Symptoms
The symptoms of fentanyl overdose are expected to be an extension of its pharmacological actions e.g. lethargy, coma and severe respiratory depression. Other symptoms may be hypothermia, decreased muscle tonus, bradycardia and hypotension. Signs of toxicity are deep sedation, ataxia, miosis, convulsions and respiratory depression which is the main symptom.
Treatment
For management of respiratory depression immediate countermeasures should be started including physical or verbal stimulation of the patient. These actions can be followed by administration of a specific opioid antagonist such as naloxone. Respiratory depression following an overdose may outlast the duration of action of the opioid antagonist. The half-life of the antagonist may be short, therefore repeated administration or continuous infusion may be necessary. Reversal of the narcotic effect may result in acute onset of pain and release of catecholamines.
If the clinical situation warrants, a patent airway should be established and maintained, possibly with an oropharyngeal airway or endotracheal tube and oxygen should be administered and respiration assisted or controlled, as appropriate. Adequate body temperature and fluid intake should be maintained.
If severe or persistent hypotension occurs, hypovolemia should be considered and the condition should be managed with appropiate parenteral fluid therapy.
Instanyl 50 micrograms nasal spray, solution in single-dose container
23 months
Instanyl 100 micrograms nasal spray, solution in single-dose container
36 months
Instanyl 200 micrograms nasal spray, solution in single-dose container
42 months
Patients without maintenance opioid therapy as there is an increased risk of respiratory depression.
Treatment of acute pain other than breakthrough pain.
Severe respiratory depression or severe obstructive lung conditions.
Previous facial radiotherapy.
Recurrent episodes of epistaxis.
Not applicable.
Sodium dihydrogen phosphate dihydrate
Disodium phosphate dihydrate
Water for injections
Nasal spray, solution (nasal spray)
Clear, colourless solution.
Summary of the safety profile
Typical opioid adverse reactions are to be expected with Instanyl. Frequently, most of these will cease or decrease in intensity with continued use of the medicinal product. 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 closely monitored for these.
The clinical trials of Instanyl were designed to evaluate safety and efficacy in treating breakthrough pain. All patients were also taking concomitant opioids, such as sustained-release morphine or transdermal fentanyl, for their persistent pain. Thus, it is not possible to definitively separate the effects of Instanyl alone. The adverse reactions considered to be at least possibly related to treatment in the clinical trials of Instanyl are included in the table below.
Tabulated list of adverse reactions
The following categories are used to rank the undesirable effects by frequency of occurrence: very common (>1/10); common (>1/100 to <1/10); uncommon (>1/1000 to <1/100); rare (>1/10,000 to <1/1000); and very rare (<1/10,000), not known (cannot be estimated from the available data).
Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.
The following adverse reactions have been reported with Instanyl and/or other fentanyl-containing compounds during clinical studies and post marketing experience:
|
System organ class |
Common |
Uncommon |
Not known |
|
Psychiatric disorders |
Insomnia |
Hallucination, drug dependence (addiction), drug abuse | |
|
Nervous system disorders |
Somnolence, dizziness, headache |
Sedation, myoclonus, paraesthesia, dysaesthesia, dysgeusia |
Convulsion |
|
Ear and Labyrinth disorders |
Vertigo |
Motion sickness | |
|
Cardiac disorders |
Hypotension | ||
|
Vascular disorders |
Flushing, hot flush | ||
|
Respiratory, thoracic and mediastinal disorders |
Throat irritation |
Respiratory depression, epistaxis, nasal ulcer, rhinorrhea |
Nasal septum perforation |
|
Gastrointestinal disorders |
Nausea, vomiting |
Constipation, stomatitis, dry mouth |
Diarrhoea |
|
Skin and subcutaneous tissue disorders |
Hyperhidrosis |
Pain of skin, pruritus | |
|
Pregnancy, puerperium and perinatal conditions |
Neonatal withdrawal syndrome | ||
|
General disorders and administration site conditions |
Pyrexia |
Fatigue, malaise peripheral oedema, withdrawal syndrome* | |
|
Injury, poisoning and procedural complications |
Fall |
*opioid withdrawal symptoms such as nausea, vomiting, diarrhoea, anxiety, chills, tremor, and sweating have been observed with transmucosal fentanyl
Reporting of suspected adverse reactions
Reporting 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 or search for MHRA Yellow Card in the Google Play or Apple App Store.
