• Srinivas R Nalamachu, Neha Parikh, Larry Dillaha, and Richard Rauck.
• International Clinical Research Institute, Overland Park, Kansas.
• J Opioid Manag. 2014 Jul 1;10(4):247-54.

ObjectiveTo examine the relationship between the dose of fentanyl sublingual spray needed to control breakthrough cancer pain (BTCP) and the dose of around-the-clock (ATC) opioid used to control background pain.DesignAnalysis was based on the open-label, dose-titration phase (up to 26 days) of a randomized, double-blind, placebo-controlled trial.PatientsOpioid-tolerant cancer patients (aged ≥18 years) with chronic pain of ≤moderate severity in the 24 hours before screening while receiving stable doses of scheduled ATC opioid therapy for ≥1 week and 1 to 4 episodes of BTCP per day.InterventionsFentanyl sublingual spray was initiated at 100 µg. Dose titration proceeded until a dose was reached that provided adequate pain relief for two consecutive BTCP episodes without intolerable adverse effects (AEs).ResultsOverall, 98/130 (75.4 percent) patients completed the dose-titration phase and achieved pain relief, and 73.5 percent of those who completed the titration period attained an effective dose of ≥600 µg (median effective dose, 800 µg). No clinically relevant correlation was found between effective doses of fentanyl sublingual spray for the treatment of BTCP and the ATC opioid doses used to control persistent pain (Spearman rank correlation [rs]=0.351, n=98). Sixty percent of patients reported ≥1 AE during the dose-titration phase. The most common AEs considered related to study treatment were nausea (6.2 percent), somnolence (4.6 percent), dizziness (3.8 percent), and vomiting (3.8 percent).ConclusionsThese findings highlight the importance of titrating the dose of fentanyl sublingual spray to optimize dosing for individual patients.

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