Management of Breakthrough Pain in Cancer Patients - Episode 7

TIRF Products for Breakthrough Cancer Pain

Transmucosal immediate-release fentanyl (TIRF) products are available for the management of breakthrough pain in opioid-tolerant patients with cancer.

One of the first agents in this class was the rapid-acting lozenge fentanyl citrate (Actiq), Jeri L. Ashley, RN, notes. According to Jeffrey A. Gudin, MD, this medication laid the foundation for the entire TIRF category of analgesics. However, long-time users of this approach experienced dental issues and other detrimental effects, warranting the advent of other fentanyl products.

To avoid some of the concerns with lozenges, fentanyl sublingual tablets (Abstral) or fentanyl buccal tablets (Fentora) can be utilized, Marc Rappaport, DO, says. Additionally, these tablets are administered in areas that avoid treatment-related mucositis, which is a very useful delivery route for patients with cancer, Rappaport notes.

TIRF medications are some of the most powerful opioid analgesics available, warranting proper education prior to administration, according to Vitaly Gordin, MD. As a result, a Risk Evaluation and Mitigation Strategy (REMS) has been put in place, the completion of which is required before TIRFs can be prescribed, Charles E. Argoff, MD, notes. In general, the TIRF REMS is similar to other programs commonly seen for the treatment of patients with cancer, particularly multiple myeloma, Rappaport suggests.

In addition to the REMS, education is needed for everyone involved in the treatment process, including clinicians, patients, and pharmacists. Time must be spent with each patient to carefully discuss the titration schedule, Rappaport notes. These treatments must be carefully titrated until an appropriate dose is found, to ensure they are administered safely and effectively.

One of the primary deterrents to the use of TIRF medications is the need to complete the REMS program. In general, Gordin notes, the test is short and the material in the program is very useful. Additionally, these analgesics can be very beneficial for patients with breakthrough pain, delivering a major impact on quality of life, Rappaport explains. There is a learning curve for TIRF products, but once this challenge is overcome, physicians are better able to help their patients with their pain complaints, Argoff says.

The TIRF REMS program can be accessed at