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New Drugs in Palliative Care

New Drugs in Palliative Care . Dr Chloe Webb Palliative Care Registrar Beaumont Hospital. Drugs Covered. Targin Pecfent Effentora Palexia Oxynorm Dispersa Relistor. Durogesic Dtrans Buprenorphine Transtec Butrans. Targin. Targin. Indication Opioid analgesic

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New Drugs in Palliative Care

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  1. New Drugs in Palliative Care Dr Chloe Webb Palliative Care Registrar Beaumont Hospital

  2. Drugs Covered • Targin • Pecfent • Effentora • Palexia • Oxynorm Dispersa • Relistor • Durogesic Dtrans • Buprenorphine • Transtec • Butrans

  3. Targin

  4. Targin Indication • Opioid analgesic • Combines oxycodone with opioid antagonist naloxone • Naloxone is added to counteract opioid-induced constipation -Blocks the action of oxycodone at opioid receptors locally in the gut. • Oral use • Twice daily dose

  5. Targin • Recommended starting dose in opioid naïve patients - 10 mg/5 mg oxycodone/naloxone BD • Max daily dose ofTargin- 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

  6. PecFent Fentanyl Nasal Spray Indication • Management of breakthrough pain in adults already receiving maintenance opioid therapy for chronic cancer pain • 60mg PO morphine daily, • 25mcg/hr TD fentanyl, • 30mg POoxycodone daily, • 8mg PO hydromorphone daily

  7. PecFent • Nasal 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 pathologies • e.g. nausea / vomiting or dry / ulcerated buccal membrane

  8. PecFent • Available in two strengths: • Yellow pack – 100mcg/spray strength • Violet pack – 400mcg/spray strength

  9. Pecfent • Starting 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

  10. Patient Instructions • Blow your nose if you feel you need to • Sit down with head upright • Put 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

  11. Effentora

  12. Effentora • Buccal Fentanyl Indication • Treatment 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 POoxycodone daily, • 8mg PO hydromorphone daily

  13. Effentora • Individually titrated to an “effective”/maintenance dose • The 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

  14. Effentora - Titration • 100mcg initially -If pain still present within 30mins -Give 2ndsame strength Effentora tablet. • Increase dose to the next strength to treat the next episode of pain. • Multiple tablets may be usedto treat a single episode of pain - up to four 100mcgs - up to four 200mcgs • Doses >800mcgs were not evaluated in clinical studies.

  15. 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 ~15-25mins • Shouldn’t be sucked or chewed • If any tablet remains after 30mins – swallow with a glass of water

  16. Palexia

  17. Palexia • Tapentadol Indication • Relief 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).

  18. Palexia SR • Starting 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

  19. Palexia

  20. Oxynorm Dispersa • Orodispersible oxycodone Indication • Treatment of severe pain/breakthrough pain • Oral use • Taken every 4-6hours as needed • Dissolves on tongue

  21. Relistor • Methylnaltrexone bromide • Subcutaneous injection Indication • Treatment of opioid-induced constipation in palliative care patients when response to usual laxative therapy has not been sufficient • Given on top of usual laxatives

  22. Relistor Dose • Recommended 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 motion • Single dose alternate days. • Doses may also be given with longer intervals, as per clinical need. • Rotate injection sites (upper arms & legs, abdomen)

  23. Relistor • Use with caution in patients with known or suspected GI lesions. - Increased risk of GI perforation • Advise patients to discontinueand 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]

  24. Durogesic

  25. Durogesic • Transdermal fentanyl patch Indication • Management of chronic intractable pain in patients requiring opioid analgesia • Reapplied every 72hours • Initial dose - based on the patient's current opioid use. • Recommended that Durogesic DTrans be used in opioid tolerant patients

  26. Durogesic DTrans Opioid-tolerant patients • Use Equianalgesic potency conversion chart to convert from PO/parenteral opioids to Durogesic Dtrans. • Dose may be titrated upor down - increments of 12/25 µg/h - achieve the lowestappropriate dose of Durogesic Dtrans - depends on response and supplementary analgesic requirements.

  27. Durogesic DTrans Opioid-naïve patients • The 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 1stline strong opioid • severe dysphagia, • renal failure • high risk of diversion and tablet misuse.

  28. Durogesic – Patient Instruction • Apply to upper arm or chest area • Don’t apply patch in same place twice in a row • Clean and dry skin • Takes 18-24hr to become therapeutic intially • Open the pouch – tear off edge of pouch • Mind not to tear patch • Peel off backing – try not to touch sticky side • Press onto skin firmly (hold for 30secs) • Wash your hands

  29. Butrans & Transtec • Transdermal Buprenorphine Indication • Pain of moderate to severe intensity • Alternative to both weak opioids and morphine • Not suitable for the treatment of acute pain • Take into account previous opioid history • Opioid naive pts – prescribe lowest strength (5mcg/h)

  30. Buprenorphine Butrans Transtec • 7 day patch • Doses available • 5, 10 and 20mcg/h • Onset of action • 18–24h • Peak plasma concentration • 3 days • 4 day patch • Doses available • 35, 52.5, 70mcg/h • Onset of action • 21h for 35mcg/h patch; • 11h for 70mcg/h patch • Peak plasma concentration • 60 hrs

  31. Butrans vs Morphine

  32. References • Palliative Care Formulary 3 - Robert Twycross and Andrew Wilcock • www.palliativedrugs.com • www.medicines.ie • Archimedes Pharma • Cephalon • JanssenCilag • Grunenthal • Mundipharma • Wyeth

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