Durogesic D-Trans

Fentanyl.

Durogesic is a transdermal system providing continuous systemic delivery of fentanyl, a potent opioid analgesic, for 72 hours. Durogesic is a rectangular transparent patch comprising a protective layer and two functional layers. From the outer surface to the surface adhering to the skin, these layers are: a backing layer of polyester; an adhesive layer of polyacrylate with fentanyl.
Durogesic is available in different strengths, the composition of which per unit area is identical. The strength is imprinted on the patch in orange, pink, and green on Durogesic 12, 25, and 50 μg/hour patches respectively.
Apart from fentanyl, there are no other active components.
Durogesic 12 μg/hour: Active substance: fentanyl 2.1 mg.
The surface area is 5.25 cm². The system releases approximately 12.5 μg/hour fentanyl into the systemic circulation (which represents 0.3 mg/24h).
Durogesic 25 μg/hour: Active substance: fentanyl 4.2 mg.
The surface area is 10.5 cm². The system releases approximately 25 μg/hour fentanyl into the systemic circulation (which represents 0.6 mg/24h).
Durogesic 50 μg/hour: Active substance: fentanyl 8.4 mg.
The surface area is 21.0 cm². The system releases approximately 50 μg/hour fentanyl into the systemic circulation (which represents 1.2 mg/24h).
Excipients/Inactive Ingredients: Durogesic 12 μg/hour: Backing: polyethylene terephthalate (PET) / ethylene-vinyl acetate (EVA) copolymer.
Adhesive layer: polyacrylate Duro-Tak 87-4287.
Protective liner: siliconized polyethylene terephthalate.
Orange ink.
Durogesic 25 μg/hour: Backing: polyethylene terephthalate (PET) / ethylene-vinyl acetate (EVA) copolymer.
Adhesive layer: polyacrylate Duro-Tak 87-4287.
Protective liner: siliconized polyethylene terephthalate.
Red ink.
Durogesic 50 μg/hour: Backing: polyethylene terephthalate (PET) / ethylene-vinyl acetate (EVA) copolymer.
Adhesive layer: polyacrylate Duro-Tak 87-4287.
Protective liner: siliconized polyethylene terephthalate.
Green ink.

