Pharmacokinetic Profile of Fentanyl in the Koala (Phascolarctos cinereus) after Intravenous Administration, and Absorption via a Transdermal Patch

Fentanyl was administered as a single intravenous bolus injection at 5 µg/kg to five koalas and fentanyl plasma concentrations for a minimum of 2 h were quantified by an enzyme-linked immunosorbent assay (ELISA). The median (range) fentanyl elimination half-life and clearance were 0.53 (0.38–0.91) h, and 10.01 (7.03–11.69) L/kg/h, respectively. Assuming an analgesic therapeutic plasma concentration of 0.23 ng/mL (extrapolated from human studies), an intravenous constant infusion rate was estimated at approximately between 1.7 to 2.7 µg/kg/h (using the clearance 95% confidence intervals). A transdermal fentanyl patch was applied to the antebrachium of an additional two koalas for 72 h. Fentanyl plasma concentrations were determined during the patch application and after patch removal at 80 h. The fentanyl plasma concentration was greater than 0.23 ng/mL after 12 to 16 h. While the patch was applied, the maximum fentanyl concentration was approximately 0.7 ng/mL from 32 to 72 h. Fentanyl plasma concentrations increased to 0.89 ng/mL 1 h after the patch was removed, and then decreased to a mean of 0.47 ng/mL at 80 h. The transdermal fentanyl patch is likely to provide some level of analgesia but should be initially co-administered with another faster acting analgesic for the first 12 h.

Optimization of the medication-use process for fentanyl patches at a small community hospital

Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To describe a community hospital pharmacy department’s novel approach to addressing safe use of fentanyl patches in acute and subacute care patients. Summary Beginning in 2017, improvement opportunities were identified within the medication-use process for fentanyl patches at Cleveland Clinic Euclid Hospital. Prescribing was addressed through development of a procedure requiring an opioid status verification by a pharmacist for all fentanyl patch orders. This procedure includes determination of indication, review of prior opioid use, and documentation within the medical record. At baseline in 2017, 11 of 45 fentanyl patches were initiated for acute pain. In the first year of the procedure, 1 of 13 orders was initiated for acute pain, and in the second year 2 of 24 orders for fentanyl patches were initiated for acute pain. With each review, the pharmacy department identified additional safety and clinical education opportunities. Subsequently, inventory and dispensing practices for patches were assessed. The hospital’s inventory was decreased and dispensing practices were altered to mitigate accessibility of the patches. This resulted in a decrease of 73.65% in the on-hand quantity from 2018 to 2020. The overall morphine milligram equivalents (MME) per 24 hours of this dosage form available in the hospital were reduced from 56,073.6 MME in 2018 to 13,557.6 MME in 2020 (75.82% decrease). Conclusion Evaluation of the fentanyl patch medication-use process and pharmacy-driven interventions resulted in an increase in appropriate utilization of fentanyl patches and a decrease in accessible MME of this potent dosage form.

Acute Cytotoxic Cerebellar Edema Subsequent to Fentanyl Patch Intoxication in an Infant

The opioid epidemic continues to have devastating consequences for children and families across the United States with rising prevalence of opioid use and abuse. Given the ease of access to these medications, accidental ingestion and overdose by children are becoming increasingly more common. The recognition of opioid-induced neurotoxicity and the associated life-threatening complication of acute cerebellar cytotoxic edema are crucial, as are the high morbidity and mortality without timely intervention. We discuss an infant with acute cytotoxic cerebellar edema following mucosal exposure to a transdermal fentanyl patch.

The Use of Thoracic Epidural for Rapid Opioid Taper

BACKGROUND: Inflammatory Bowel Disease (IBD) is often associated with significant abdominal pain that can be challenging to control. Although controversial, opioids are often prescribed for the management of abdominal pain in patients with IBD. There have been several methods described for the rapid taper of patients on long-term, high-dose opioids. However, to date, there have been no reported cases using epidural analgesia for rapid opioid taper. CASE REPORT: We present a case of a 36-year-old man with ulcerative colitis and recurrent bowel obstructions on a high-dose transdermal fentanyl patch whose opioid consumption was rapidly tapered during inpatient hospitalization utilizing thoracic epidural analgesia. CONCLUSION: The potential role of epidural analgesia in rapid opioid taper has yet to be explored. In patients with chronic pain and inflammatory bowel disease or recurrent bowel obstructions, epidural analgesia may be particularly helpful to improve gastrointestinal motility while also being used to rapidly taper opioid dosage. KEY WORDS: Inflammatory bowel disease, ulcerative colitis, Crohn’s disease, epidural, opioids, rapid opioid taper, fentanyl patch