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity,genotoxicity and carcinogenicity.
In a fertility and early embryonic development study in rats, a male-mediated effect was observed at high doses (300 µg/kg/day, s.c.) and is consistent with the sedative effects of fentanyl in animal studies. Furthermore, studies in female rats revealed reduced fertility and enhanced embryonal mortality. More recent studies showed that effects on the embryo were due to maternal toxicity and not to direct effects of the substances on the developing embryo. In a study on pre- and postnatal development the survival rate of offspring was significantly reduced at doses which slightly reduced maternal weight. This effect could either be due to altered maternal care or a direct effect of fentanyl on the pups. Effects on somatic development and behaviour of the offspring were not observed. Teratogenic effects have not been demonstrated.
Local tolerance studies with Instanyl in mini-pigs demonstrated that Instanyl administration was well tolerated.
Carcinogenicity studies (26-week dermal alternative bioassay in Tg.AC transgenic mice; two-year subcutaneous carcinogenicity study in rats) with fentanyl did not reveal any findings indicative of oncogenic potential. Evaluation of brain slides from the carcinogenicity study in rats revealed brain lesions in animals administered high doses of fentanyl citrate. The relevance of these findings to humans is unknown.
Instanyl is indicated for the management of breakthrough pain in adults already receiving maintenance opioid therapy for chronic cancer pain. Breakthrough pain is a transitory exacerbation of pain that occurs on a background of otherwise controlled persistent pain.
Patients receiving maintenance opioid therapy are those who are taking at least 60 mg of oral morphine daily, at least 25 micrograms of transdermal fentanyl per hour, at least 30 mg oxycodone daily, at least 8 mg of oral hydromorphone daily or an equianalgesic dose of another opioid for a week or longer.
Pharmacotherapeutic group: Analgesics, opioids, ATC code: N02AB03
Mechanism of action
Fentanyl is an opioid analgesic interacting primarily with the opioid μ-receptor as a pure agonist with low affinity for the δ- and κ-opioid receptors. The primary therapeutic action is analgesia. The secondary pharmacological effects are respiratory depression, bradycardia, hypothermia, constipation, miosis, physical dependence and euphoria.
Clinical safety and efficacy
The efficacy and safety of Instanyl (50, 100 and 200 micrograms) have been assessed in two randomised, double-blind, cross-over, placebo-controlled pivotal studies in 279 opioid-tolerant adult cancer patients (age 32-86 years) with breakthrough pain (BTP). The patients had an average of 1 to 4 episodes per day while taking maintenance opioid therapy. Patients in the second pivotal study had earlier participated in the Instanyl pharmacokinetic study or in the first pivotal study.
The clinical studies demonstrated the efficacy and safety of Instanyl. No distinct correlation between the maintenance opioid dose and Instanyl doses have been established, however in the second pivotal study patients with low maintenance opioid dose tended to achieve effective pain relief with a correspondingly lower strength of Instanyl compared to patients taking higher levels of maintenance opioid dose. This was most distinct for patients ending on Instanyl 50 micrograms.
In the clinical studies in cancer patients, the most frequent strengths used were 100 and 200 micrograms; however, patients should be titrated to the optimal dose of Instanyl for treating BTP in cancer.
All three strengths of Instanyl showed statistically significant (p<0.001) higher pain intensity difference at 10 minutes (PID10) compared with placebo. Furthermore Instanyl was significantly superior to placebo in BTP relief at 10, 20, 40, and 60 minutes following administration. The results of summary of PID at 60 minutes (SPID0-60) showed that all strengths of Instanyl had significantly higher mean SPID0-60 scores compared with placebo (p<0.001) demonstrating better pain relief of Instanyl compared to placebo during 60 minutes.
The safety and efficacy of Instanyl have been evaluated in patients taking the medicinal product at the onset of a breakthrough pain episode. Instanyl should not be used pre-emptively.
The clinical experience with Instanyl in patients with background opioid treatment equivalent to > 500 mg/day morphine or > 200 micrograms/hour transdermal fentanyl is limited.
Instanyl in doses above 400 micrograms have not been evaluated in clinical trials.
Opioids may influence the hypothalamic-pituitary-adrenal or -gonadal axes. Some changes that can be seen include an increase in serum prolactin, and decreases in plasma cortisol and testosterone. Clinical signs and symptoms may be manifest from these hormonal changes.
