FENTORA (fentanyl buccal tablet) is a potent opioid analgesic, intended for buccal mucosal administration. FENTORA is formulated as a flat-faced, round, beveled-edge white tablet.

FENTORA is designed to be placed and retained within the buccal cavity for a period sufficient to allow disintegration of the tablet and absorption of fentanyl across the oral mucosa.

FENTORA employs the OraVescent® drug delivery technology, which generates a reaction that releases carbon dioxide when the tablet comes in contact with saliva. It is believed that transient pH changes accompanying the reaction may optimize dissolution (at a lower pH) and membrane permeation (at a higher pH) of fentanyl through the buccal mucosa.

Active Ingredient: Fentanyl citrate, USP is N-(1-Phenethyl-4-piperidyl) propionanilide citrate (1:1). Fentanyl is a highly lipophilic compound (octanol-water partition coefficient at pH 7.4 is 816:1) that is freely soluble in organic solvents and sparingly soluble in water (1:40). The molecular weight of the free base is 336.5 (the citrate salt is 528.6). The pKa of the tertiary nitrogens are 7.3 and 8.4. The compound has the following structural formula:

All tablet strengths are expressed as the amount of fentanyl free base, e.g., the 100 microgram strength tablet contains 100 micrograms of fentanyl free base.

Inactive Ingredients: Mannitol, sodium starch glycolate, sodium bicarbonate, sodium carbonate, citric acid, and magnesium stearate.

(See BOXED WARNING and CONTRAINDICATIONS.)

FENTORA is indicated only for the management of breakthrough pain in patients with cancer who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. Patients considered opioid tolerant are those who are taking at least 60 mg of oral morphine/day, at least 25 mcg of transdermal fentanyl/hour, at least 30 mg of oxycodone daily, at least 8 mg of oral hydromorphone daily or an equianalgesic dose of another opioid for a week or longer.

This product must not be used in opioid non-tolerant patients because life-threatening hypoventilation could occur at any dose in patients not on a chronic regimen of opiates. For this reason, FENTORA is contraindicated in the management of acute or postoperative pain.

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.

Physicians should individualize treatment using a progressive plan of pain management. Healthcare professionals should follow appropriate pain management principles of careful assessment and ongoing monitoring. (See BOXED WARNING and Dose Titration.)

Patients with hepatic and/or renal impairment

Caution should be exercised for patients with hepatic and/or renal impairment, and the lowest possible dose should be used in these patients. (See PRECAUTIONS.)

Patients receiving CYP3A4 inhibitors

Particular caution should be exercised for patients receiving CYP3A4 inhibitors, and the lowest possible dose should be used in these patients. (See PRECAUTIONS.)

Patients with mucositis

No dose adjustment appears necessary in patients with Grade 1 mucositis. The safety and efficacy of FENTORA when used in patients with mucositis more severe than Grade 1 have not been studied.

Administration of FENTORA

Dose Titration: Patients should be titrated to a dose of FENTORA that provides adequate analgesia with tolerable side effects.

Starting Dose: The initial dose of FENTORA should be 100 mcg.

For patients switching from oral transmucosal fentanyl citrate to FENTORA, the starting dose of FENTORA should be initiated as shown in Table 7 below. (See PHARMACOKINETICS, Absorption.)

Table 7. Dosing Conversion Recommendations

Current Actiq (oral transmucosal fentanylcitrate ) Dose(mcg)	Initial FENTORA Dose (mcg)
200	100
400	100
600	200
800	200
1200	400
1600	400

Re-dosing Patients Within a Single Episode: Dosing may be repeated once during a single episode of breakthrough pain if pain is not adequately relieved by one FENTORA dose. Re-dosing may occur 30 minutes after the start of administration of FENTORA and the same dosage strength should be used.

Increasing the Dose: From an initial dose, patients should be closely followed and the dosage strength changed until the patient reaches a dose that provides adequate analgesia with tolerable side effects using a single FENTORA tablet. Patients should record their use of FENTORA over several episodes of breakthrough pain and discuss their experience with their physician to determine if a dosage adjustment is warranted.

Titration should be initiated using multiples of the 100 mcg FENTORA tablet. Patients needing to titrate above 100 mcg can be instructed to use two 100 mcg tablets (one on each side of the mouth in the buccal cavity). If this dose is not successful in controlling the breakthrough pain episode, the patient may be instructed to place two 100 mcg tablets on each side of the mouth in the buccal cavity (total of four 100 mcg tablets). Although not bioequivalent, four 100 mcg FENTORA tablets were found to deliver approximately 12% and 13% higher values for Cmax and AUC_0-inf, respectively, compared to one 400 mcg FENTORA tablet. Consequently, patients converting from four 100 mcg tablets to one 400 mcg FENTORA tablet would be expected to experience a decrease in plasma concentration. The impact of this decrease on pain relief has not been evaluated clinically. Titrate above 400 mcg by 200 mcg increments bearing in mind (1) Using more than 4 tablets simultaneously has not been studied and (2) It is important to minimize the number of strengths available to patients at any time to prevent confusion and possible overdose.

To reduce the risk of overdose during titration, patients should have only one strength FENTORA tablet available at any one time. Patients should be strongly encouraged to use all of their FENTORA tablets of one strength prior to being prescribed the next strength. If this is not practical, unused FENTORA should be disposed of safely. (See DISPOSAL OF FENTORA.) Dispose of any unopened FENTORA tablets remaining from a prescription as soon as they are no longer needed.