Pharmacotherapeutic group: Analgesics, Opioids, phenylpiperidine derivatives. ATC code: N02AB03.
Pharmacology: Pharmacodynamics: Mechanism of action: Fentanyl is an opioid analgesic, interacting predominantly with the μ opioid receptor. Its primary therapeutic actions are analgesia and sedation.
Pharmacokinetics: Absorption: DUROGESIC provides continuous systemic delivery of fentanyl during the 72-hour application period. Following DUROGESIC application, the skin under the system absorbs fentanyl, and a depot of fentanyl concentrates in the upper skin layers. Fentanyl then becomes available to the systemic circulation. The polymer matrix and the diffusion of fentanyl through the layers of the skin ensure that the release rate is relatively constant. The concentration gradient existing between the system and the lower concentration in the skin drives drug release. The average bioavailability of fentanyl after application of the transdermal patch is 92%.
After the first DUROGESIC application, serum fentanyl concentrations increase gradually, generally leveling off between 12 and 24 hours and remaining relatively constant for the remainder of the 72-hour application period. By the end of the second 72-hour application, a steady-state serum concentration is reached and is maintained during subsequent applications of a patch of the same size. Due to accumulation, the AUC and C_max values over a dosing interval at steady state are approximately 40% higher than after a single application. Patients reach and maintain a steady-state serum concentration that is determined by individual variation in skin permeability and body clearance of fentanyl. High inter-subject variability in plasma concentrations has been observed.
A pharmacokinetic model has suggested that serum fentanyl concentrations may increase by 14% (range 0-26%) if a new patch is applied after 24 hours rather than the recommended 72-hour application.
Skin temperature elevation may enhance the absorption of transdermally-applied fentanyl (see Precautions). An increase in skin temperature through the application of a heating pad on low setting over the DUROGESIC system during the first 10 hours of a single application increased the mean fentanyl AUC value by 2.2-fold and the mean concentration at the end of heat application by 61%.
Distribution: Fentanyl is rapidly distributed to various tissues and organs, as indicated by the large volume of distribution (3 to 10 L/kg after intravenous dosing in patients). Fentanyl accumulates in skeletal muscle and fat and is released slowly into blood.
In a study in cancer patients treated with transdermal fentanyl, plasma protein binding was on average 95% (range 77-100%). Fentanyl crosses the blood-brain barrier easily. It also crosses the placenta and is excreted in breast milk.
Biotransformation: Fentanyl is a high clearance active substance and is rapidly and extensively metabolised primarily by CYP3A4 in the liver. The major metabolite, norfentanyl, and other metabolites are inactive. Skin does not appear to metabolise fentanyl delivered transdermally. This was determined in a human keratinocyte cell assay and in clinical studies in which 92% of the dose delivered from the system was accounted for as unchanged fentanyl that appeared in the systemic circulation.
Elimination: Following a 72-hour patch application, the mean fentanyl half-life ranges from 20 to 27 hours. As a result of continued absorption of fentanyl from the skin depot after removal of the patch, the half-life of fentanyl after transdermal administration is about 2- to 3-fold longer than intravenous administration.
After intravenous administration, fentanyl mean total clearance values across studies range in general between 34 and 66 L/h.
Within 72 hours of IV fentanyl administration, approximately 75% of the dose is excreted into the urine and approximately 9% of the dose into the faeces. Excretion occurs primarily, as metabolites, with less than 10% of the dose excreted as unchanged active substance.
Linearity/non-Linearity: The serum fentanyl concentrations attained are proportional to the DUROGESIC patch size. The pharmacokinetics of transdermal fentanyl do not change with repeated application.
Pharmacokinetic/Pharmacodynamic Relationships: There is a high inter-subject variability in fentanyl pharmacokinetics, in the relationships between fentanyl concentrations, therapeutic and adverse effects, and in opioid tolerance. The minimum effective fentanyl concentration depends on the pain intensity and the previous use of opioid therapy. Both the minimum effective concentration and the toxic concentration increase with tolerance. An optimal therapeutic concentration range of fentanyl can therefore not be established. Adjustment of the individual fentanyl dose must be based on the patient's response and level of tolerance. A lag time of 12 to 24 hours after application of the first patch and after a dose increase must be taken into account.
Special populations: Elderly: Data from intravenous studies with fentanyl suggest that elderly patients may have reduced clearance, a prolonged half-life, and they may be more sensitive to the drug than younger patients. In a study conducted with DUROGESIC, healthy elderly subjects had fentanyl pharmacokinetics which did not differ significantly from healthy young subjects although peak serum concentrations tended to be lower and mean half-life values were prolonged to approximately 34 hours. Elderly patients should be observed carefully for signs of fentanyl toxicity and the dose reduced if necessary (see Precautions).
Renal impairment: The influence of renal impairment on the pharmacokinetics of fentanyl is expected to be limited because urinary excretion of unchanged fentanyl is less than 10% and there are no known active metabolites eliminated by the kidney. However, as the influence of renal impairment on the pharmacokinetics of fentanyl has not been evaluated, caution is advised (see Dosage & Administration and Precautions).
Hepatic impairment: Patients with hepatic impairment should be observed carefully for signs of fentanyl toxicity and the dose of DUROGESIC should be reduced if necessary (see Precautions). Data in subjects with cirrhosis and simulated data in subjects with different grades of impaired liver function treated with transdermal fentanyl suggest that fentanyl concentrations may be increased, and fentanyl clearance may be decreased compared to subjects with normal liver function. The simulations suggest that the steady-state AUC of patients with Child-Pugh Grade B liver disease (Child-Pugh Score = 8) would be approximately 1.36 times larger compared with that of patients with normal liver function (Grade A; Child-Pugh Score = 5.5). As for patients with Grade C liver disease (Child-Pugh Score = 12.5), the results indicate that fentanyl concentration accumulates with each administration, leading these patients to have an approximately 3.72 times larger AUC at steady state.
Toxicology: Preclinical safety data: Non-clinical data reveal no special hazard for humans based on conventional studies of repeated dose toxicity.
Standard reproductive and developmental toxicity studies have been carried out using parenteral administration of fentanyl. In a rat study fentanyl did not influence male fertility. Some studies with female rats revealed reduced fertility and enhanced embryo mortality.
Effects on the embryo were due to maternal toxicity and not to direct effects of the substance on the developing embryo. There was no indication of teratogenic effects in studies in two species (rats and rabbits). 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.
Mutagenicity testing in bacteria and in rodents yielded negative results. Fentanyl induced mutagenic effects in mammalian cells in vitro, comparable to other opioid analgesics. A mutagenic risk for the use of therapeutic doses seems unlikely since effects appeared only at high concentrations.
A carcinogenicity study (daily subcutaneous injections of fentanyl hydrochloride for two years in Sprague Dawley rats) did not induce any findings indicative of oncogenic potential.

