Quatrofen
SUMMARY OF PRODUCT CHARACTERISTICS
1. NAME OF THE MEDICINAL PRODUCT
Quatrofen, 12 micrograms/hour Transdermal patch
Quatrofen, 25 micrograms/hour Transdermal patch
Quatrofen, 50 micrograms/hour Transdermal patch
Quatrofen, 75 micrograms/hour Transdermal patch
Quatrofen, 100 micrograms/hour Transdermal patch
2. QUALITATIVE AND QUANTITATIVE COMPOSITION
Quatrofen 12 micrograms/hour: Each transdermal patch contains 1.38 mg fentanyl in a patch of 4.2 cm2 and releases fentanyl 12 micrograms/hour
Quatrofen 25 micrograms/hour: Each transdermal patch contains 2.75 mg fentanyl in a patch of 8.4 cm2 and releases fentanyl 25 micrograms/hour
Quatrofen 50 micrograms/hour: Each transdermal patch contains 5.50 mg fentanyl in a patch of 16.8 cm2 and releases fentanyl 50 micrograms/hour
Quatrofen 75 micrograms/hour: Each transdermal patch contains 8.25 mg fentanyl in a patch of 25.2 cm2 and releases fentanyl 75 micrograms/hour
Quatrofen 100 micrograms/hour: Each transdermal patch contains 11.0 mg fentanyl in a patch of 33.6 cm2 and releases fentanyl 100 micrograms/hour
For the full list of excipients, see section 6.1.
3. PHARMACEUTICAL form
Transdermal patch.
Rectangular, translucent patch on a removable protective film. The protective film is larger than the patch.
Patches are marked with a coloured imprint stating the trade name and strength:
Quatrofen 12 micrograms/hour patch: brown imprint
Quatrofen 25 micrograms/hour patch: red imprint
Quatrofen 50 micrograms/hour patch: green imprint
Quatrofen 75 micrograms/hour patch: light blue imprint
Quatrofen 100 micrograms/hour patch: grey imprint
4. Clinical particulars
4.1 Therapeutic indications
Adults:
Severe chronic pain, which can be adequately managed only with opioid analgesics.
Children:
Long term management of severe chronic pain in children receiving opioid therapy from 2 years of age.
4.2 Posology and method of administration
Posology
Fentanyl transdermal patches release the active substance over 72 hours. The fentanyl release rate is 12, 25, 50, 75 and 100 microgram/hour and the corresponding active surface area is 4.2, 8.4, 16.8, 25.2 and 33.6 cm2.
The required fentanyl dosage is adjusted individually and should be assessed regularly after each administration.
Choice of initial dosage
The dosage level of fentanyl is based upon the previous use of opioids and takes into account the possible development of tolerance, concomitant medicinal treatment, the patient's general state of health and the degree of severity of the disorder.
Adults:
Opioid-tolerant patients
To convert opioid-tolerant patients from oral or parenteral opioids to Quatrofen refer to Equianalgesic potency conversion below. The dosage may subsequently be titrated upwards or downwards, if required, in increments of either 12 or 25 mcg/hr to achieve the lowest appropriate dose of Quatrofen depending on response and supplementary analgesic requirements.
Opioid-naive patients
The initial dosage should not exceed 12 micrograms/hour when the opioid response pattern for the pain condition is not fully known.
Clinical experience with fentanyl transdermal patch is limited in opioid-naïve patients. In the circumstances in which therapy with fentanyl transdermal patch is considered appropriate in opioid-naïve patients, it is recommended that these patients be titrated with low doses of immediate release opioids (e.g., morphine, hydromorphone, oxycodone, tramadol, and codeine) to attain equianalgesic dosage relative to fentanyl transdermal patch. Patients can then be converted to fentanyl transdermal patch. The dose may subsequently be titrated upwards or downwards, if required, in increments of 12 or 25 mcg/hr to achieve the lowest appropriate dose of fentanyl transdermal patch depending on the response and supplementary analgesic requirements (see also section 4.4 Special warnings and precautions for use: Opioid naïve and not opioid-tolerant states).
Equianalgesic potency conversion
1. Calculate the previous 24-hour analgesic requirement.
2. Convert this amount to the equianalgesic oral morphine dose using Table 1. All IM and oral doses in this chart are considered equivalent to 10 mg of IM morphine in analgesic effect.
