Parenteral rescue medication (i.e. subcutaneous, intravenous)

Parenteral opioids are frequently used in the management of breakthrough pain in the secondary care setting (i.e. hospital, hospice), and sometimes in the primary care setting (i.e. home, nursing home) [1]. Parenteral opioids are associated with a rapid onset of analgesia (5-10 min), but can be associated with a prolonged duration of effect (see above) [1]. However, their use is limited by practical issues [1], and, to a lesser extent, by the reluctance of patients to use parenteral routes of administration [2].

Oral transmucosal rescue medication (i.e. buccal, sublingual)

The oral transmucosal routes of administration are well established in the management of breakthrough pain episodes [3]. A number of commercial formulations are being / have been developed utilising these routes of administration:

Abstral® (Prostrakan)

Formulation: Fentanyl citrate; tablet; sublingual administration
Status: Marketing authorisation in Europe for the management of breakthrough cancer pain

Product information
AbstralSPC (UK)
AbstralPIL (UK)
How To Use Abstral (UK)

Other information
EMEA Report Abstral

Pharmaceutical company website:
http://www.prostrakan.com

Actiq® (Cephalon)

Synonym: Oral transmucosal fentanyl citrate (OTFC)
Formulation: Fentanyl citrate; lozenge on a stick; buccal administration
Status: Marketing authorisation in Europe and elsewhere in the world for the management of breakthrough cancer pain

Product information
ActiqSPC (UK)
ActiqPIL (UK)
How To Use Actiq (UK)

Pharmaceutical company websites:
http://www.cephalon.com
http://www.actiq.com (US site)

Effentora® / Fentora® (Cephalon)

Synonym: Fentanyl buccal tablet
Formulation: Fentanyl citrate; effervescent tablet (Oravescent® technology); buccal administration
Status: Marketing authorisation in Europe and elsewhere in the world for the management of breakthrough cancer pain

Product information
EffentoraSPC (UK)
EffentoraPIL (UK)
How To Use Effentora (UK)

Other information
Effentora Formulary Monograph (UK)
Effentora Titration Schedule (UK)
EMEA Report Effentora
EMEA Public Summary Effentora

Pharmaceutical company websites:
http://www.cephalon.com
http://www.fentora.com (US site)

Onsolis® (MEDA AB)

Synonym: BEMA® fentanyl
Formulation: Fentanyl citrate; soluble film (BEMA® technology http://www.biodeliverysciences.com); buccal administration
Status: Approved by FDA in United States for the management of breakthrough cancer pain; marketing authorisation applied for in Europe for the management of breakthrough cancer pain

Pharmaceutical company website:
http://www.meda.se
http://onsolis.com (US site)

Intranasal rescue medication

The intranasal route of administration is also well established in the management of breakthrough pain episodes [1]. A couple of commercial formulations are being / have been developed utilising this route of administration:

Instanyl® (Nycomed)

Formulation: Fentanyl citrate; aqueous spray; nasal administration
Status: Marketing authorisation in Europe for the management of breakthrough cancer pain

Product information
InstanylSPC(UK)
InstanylPIL(UK)
How To Use Instanyl (UK)
How To Prescribe Instanyl(UK)
How To Dispense Instanyl(UK)

Other information
EMEA Report Instanyl
EMEA Public Summary Instanyl

Pharmaceutical company website:
http://www.nycomed.com

Nasalfent® (Archimedes Pharma Ltd)

Formulation: Fentanyl citrate; aqueous spray (PecSys® technology); nasal administration
Status: Marketing authorisation applied for in Europe for the management of breakthrough cancer pain

Synonym: Fentanyl Pectin Nasal Spray

Pharmaceutical company website:
http://www.archimedespharma.com

Intrapulmonary rescue medication
The intrapulmonary route of administration has also been used in the management of breakthrough pain episodes [4]. A number of commercial formulations are being developed utilising this route of administration.

References
[1]. Dale O. Opioid drugs via other routes. In: Davies A, editor. Cancer-related breakthrough pain. Oxford: Oxford University Press; 2006. p. 73-82.
[2]. Walker G, Wilcock A, Manderson C, Weller R, Crosby V. The acceptability of different routes of administration of analgesia for breakthrough pain. Palliative Medicine 2003; 17: 219-21.
[3]. Zeppetella G. Oral transmucosal opioid drugs. In: Davies A, editor. Cancer-related breakthrough pain. Oxford: Oxford University Press; 2006. p. 57-71.
[4]. Dale O. Opioid drugs via other routes. In: Davies A, editor. Cancer-related breakthrough pain. Oxford: Oxford University Press; 2006. p. 73-82.