Adults: DUROGESIC is indicated for management of severe chronic pain that requires continuous long term opioid administration.

Posology: DUROGESIC doses should be individualised based upon the status of the patient and should be assessed at regular intervals after application. The lowest effective dose should be used. The patches are designed to deliver approximately 12, 25, and 50 mcg/h fentanyl to the systemic circulation, which represent about 0.3, 0.6, and 1.2 mg per day respectively.
Initial dosage selection: The appropriate initiating dose of DUROGESIC should be based on the patient's current opioid use. It is recommended that DUROGESIC be used in patients who have demonstrated opioid tolerance. Other factors to be considered are the current general condition and medical status of the patient, including body size, age, and extent of debilitation as well as degree of opioid tolerance.
Adults: Opioid-tolerant patients: To convert opioid-tolerant patients from oral or parenteral opioids to DUROGESIC refer to Equianalgesic potency conversion as follows. The dosage may subsequently be titrated upwards or downwards, if required, in increments of either 12 or 25 mcg/h to achieve the lowest appropriate dosage of DUROGESIC depending on response and supplementary analgesic requirements.
Opioid-naïve patients: Generally, the transdermal route is not recommended in opioid-naïve patients. Alternative routes of administration (oral, parenteral) should be considered. To prevent overdose it is recommended that opioid-naïve patients receive low doses of immediate-release opioids (eg, morphine, hydromorphone, oxycodone, tramadol, and codeine) that are to be titrated until an analgesic dosage equivalent to DUROGESIC with a release rate of 12 mcg/h or 25 mcg/h is attained. Patients can then switch to DUROGESIC.
In the circumstance in which commencing with oral opioids is not considered possible and DUROGESIC is considered to be the only appropriate treatment option for opioid-naïve patients, only the lowest starting dose (ie, 12 mcg/h) should be considered. In such circumstances, the patient must be closely monitored. The potential for serious or life-threatening hypoventilation exists even if the lowest dose of DUROGESIC is used in initiating therapy in opioid-naïve patients (see Precautions and Overdosage).
Equianalgesic potency conversion: In patients currently taking opioid analgesics, the starting dose of DUROGESIC should be based on the daily dose of the prior opioid. To calculate the appropriate starting dose of DUROGESIC, follow the following steps.
1. Calculate the 24-hour dose (mg/day) of the opioid currently being used.
2. Convert this amount to the equianalgesic 24-hour oral morphine dose using the multiplication factors in Table 1 for the appropriate route of administration.
3. To derive the DUROGESIC dosage corresponding to the calculated 24-hour, equianalgesic morphine dosage, use dosage-conversion Table 2 or 3 as follows: a. Table 2 is for adult patients who have a need for opioid rotation or who are less clinically stable (conversion ratio of oral morphine to transdermal fentanyl approximately equal to 150:1).
b. Table 3 is for adult patients who are on a stable, and well-tolerated, opioid regimen (conversion ratio of oral morphine to transdermal fentanyl approximately equal to 100:1).
See Tables 1, 2 and 3.