3. To derive the dosage of Quatrofen corresponding to the calculated 24-hour, equianalgesic morphine dosage, use the dosage-conversion Table 2 or Table 3 as follows:
Table 2 is for adult patients who have been stabilised on oral morphine or another immediate-release opioid over several weeks and who need opioid rotation (conversion ratio of oral morphine to transdermal fentanyl approximately equal to 150:1).
Table 3 is for highly opioid-tolerant adult patients who have been on a stable and well-tolerated opioid regimen for a long period, and who need opioid rotation (conversion ratio of oral morphine to transdermal fentanyl approximately equal to 100:1).
Tables 2 and 3 should not be used to switch from transdermal fentanyl to another opioid treatment.
Table 1: Equianalgesic potency conversion
|
Name of medicinal product |
Equianalgesic dosage (mg) |
|
|
|
i.m.* |
Oral |
|
|
|
|
|
Morphine |
10 |
30 - 40 (assuming repeated administration)** |
|
|
|
60 (assuming a single dose or occasional doses) |
|
Hydromorphone |
1.5 |
7.5 |
|
Methadone |
10 |
20 |
|
Oxycodone |
10-15 |
20-30 |
|
Levorphanol |
2 |
4 |
|
Oxymorphine |
1 |
10 (rectal) |
|
Diamorphine |
5 |
60 |
|
Pethidine |
75 |
- |
|
Codeine |
- |
200 |
|
Buprenorphine |
0.4 |
0.8 (sublingual) |
|
Ketobemidone |
10 |
30 |
|
|
|
|
* Based on studies conducted with single doses, in which the i.m. dosage of each above-mentioned agent was compared with morphine in order to achieve an equivalent efficacy. Oral dosages are the recommended dosages when changing from parenteral to oral administration.
** The efficacy ratio of 3:1 for morphine i.m./oral dosages is based upon a study conducted in patients suffering from chronic pain.
Table 2: Recommended initial dose of Quatrofen based upon daily oral morphine dose(for patients stabilised on oral morphine or immediate release opioid for several weeks and who need opioid rotation)
|
Oral morphine dose per 24-hours (mg/day) |
Dose of Quatrofen transdermal patch micrograms/hour |
|
<44 |
12 |
|
45-134 |
25 |
|
135-224 |
50 |
|
225-314 |
75 |
|
315-404 |
100 |
|
405-494 |
125 |
|
495-584 |
150 |
|
585-674 |
175 |
|
675-764 |
200 |
|
765-854 |
225 |
|
855-944 |
250 |
|
945-1034 |
275 |
|
1035-1124 |
300 |
|
|
|
Conversion schemes are based on clinical trials. Schemes based on other trials have been found useful in clinical practice and may be used.
Table 3: Recommended starting dosage of Quatrofen based upon daily oral morphine dosage (for patients on stable and well tolerated opioid therapy for long periods and who need opioid rotation)
|
Oral morphine dose per 24-hours (mg/day) |
Dose of Quatrofen transdermal patch micrograms/hour |
|
|
|
|
< 44 |
12 |
|
45-89 |
25 |
|
90-149 |
50 |
|
150-209 |
75 |
|
210-269 |
100 |
|
270-329 |
125 |
|
330-389 |
150 |
|
390-449 |
175 |
|
450-509 |
200 |
|
510-569 |
225 |
|
570-629 |
250 |
|
630-689 |
275 |
|
690-749 |
300 |
|
|
|
Previous analgesic therapy should be phased out gradually from the time of the first patch application until analgesic efficacy with Quatrofen is attained. For both strong opioid-naïve and opioid tolerant patients, the initial evaluation of the analgesic effect of Quatrofen should not be made until the patch has been worn for 24 hours due to the gradual increase in serum fentanyl concentrations up to this time.
Dose titration and maintenance therapy
The patch should be replaced every 72 hours. The dose should be titrated individually until a balance between analgesic efficacy and tolerability is attained. In patients who experience a marked decrease in the period 48-72 hours after application, replacement of fentanyl after 48 hours may be necessary. The dose 12 micrograms/hour is appropriate for dose titration in the lower dosage area. If analgesia is insufficient at the end of the initial application period, the dose may be increased after 3 days, until the desired effect is obtained for each patient. Additional dose adjustment should normally be performed in 12 micrograms/hour or 25 micrograms/hour increments, although the supplementary analgesic requirements and pain status of the patient should be taken into account. More than one patch may be used for dose adjustments and for doses greater than 100 micrograms/hour. Patients may require periodic supplemental doses of a short-acting analgesic for breakthrough pain. Additional or alternative methods of analgesia or alternative administration of opioids should be considered when the Quatrofen dose exceeds 300 micrograms/hour.
