Prescribing and administration guideline for Alfentanil spray in a palliative care setting

This information is intended to support any staff caring for patients using alfentanil spray for pain in a palliative care setting. It is an unlicensed preparation which is restricted to specialist initiation only.

Indications

Alfentanil is a strong lipophylic opioid with agonist activity at mu and kappa opiate receptors. When administered by the buccal or nasal route, it works quickly and the effects last 10-15 minutes. It may, therefore, be helpful for both incident and spontaneous pain:

Incident (predictable pain): is related to movement or activity. This might be in association with personal care, dressing changes, or transfers, for example.
Spontaneous (unpredictable pain): is unrelated to movement or activity. Alfentanil may be an alternative for patients who do not tolerate immediate release Morphine or Oxycodone. However, Alfentanil has a shorter duration of action.

Alfentanil is a third line opioid and should be used under specialist advice. For hospital in-patients, it is normally more cost effective to use the intravenous vials of Alfentanil and administer it sublingually. However, patients may bring their own sprays in to hospital, or may need to practice using the spray in preparation for discharge home.

Do not confuse Alfentanil with Fentanyl; Fentanyl is four times more potent than Alfentanil.

Prescribing information

Formulation	5mg Alfentanil in 5ml
Dose	Each metered dose spray delivers 0.14ml/140micrograms of Alfentanil. The dose for incident pain is independent of background analgesia, therefore the starting dose is usually 1 spray, titrated upwards as needed (this can be under the supervision of the palliative care team). After priming, the bottle should deliver a further 32 sprays
Route of administration	Alfentanil spray can be used buccally or nasally and is supplied with adaptors for both routes. It is most usually used buccally in NHS Borders, and the delivery route should be specified on the prescription.
Shelf life	The pump spray should only be used for 28 days after it has been opened.
Prescribing	Alfentanil is a schedule 2 controlled drug and normal controlled drug requirements must be followed: Name, address and CHI number must be present in prescriber’s own handwriting (addressograph not accepted). Form, strength and dosing information must be clearly written (“as required” not accepted). Total quantity of mililitres to be dispensed must be written in words and figures (“1 (one) bottle” not accepted). For example: Alfentanil spray 5mg in 5ml. 1 spray to be taken sublingually 2 hourly when required for pain. Supply 1x5ml (one x five mililitre) bottle.
Cautions	Liver impairment: reduced clearance. Dose reduction of 30-50% may be necessary. Renal impairment: no dose reduction required.
Side effects	Alfentanil is a strong opioid drug and the side effects include nausea, vomiting, constipation, confusion, drowsiness and rarely respiratory depression.
Drug interactions	Alfentanil is metabolised by the cytochrome P450 enzyme system. Therefore, drugs which induce the cytochrome P450 system (such as Carbamazepine, Phenytoin and Glucocorticoids) will reduce Alfentanil levels. Drugs which inhibit the cytochrome P450 system (such as Midazolam, Erythromycin, Ciprofloxacin and Fluconazole) will increase Alfentanil levels. Alcohol may potentiate the effects of Alfentanil.

Administration information

1. Assembling the spray

Alfentanil spray bottles come in 4 parts:

A glass bottle containing 5mg in 5ml Alfentanil
A plastic bag containing the other 3 parts:
- The pump mechanism which screws into the glass bottle
- A buccal spray head with a 4 inch long delivery tube
- A nostril shaped spray head with a clear plastic cover

Alfentanil is usually administered buccally. To ensure clarity, if the spray is prescribed for use by the buccal route, please dispose of the nostril spray head. Conversely, if the spray is prescribed for use by the nasal route, please dispose of the buccal spray head. Open the glass bottle and screw the pump mechanism and spray head into it.

Before using the pump for the first time, it will need to be primed. This is achieved by fully depressing the spray button two or three times which fills the pump mechanism.
This only needs to be done when setting up the pump for the first time, not before each use.

2. Administering the spray

To administer the spray, place the delivery tube inside the mouth or nose as appropriate and spray the prescribed number of doses. For buccal use, spray onto the inside of the cheek.

Storage, ordering, and record keeping requirements

1. Ward stock

Alfentanil is a Schedule 2 controlled drug and must be ordered and stored following the normal procedures for controlled drugs.

Order Alfentanil spray in a Controlled Drug (CD) order book, including the patient’s name and CHI number. Pharmacy will add a patient specific label to the bottle during dispensing – note, this will only contain patient name, CHI and ward, no dosing information will be attached. Once order received from Pharmacy, document supply in ward CD book and then transfer 1 bottle from ward stock to a new page in the CD register specific for that patient and record as “Alfentanil 5mg/5ml for xxx (patient’s name)". The spray should be kept in the CD cupboard.

Each time a dose is given, record the number of sprays administered. Do not forget to record the number of sprays needed to prime the bottle when a new bottle is started. Each bottle should deliver 35 sprays – including the 2 or 3 required to prime it. Use this number as the total in the number received column and reduce the total after each use by the number of sprays used. For example:

2. Discharge prescriptions

If a patient is discharged from the BGH using an Alfentanil spray, sufficient supply will be given to the patient on discharge. The use of the spray will be highlighted on the discharge letter and these instructions will accompany the letter.

Availability

Alfentanil spray is unlicensed. It is manufactured by Torbay hospital as a special order. Community pharmacies can order supplies of Alfentanil spray, however this can take a few days therefore patients should be discharged with sufficient stock.
Contact ward pharmacist if advice is required.

Issued by the Specialist Palliative Care Team, Margaret Kerr Unit, BGH.

Adapted from guidelines including the Scottish Palliative Care Guidelines, The Royal Bournemouth and Christchurch Hospitals NHS Trust, St Christopher’s Hospice and palliativedrugs.com.

For further advice or guidance please contact the Palliative Care Team by email (palliativecareteam@borders.scot.nhs.com) or duty bleep 6838, or Pharmacy on 01896 826610 or consult www.palliativecareguidelines.scot.nhs.uk

Last reviewed: 31/01/2022

Next review date: 31/01/2026

Author(s): Smithson R.

Version: PC002/02

Author email(s): rebecca.smithson@borders.scot.nhs.uk.

Reviewer name(s): Area Drugs and Therapeutic Committee (ADTC).

Related guidelines