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Initial evaluation of the maximum analgesic effect of DUROGESIC cannot be made before the patch is worn for 24 hours. This delay is due to the gradual increase in serum fentanyl concentration in the 24 hours following initial patch application.
Previous analgesic therapy should therefore be gradually phased out after the initial dose application until analgesic efficacy with DUROGESIC is attained.
Dose titration and maintenance therapy: The DUROGESIC patch should be replaced every 72 hours.
The dose should be titrated individually on the basis of average daily use of supplemental analgesics, until a balance between analgesic efficacy and tolerability is attained. Dosage titration should normally be performed in 12 mcg/h or 25 mcg/h increments, although the supplementary analgesic requirements (oral morphine 45/90 mg/day ≈ DUROGESIC 12/25 mcg/h) and pain status of the patient should be taken into account. After an increase in dose, it may take up to 6 days for the patient to reach equilibrium on the new dose level. Therefore after a dose increase, patients should wear the higher dose patch through two 72-hour applications before any further increase in dose level is made.
More than one DUROGESIC patch may be used for doses greater than 100 mcg/h. Patients may require periodic supplemental doses of a short acting analgesic for "breakthrough" pain. Some patients may require additional or alternative methods of opioid administration when the DUROGESIC dose exceeds 300 mcg/h.
If analgesia is insufficient during the first application only, the DUROGESIC patch may be replaced after 48 hours with a patch of the same dose, or the dose may be increased after 72 hours.
If the patch needs to be replaced (eg, the patch falls off ) before 72 hours, a patch of the same strength should be applied to a different skin site. This may result in increased serum concentrations (see Pharmacology: Pharmacokinetics under Actions) and the patient should be monitored closely.
Discontinuation of DUROGESIC: If discontinuation of DUROGESIC is necessary, replacement with other opioids should be gradual, starting at a low dose and increasing slowly. This is because fentanyl concentrations fall gradually after DUROGESIC is removed. It may take 20 hours or more for the fentanyl serum concentrations to decrease 50%. In general, the discontinuation of opioid analgesia should be gradual in order to prevent withdrawal symptoms (see Adverse Reactions).
Opioid withdrawal symptoms are possible in some patients after conversion or dose adjustment.
Tables 1, 2, and 3 should only be used to convert from other opioids to DUROGESIC and not from DUROGESIC to other therapies to avoid overestimating the new analgesic dose and potentially causing overdose.
Special populations: Elderly patients: Elderly patients should be observed carefully and the dose should be individualised based upon the status of the patient (see Precautions and Pharmacology: Pharmacokinetics under Actions).
In opioid-naïve elderly patients, treatment should only be considered if the benefits outweigh the risks. In these cases, only DUROGESIC 12 mcg/h dosage should be considered for initial treatment.
Renal and hepatic impairment: Patients with renal or hepatic impairment should be observed carefully and the dose should be individualised based upon the status of the patient (see Precautions and Pharmacology: Pharmacokinetics under Actions).
In opioid-naïve patients with renal or hepatic impairment, treatment should only be considered if the benefits outweigh the risks. In these cases, only DUROGESIC 12 mcg/h dosage should be considered for initial treatment.
Method of administration: DUROGESIC is for transdermal use.
DUROGESIC should be applied to non-irritated and non-irradiated skin on a flat surface of the torso or upper arms.
Hair at the application site (a non-hairy area is preferable) should be clipped (not shaved) prior to application. If the site of DUROGESIC application requires cleansing prior to application of the patch, this should be done with clear water. Soaps, oils, lotions, or any other agent that might irritate the skin or alter its characteristics should not be used. The skin should be completely dry before the patch is applied. Patches should be inspected prior to use. Patches that are cut, divided, or damaged in any way should not be used.
DUROGESIC should be applied immediately upon removal from the sealed package. To remove the patch from the protective sachet, locate the pre-cut notch (indicated by an arrow on the patch label) along the edge of the seal. Fold the sachet at the notch, then carefully tear the sachet material. Further open the sachet along both sides, folding the sachet open like a book. The release liner for the patch is slit. Fold the patch in the middle and remove each half of the liner separately. Avoid touching the adhesive side of the patch. Apply the patch to the skin by applying light pressure with the palm of the hand for about 30 seconds. Make certain that the edges of the patch are adhering properly. Then wash hands with clean water.
DUROGESIC may be worn continuously for 72 hours. A new patch should be applied to a different skin site after removal of the previous transdermal patch. Several days should elapse before a new patch is applied to the same area of the skin.