Opioid Withdrawal symptoms (see section 4.8, Undesirable effects) have been reported when changing from long-term treatment with Morphine to transdermal fentanyl despite adequate analgesic efficacy. In case of withdrawal symptoms it is recommended to treat those with short-acting Morphine in low doses.
Discontinuation of Quatrofen
If discontinuation of the patch is necessary, any replacement with other opioids should be gradual, starting at a low dose and increasing slowly. This is because fentanyl levels fall gradually after the patch is removed; it takes at least 17 hours for the fentanyl serum concentration to decrease by 50% (see section 5.2). As a general rule, the discontinuation of opioid analgesia should be gradual, in order to prevent withdrawal symptoms (nausea, vomiting, diarrhea, anxiety and muscular tremor).
Table 2 and Table 3 should not be used to convert from Quatrofen to other therapies to avoid overestimating the new analgesic dose and potentially causing overdose.
Use in older people
Elderly or cachectic patients should be observed carefully and the dose reduced if necessary (see section 4.4).
Use in patients with hepatic or renal impairment
Patients with impaired hepatic or renal function should carefully be observed for symptoms of an overdosage and the dose should possibly be reduced (see section 4.4).
Use in febrile patients
Dose adjustment may be necessary in patients during episodes of fever (see section 4.4).
Use in paediatric population
Children aged 16 years and above: follow adult dosage.
Children aged 2 to 16 years old:
Quatrofen should be administered only to opioid-tolerant paediatric patients (ages 2 to 16 years) who are already receiving at least 30 mg oral morphine equivalent per day. To convert paediatric patients from oral or parenteral opioids to Quatrofen, refer to “Equianalgesic potency conversion” (Table 1), and “Recommended initial Quatrofen dose based upon daily oral morphine dose” (Table 4).
Table 4: Recommended initial dose of Quatrofen based upon daily oral morphine dose1
|
Oral morphine dose per 24-hours (mg/day) |
Dose of Quatrofen transdermal patch micrograms/hour |
|
|
|
|
For paediatric patients2 |
For paediatric patients2 |
|
30-44 |
12 |
|
45-134 |
25 |
|
|
|
1 In clinical trials these ranges of daily oral morphine doses were used as a basis for conversion to Quatrofen.
2 Conversion to Quatrofen doses greater than 25 micrograms/hour is the same for adult and paediatric patients.
For children who receive more than 90 mg oral morphine a day, only limited information is currently available from clinical trials. In the paediatric studies, the required fentanyl transdermal patch dose was calculated conservatively: 30 mg to 44 mg oral morphine per day or its equivalent opioid dose was replaced by one fentanyl 12 microgram/hour patch. It should be noted that this conversion schedule for children only applies to the switch from oral morphine (or its equivalent) to fentanyl patches. The conversion schedule could not be used to convert from fentanyl into other opioids, as overdose could then occur.
The analgesic effect of the first dose of Quatrofen patches will not be optimal within the first 24 hours. Therefore, during the first 12 hours after switching to Quatrofen, the patients should be given the previous regular dose of analgesics. In the next 12 hours, these analgesics should be provided based on clinical need.
Since peak fentanyl levels occur after 12 to 24 hours of treatment, monitoring of the patient for adverse events, which may include hypoventilation, is recommended for at least 48 hours after initiation of Quatrofen therapy or up-titration of the dose (see also section 4.4 Special warnings and precautions for use).
Dose titration and maintenance.
If the analgesic effect of Quatrofen is insufficient, supplementary morphine or another short-duration opioid should be administered. Depending on the additional analgesic needs and the pain status of the child, it may be decided to increase the dose. Dose adjustments should be done in 12 micrograms/hour steps.
Method of administration
For transdermal use.
Fentanyl transdermal patch should be applied to non-irritated and non-irradiated skin on a flat surface of the torso or upper arm. In young children the upper back is the preferred location to apply the patch, to minimize the potential of the child removing the patch. Hair at the application site (hairless area is preferred) should be clipped (not shaved) prior to system application. If the site requires to be cleansed prior to application of the patch, this should be done with water. Soaps, oils, lotions, alcohol or any other agent that might irritate the skin or alter its characteristics should not be used. The skin should be completely dry before application of the patch.
Patches should be inspected prior to use. The transdermal patch should not be divided or cut (see section 4.4). Patches that are cut, divided, or damaged in any way should not be used.