Absorption
Fentanyl is highly lipophilic. Fentanyl exhibits three compartment distribution kinetics. Animal data shows 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 approximately 80%. The absolute bioavailability of Instanyl is about 89%.
Clinical data show that fentanyl is absorbed very rapidly through the nasal mucosa. Administration of Instanyl in single doses ranging from 50 to 200 micrograms fentanyl per dose in opioid tolerant cancer patients produces a rapid Cmax level of 0.35 to 1.2 ng/ml. The corresponding median Tmax are 12-15 minutes. However, higher values for Tmax were observed in a dose-proportionality study in healthy volunteers.
Distribution
After intravenous administration of fentanyl the initial distribution half-life is approximately 6 minutes and a similar half-life is seen after the nasal administration of Instanyl. The elimination half-life is approximately 3-4 hours for Instanyl in cancer patients.
Biotransformation
Fentanyl is metabolised primarily in the liver via CYP3A4. The major metabolite, norfentanyl is inactive.
Elimination
About 75% of fentanyl is excreted into the urine, mostly as inactive metabolites, with less than 10% as unchanged active substance. About 9% of the dose is recovered in the faeces primarily as metabolites.
Linearity
Instanyl shows linear kinetics. Dose linearity from 50 micrograms to 400 micrograms of Instanyl has been demonstrated in healthy subjects.
A drug-drug-interaction study was performed with a nasal vasoconstrictor (oxymetazoline). Subjects with allergic rhinitis received oxymetazoline nasal spray one hour prior to Instanyl. Comparable bioavailability (AUC) of fentanyl was achieved with and without oxymetazoline, while fentanyl Cmax decreased and Tmax increased by a factor two when oxymetazoline was administered. The overall extent of fentanyl exposure in subjects with allergic rhinitis without prior treatment with nasal vasoconstrictor is comparable to that in healthy subjects. Concomitant use of nasal vasoconstrictor should be avoided.
Bioequivalence
A pharmacokinetic study has shown that Instanyl single-dose and multi-dose nasal spray are bioequivalent.
8 May 2018
Instanyl 50 micrograms nasal spray, solution in single-dose container
Instanyl 100 micrograms nasal spray, solution in single-dose container
Instanyl 200 micrograms nasal spray, solution in single-dose container
Takeda Pharma A/S
Dybendal Alle 10
DK-2630 Taastrup
Denmark
Store below 30°C.
Keep the blister in the outer carton. Keep stored upright.
Single-dose container consisting of a vial (clear type I glass) integrated in a polypropylene spray container, packed in child-resistant blister.
Pack sizes: 2, 6, 8 and 10 single-dose containers.
Not all pack sizes may be marketed.
Instanyl 50 micrograms nasal spray, solution in single-dose container
EU/1/09/531/010-013
Instanyl 100 micrograms nasal spray, solution in single-dose container
EU/1/09/531/014-017
Instanyl 200 micrograms nasal spray, solution in single-dose container
EU/1/09/531/018-021
Pregnancy
There are no adequate data from the use of fentanyl in pregnant women. Studies in animals have shown reproductive toxicity. The potential risk for humans is unknown. Instanyl should not be used in 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 Instanyl is administered, an antidote for the child should be readily available.
Breast-feeding
Fentanyl 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 breastfeeding should not be restarted until at least 5 days after the last administration of fentanyl.
Fertility
There are no human data on fertility available. In animal studies, male and female fertility was impaired at sedative doses.
Instanyl 50 micrograms nasal spray, solution in single-dose container
Each single-dose container contains one dose (100 microlitres) of fentanyl citrate equivalent to 50 micrograms fentanyl.
Instanyl 100 micrograms nasal spray, solution in single-dose container
Each single-dose container contains one dose (100 microlitres) of fentanyl citrate equivalent to 100 micrograms fentanyl.
Instanyl 200 micrograms nasal spray, solution in single-dose container
Each single-dose container contains one dose (100 microlitres) of fentanyl citrate equivalent to 200 micrograms fentanyl.
Respiratory depression
Clinical significant respiratory depression may occur with fentanyl, and patients must be observed for these effects. 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.