Symptoms and signs: The manifestations of fentanyl overdose are an extension of its pharmacologic actions, the most serious effect being respiratory depression.
Treatment: For management of respiratory depression, immediate countermeasures include removing the DUROGESIC patch and physically or verbally stimulating 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 interval between IV antagonist doses should be carefully chosen because of the possibility of re-narcotization after the patch is removed; repeated administration or a continuous infusion of naloxone 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 appropriate parenteral fluid therapy.

Hypersensitivity to the active substance or to any of the excipients listed in Description.
Acute or postoperative pain because there is no opportunity for dose titration during short-term use and because serious or life-threatening hypoventilation could result.
Severe respiratory depression.

Patients who have experienced serious adverse events should be monitored for at least 24 hours after removal of DUROGESIC, or more, as clinical symptoms dictate, because serum fentanyl concentrations decline gradually and are reduced by about 50% 20 to 27 hours later.
Patients and their carers must be instructed that DUROGESIC contains an active substance in an amount that can be fatal, especially to a child. Therefore, they must keep all patches out of the sight and reach of children, both before and after use.
Opioid-naïve and not opioid-tolerant states: Use of DUROGESIC in the opioid-naïve patient has been associated with very rare cases of significant respiratory depression and/or fatality when used as initial opioid therapy, especially in patients with non-cancer pain. The potential for serious or life-threatening hypoventilation exists even if the lowest dose of DUROGESIC is used in initiating therapy in opioid-naïve patients, especially in elderly or patients with hepatic or renal impairment. The tendency of tolerance development varies widely among individuals. It is recommended that DUROGESIC is used in patients who have demonstrated opioid tolerance (see Dosage & Administration).
Respiratory depression: Some patients may experience significant respiratory depression with DUROGESIC; patients must be observed for these effects. Respiratory depression may persist beyond the removal of the DUROGESIC patch. The incidence of respiratory depression increases as the DUROGESIC dose is increased (see Overdosage). Central nervous system depressants may increase the respiratory depression (see Interactions).
Chronic pulmonary disease: DUROGESIC may have more severe adverse effects in patients with chronic obstructive or other pulmonary disease. In such patients, opioids may decrease respiratory drive and increase airway resistance.
Drug dependence and potential for abuse: Tolerance, physical dependence, and psychological dependence may develop upon repeated administration of opioids.
Fentanyl can be abused in a manner similar to other opioid agonists. Abuse or intentional misuse of DUROGESIC may result in overdose and/or death. Patients with a prior history of drug dependence/alcohol abuse are more at risk to develop dependence and abuse in opioid treatment. Patients at increased risk of opioid abuse may still be appropriately treated with modified-release opioid formulations; however, these patients will require monitoring for signs of misuse, abuse, or addiction.
Central Nervous System conditions including increased intracranial pressure: DUROGESIC should be used with caution in patients who may be particularly susceptible to the intracranial effects of CO₂ retention such as those with evidence of increased intracranial pressure, impaired consciousness, or coma. DUROGESIC should be used with caution in patients with brain tumours.
Cardiac disease: Fentanyl may produce bradycardia and should therefore be administered with caution to patients with bradyarrhythmias.
Hypotension: Opioids may cause hypotension, especially in patients with acute hypovolaemia. Underlying, symptomatic hypotension and/or hypovolaemia should be corrected before treatment with fentanyl transdermal patches is initiated.
Hepatic impairment: Because fentanyl is metabolised to inactive metabolites in the liver, hepatic impairment might delay its elimination. If patients with hepatic impairment receive DUROGESIC, they should be observed carefully for signs of fentanyl toxicity and the dose of DUROGESIC reduced if necessary (see Pharmacology: Pharmacokinetics under Actions).
Renal impairment: Even though impairment of renal function is not expected to affect fentanyl elimination to a clinically relevant extent, caution is advised because fentanyl pharmacokinetics has not been evaluated in this patient population (see Pharmacology: Pharmacokinetics under Actions). If patients with renal impairment receive DUROGESIC, they should be observed carefully for signs of fentanyl toxicity and the dose reduced if necessary. Additional restrictions apply to opioid-naïve patients with renal impairment (see Dosage & Administration).