Since the transdermal patch is protected outwardly by a waterproof covering foil, it may also be worn when taking a short shower.
The Quatrofen patch should be removed from the protective pouch by first folding the notch (located close to the tip of the arrow on the pouch label) and then carefully tearing the pouch material. If scissors are used to open the pouch, this should be done close to the sealed edge so as not to damage the patch inside.
Fentanyl transdermal patch is to be attached as soon as the pack has been opened and avoid touching the adhesive side of the patch.
Following removal of the protective layer, the transdermal patch should be pressed firmly in place with the palm of the hand for approximately 30 seconds, making sure the contact is complete, especially around the edges. An additional fixing of the transdermal patch may be necessary. Then wash hands with clean water. Fentanyl transdermal patch should be worn continuously for 72 hours after which the transdermal patch is replaced. A new transdermal patch should always be applied to a different site from the previous one. The same application site may be re-used only after an interval of at least 7 days.
For disposal instructions see section 6.6.
4.3 Contraindications
Quatrofen is contraindicated in patients with known hypersensitivity to fentanyl or to any of the excipients listed in section 6.1.
Acute or postoperative pain, since dose titration is not possible during short-term use and because of the possibility of serious or life‑threatening hypoventilation.
Severe respiratory depression.
4.4 Special warnings and precautions for use
.Patients who have experiencedserious adverse events should be monitored for up to 24 hours after fentanyl transdermal patch removal since serum fentanyl concentrations decline gradually and are reduced by about 50 % 17 (range 13-22) hours later.
Fentanyl transdermal patches should be kept out of sight and reach of children before and after use.
Do not cut the transdermal patches. A patch that has been divided, cut, or damaged in any way should not be used.
Respiratory depression
As with all potent opioids some patients may experience significant respiratory depression with the fentanyl transdermal patch; patients must be observed for these effects. Respiratory depression may persist beyond the removal of the patch. The incidence of respiratory depression increases as the fentanyl dose is increased (see Section 4.9, Overdose, concerning respiratory depression). CNS active drugs may increase the respiratory depression (see section 4.5, Interactions with other medicinal products and other forms of interaction).
Serotonin Syndrome
Caution is advised when fentanyl transdermal patches is coadministered with drugs that affect the serotonergic 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. hyper-reflexia, incoordination, rigidity), and/or gastrointestinal symptoms (e.g, nausea, vomiting, diarrhoea).
If serotonin syndrome is suspected, rapid discontinuation of fentanyl transdermal patches should be considered.
Chronic pulmonary disease
Fentanyl 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 such as fentanyl. Iatrogenic addiction following opioid administration is rare. 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. Fentanyl can be abused in a manner similar to other opioid agonists. Abuse or intentional misuse of Quatrofen may result in overdose and/or death.
Increased intracranial pressure
Quatrofen 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. Fentanyl should be used with caution in patients with brain tumors.
Cardiac disease
Fentanyl may produce bradycardia and should therefore be administered with caution to patients with bradyarrhythmias.
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 transdermal fentanyl, they should be observed carefully for signs of fentanyl toxicity and the dose of fentanyl reduced if necessary (see Section 5.2, Pharmacokinetic properties).
Renal impairment
Less than 10% of fentanyl is excreted unchanged by the kidney and, unlike morphine, there are no known active metabolites eliminated by the kidney. If patients with renal impairment receive transdermal fentanyl they should be observed carefully for signs of fentanyl toxicity and the dose reduced if necessary (see Section 5.2, Pharmacokinetic properties).
Fever/external heat application
A pharmacokinetic model suggests that serum fentanyl concentrations may increase by about one-third if the skin temperature increases to 40° C.
Therefore, patients with fever should be monitored for opioid side effects and the fentanyl 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. A clinical pharmacology trial conducted in healthy adult subjects has shown that the application of heat over a fentanyl transdermal system increased mean fentanyl AUC values by 120% and mean Cmax values by 61%.
All patients should be advised to avoid exposing the Fentanyl transdermal patch application site to direct external heat sources such as heating pads, electric blankets, heated water beds, heat or tanning lamps, intensive sunbathing, hot water bottles, Prolonged hot baths, saunas and hot whirlpool spa baths while wearing the patch, since there is potential for temperature dependent increases in release of fentanyl from the patch..
