Cephalon, Inc. announced that the US Food and Drug Administration (FDA) approved the Risk Evaluation and Mitigation Strategy (REMS) for Fentora (fentanyl buccal tablet) [C-II] and Actiq (oral transmucosal fentanyl citrate) [C-II]. Both products are indicated for the management of breakthrough pain in opioid-tolerant patients with cancer. Under this REMS, pharmacies and healthcare professionals who prescribe Fentora and Actiq will enroll by completing an education module and knowledge assessment focused on safety information including appropriate patient selection. Healthcare professionals who prescribe these products will also educate patients as part of the programme. Cephalon expects that enrollment in the REMS programme will begin in September 2011.
The goals of the REMS are to ensure proper patient selection, to prevent accidental exposure and inappropriate conversion between fentanyl products, as well as to mitigate the potential risks of misuse, abuse, addiction, and overdose. The newly-approved REMS will replace the existing risk management programmes for Actiq and Fentora.
“The Fentora and Actiq REMS demonstrate Cephalon's commitment to patient safety while maintaining access to these medicines for the often debilitating breakthrough pain experienced by many opioid-tolerant patients with cancer,” said Dr Lesley Russell, chief medical officer, Cephalon. “The programme provides education and systems to support safe use of Fentora and Actiq, preserving availability of the medicines to patients through retail pharmacies and using other systems already familiar to prescribers and pharmacists.”
When implemented, the Fentora and Actiq REMS will provide checks and balances within the distribution channel to provide safeguards to help assure dispensing to patients appropriate for the medications. All stakeholders can enroll in the system any time beginning in September 2011. There will be a transition period of about six months following launch of the REMS after which no prescription may be dispensed unless the prescriber and pharmacy are enrolled.
Cephalon will provide regular updates to FDA regarding the effectiveness of the REMS. Based on these evaluations, Cephalon plans to open discussions with FDA regarding the Company's pending supplemental New Drug Application for Fentora as a treatment for opioid-tolerant patients with non-cancer breakthrough pain.
Reports of serious adverse events, including deaths in patients treated with Actiq have been reported. Deaths occurred as a result of improper patient selection (e.g., use in opioid non-tolerant patients) and/or improper dosing. The substitution of Actiq for any other fentanyl product may result in fatal overdose.
Actiq is indicated only for the management of breakthrough cancer pain in patients with malignancies who are already receiving and who are tolerant to around-the-clock opioid therapy for their underlying persistent cancer pain. Patients considered opioid tolerant are those who are taking around-the-clock medicine consisting of at least 60 mg of oral morphine daily, at least 25 mcg of transdermal fentanyl/hour, at least 30 mg of oral oxycodone daily, at least 8 mg oral hydromorphone daily or an equianalgesic dose of another opioid for a week or longer.
Actiq is not indicated for use in opioid non-tolerant patients including those with only as needed (PRN) prior exposure. Life-threatening respiratory depression could occur at any dose in opioid non-tolerant patients. Deaths have occurred in opioid non-tolerant patients. ACTIQ is contraindicated in the management of acute or postoperative pain including headache/migraine.
When prescribing, do not convert patients on a mcg per mcg basis to Actiq from other fentanyl products. When dispensing, do not substitute an Actiq prescription for other fentanyl products. Substantial differences exist in the pharmacokinetic profile of Actiq compared to other fentanyl products that result in clinically important differences in the extent of absorption of fentanyl. As a result of these differences, the substitution of Actiq for any other fentanyl product may result in fatal overdose.
Special care must be used when dosing Actiq. If the breakthrough pain episode is not relieved 15 minutes after completion of the Actiq unit, patients may take only one additional dose using the same strength and then must wait at least 4 hours before taking another dose.
Actiq contains fentanyl, an opioid agonist and a Schedule II controlled substance, with an abuse liability similar to other opioid analgesics. It can be abused in a manner similar to other opioid agonists, legal or illicit. This should be considered when prescribing or dispensing Actiq in situations where the physician or pharmacist is concerned about an increased risk of misuse, abuse or diversion. Schedule II opioid substances which include morphine, oxycodone, hydromorphone, oxymorphone, and methadone have the highest potential for abuse and risk of fatal overdose due to respiratory depression.
Patients and their caregivers must be instructed that Actiq contains a medicine in an amount which can be fatal to a child. Death has been reported in children who have accidentally ingested Actiq. All units must be kept out of the reach of children and opened units properly discarded.
Actiq is intended to be used only in the care of cancer patients and only by oncologists and pain specialists who are knowledgeable of and skilled in the use of Schedule II opioids to treat cancer pain.
The concomitant use of Actiq with strong and moderate cytochrome P450 3A4 inhibitors may result in an increase in fentanyl plasma concentrations, and may cause potentially fatal respiratory depression.