Fever/external heat application: Fentanyl concentrations may increase if the skin temperature increases (see Pharmacology: Pharmacokinetics under Actions). Therefore, patients with fever should be monitored for opioid undesirable effects and the DUROGESIC dose should be adjusted if necessary. There is a potential for temperature-dependent increases in fentanyl released from the system resulting in possible overdose and death.
All patients should be advised to avoid exposing the DUROGESIC application site to direct external heat sources such as heating pads, electric blankets, heated water beds, heat or tanning lamps, sunbathing, hot water bottles, prolonged hot baths, saunas and hot whirlpool spa baths.
Serotonin syndrome: Caution is advised when DUROGESIC is co-administered with medicinal products that affect the serotonergic neurotransmitter systems.
The development of a potentially life-threatening serotonin syndrome may occur with the concomitant use of serotonergic active substances such as Selective Serotonin Re-uptake Inhibitors (SSRIs) and Serotonin Norepinephrine Re-uptake Inhibitors (SNRIs), and with active substances which impair metabolism of serotonin (including Monoamine Oxidase Inhibitors [MAOIs]). This may occur within the recommended dose.
Serotonin syndrome may include mental-status changes (eg, agitation, hallucinations, coma), autonomic instability (eg, tachycardia, labile blood pressure, hyperthermia), neuromuscular abnormalities (eg, hyperreflexia, incoordination, rigidity), and/or gastrointestinal symptoms (eg, nausea, vomiting, diarrhoea).
If serotonin syndrome is suspected, treatment with DUROGESIC should be discontinued.
Interactions with other medicinal products: CYP3A4 inhibitors: The concomitant use of DUROGESIC with cytochrome P450 3A4 (CYP3A4) inhibitors may result in an increase in fentanyl plasma concentrations, which could increase or prolong both the therapeutic and adverse effects, and may cause serious respiratory depression. Therefore, the concomitant use of DUROGESIC and CYP3A4 inhibitors is not recommended unless the benefits outweigh the increased risk of adverse effects. Generally, a patient should wait for 2 days after stopping treatment with a CYP3A4 inhibitor before applying the first DUROGESIC patch. However, the duration of inhibition varies and for some CYP3A4 inhibitors with a long elimination half-life, such as amiodarone, or for time-dependent inhibitors such as erythromycin, idelalisib, nicardipine and ritonavir, this period may need to be longer. Therefore, the product information of the CYP3A4 inhibitor must be consulted for the active substance's half-life and duration of the inhibitory effect before applying the first DUROGESIC patch. A patient who is treated with DUROGESIC should wait at least 1 week after removal of the last patch before initiating treatment with a CYP3A4 inhibitor. If concomitant use of DUROGESIC with a CYP3A4 inhibitor cannot be avoided, close monitoring for signs or symptoms of increased or prolonged therapeutic effects and adverse effects of fentanyl (in particular respiratory depression) is warranted, and the DUROGESIC dosage must be reduced or interrupted as deemed necessary (see Interactions).
Accidental exposure by patch transfer: Accidental transfer of a fentanyl patch to the skin of a non-patch wearer (particularly a child), while sharing a bed or being in close physical contact with a patch wearer, may result in an opioid overdose for the non-patch wearer. Patients should be advised that if accidental patch transfer occurs, the transferred patch must be removed immediately from the skin of the non-patch wearer (see Overdosage).
Gastrointestinal tract: Opioids increase the tone and decrease the propulsive contractions of the smooth muscle of the gastrointestinal tract. The resultant prolongation in gastrointestinal transit time may be responsible for the constipating effect of fentanyl. Patients should be advised on measures to prevent constipation and prophylactic laxative use should be considered. Extra caution should be used in patients with chronic constipation. If paralytic ileus is present or suspected, treatment with DUROGESIC should be stopped.
Patients with myasthenia gravis: Non-epileptic (myo)clonic reactions can occur. Caution should be exercised when treating patients with myasthenia gravis.
Concomitant use of mixed opioid agonists/antagonists: The concomitant use of buprenorphine, nalbuphine or pentazocine is not recommended (see also Interactions).
Effects on ability to drive and use machines: DUROGESIC may impair mental and/or physical ability required for the performance of potentially hazardous tasks such as driving or operating machinery.
Use in the Elderly: Data from intravenous studies with fentanyl suggest that elderly patients may have reduced clearance, a prolonged half-life, and they may be more sensitive to the active substance than younger patients. If elderly patients receive DUROGESIC, they should be observed carefully for signs of fentanyl toxicity and the dose reduced if necessary (see Pharmacology: Pharmacokinetics under Actions).

