Fentanyl is an opioid analgesic drug. Subcutaneous fentanyl can be considered for patients in whom subcutaneous morphine is contraindicated. It has been investigated as an intervention to relieve breakthrough dyspnea in patients who have cancer. Healthcare professionals should be aware of the different formulations for these medications, the length of their half-life, and the onset of action.
Simon, S.T., Koskeroglu, P., Gaertner, J., & Voltz, R. (2013). Fentanyl for the relief of refractory breathlessness: A systematic review. Journal of Pain and Symptom Management, 46, 874–886.
PHASE OF CARE: Multiple phases of care
APPLICATIONS: Elder care, palliative care
All studies reported the successful relief of breathlessness after fentanyl application, but the only RCT (N = 12) failed to demonstrate a statistically significant difference when fentanyl was compared to a placebo. The nature and incidence of fentanyl-related adverse events such as somnolence and dizziness were comparable to other opioids, and no respiratory depression was observed.
There is no conclusive evidence about use of fentanyl to relieve breathlessness because of the lack of sufficiently powered, controlled studies. The descriptive and quasi-experimental studies included in this review show promising results for the use of fentanyl for breathlessness. All studies reported an improvement in breathlessness, but a fully powered RCT to conclusively determine the effect of fentanyl on breathlessness is warranted.
The descriptive and quasi-experimental studies included were at-risk for bias because of the lack of a control. The doses of fentanyl varied considerably, which limits conclusions about the appropriate dose. Missing data included the time of response after the administration of fentanyl, which is important when comparing fentanyl to other opioids.
The clinical experience of fentanyl for breathlessness is promising. Considering emerging data, which suggests that breathless episodes often last less than 10 minutes, the current standard (immediate-release morphine) has a longer onset of action than the symptom episode duration. Fentanyl's time of onset still is unknown, but it may better match the characteristics of breathlessness episodes, which is clinically important.
Benitez-Rosario, M.A., Rosa-Gonzalez, I., Gonzalez-Davila, E., & Sanz, E. (2018). Fentanyl treatment for end-of-life dyspnoea relief in advanced cancer patients. Supportive Care in Cancer, 27, 157–164.
The purpose of the study was to assess the effects of subcutaneous or IV fentanyl on dyspnea in patients with advanced cancer.
Subcutaneous or IV fentanyl for breathlessness at rest or with minimal exertion for patients with (a) decline in renal function and escalating doses transdermal fenatanyl/ or other opioid, and (b) alternative to transdermal fentanyl at discharge
PHASE OF CARE: End-of-life care
APPLICATIONS: Pediatrics, elder care, palliative care
Retrospective cohort study
Breathlessness was measured on a 0-4 scale, other symptoms were measured with ESAS, MMSE/Pfeiffer, and Likert scales
Total percent of responders to fentanyl was 76%. Fentanyl efficacy was not statistically related to age, gender, cancer type, previous opioid treatment, steroid and midazolam doses, and PPS. The median fentanyl dose in responders was 25 mcg/h (interquartile range = 12–70). It was significantly related to age (37 versus 12 mcg/h, for ≤ 75 versus > 75 years, respectively; p = 0.02). There was not a significant difference between fentanyl doses of responders and non-responders. 36, 23, and 15 patients had sustained improvements in dyspnea over 48, 72, and 96 hours. Fentanyl had no significant toxicity.
Subcutaneous and IV fentanyl may be associated with dyspnea relief in patients with advanced cancer. No severe adverse effects were noted.
Subcutaneous and IV fentanyl may be related to dyspnea at rest relief in patients with advanced cancer. Additional research is need to confirm these results.
Hui, D., Xu, A., Frisbee-Hume, S., Chisholm, G., Morgado, M., Reddy, S., & Bruera, E. (2013). Effects of prophylactic subcutaneous fentanyl on exercise-induced breakthrough dyspnea in cancer patients: A preliminary double-blind, randomized, controlled trial. Journal of Pain and Symptom Management, 47, 209–217.
To study the feasibility of a randomized, controlled trial exploring the effects of fentanyl on breakthrough dyspnea, walking distance, vital signs, and adverse events in patients with cancer
Double-blinded, placebo-controlled, randomized trial
The prophylactic administration of subcutaneous fentanyl appears to be a safe and well-tolerated method for reducing dyspnea, fatigue, and respiratory rate while also enhancing physiologic function and activity levels among patients with cancer. However, the generalizability of these findings are limited because of the small sample size.