Interactions with other Medicinal Products
Interactions with CYP3A4 Inhibitors:
The concomitant use of transdermal fentanyl with cytochrome P450 3A4 (CYP3A4) inhibitors (e.g. ritonavir, ketoconazole, itraconazole, troleandomycin, clarithromycin, erythromycin, nelfinavir, nefazodone, verapamil, diltiazem, and amiodarone) 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. In this situation special patient care and observation are appropriate. Therefore, the concomitant use of transdermal fentanyl and CYP3A4 inhibitors is not recommended unless the patient is closely monitored. Patients, especially those who are receiving transdermal fentanyl and CYP3A4 inhibitors, should be monitored for signs of respiratory depression and dosage adjustments should be made if warranted.
OlderPatients
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. If elderly patients receive transdermal fentanyl, they should be observed carefully for signs of fentanyl toxicity and the dose reduced if necessary (see Section 5.2, Pharmacokinetic properties).
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 fentanyl patch should be stopped.
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 section 4.9 Overdose).
Use in paediatrics
Quatrofen should not be administered to opioid naïve paediatric patients (see section 4.2 Posology and method of administration). The potential for serious or life-threatening hypoventilation exists regardless of the dose of Quatrofen transdermal system administered.
Fentanyl transdermal patch was not studied in children under 2 years of age. Quatrofen should be administered only to opioid-tolerant children age 2 years or older (see section 4.2 Posology and method of administration). Quatrofen should not be used in children under 2 years of age.
To guard against accidental ingestion by children, use caution when choosing the application site for Quatrofen (see section 4.2 Posology and method of administration) and monitor adhesion of the patch closely.
Lactation
As fentanyl is excreted into breast milk, breastfeeding should be discontinued during treatment with transdermal fentanyl (see also Section 4.6).
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 agonists/antagonists
The concomitant use of buprenorphine, nalbuphine or pentazocine is not recommended (see also Section 4.5).
4.5 Interaction with other medicinal products and other forms of interaction
The concomitant use of other central nervous system depressants, including opioids, sedatives, hypnotics, general anaesthetics, phenothiazines, tranquilizers, skeletal muscle relaxants, sedating antihistamines and alcoholic beverages may produce additive depressant effects; hypoventilation, hypotension, and profound sedation, coma or death may occur. Therefore, the use of any of these drugs concomitantly with transdermal fentanyl requires special patient care and observation.
Fentanyl, a high clearance drug, is rapidly and extensively metabolised mainly by CYP3A4.
The concomitant use of transdermal fentanyl with cytochrome P450 3A4 (CYP3A4) inhibitors (e.g. ritonavir, ketoconazol, itraconazol, fluconazole, voriconazole, troleandomycin, clarithromycin, nelfinavir, nefazodone, verapamil, diltiazem, and amiodarone) 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.In this situation, special patient care and observation are appropriate. The concomitant use of CYP3A4inhibitors and transdermal fentanyl is not recommended, unless the patient is closely monitored (See also Special warnings and precautions for use, Section 4.4).
The concomitant use with CYP3A4 inducers (e.g. rifampicin, carbamazepine, phenobarbital, phenytoin) could result in a decrease in fentanyl plasma concentrations and a decreased therapeutic effect. This may require a dose adjustment of transdermal fentanyl. After stopping the treatment of a CYP3A4 inducer, the effects of the inducer decline gradually and may result in a fentanyl plasma increase concentration which could increase or prolong both the therapeutic and adverse effects, and may cause serious respiratory depression. In this situation, careful monitoring and dose adjustment should be made if warranted.
Monoamine Oxidase Inhibitors (MAOI):
Transdermal fentanyl is not recommended for use in patients who require the concomitant administration of an MAOI. Severe and unpredictable interactions with MAOIs, involving the potentiation of opiate effects or the potentiation of serotoninergic effects, have been reported. Therefore, fentanyl should not be used within 14 days after discontinuation of treatment with MAOIs.
Serotonergic Drugs
Coadministration of transdermal fentanyl with a serotonergic 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.
Concomitant use of mixed 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 Section 4.4).
4.6 Fertility, pregnancy and lactation
Pregnancy
There are no adequate data from the use of transdermal fentanyl in pregnant women. Studies in animals have shown some reproductive toxicity (see section 5.3 Preclinical safety data). The potential risk for humans is unknown, although fentanyl as an IV anesthetic has been found to cross the placenta in early human pregnancies. Neonatal withdrawal syndrome has been reported in newborn infants with chronic maternal use of transdermal fentanyl during pregnancy. Transdermal fentanyl should not be used during pregnancy unless clearly necessary.
