Due to the risk of fatal respiratory depression, nasal fentanyl citrate is contraindicated in opioid non-tolerant patients and in management of acute or postoperative pain, including headache/migraines. Monitor for respiratory depression during treatment. Accidental ingestion of fentanyl can result in a fatal overdose, especially in children; keep out of reach of children. Use with CYP3A4 inhibitors or inducers may change fentanyl plasma levels resulting in fatal overdose and monitoring is recommended. Concomitant use of opioids with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing for patients with inadequate alternative treatment options, limit dosage and duration to the minimum required, and monitor for respiratory depression and sedation. When prescribing, do not convert patients on a mcg per mcg basis from any other fentanyl products. When dispensing, do not substitute with any other fentanyl products. Fentanyl is a Schedule II controlled substance with abuse liability similar to other opioid analgesics. Assess risk prior to initiation and monitor for signs of misuse, abuse, and addiction during treatment. Only available through a restricted program called the Transmucosal Immediate Release Fentanyl Risk Evaluation and Mitigation Strategy (TIRF REMS) Access program. Outpatients, healthcare professionals who prescribe to outpatients, pharmacies, and distributors are required to enroll in the program. Prolonged use during pregnancy may result in neonatal opioid withdrawal syndrome. If prolonged use is required in a pregnant woman, advise patient of potential fetal risk and ensure appropriate treatment will be available .
Medically reviewed on June 7, 2018
Commonly used brand name(s)
In the U.S.
Available Dosage Forms:
Therapeutic Class: Analgesic
Chemical Class: Fentanyl
Uses For fentanyl
Fentanyl nasal spray is used to treat breakthrough cancer pain. Breakthrough episodes of cancer pain are the flares of pain which “breaks through” the medication used to control the persistent pain. Fentanyl belongs to the group of medicines called narcotic analgesics, which are medicines used to relieve pain. Nasal fentanyl is only used in patients who are already taking narcotic analgesics and who are tolerant to opioid medicines for cancer pain.
Fentanyl acts in the central nervous system (CNS) to relieve pain. Some of its side effects are also caused by actions in the CNS. When a narcotic is used for a long time, it may become habit-forming (causing mental or physical dependence). However, people who have continuing pain should not let the fear of dependence keep them from using narcotics to relieve their pain. Mental dependence (addiction) is not likely to occur when narcotics are used for this purpose. Physical dependence may lead to withdrawal side effects if treatment is stopped suddenly. However, severe withdrawal side effects can usually be prevented by reducing the dose gradually over a period of time before treatment is stopped completely. Your doctor will take this into consideration when deciding on the amount of nasal fentanyl you should receive.
Fentanyl is available only under a restricted distribution program called TIRF REMS Program.
Before Using fentanyl
In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For fentanyl, the following should be considered:
Tell your doctor if you have ever had any unusual or allergic reaction to fentanyl or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully.
Appropriate studies have not been performed on the relationship of age to the effects of nasal fentanyl in the pediatric population. Safety and efficacy have not been established.
Appropriate studies performed to date have not demonstrated geriatric-specific problems that would limit the usefulness of nasal fentanyl in the elderly. However, elderly patients may be more sensitive to the effects of narcotic analgesics than younger adults and are more likely to have age-related kidney disease, which may require caution and an adjustment in the dose for patients receiving nasal fentanyl.
There are no adequate studies in women for determining infant risk when using this medication during breastfeeding. Weigh the potential benefits against the potential risks before taking this medication while breastfeeding.
Interactions with Medicines
Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are taking fentanyl, it is especially important that your healthcare professional know if you are taking any of the medicines listed below. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.
Using fentanyl with any of the following medicines is not recommended. Your doctor may decide not to treat you with this medication or change some of the other medicines you take.
Using fentanyl with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.
- Chloral Hydrate
- Eslicarbazepine Acetate
- Methylene Blue
- Morphine Sulfate Liposome
- Nitrous Oxide
- Opium Alkaloids
- Sodium Oxybate
- St John's Wort
- Tolonium Chloride
Interactions with Food/Tobacco/Alcohol
Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.
Using fentanyl with any of the following is usually not recommended, but may be unavoidable in some cases. If used together, your doctor may change the dose or how often you use fentanyl, or give you special instructions about the use of food, alcohol, or tobacco.
- Grapefruit Juice
Other Medical Problems
The presence of other medical problems may affect the use of fentanyl. Make sure you tell your doctor if you have any other medical problems, especially:
- Adrenal problems or
- Alcohol abuse, or history of or
- Brain tumor, history of or
- Breathing problems (eg, chronic obstructive pulmonary disease [COPD], cor pulmonale, hypoxia) or
- Drug dependence, especially with narcotics, history of or
- Head injuries, history of or
- Increased pressure in the head or
- Seizures, history of—Use with caution. May increase risk for more serious side effects.
