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Included as part of the PRECAUTIONS section.



Hypoventilation (Respiratory Depression)

Serious or fatal respiratory depression can occur even at recommended doses in patients using ABSTRAL. Respiratory depression is more likely to occur in patients with underlying respiratory disorders and elderly or debilitated patients, usually following large initial doses, including ABSTRAL, in opioid non-tolerant patients, or when opioids are given in conjunction with other drugs that depress respiration.

Respiratory depression from opioids is manifested by a reduced urge to breathe and a decreased rate of respiration, often associated with the “sighing” pattern of breathing (deep breaths separated by abnormally long pauses). Carbon dioxide retention from opioid- induced respiratory depression can exacerbate the sedating effects of opioids. This makes overdoses involving drugs with sedative properties and opioids especially dangerous.

ABSTRAL And Other Fentanyl Products

ABSTRAL is NOT equivalent to all other fentanyl products used to treat breakthrough pain on a mcg per mcg basis. There are differences in the pharmacokinetics of ABSTRAL relative to other fentanyl products which could potentially result in clinically important differences in the amount of fentanyl absorbed and could result in a fatal overdose.

When prescribing ABSTRAL to a patient, DO NOT convert on a mcg to mcg basis from other fentanyl products. Directions for safely converting patients to ABSTRAL from other fentanyl products are not currently available except for Actiq [see Conversion from Actiq ]. This includes oral, transdermal, or parenteral formulations of fentanyl. Therefore, for opioid-tolerant patients starting treatment for breakthrough pain, the initial dose of ABSTRAL is 100 mcg. Individually titrate each patient's dose to provide adequate analgesia while minimizing side effects. [See DOSAGE AND ADMINISTRATION]

When dispensing ABSTRAL to a patient, DO NOT substitute it for any other fentanyl product prescription.

Patient/Caregiver Instructions

Patients and their caregivers must be instructed that ABSTRAL contains a medicine in an amount which can be fatal to a child. Even though ABSTRAL is provided in child-resistant packaging, patients and their caregivers must be instructed to keep tablets out of the reach of children. [see HOW SUPPLIED/Storage and Handling, and PATIENT INFORMATION].

Taking ABSTRAL could be fatal in individuals for whom it is not prescribed and for those who are not opioid-tolerant.

Physicians and dispensing pharmacists must specifically question patients or caregivers about the presence of children in the home (on a full time or visiting basis) and counsel them regarding the dangers to children from inadvertent exposure.

Additive CNS Depressant Effects

The concomitant use of ABSTRAL with other CNS depressants, including other opioids, sedatives or hypnotics, general anesthetics, phenothiazines, tranquilizers, skeletal muscle relaxants, sedating antihistamines, and alcoholic beverages may produce increased depressant effects (e.g., hypoventilation, hypotension, and profound sedation). Concomitant use with potent inhibitors of cytochrome P450 3A4 isoform (e.g., erythromycin, ketoconazole, and certain protease inhibitors) may increase fentanyl levels, resulting in increased depressant effects [see DRUG INTERACTIONS].

Patients on concomitant CNS depressants must be monitored for a change in opioid effects and the dose of ABSTRAL adjusted, if warranted.

Effects On Ability To Drive And Use Machines

Opioid analgesics impair the mental and/or physical ability required for the performance of potentially dangerous tasks (e.g., driving a car or operating machinery). Warn patients taking ABSTRAL of these dangers and counsel them accordingly.

Chronic Pulmonary Disease

Because potent opioids can cause hypoventilation, titrate ABSTRAL with caution in patients with chronic obstructive pulmonary disease or pre-existing medical conditions predisposing them to hypoventilation. In such patients, even normal therapeutic doses of ABSTRAL may further decrease respiratory drive to the point of respiratory failure.

Head Injuries And Increased Intracranial Pressure

Administer ABSTRAL with extreme caution in patients who may be particularly susceptible to the intracranial effects of CO2 retention such as those with evidence of increased intracranial pressure or impaired consciousness. Opioids may obscure the clinical course of a patient with a head injury; use only if clinically warranted.

Cardiac Disease

Intravenous administration of fentanyl may produce bradycardia. Therefore, use ABSTRAL with caution in patients with bradyarrhythmias.

MAO Inhibitors

ABSTRAL is not recommended for use in patients who have received MAO inhibitors within the past 14 days. Severe and unpredictable potentiation by MAO inhibitors has been reported with opioid analgesics.

Transmucosal Immediate Release Fentanyl (TIRF) Risk Evaluation And Mitigation Strategy (REMS) Access Program

Because of the risk for misuse, abuse, addiction, and overdose [see Drug Abuse and Dependence], ABSTRAL is available only through a restricted program called the TIRF REMS Access program. Under the TIRF REMS Access program, outpatients, healthcare professionals who prescribe to outpatients, pharmacies, and distributors must enroll in the program. For inpatient administration (e.g., hospitals, hospices, and long-term care facilities that prescribe for inpatient use) of ABSTRAL, patient and prescriber enrollment is not required.

