530 Use of Buccal Fentanyl as a breakthrough opioid for symptom management in patients receiving palliative care

Objectives

Using transmucosal fentanyl as an opioid for rapid acting, needle-free breakthrough relief of symptoms is established within paediatric palliative medicine.^{1 2} Medication administration via the buccal route is commonly used in paediatric palliative medicine, especially towards the end of life. It does not rely on enteral absorption; it is generally well tolerated, and parents/carers can be taught to administer medication via this route. Buccal administration of fentanyl is possible^{3 4} but infrequently used as dosing guidance is not readily available including within the APPM formulary.²

Methods

We performed a multi-centre retrospective case review of patients using buccal fentanyl under supervision of tertiary specialist palliative care teams (SPCTs). Information was gathered on patient age, diagnosis, symptoms (pain, dyspnoea), weight, starting doses, dose escalation, maximum doses, other symptom medications, setting in which patient was cared for, any administration difficulties and adverse effects.

Results

Buccal fentanyl (IV solution administered into the buccal cavity) was used in the management of 9 patients under the two SPCTs, with problems across the paediatric palliative care spectrum including those with severe neurological impairment and oncology diagnoses. Patients were aged 5 weeks to 17yrs 11 months with weights ranging from 4kg to 61.3kg (mean = 24.4kg). Fentanyl was used to manage pain and dyspnoea in 6 patients, dyspnoea in two, and pain in one. Starting doses for dyspnoea ranged from 0.4micrograms/kg to 0.9micrograms/kg (mean = 0.7micrograms/kg) and for pain ranged from 0.4micrograms/kg to 1.5micrograms/kg (mean = 0.9 micrograms/kg). Three patients required dose escalation as part of their ongoing management with the highest dose required 20 micrograms/kg. Six patients were opioid naïve at the time of starting fentanyl. Patients were cared for across community, hospice and hospital settings. No adverse effects were encountered. Administration difficulties occurred for one patient on high-dose fentanyl due to the large volume of the IV solution required for buccal administration (200 micrograms = 4mls).

Conclusions

The use of buccal fentanyl for breakthrough opioid medication as part of a palliative care symptom plan appears a safe and effective method of delivering fast-acting symptom relief which is well tolerated by patients and acceptable to families. This case series has demonstrated safe and effective starting doses for pain and dyspnoea management. For patients requiring higher doses the large volume of IV solution required for buccal administration may mean alternative preparations for trans-mucosal fentanyl administration become more practical.

References

Coombes L, Burke K, Anderson AK. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain. Scandinavian Journal of Pain 2017;17(1):256–259. Association for Paediatric Palliative Medicine, The Association of Paediatric Palliative Medicine Master Formulary 2020 (5th Edition). Available at https://www.appm.org.uk/_webedit/uploaded-files/All%20Files/Event%20Resources/2020%20APPM%20Master%20Formulary%202020%20protected.pdf [Accessed 04/02/2023]. Sutherland AE, Presland M, Harrop E, et al. BMJ Supportive & Palliative Care Epub ahead of print: [04/02/223]. doi:10.1136/bmjspcare-2020-002784 Harrop E, Jamieson L, Choy TH, et al. BMJ Supportive & Palliative Care 2018;8:355–356.