Chronic pulmonary disease
In patients with chronic obstructive pulmonary diseases, fentanyl may have more severe adverse reactions. In these patients, opioids may decrease respiratory drive and increase airway resistance.
Impaired renal or hepatic function
Fentanyl should be administered with caution to patients with moderate to severe hepatic or renal impairment. The influence of hepatic and renal impairment on the pharmacokinetics of Instanyl have not been evaluated; however, when administered intravenously the clearance of fentanyl has shown to be altered due to hepatic and renal impairment caused by alterations in metabolic clearance and plasma proteins.
Increased intracranial pressure
Fentanyl should be used with caution in patients with evidence of increased intracranial pressure, impaired consciousness or coma.
Instanyl should be used with caution in patients with cerebral tumour or head injury.
Cardiac disease
Fentanyl may produce bradycardia. Fentanyl should therefore be used with caution in patients with previous or pre-existing bradyarrhythmias. Opioids may cause hypotension, especially in patients with hypovolaemia. Instanyl should therefore be used with caution in patients with hypotension and/or hypovolaemia.
Serotonin Syndrome
Caution is advised when Instanyl is coadministered with drugs that affect the serotoninergic neurotransmitter systems.
The development of a potentially life-threatening serotonin syndrome may occur with the concomitant use of serotonergic drugs such as Selective Serotonin Re-uptake Inhibitors (SSRIs) and Serotonin Norepinephrine Re-uptake Inhibitors (SNRIs), and with drugs which impair metabolism of serotonin (including Monoamine Oxidase Inhibitors [MAOIs]). This may occur within the recommended dose.
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 Instanyl should be discontinued.
Hyperalgesia
As with other opioids, in case of insufficient pain control in response to an increased dose of fentanyl, the possibility of opioid-induced hyperalgesia should be considered. A fentanyl dose reduction or discontinuation of fentanyl treatment or treatment review may be indicated.
Nasal conditions
If the patient experiences recurrent episodes of epistaxis or nasal discomfort while taking Instanyl, an alternative administration form for treatment of breakthrough pain should be considered.
Common cold
The overall extent of fentanyl exposure in subjects with common cold without prior treatment with nasal vasoconstrictor is comparable to that in healthy subjects.
Abuse potential and dependence
Tolerance 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 known to occur in the treatment of cancer related pain.
Withdrawal symptoms
Withdrawal symptoms may be precipitated through the administration of substances with opioid antagonist activity, e.g. naloxone, or mixed agonist/antagonist analgesic (e.g. pentazocine, butorphanol, buprenorphine, nalbuphine).
No studies of the effects on the ability to drive and use machines have been performed. However, opioid analgesics are known to impair the mental and/or physical ability required for driving or operating machinery. Patients should be advised not to drive or operate machinery if they experience somnolence, dizziness, visual disturbances or other adverse reaction which can impair their ability to drive and operate machinery.
Treatment should be initiated by and remain under the supervision of a physician experienced in the management of opioid therapy in cancer patients. Physicians should keep in mind the potential of abuse of fentanyl.
Posology
Patients should be individually titrated to the dose that provides adequate analgesia with tolerable adverse drug reactions. Patients must be carefully monitored during the titration process.
Titration to a higher dose necessitates contact with the health care professional. In absence of adequate pain control, the possibility of hyperalgesia, tolerance and progression of underlying disease should be considered.
The dose of Instanyl for treatment of breakthrough pain was independent of the daily maintenance dose of opioid in the clinical studies.
Maximum daily dose: Treatment of up to four breakthrough pain episodes, each with no more than two doses separated by at least 10 minutes.
Patients should wait 4 hours before treating another breakthrough pain episode with Instanyl during both titration and maintenance therapy. On exceptional occasions where a new episode occurs earlier, patients can use Instanyl to treat it but they must wait at least 2 hours before doing so. Dose adjustment of the background opioid therapy following pain reassessment should be considered if the patient frequently presents with breakthrough pain episodes that are less than 4 hours apart or with more than four breakthrough pain episodes per 24 hours.
Dose titration
Before patients are titrated with Instanyl, it is expected that their background persistent pain is controlled by use of chronic opioid therapy and that they are experiencing no more than four episodes of breakthrough pain per day.