Pregnancy: There are no adequate data from the use of DUROGESIC in pregnant women. Studies in animals have shown some reproductive toxicity (see Pharmacology: Toxicology: Preclinical safety data under Actions). The potential risk for humans is unknown, although fentanyl as an IV anaesthetic has been found to cross the placenta in human pregnancies. Neonatal withdrawal syndrome has been reported in newborn infants with chronic maternal use of DUROGESIC during pregnancy. DUROGESIC should not be used during pregnancy unless clearly necessary.
Use of DUROGESIC during childbirth is not recommended because it should not be used in the management of acute or postoperative pain (see Contraindications). Moreover, because fentanyl passes through the placenta, the use of DUROGESIC during childbirth might result in respiratory depression in the newborn infant.
Breastfeeding: Fentanyl is excreted into human milk and may cause sedation/respiratory depression in a breastfed infant. Breastfeeding should therefore be discontinued during treatment with DUROGESIC and for at least 72 hours after removal of the patch.
Fertility: There are no clinical data on the effects of fentanyl on fertility. Some studies in rats have revealed reduced fertility and enhanced embryo mortality at maternally toxic doses (see Pharmacology: Toxicology: Preclinical safety data under Actions).

The safety of DUROGESIC was evaluated in 1565 adult and 289 paediatric subjects who participated in 11 clinical studies (1 double-blind, placebo-controlled; 7 open-label, active-controlled; 3 open-label, uncontrolled) used for the management of chronic malignant or non-malignant pain. These subjects received at least one dose of DUROGESIC and provided safety data. Based on pooled safety data from these clinical studies, the most commonly reported (ie ≥10% incidence) adverse reactions were: nausea (35.7%), vomiting (23.2%), constipation (23.1%), somnolence (15.0%), dizziness (13.1%), and headache (11.8%).
The adverse reactions reported with the use of DUROGESIC from these clinical studies, including the previously mentioned adverse reactions, and from post-marketing experiences are listed as follows in Table 4.
The displayed frequency categories use the following convention: 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); not known (cannot be estimated from the available clinical data). The adverse reactions are presented by System Organ Class and in order of decreasing seriousness within each frequency category. (See Table 4.)

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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 local regulatory guideline.

