approximately 120 %.The main pharmacokinetic parameters are shown in the following table. Pharmacokinetic parameters in adult subjects receiving PecFent and OTFC
|Pharmacokinetic parameters(mean (%CV))||PecFent||OTFC|
|100 micrograms||200 micrograms||400 micrograms||800 micrograms||200 micrograms|
|Tmax (hours)*||0.33 (0.08-1.50)||0.25 (0.17-1.60)||0.35 (0.25-0.75)||0.34 (0.17-3.00)||1.50 (0.50-8.00)|
|Cmax (pg/ml)||351.5 (51.3)||780.8 (48.4)||1552.1 (26.2)||2844.0 (56.0)||317.4 (29.9)|
|AUC (pg.hour/ml)||2460.5 (17.9||4359.9 (29.8)||7513.4 (26.7)||17272 (48.9)||3735.0 (32.8)|
|t1/2 (hour)||21.9 (13.6)||24.9 (51.3)||15.0 (24.7)||24.9 (92.5)||18.6 (31.4)|
DistributionFentanyl is highly lipophilic and is well distributed beyond the vascular system, with a large apparent volume of distribution. Animal data have shown that, following absorption, fentanyl is rapidly distributed to the brain, heart, lungs, kidneys and spleen followed by a slower redistribution to muscles and fat.The plasma protein binding of fentanyl is 80 85 %. The main binding protein is alpha-1-acid glycoprotein, but both albumin and lipoproteins contribute to some extent. The free fraction of fentanyl increases with acidosis.
BiotransformationThe metabolic pathways following nasal administration of PecFent have not been characterised in clinical studies. Fentanyl is metabolised in the liver to norfentanyl by cytochrome CYP3A4 isoform. Norfentanyl is not pharmacologically active in animal studies. It is more than 90 % eliminated by biotransformation to N-dealkylated and hydroxylated inactive metabolites.
EliminationDisposition of fentanyl following intranasal administration of PecFent has not been characterised in a mass balance study. Less than 7 % of an administered dose of fentanyl is excreted unchanged in the urine and only about 1 % is excreted unchanged in the faeces. The metabolites are mainly excreted in the urine, while faecal excretion is less important.The total plasma clearance of fentanyl following intravenous administration is approximately 42 L/h.
Linearity/non-linearityDose-proportionality was demonstrated for Cmax and AUC in the dose range 100 micrograms to 800 micrograms.The effect of renal or hepatic impairment on the pharmacokinetics of PecFent has not been studied.
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PecFent (fentanyl citrate) nasal spray - Important risk minimisation information for patients and their carers
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