- Bradyarrhythmia (slow heart rhythm) or
- Gallbladder disease or
- Hypotension (low blood pressure) or
- Pancreatitis (inflammation or swelling of the pancreas), acute—Use with caution. May make these conditions worse.
- Kidney disease or
- Liver disease—Use with caution. The effects may be increased because of slower removal of the medicine from the body.
- Lung or breathing problems, severe (eg, bronchial asthma, respiratory depression) or
- Stomach or bowel blockage (including paralytic ileus), known or suspected—Should not be used in patients with these conditions.
Proper Use of fentanyl
Fentanyl nasal sprays are for use in opioid-tolerant patients only. If you are not sure whether or not you are opioid-tolerant, check with your doctor before using fentanyl.
Fentanyl should come with a Medication Guide and patient instructions. Read and follow these instructions carefully. Ask your doctor if you have any questions.
Fentanyl is for use only in the nose. Do not get any of it in your eyes or on your skin. If it does get on these areas, rinse it off with water right away.
Fentanyl nasal spray works differently than other fentanyl products, even at the same dose (number of milligrams). Do not substitute or convert it to other products containing fentanyl.
To use the nasal spray:
- Keep the spray in the child-resistant container until ready to use.
- If you are using the nasal spray for the first time, you will need to prime the spray. To do this, you should release four sprays into the pouch. Now it is ready to use.
- If you have not used the medicine for more than 5 days, re-prime by spraying once into the pouch.
- Before using fentanyl, gently blow your nose to clear the nostrils.
- Insert the tip of the Lazanda® bottle into the nose. Point towards the bridge of the nose and tilt the bottle slightly.
- Press down firmly on the finger grips until you hear a "click" sound and the number in the dose counter window adds up. This confirms a spray has been taken.
- Return the spray bottle to the child-resistant container after each use.
The dose of fentanyl will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of fentanyl. If your dose is different, do not change it unless your doctor tells you to do so.
The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.
- For nasal dosage form (spray):
- For cancer pain:
- Adults—At first, 100 micrograms (mcg) or 1 spray in one nostril during an episode of breakthrough cancer pain. Your doctor may increase your dose as needed and tolerated, up to a maximum of 800 mcg or 1 spray containing 400 mcg of fentanyl in each nostril. However, patients should not use more than 4 doses per 24 hours. Wait at least 2 hours before treating another episode of breakthrough cancer pain. If pain relief is not achieved within 30 minutes, a rescue medicine may be used as directed by your doctor. Patients should record their use over several episodes of breakthrough cancer pain and review their experience with their doctor to determine if a dosage adjustment is warranted.
- Children—Use and dose must be determined by your doctor.
- For cancer pain:
Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.
Keep out of the reach of children.
Do not keep outdated medicine or medicine no longer needed.
Ask your healthcare professional how you should dispose of any medicine you do not use.
Ask your pharmacist about the best way to dispose of medicine that you do not use. Throw away any spray bottle and start using a new one if you have used 8 sprays or if it has been 60 days or more since it has been used. Dispose any used, partially used, or unneeded spray bottles by emptying and spraying the remaining solution into the pouch. The sealed pouch and the empty bottle should be placed in a child-resistant container before discarding it in the trash can. Wash your hands with soap and water right away after handling the pouch.
Precautions While Using fentanyl
It is very important that your doctor check your progress at regular visits. This will allow your doctor to make sure that fentanyl is working properly and to check you for any problems or unwanted effects that may be caused by fentanyl.
Do not use Lazanda® if you need pain medicine for just a short time, such as during a headache or migraine attack, tooth pain, or when recovering from surgery or an injury.
After you have been using fentanyl for awhile, "breakthrough" pain may occur more often than usual, and it may not be relieved by your regular dose of medicine. If this occurs, do not increase the amount of nasal fentanyl or other narcotic that you are using without first checking with your doctor.
Using too much nasal fentanyl, or taking too much of another narcotic while using nasal fentanyl, may cause an overdose. If this occurs, get emergency help right away. An overdose can cause severe breathing problems (breathing may even stop), unconsciousness, and death. Serious signs of an overdose include very slow breathing (fewer than 8 breaths a minute) and drowsiness that is so severe that you are not able to answer when spoken to or, if asleep, cannot be awakened. Other signs of an overdose may include cold, clammy skin, low blood pressure, pinpoint pupils of the eyes, and slow heartbeat. It may be best to have a family member or a friend check on you several times a day when you start using a narcotic regularly, and whenever your dose is increased, so that he or she can get help for you if you cannot do so yourself.
Lazanda® contains an amount of fentanyl which can be fatal to a child. Patients and their caregivers should keep fentanyl out of the reach of children, and discard used and unused bottle sprays in its child-resistant container properly.