Required components of the TIRF REMS Access program are:

  • Healthcare professionals who prescribe ABSTRAL must review the prescriber educational materials for the TIRF REMS Access program, enroll in the program, and comply with the REMS requirements.
  • To receive ABSTRAL, outpatients must understand the risks and benefits and sign a Patient-Prescriber Agreement.
  • Pharmacies that dispense ABSTRAL must enroll in the program and agree to comply with the REMS requirements.
  • Wholesalers and distributors that distribute ABSTRAL must enroll in the program and distribute only to authorized pharmacies.
  • Further information, including a list of qualified pharmacies/distributors, is available at or by calling 1-866-822-1483.

Patient Counseling Information

See FDA-approved patient labeling (Medication Guide)

Patient/Caregiver Instructions
  • Before initiating treatment with Abstral, explain the statements below to patients and/or caregivers. Instruct patients to read the Medication Guide each time Abstral is dispensed because new information may be available.
  • TIRF REMS Access Program
    • Outpatients must be enrolled in the TIRF REMS Access program before they can receive Abstral.
    • Allow patients the opportunity to ask questions and discuss any concerns regarding Abstral or the TIRF REMS Access program.
    • As a component of the TIRF REMS Access program, prescribers must review the contents of the Abstral Medication Guide with every patient before initiating treatment with Abstral.
    • Advise the patient that Abstral is available only from pharmacies that are enrolled in the TIRF REMS Access program, and provide them with the telephone number and website for information on how to obtain the drug.
    • Advise the outpatient that only enrolled health care providers may prescribe Abstral.
    • Patient must sign the Patient-Prescriber Agreement to acknowledge that they understand the risks of Abstral.
    • Advise patients that they may be requested to participate in a survey to evaluate the effectiveness of the TIRF REMS Access program.
  • Instruct patients and their caregivers that ABSTRAL contains medicine in an amount that could be fatal in children, in individuals for whom ABSTRAL is not prescribed, and in those who are not opioid tolerant. Patients and their caregivers must be instructed to keep ABSTRAL, both used and unused dosage units, out of the reach of children. Patients and their caregivers must be instructed to dispose of any unneeded tablets remaining from a prescription as soon as possible [see HOW SUPPLIED/Storage and Handling, and WARNINGS AND PRECAUTIONS]
  • Instruct patients and their caregivers to read the Medication Guide each time ABSTRAL is dispensed because new information may be available.
  • Instruct patients not to take Abstral for acute pain, postoperative pain, pain from injuries, headache, migraine, or any other short- term pain, even if they have taken other opioid analgesics for these conditions.
  • Instruct patients on the meaning of opioid tolerance and Abstral is only to be used as a supplemental pain medication for patients with pain requiring regular opioids, who have developed tolerance to the opioid medication and who need additional opioid treatment of breakthrough pain episodes.
  • Instruct that if they are not taking an opioid medication on a regular around-the-clock basis, they must not take Abstral.
  • You must not take more than 2 doses of ABSTRAL for each episode of breakthrough cancer pain.
  • You must wait two hours before treating a new episode of breakthrough pain with ABSTRAL.
  • Instruct patients NOT to share Abstral and that sharing Abstral with anyone else could result in the other individual's death due to overdose.
  • Advise patients that Abstral contains fentanyl, which is a pain medication similar to hydromorphone, methadone, morphine, oxycodone, and oxymorphone.
  • Advise patients that the active ingredient in Abstral, fentanyl, is a drug that some people abuse. Abstral is to be taken only by the patient for whom it was prescribed, and protected from theft or misuse in the work or home environments.
  • Instruct patients to talk to their doctor if breakthrough pain is not alleviated or worsens after taking Abstral.
  • Instruct patients to use Abstral exactly as prescribed by their doctor and not to take Abstral more often than prescribed.
  • Caution patients that Abstral can affect a person's ability to perform activities that require a high level of attention (such as driving or using heavy machinery). Warn patients taking Abstral of these dangers and counsel accordingly.
  • Warn patients not to combine Abstral with alcohol, sleep aids, or tranquilizers except by order of the prescribing physician, because dangerous additive effects may occur resulting in serious injury or death.
  • Inform female patients that if they become pregnant or plan to become pregnant during treatment with Abstral to ask their doctor about the effects that Abstral (or any medicine) may have on them and their unborn child.