Use of transdermal fentanyl during childbirth is not recommended because it should not be used in the management of acute or postoperative pain (see Section 4.4, Special warnings and precautions for use). Moreover, because fentanyl passes through the placenta, the use of transdermal fentanyl during childbirth might result in respiratory depression in the newborn infant.
Breastfeeding
Fentanyl is excreted into breast milk and may cause sedation and respiratory depression in the breastfed infant. Breastfeeding should therefore be discontinued during treatment with transdermal fentanyl and for at least 72 hours after removal of the patch.
4.7 Effects on ability to drive and use machines
Transdermal fentanyl may impair mental and/or physical ability required for the performance of potentially hazardous tasks such as driving a car or operating machinery.
4.8 Undesirable effects
The safety of transdermal fentanyl was evaluated in 1854 subjects who participated in 11 clinical trials (double-blind transdermal fentanyl [placebo or active control] and/or open label transdermal fentanyl [no control or active control]) used for the management of chronic malignant or non-malignant pain. These subjects took at least 1 dose of transdermal fentanyl and provided safety data. Based on pooled safety data from these clinical trials, the most commonly reported adverse drug reactions (ADRs) were (with % incidence): nausea (35.7%), vomiting (23.2%), constipation (23.1%), somnolence (15.0%), dizziness (13.1%), and headache (11.8%).
The ADRs reported with the use of transdermal fentanyl from these clinical trials, including the above-mentioned ADRs, and from post-marketing experiences are listed below.
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); and not known (cannot be estimated from the available clinical trial data).
Table 5: Adverse Drug Reactions in Adult and Paediatric Subjects
|
System Organ Class |
Adverse Drug Reactions |
||||
|
Frequency Category |
|||||
|
Very Common |
Common |
Uncommon |
Rare |
Not Known |
|
|
Immune System Disorders |
|
Hypersensitivity |
|
|
Anaphylactic shock, Anaphylactic reaction, Anaphylactoid reaction |
|
Metabolism and Nutrition Disorders |
|
Anorexia |
|
|
|
|
Psychiatric Disorders |
|
Insomnia, Depression, Anxiety, Confusional state, Hallucination |
Agitation, Disorientation, Euphoric mood |
|
|
|
Nervous System Disorders |
Somnolence, Dizziness, Headache |
Tremor, Paraesthesia |
Hypoaesthesia, Convulsion (including clonic convulsions and grand mal convulsion), Amnesia, Depressed level of consciousness, Loss of consciousness |
|
|
|
Eye Disorders |
|
|
|
Miosis |
|
|
Ear and Labyrinth Disorders |
|
Vertigo |
|
|
|
|
Cardiac Disorders |
|
Palpitations, Tachycardia |
Bradycardia, Cyanosis |
|
|
|
Vascular Disorders |
|
Hypertension |
Hypotension |
|
|
|
Respiratory, Thoracic and Mediastinal Disorders |
|
Dyspnoea |
Respiratory depression, Respiratory distress |
Apnoea, |
Bradypnoea, |
|
Gastrointestinal Disorders |
Nausea, Vomiting, Constipation |
Diarrhoea, Dry mouth, Abdominal pain, Abdominal pain upper, Dyspepsia |
Ileus |
Subileus |
|
|
Skin and Subcutaneous Tissue Disorders |
|
Hyperhidrosis, Pruritus, Rash, Erythema |
Eczema, Dermatitis allergic, Skin disorder, Dermatitis, Dermatitis contact |
|
|
|
Musculoskeletal and Connective Tissue Disorders |
|
Muscle spasms |
Muscle twitching |
|
|
|
Renal and Urinary Disorders |
|
Urinary retention |
|
|
|
|
Reproductive System and Breast Disorders |
|
|
Erectile dysfunction, Sexual dysfunction |
|
|
|
General Disorders and Administration Site Conditions |
|
Fatigue, Oedema peripheral, Asthenia, Malaise, Feeling cold |
Application site reaction, Influenza like illness, Feeling of body temperature change, Application site hypersensitivity, Drug withdrawal syndrome, Pyrexia |
Application site dermatitis, Application site eczema |
|
As with other opioid analgesics, tolerance, physical dependence and psychological dependence can develop on repeated use of fentanyl (see Section 4.4, Special warnings and special precautions for use).