Fentanyl will add to the effects of alcohol and other central nervous system (CNS) depressants. This effect may last for a few days after you stop using fentanyl. CNS depressants are medicines that slow down the nervous system, which may cause drowsiness or make you less alert. Some examples of CNS depressants are antihistamines or medicine for hay fever, allergies, or colds, sedatives, tranquilizers, benzodiazepines, sleeping medicines, other prescription pain medicine or narcotics, barbiturates or seizure medicine, muscle relaxants, or anesthetics (numbing medicines), including some dental anesthetics. Check with your doctor before taking any of the other medicines listed above while you are using fentanyl.
Fentanyl may cause some people to become drowsy, dizzy, or lightheaded, or to feel a false sense of well-being. Make sure you know how you react to fentanyl before you drive, use machines, or do anything else that could be dangerous if you are dizzy or not alert and clearheaded. These effects usually go away after a few days of treatment, when your body gets used to the medicine. However, check with your doctor if drowsiness that is severe enough to interfere with your activities continues for more than a few days.
Fentanyl may cause serious allergic reactions, including anaphylaxis. Anaphylaxis can be life-threatening and requires immediate medical attention. Call your doctor right away if you have a rash, itching, hoarseness, trouble breathing, trouble swallowing, or any swelling of your hands, face, or mouth while you are using fentanyl.
Fentanyl may be habit-forming. If you feel that the medicine is not working as well, do not use more than your prescribed dose. Call your doctor for instructions.
Using narcotics for a long time may cause severe constipation. To prevent this, your doctor may tell you to take laxatives, drink a lot of fluids, or increase the amount of fiber in your diet. Be sure to follow the directions carefully, because continuing constipation can lead to more serious problems.
Do not use fentanyl if you have taken a monoamine oxidase (MAOI) inhibitor in the previous 2 weeks. Some examples of MAO inhibitors are isocarboxazid (Marplan®), phenelzine (Nardil®), selegiline (Eldepryl®), or tranylcypromine (Parnate®). If you use the 2 medicines close together it may cause serious side effects like confusion, agitation, restlessness, stomach or intestinal symptoms, a sudden high temperature, an extremely high blood pressure, or severe convulsions.
Using fentanyl while you are pregnant may cause serious unwanted effects in your newborn baby. Tell your doctor right away if you think you are pregnant or if you plan to become pregnant while using fentanyl.
Using too much of fentanyl may cause reduced infertility (unable to have children). Talk with your doctor before using fentanyl if you plan to have children.
Do not eat grapefruit or drink grapefruit juice while you are using fentanyl. Grapefruit and grapefruit juice may change the amount of fentanyl that is absorbed in the body.
Do not take other medicines unless they have been discussed with your doctor. This includes prescription or nonprescription (over-the-counter [OTC]) medicines and herbal or vitamin supplements.
Fentanyl Side Effects
Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.
Check with your doctor immediately if any of the following side effects occur:
- Abdominal or stomach pain
- black, tarry stools
- bladder pain
- bloating or swelling of the face, arms, hands, lower legs, or feet
- bloody nose
- bloody or cloudy urine
- blurred vision
- body aches or pain
- chest pain
- clay-colored stools
- cough producing mucus
- dark urine
- decreased urination
- decreased weight
- difficult or labored breathing
- difficult, burning, or painful urination
- difficulty with breathing
- dizziness or lightheadedness
- dry mouth
- ear congestion
- frequent urge to urinate
- increase in heart rate
- increased sweating
- joint pain, stiffness, or swelling
- loss of appetite
- loss of voice
- lower back or side pain
- pain, redness, or swelling in the arm or leg
- pale skin
- pounding in the ears
- rapid breathing
- rapid weight gain
- redness of the skin
- runny or stuffy nose
- shortness of breath
- slow or fast heartbeat
- sore throat
- sudden shortness of breath or troubled breathing
- sunken eyes
- swelling of the eyelids, face, lips, hands, or feet
- tightness in the chest
- tingling of the hands or feet
- troubled breathing or swallowing
- troubled breathing with exertion
- ulcers, sores, or white spots in the mouth
- unpleasant breath odor
- unusual bleeding or bruising
- unusual tiredness or weakness
- unusual weight gain or loss
- vomiting of blood
- wrinkled skin
- yellow eyes or skin
Incidence not known
- Irregular, fast or slow, or shallow breathing
- pale or blue lips, fingernails, or skin
Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:
- Difficulty having a bowel movement (stool)
- sleepiness or unusual drowsiness
- Acid or sour stomach
- back pain
- burning feeling in the chest or stomach
- change in taste
- confusion about identity, place, and time
- decreased appetite
- difficulty with moving
- drooping upper eyelids
- dry eyes
- flushed, dry skin
- fruit-like breath odor
- increased hunger
- increased thirst
- increased urination
- irregular heartbeats
- irritation or soreness of the mouth
- lack or loss of strength
- loss of taste
- muscle aches
- muscle pain or stiffness
- pain in the arms or legs
- pain in the rectum
- stomach discomfort or upset
- stomach bloating
- tenderness in the stomach area
- trouble with sleeping
- troubled breathing
- unable to sleep
- unexplained weight loss
Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.
Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.
See also: Side effects (in more detail)
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