Method of titration
The initial strength should be one dose of 50 micrograms in one nostril, titrating upwards as necessary through the range of available strengths (50, 100, and 200 micrograms). If adequate analgesia is not obtained redosing of the same strength may be administered at the earliest after 10 minutes. Each titration step (dose strength) should be evaluated in several episodes.
Maintenance therapy
Once the dose has been established according to the steps described above, the patient should be maintained on this strength of Instanyl. If the patient has insufficient pain relief, redosing with same strength can be done at the earliest after 10 minutes.
Dose adjustment
Generally, the maintenance strength of Instanyl should be increased when a patient requires more than one dose per breakthrough pain episode for several consecutive episodes.
Dose adjustment of the background opioid therapy following pain reassessment should be considered if the patient frequently presents with breakthrough pain episodes that are less than 4 hours apart or with more than four breakthrough pain episodes per 24 hours.
If adverse reactions are intolerable or persistent, the strength should be reduced or treatment with Instanyl be replaced by other analgesics.
Discontinuation of therapy
Instanyl should be discontinued immediately if the patient no longer experiences breakthrough pain episodes. The treatment for the persistent background 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 is necessary in order to avoid the possibility of abrupt withdrawal effects.
Special populations
Elderly
Limited data on pharmacokinetics, efficacy and safety are available for the use of Instanyl in patients above >65 years of age. Elderly patients may have a reduced clearance, a prolonged half-life and higher sensitivity to fentanyl than younger patients. Caution should therefore be taken in treatment of elderly, cachectic or debilitated patients.
In clinical trials elderly patients tend to titrate to a lower effective strength than patients less than 65 years of age. Particular caution should be exercised when titrating Instanyl in elderly patients.
Hepatic impairment
Instanyl should be administered with caution to patients with moderate to severe hepatic impairment.
Renal impairment
Instanyl should be administered with caution to patients with moderate to severe renal impairment.
Paediatric population
The safety and efficacy of Instanyl in children aged below 18 years have not yet been established.
No data are available.
Method of administration
Instanyl is intended for nasal use.
It is recommended that the patient's head is in upright position when administrating Instanyl.
Each single-dose container contains only one dose. The single-dose container should not be tested before use.
Because of the possible misuse of fentanyl unused nasal spray single-dose containers must be returned systematically and suitably in the child-resistant blister and disposed of in accordance with local requirements or returned to the pharmacy.
Date of first authorisation: 20 July 2009
Date of latest renewal: 23 April 2014
Coadministration of fentanyl with a serotoninergic agent, 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.
Instanyl is not recommended for use in patients who have received Monoamine Oxidase Inhibitors (MAOIs) within 14 days because severe and unpredictable potentiation by MAOIs inhibitors has been reported with opioid analgesics.
Fentanyl is metabolised mainly via the human cytochrome P450 3A4 isoenzyme system (CYP3A4), therefore potential interactions may occur when Instanyl is given concurrently with medicinal products that affect CYP3A4 activity. Co-administration with medicinal products that induce 3A4 activity may reduce the efficacy of Instanyl. The concomitant use of Instanyl with strong CYP3A4 inhibitors (e.g. ritonavir, ketoconazole, itraconazole, troleandomycin, clarithromycin, and nelfinavir) or moderate CYP3A4 inhibitors (e.g., amprenavir, aprepitant, diltiazem, erythromycin, fluconazole, fosamprenavir, and verapamil) may result in increased fentanyl plasma concentrations, potentially causing serious adverse drug reactions including fatal respiratory depression.
Patients receiving Instanyl concomitantly with moderate or strong CYP3A4 inhibitors should be carefully monitored for an extended period of time. Dose increase should be done with caution.
In a pharmacokinetic interaction study it was found that the maximum plasma concentration of nasally applied fentanyl was reduced about 50% by the concomitant use of oxymetazoline, while the time to reach Cmax (Tmax) was doubled. This may reduce the efficacy of Instanyl. It is recommended that concomitant use of nasal decongestants is avoided
The concomitant use of other central nervous system depressants, including other opioids, sedatives or hypnotics, general anaesthetics, phenothiazines, tranquillisers, skeletal muscle relaxants, sedating antihistamines and alcohol may produce additive depressant effects.
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 Instanyl with other medicinal products (other than oxymetazoline) administered via the nose has not been evaluated in the clinical trials. It is recommended that alternative administration forms should be considered for concomitant treatment of concurrent diseases that can be treated via nasal administration.