Opioid withdrawal symptoms (such as nausea, vomiting, diarrhoea, anxiety, and shivering) are possible in some patients after conversion from their previous opioid analgesics to fentanyl transdermal patch or if therapy is stopped suddenly (see Section 4.2, Posology and method of administration). There have been very rare reports of newborn infants experiencing neonatal withdrawal syndrome when mothers chronically used transdermal fentanyl during pregnancy (see Section 4.6, Fertility, pregnancy and lactation).
Paediatric Subjects
The adverse event profile in children and adolescents treated with fentanyl transdermal patch was similar to that observed in adults. No risk was identified in the paediatric population beyond that expected with the use of opioids for the relief of pain associated with serious illness and there does not appear to be any paediatric-specific risk associated with fentanyl transdermal patch use in children as young as 2 years old when used as directed. Very common adverse events reported in paediatric clinical trials were fever, vomiting and nausea.
The safety of fentanyl transdermal patch was evaluated in 289 paediatric subjects (<18 years) who participated in 3 clinical trials for the management of chronic or continuous pain of malignant or non-malignant origin. These subjects took at least one dose of fentanyl transdermal patch and provided safety data. Although the enrolment criteria for the paediatric studies restricted enrolment to subjects who were a minimum of 2 years of age, 2 subjects in these studies received their first dose of fentanyl transdermal patch at an age of 23 months.
Based on pooled safety data from these 3 clinical trials in paediatric subjects, the most commonly reported (ie ≥10% incidence) Adverse Drug Reactions (ADRs) were (with % incidence): vomiting (33.9%), nausea (23.5%), headache (16.3%), constipation (13.5%), diarrhoea (12.8%), and pruritus (12.8%). Table B displays all ADRs reported in fentanyl transdermal patch-treated paediatric subjects in the aforementioned clinical trials.
The ADRs for the paediatric population presented in Table 6 were assigned to frequency categories using the same conventions as used for Table 5.
Table 6: Adverse Drug Reactions in Paediatric Subjects in clinical trials
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|
|
|
|
|
System Organ Class |
Adverse Drug Reactions |
||
|
Frequency Category |
|||
|
Very Common
(≥1/10) |
Common |
Uncommon |
|
|
Immune System Disorders |
|
Hypersensitivity |
|
|
Metabolism and Nutrition Disorders |
|
Anorexia |
|
|
Psychiatric Disorders |
|
Insomnia Somnolence, Anxiety, Depression, Hallucination |
Confusional state |
|
Nervous System Disorders |
Headache |
Dizziness, Tremor, Hypoaesthesia, |
Paraesthesia |
|
Eye Disorders |
|
|
Miosis |
|
Ear and Labyrinth Disorders |
|
|
Vertigo |
|
Cardiac Disorders |
|
|
Cyanosis |
|
Respiratory, Thoracic and Mediastinal Disorders |
|
Respiratory depression, |
|
|
Gastrointestinal Disorders |
Nausea, Vomiting, Constipation, Diarrhoea, |
Abdominal pain, Abdominal pain upper, Dry mouth |
|
|
Skin and Subcutaneous Tissue Disorders |
Pruritus, |
Rash, Hyperhidrosis, Erythema |
Contact dermatitis, Skin disorder, Allergic dermatitis, Eczema, |
|
Musculoskeletal and Connective Tissue Disorders |
|
Muscle spasms |
|
|
Renal and Urinary Disorders |
|
Urinary retention |
|
|
General Disorders and Administration Site Conditions |
|
Peripheral oedema Fatigue, Application site reaction, Asthenia |
Drug withdrawal syndrome, Influenza-like illness |
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 national reporting system listed in Appendix V*.
4.9 Overdose
Symptoms
The manifestations of fentanyl overdose are an extension of its pharmacological actions, the most serious effect being respiratory depression.
Treatment
For management of respiratory depression immediate countermeasures include removing the 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, hypovolaemia should be considered, and the condition should be managed with appropriate parenteral fluid therapy.
5. PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Analgesics, opioids
ATC code: N02AB03
Quatrofen is a transdermal patch that provides continuous delivery of fentanyl. Fentanyl is an opioid analgesic with affinity mainly to the µ-receptor. The predominant pharmacological effects are pain relief and sedation. Patients not previously treated with opioids will have pain relief at a fentanyl concentration between 0.3 and 1.5 ng/ml. In this group of patients the frequency of adverse effects will increase at serum concentrations above 2 ng/ml. Both the lowest effective fentanyl concentration and the concentration causing adverse reactions will increase with the development of increasing tolerance. Development of tolerance varies considerably between individual subjects.