Disposal of Unopened ABSTRAL Blister Packages When No Longer Needed

  • Advise patients and their household members to dispose of any unopened packs remaining from a prescription as soon as they are no longer needed.
  • Instruct patients that, to dispose of any unused ABSTRAL tablets, remove them from the blister cards and flush them down the toilet. Do not dispose of the ABSTRAL blister cards or cartons down the toilet.
  • Detailed instructions for the proper storage, administration, disposal, and important instructions for managing an overdose of ABSTRAL are provided in the ABSTRAL Medication Guide. Ensure patients read this information in its entirety and give them an opportunity to have their questions answered.
  • In the event that a caregiver requires additional assistance in disposing of excess units that remain in the home after the drug is no longer needed, instruct them to call the toll-free number for Galena Biopharma, Inc. 1-888-227-8725 or seek assistance from their local DEA office.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

Long-term studies in animals have not been performed to evaluate the carcinogenic potential of fentanyl.

Fentanyl citrate was not mutagenic in the in vitro Ames reverse mutation assay in S. typhimurium or E. coli, or the mouse lymphoma mutagenesis assay, and was not clastogenic in the in vivo mouse micronucleus assay.

Fentanyl has been shown to impair fertility in rats at doses of 30 mcg/kg intravenously and 160 mcg/kg subcutaneously. Conversion to the human equivalent doses indicates that this is within the range of the human recommended dosing for ABSTRAL.

Use In Specific Populations


Category C

There are no adequate and well-controlled studies in pregnant women.

Use ABSTRAL during pregnancy only if the potential benefit justifies the potential risk to the fetus. No epidemiological studies of congenital anomalies in infants born to women treated with fentanyl during pregnancy have been reported.

Chronic maternal treatment with fentanyl during pregnancy has been associated with transient respiratory depression, behavioral changes, or seizures in newborn infants characteristic of neonatal abstinence syndrome.

In women treated acutely with intravenous or epidural fentanyl during labor, symptoms of neonatal respiratory or neurological depression were no more frequent than would be expected in infants of untreated mothers.

Transient neonatal muscular rigidity has been observed in infants whose mothers were treated with intravenous fentanyl.

Fentanyl is embryocidal in rats as evidenced by increased resorptions in pregnant rats at doses of 30 mcg/kg intravenously or 160 mcg/kg subcutaneously. Conversion to human equivalent doses indicates this is within the range of the human recommended dosing for ABSTRAL.

Fentanyl citrate was not teratogenic when administered to pregnant animals. Published studies demonstrated that administration of fentanyl (10, 100, or 500 mcg/kg/day) to pregnant rats from day 7 to 21, of their 21 day gestation, via implanted microosmotic minipumps, was not teratogenic (the high dose was approximately 6times the human dose of 800 mcg per pain episode on a mcg/m² basis). Intravenous administration of fentanyl (10 mcg/kg or 30 mcg/kg) to pregnant female rats from gestation day 6 to 18, was embryo- or feto-toxic, and caused a slightly increased mean delivery time in the 30 mcg/kg/day group, but was not teratogenic.

Labor And Delivery

Fentanyl readily crosses the placenta. Therefore do not use ABSTRAL during labor and delivery (including caesarean section) since it may cause respiratory depression in the fetus or in the newborn infant.

Nursing Mothers

Fentanyl is excreted in human milk; therefore, do not use ABSTRAL in women who are nursing because of the possibility of sedation and/or respiratory depression in their infants. Symptoms of opioid withdrawal may occur in infants at the cessation of nursing by women using ABSTRAL.

Pediatric Use

The safety and efficacy of ABSTRAL have not been established in patients below 18 years of age.

Geriatric Use

Of the 270 opioid tolerant patients with breakthrough cancer pain in the Phase 3 clinical studies of Abstral, 58 (21%) were 65 years of age and older. There was no difference in the median titrated dose in patients aged 65 years and older compared to those < 65 years. No clinically meaningful difference was noted in the safety profile of the group 65 years of age and older as compared to younger patients in ABSTRAL clinical trials.

Elderly patients have been shown to be more sensitive to the effects of fentanyl when administered intravenously, compared with the younger adult population. Therefore, exercise caution when individually titrating ABSTRAL in elderly patients to provide adequate efficacy while minimizing risk.

Patients With Renal And Hepatic Impairment

Insufficient information exists to make recommendations regarding the use of ABSTRAL in patients with impaired renal or hepatic function. Fentanyl is metabolized primarily via human cytochrome P450 3A4 isoenzyme system and the inactive metabolite is mostly eliminated in urine. If the drug is used in these patients, use the drug with caution because of the reduced hepatic metabolism and renal excretion capacity in such patients.


Both male and female opioid-tolerant cancer patients were studied for the treatment of breakthrough cancer pain. No clinically relevant gender differences were noted either in efficacy or in observed adverse reactions.

This monograph has been modified to include the generic and brand name in many instances.

Last reviewed on RxList: 12/28/2016


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