Pharmacodynamic-related interactions: Centrally-acting medicinal products and alcohol: The concomitant use of other central nervous system depressants, (including opioids, sedatives, hypnotics, general anaesthetics, phenothiazines, tranquilizers, sedating antihistamines, and alcoholic beverages) and skeletal muscle relaxants, may produce additive depressant effects; hypoventilation, hypotension, profound sedation, coma or death may occur. Therefore, the use of any of these medicinal products concomitantly with DUROGESIC requires special patient care and observation.
Monoamine Oxidase Inhibitors (MAOI): DUROGESIC is not recommended for use in patients who require the concomitant administration of a MAOI. Severe and unpredictable interactions with MAOIs, involving the potentiation of opiate effects or the potentiation of serotoninergic effects, have been reported. Therefore, DUROGESIC should not be used within 14 days after discontinuation of treatment with MAOIs.
Serotonergic medicinal products: Co-administration of fentanyl with a serotonergic medicinal products, 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.
Concomitant use of mixed opioid agonists/antagonists: The concomitant use of buprenorphine, nalbuphine or 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 (see also Precautions).
Pharmacokinetic-related interactions: CYP3A4 Inhibitors: Fentanyl, a high clearance active substance, is rapidly and extensively metabolised mainly by CYP3A4.
The concomitant use of DUROGESIC with cytochrome P450 3A4 (CYP3A4) inhibitors may result in an increase in fentanyl plasma concentrations, which could increase or prolong both the therapeutic and adverse effects, and may cause serious respiratory depression. The extent of interaction with strong CYP3A4 inhibitors is expected to be greater than with weak or moderate CYP3A4 inhibitors. Cases of serious respiratory depression after coadministration of CYP3A4 inhibitors with transdermal fentanyl have been reported, including a fatal case after coadministration with a moderate CYP3A4 inhibitor. The concomitant use of CYP3A4 inhibitors and DUROGESIC is not recommended, unless the patient is closely monitored (see Precautions). Examples of active substances that may increase fentanyl concentrations include: amiodarone, cimetidine, clarithromycin, diltiazem, erythromycin, fluconazole, itraconazole, ketoconazole, nefazodone, ritonavir, verapamil and voriconazole (this list is not exhaustive). After coadministration of weak, moderate or strong CYP3A4 inhibitors with short-term intravenous fentanyl administration, decreases in fentanyl clearance were generally ≤25%, however with ritonavir (a strong CYP3A4 inhibitor), fentanyl clearance decreased on average 67%. The extent of the interactions of CYP3A4 inhibitors with long-term transdermal fentanyl administration is not known, but may be greater than with short-term intravenous administration.
CYP3A4 Inducers: The concomitant use of transdermal fentanyl with CYP3A4 inducers may result in a decrease in fentanyl plasma concentrations and a decreased therapeutic effect. Caution is advised upon concomitant use of CYP3A4 inducers and DUROGESIC. The dose of DUROGESIC may need to be increased or a switch to another analgesic active substance may be needed. A fentanyl dose decrease and careful monitoring is warranted in anticipation of stopping concomitant treatment with a CYP3A4 inducer. The effects of the inducer decline gradually and may result in increased fentanyl plasma concentrations, which could increase or prolong both the therapeutic and adverse effects, and may cause serious respiratory depression. Careful monitoring should be continued until stable drug effects are achieved. Examples of active substance that may decrease fentanyl plasma concentrations include: carbamazepine, phenobarbital, phenytoin and rifampicin (this list is not exhaustive).
Paediatric population: Interaction studies have only been performed in adults.

Special precautions for disposal and other handling: Instructions for disposal: Used patches should be folded so that the adhesive side of the patch adheres to itself and then they should be safely discarded. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Incompatibilities: Not applicable.

Store in original unopened pouch.

Putting a patch on: Step 1: Preparing the skin.
Make sure your skin is completely dry, clean and cool before you put the patch on.
If you need to clean the skin, just use cold water.
Do not use soap or any other cleansers, creams, moisturisers, oils or talc before applying the patch.
Do not stick a patch on straight after a hot bath or shower.
Step 2: Open the sachet.
Each patch is sealed in its own sachet.
Tear or cut open the sachet at the notch.
Gently tear or cut off the edge of the sachet completely (if you use scissors, cut close to the sealed edge of the sachet to avoid damaging the patch).
Grasp both sides of the opened sachet and pull apart.
Take the patch out and use straight away.
Keep the empty sachet to dispose of the used patch later.
Use each patch once only.
Do not take the patch out of its sachet until you are ready to use it.
Inspect the patch for any damage.
Do not use the patch if it has been divided, cut or looks damaged.
Never divide or cut the patch.
Step 3: Peel and press.
Make sure that the patch will be covered by loose clothing and not stuck under a tight or elasticated band.
Carefully peel one half of the shiny plastic backing away from the centre of the patch. Try not to touch the sticky side of the patch.
Press this sticky part of the patch onto the skin.
Remove the other part of the backing and press the whole patch onto the skin with the palm of your hand.
Hold for at least 30 seconds. Make sure it sticks well, especially the edges.
Step 4: Disposing of the patch.
As soon as you take a patch off, fold it firmly in half so that the sticky side sticks to itself.
Put it back in its original sachet and dispose of the sachet as instructed by your pharmacist.
Keep used patches out of sight and reach of children - even used patches contain some medicine which may harm children and may even be fatal.
Step 5: Wash.
Always wash your hands after you have handled the patch using clean water only.

Analgesics (Opioid)

N02AB03 - fentanyl ; Belongs to the class of phenylpiperidine derivative opioids. Used to relieve pain.

DD, P₁S₁