Paediatric population
The safety of transdermal fentanyl was evaluated in three open-label trials in 289 paediatric patients with chronic pain, 2 years of age through to 18 years of age, of which 66 children were aged to 2 to 6 years. In these studies, 30 mg to 45 mg oral morphine per day was replaced by one transdermal fentanyl 12 microgram/h patch. Starting dose of 25 microgram/h and higher were used by 181 patients who had been on prior daily opioid doses of at least 45 mg per dose of oral morphine
5.2 Pharmacokinetic properties
The fentanyl transdermal patch provides systemic delivery over the 72 hour administration period.
Absorption
After the first patch application serum fentanyl concentrations increase gradually, generally levelling off between 12 and 24 hours and remaining relatively constant for the remainder of the 72-hour application period. By the second 72-hour application, a steady- state serum concentration is reached and is maintained during subsequent applications of the patch of the same size.
The absorption of fentanyl may differ somewhat between different application sites. A somewhat lower (approximately 25%) fentanyl absorption has been observed in studies with healthy volunteers after the patch has been applied on the chest compared with the upper arm and the back.
Distribution:
The plasma protein binding for fentanyl is 84 %.
Biotransformation
Fentanyl shows linear kinetics and is metabolised primarily in the liver via CYP3A4. The major metabolite, norfentanyl, is inactive.
Elimination
After the fentanyl patch is removed, serum fentanyl concentrations decline gradually falling approximately 50% in 13-22 hours in adults or 22-25 hours in children. Continued absorption of fentanyl from the skin accounts for a slower disappearance of the drug from the serum than is seen after an intravenous infusion. Around 75% of fentanyl is excreted into the urine, mostly as metabolites, with less than 10% as unchanged drug. About 9% of the dose is recovered in the faeces, primarily as metabolites.
Pharmacokinetics in special groups
Impaired hepatic or renal function could cause increased serum concentrations. Elderly, cachectic or generally impaired patients may have a lower fentanyl clearance, which could cause a longer terminal half life for the compound (see section 4.2 and 4.4).
Paediatric population
Adjusting for body weight, clearance (L/hr/Kg) in paediatric patients appears to be 82 % higher in children 2 to 5 years old and 25 % higher in children 6 to 10 years old when compared to children 11 to 16 years old, who are likely to have the same clearance as adults. These findings have been taken into consideration in determining the dosing recommendations for paediatric patients.
5.3 Preclinical safety data
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity and genotoxicity.
Animal studies have shown reduced fertility and increased mortality in rat foetuses. Teratogenic effects have, however, not been demonstrated.
Mutagenicity testing in bacteria and in rodents yielded negative results. As well as other opioids fentanyl showed mutagenic effects in vitro in mammalian cells. A mutagenic risk in therapeutic condition seems unlikely since effects were induced only in very high concentrations.
Long-term carcinogenicity studies have not been performed.
6. PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Dipropylene glycol
Hydroxypropyl cellulose
Dimeticone
Silicone adhesives (amine resistant)
Release membrane, ethylenvinylacetate (EVA)
Backing film, polyethylene terephthalate film (PET)
Removable protective film, fluoropolymercoated polyester film
Printing ink
6.2 Incompatibilities
To prevent interference with the adhesive properties of Quatrofen, no creams, oils, lotions or powder should be applied to the skin area when the Quatrofen patch is applied.
6.3 Shelf life
3 years
6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
6.5 Nature and contents of container
Each patch is packed in a heat-sealed pouch made of paper, aluminium and polyacrylonitrile (PAN).
Pack sizes:
1 patch, 3 patches, 5 patches, 10 patches and 20 patches
Not all pack sizes may be marketed
6.6 Special precautions for disposal and other handling
Please refer to section 4.2 for Instructions on how to apply the patch. There are no safety and pharmacokinetic data available for other application sites.
High quantities of fentanyl remain in the transdermal patches even after use. Used transdermal patches should be folded with the adhesive surfaces inwards, so the release membrane is not exposed and due to safety and environmental reasons, discarded according to local requirements or returned to the pharmacy or hospital. Any unused medicinal product should be discarded according to local requirements or returned to the pharmacy or hospital.
Wash hands with water after applying or removing the patch.
7. MARKETING AUTHORISATION HOLDER
To be completed nationally
8. MARKETING AUTHORISATION NUMBER(S)
To be completed nationally
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
To be completed nationally
10. DATE OF REVISION OF THE TEXT
2015-04-17