Reports of serious adverse events, including deaths in patients treated with Fentora have been reported. Deaths occurred as a result of improper patient selection (e.g., use in opioid non-tolerant patients) and/or improper dosing. The substitution of Fentora for any other fentanyl product may result in fatal overdose.
Fentora is indicated only for the management of breakthrough pain in patients with cancer who are already receiving and who are tolerant to around-the-clock opioid therapy for their underlying persistent cancer pain. Patients considered opioid tolerant are those who are taking around-the-clock medicine consisting of at least 60 mg of oral morphine daily, at least 25 mcg/hour of transdermal fentanyl, at least 30 mg of oral oxycodone daily, at least 8 mg of oral hydromorphone daily or an equianalgesic dose of another opioid daily for a week or longer.
Fentora is contraindicated in the management of acute or postoperative pain including headache/migraine. It is not indicated for use in opioid non-tolerant patients including those with only as needed (PRN) prior exposure to opioids. Life-threatening respiratory depression could occur at any dose in opioid non-tolerant patients. Deaths have occurred in opioid non-tolerant patients.
When prescribing, do not convert patients on a mcg per mcg basis from any other fentanyl products to Fentora. When dispensing, do not substitute a Fentora prescription for other fentanyl products. Substantial differences exist in the pharmacokinetic profile of Fentora compared to other fentanyl products that result in clinically important differences in the extent of absorption of fentanyl. As a result of these differences, the substitution of Fentora for any other fentanyl product may result in fatal overdose.
Special care must be used when dosing Fentora. If the breakthrough pain episode is not relieved after 30 minutes, patients may take only one additional dose using the same strength and must wait at least 4 hours before taking another dose.
Fentora contains fentanyl, an opioid agonist and a Schedule II controlled substance, with an abuse liability similar to other opioid analgesics. Fentora can be abused in a manner similar to other opioid agonists, legal or illicit. This should be considered when prescribing or dispensing Fentora in situations where the physician or pharmacist is concerned about an increased risk of misuse, abuse or diversion. Schedule II opioid substances which include morphine, oxycodone, hydromorphone, oxymorphone, and methadone have the highest potential for abuse and risk of fatal overdose due to respiratory depression.
Patients and their caregivers must be instructed that Fentora contains a medicine in an amount which can be fatal to a child. Patients and their caregivers must be instructed to keep all tablets out of the reach of children.
Fentora is intended to be used only in the care of opioid tolerant cancer patients and only by healthcare professionals who are knowledgeable of and skilled in the use of Schedule II opioids to treat cancer pain.
The concomitant use of Fentora with CYP3A4 inhibitors may result in an increase in fentanyl plasma concentrations, and may cause potentially fatal respiratory depression.
Actiq and Fentora must not be used in opioid non-tolerant patients because life-threatening respiratory depression and death can occur at any dose in opioid non-tolerant patients. They are contraindicated in the management of acute or postoperative pain, including headache/migraine. They are contraindicated in patients with known hypersensitivity to any of the components or the drug fentanyl.
Clinically significant respiratory and CNS depression can occur. Monitor patients accordingl. Use with other CNS depressants and cytochrome P450 3A4 inhibitors may increase depressant effects including hypoventilation, hypotension and profound sedation. Consider dosage adjustments if warranted. Titrate Actiq and Fentora cautiously in patients with chronic obstructive pulmonary disease or pre-existing medical conditions predisposing them to respiratory depression.
Administer Actiq and Fentora with extreme caution in patients susceptible to intracranial effects of CO2 retention. Application site reactions occurred in 10% of patients in FENTORA clinical trials and ranged from paresthesia to ulceration and bleeding. Full and partially consumed Actiq units contain medicine that can be fatal to a child. Ensure proper storage and disposal. Interim safe storage container available (Actiq Child Safety Kit).
For Actiq, most common adverse reactions during titration phase (frequency greater than or equal to 5%): nausea, dizziness, somnolence, vomiting, asthenia and headache. Most common adverse reactions during longer-term treatment (frequency greater than or equal to 5%): dyspnea, constipation, anxiety, confusion, depression, rash and insomnia.
For Fentora, most common adverse reactions during titration phase (frequency greater than or equal to 10%): nausea and dizziness. Most common adverse reactions during longer-term treatment (frequency greater than or equal to 10%): nausea, vomiting, fatigue, anaemia, dizziness, peripheral edema, constipation, asthenia, dehydration and headache.
Monitor patients who begin therapy with, or increase dose of, inhibitors of CYP 3A4 for signs of opioid toxicity. Monitor patients who stop therapy with, or decrease dose of, inducers of CYP 3A4 for signs of opioid toxicity.
Cephalon is a global biopharmaceutical company dedicated to discovering, developing and bringing to market medications to improve the quality of life of individuals around the world.