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  6. Fentanyl buccal (Effentora)
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Fentanyl buccal (Effentora)

Red – For medicines normally initiated and used under specialist guidance

Introduction

Description: Contains fentanyl, a potent opioid analgesic with a rapid onset of action.

Do not confuse with Alfentanil

Third line opioid: only for use with specialist advice

Preparations

  • This guideline is for the use of Effentora – a buccal fentanyl tablet (available as 100, 200, 400, 600, 800 micrograms).  Alternatively the tablet can be placed sublingually.

Most NHS boards have only approved one or two rapid acting fentanyl products for use in their area. Check your local Formulary (refer to Abstral and PecFent medicine information sheets).

  • Rapid acting fentanyl products have different absorption and elimination characteristics and are not interchangeable.
  • Start with the lowest dose and titrate very carefully if the patient is changed to a different product.
  • The brand name should always be included in the prescription. 

 

Indications

  • Rapid acting fentanyl preparations are SMC approved for restricted use in NHSScotland; for the management of opioid responsive, breakthrough pain in adults requiring regular opioid therapy for chronic cancer pain.
  • Use is restricted to patients where other oral opioids (for example immediate-release morphine or immediate-release oxycodone) are unsuitable, ineffective or not tolerated.
  • Patients must have been on a stable dose of a regular opioid for at least 7 days equivalent to at least 60mg of oral morphine or 30mg of oral oxycodone in 24 hours or a 25 micrograms/hour fentanyl patch before rapid acting fentanyl is used.
  • Opioids with a rapid onset of action can be effective in breakthrough pain where background cancer pain is well controlled but the patient has:
    • pain related to a particular event (for example movement, dressing changes)
    • pain that occurs spontaneously, is sudden in onset, can be moderate to severe, but may not last long.

 

Cautions

  • Hepatic metabolism to an inactive metabolite is slower when higher doses of fentanyl are used. 
  • Rapid acting fentanyl products can have a variable and unpredictable half life which in some products can be up to 22 hours.
  • Liver impairment: lower doses and slower titration are needed in severe liver disease.
  • Renal impairment: no initial dose reduction. May accumulate gradually over time in patients with Grade 4-5 chronic kidney disease. Fentanyl is not removed by dialysis.
  • Monitor patients with liver or renal impairment and reduce dose if side effects develop.
  • Avoid in severe chronic obstructive pulmonary disease or respiratory depression.
  • Mouth ulcers, mucositis or dry mouth can affect absorption.
  • Effentora® has a high sodium content.

Drug interactions

  • Hepatic metabolism is reduced by grapefruit juice and a number of medications
    (for example fluconazole, QTclarithromycin, QTerythromycin) – refer to British National
    Formulary (BNF).
  • Alcohol and central nervous system depressants increase side effects.
  • Manufacturers warn of a risk of serotonin toxicity when fentanyl is used in combination with other serotoninergic drugs.

Side effects

  • Similar to other opioids: nausea, dizziness, sedation, delirium.
  • Rapid acting fentanyl preparations can accumulate if repeated doses are given.
  • Monitor the patient closely for opioid side effects; review the dose and dosing interval.
  • Titrated naloxone is only indicated in life-threatening, opioid induced respiratory depression (refer to Naloxone guideline). 

 

Dose and administration

    • Rapid acting fentanyl preparations must be individually titrated to an effective dose; patients should be monitored closely during the initial dose titration period.
    • The effective dose of rapid acting fentanyl cannot be predicted from the dose of regular opioid being used to manage background pain.
    • The licensed titration regimen may be too complex for some care settings and too rapid for some patients. In specialist palliative care there is little consensus on the most appropriate way to titrate the rapid acting fentanyl preparations – check local specialist advice. The regimen below is used by some specialists but is unlicensed (patients under specialist palliative care may have the dose escalated more quickly):
    • Start with the lowest dose of the buccal fentanyl tablet (Effentora®100 micrograms):
      • one dose of Effentora® can be given to treat an episode of pain or 5 to 10 minutes before an event anticipated to cause pain.
      • if the patient can be monitored and is not at risk of opioid toxicity, a second tablet of 100 micrograms can be given after 30 minutes, if required.
      • if the patient is still in pain after taking one or two tablets of Effentora® as above, a dose of their usual immediate release oral opioid can be given.
      • wait for 4 hours before treating another episode of breakthrough pain with Effentora® – refer to table below

Tables are best viewed in landscape mode on mobile devices

Strength of FIRST buccal tablet per episode of breakthrough pain Strength of SECOND buccal tablet to be taken 30 minutes after first tablet, if required
100 micrograms 100 micrograms
200 micrograms 200 micrograms
400 micrograms 200 micrograms
600 micrograms 200 micrograms
800 micrograms NONE – efficacy & safety of doses > 800 micrograms have not been evaluated.
  • A maximum of 4 episodes of breakthrough pain in 24 hours should be treated with buccal fentanyl tablets.
  • The dose of Effentora® can be increased in a step-wise manner if it is showing some effect and is well tolerated, usually after 24 to 48 hours. Palliative care specialists may recommend an individualised titration regimen.
    • Continue to monitor the patient carefully.
  • Make sure background pain is well controlled with regular opioids and other analgesics.
  • If pain remains poorly controlled, review the patient, reassess the background analgesia, and consider other approaches to pain management,
  • Rapid acting fentanyl should be discontinued if ineffective or no longer needed.

 

Practice points

  • Seek advice from a specialist about use of rapid acting fentanyl products.
  • Fentanyl is 100 to 150 times more potent than oral morphine; titrate and monitor carefully.
  • Even the lowest strength preparations can accumulate and cause opioid toxicity.
  • Different rapid acting fentanyl products should not be used at the same time.
  • The GP, community nurse and community pharmacist should be informed.
  • The unscheduled care service should be informed that the patient is receiving a third-line opioid under specialist supervision.
  • Fentanyl buccal tablets (Effentora®) can be prescribed by the patient’s GP in liaison with local palliative care specialists.
  • The patient should have information about who to contact if there are any queries or problems relating to use of Effentora® in the community.

 

Resources

Summary of product characteristics for Effentora from electronic medicines compendium.

 

References

Davies A. The management of cancer related breakthrough pain: recommendations of a task group of the Association for Palliative Medicine. European Journal of Pain; 2009, 13 (4): 331-338.

Twycross R & Wilcock A. Palliative Care Formulary, (Fourth Edition). Palliativedrugs.com Ltd, Nottingham, 2011