Once a successful dose has been established, if the patient experiences greater than four breakthrough pain episodes per day, the dose of the maintenance (around-the-clock) opioid used for persistent pain should be re-evaluated.

Dosage Adjustment: Dosage adjustment of both FENTORA and the maintenance (around-the-clock) opioid analgesic may be required in some patients in order to continue to provide adequate relief of breakthrough pain. Generally, the FENTORA dose should be increased when patients require more than one dose per breakthrough pain episode for several consecutive episodes.

Opening the Blister Package

Patients should be instructed not to open the blister until ready to administer. A single blister unit should be separated from the blister card by tearing it apart at the perforations. The blister unit should then be bent along the line where indicated. The blister backing should then be peeled back to expose the tablet. Patients should NOT attempt to push the tablet through the blister as this may cause damage to the tablet. The tablet should not be stored once it has been removed from the blister package as the tablet integrity may be compromised and because this increases the risk of accidental exposure to the tablet.

Tablet Administration

Patients should remove the tablet from the blister unit and immediately place the entire FENTORA tablet in the buccal cavity (above a rear molar, between the upper cheek and gum). Patients should not attempt to split the tablet.

The FENTORA tablet should not be sucked, chewed or swallowed, as this will result in lower plasma concentrations than when taken as directed.

The FENTORA tablet should be left between the cheek and gum until it has disintegrated, which usually takes approximately 14-25 minutes.

After 30 minutes, if remnants from the FENTORA tablet remain, they may be swallowed with a glass of water.

Dwell time (defined as the length of time that the tablet takes to fully disintegrate following buccal administration), does not appear to affect early systemic exposure to fentanyl.

Safety And Handling

FENTORA is supplied in individually sealed, child-resistant blister packages. The amount of fentanyl contained in FENTORA can be fatal to a child. Patients and their caregivers must be instructed to keep FENTORA out of the reach of children. (See BOXED WARNING, WARNINGS, PRECAUTIONS, and MEDICATION GUIDE )

Store at 20-25ºC (68-77ºF) with excursions permitted between 15° and 30°C (59° to 86°F) until ready to use. (See USP Controlled Room Temperature.)

FENTORA should be protected from freezing and moisture. Do not use if the blister package has been tampered with.

Disposal Of Fentora

Patients and members of their household must be advised to dispose of any tablets remaining from a prescription as soon as they are no longer needed Information is available in the Information for Patients and Caregivers and in the Medication Guide. If additional assistance is required, referral to the FENTORA 800# (1-800-896-5855) should be made.

To dispose of unused FENTORA, remove FENTORA tablets from blister packages and flush down the toilet. Do not flush FENTORA blister packages or cartons down the toilet. If you need additional assistance with disposal of FENTORA, call Cephalon, Inc., at 1-800-896-5855.

Each carton contains 7 blister cards with 4 white tablets in each card. The blisters are child-resistant, encased in peelable foil, and provide protection from moisture. Each tablet is debossed on one side with and the other side of each dosage strength is uniquely identified by the debossing on the tablet as described in the table below. The dosage strength of each tablet is marked on the tablet, the blister package and the carton. See blister package and carton for product information.

Dosage Strength (fentanyl base)	Debossing	Carton/Blister Package Color	NDC Number
100 mcg	1	Blue	NDC 63459-541-28
200 mcg	2	Orange	NDC 63459-542-28
300 mcg	3	Gray	NDC 63459-543-28
400 mcg	4	Sage green	NDC 63459-544-28
600 mcg	6	Magenta (pink)	NDC 63459-546-28
800 mcg	8	Yellow	NDC 63459-548-28

Note: Carton/blister package colors are a secondary aid in product identification. Please be sure to confirm the printed dosage before dispensing.

DEA order form required. A Schedule CII narcotic. Manufactured for: Cephalon, Inc. Frazer, PA 19355 By: CIMA LABS, INC. 10000 Valley View Road, Eden Prairie, MN 55344 and Cephalon, Inc. 4745 Wiley Post Way Salt Lake City, UT 84116. April, 2007. FDA Rev date: 12/5/2007

Pre-Marketing Clinical Trial Experience

The safety of FENTORA has been evaluated in 304 opioid tolerant cancer patients with breakthrough pain. The average duration of therapy was 76 days with some patients being treated for over 12 months.

The most commonly observed adverse events seen with FENTORA are typical of opioid side effects. Opioid side effects should be expected and managed accordingly.

The clinical trials of FENTORA were designed to evaluate safety and efficacy in treating patients with cancer and breakthrough pain; all patients were taking concomitant opioids, such as sustained-release morphine, sustained-release oxycodone or transdermal fentanyl, for their persistent pain.

The adverse event data presented here reflect the actual percentage of patients experiencing each adverse effect among patients who received FENTORA for breakthrough pain along with a concomitant opioid for persistent pain. There has been no attempt to correct for concomitant use of other opioids, duration of FENTORA therapy or cancer-related symptoms.

Table 5 lists, by maximum dose received, adverse events with an overall frequency of 5% or greater within the total population that occurred during titration. The ability to assign a dose-response relationship to these adverse events is limited by the titration schemes used in these studies.

Table 5. Adverse Events Which Occurred During Titration at a Frequency of ≥ 5%

System Organ Class MeDRA preferred term, n (%)	100 mcg (N=45)	200 mcg (N=34)	400 mcg (N=53)	600 mcg (N=56)	800 mcg (N=113)	Total (N=304)*
Gastrointestinal disorders
Nausea	4 (9)	5 (15)	10 (19)	13 (23)	18 (16)	50 (17)
Vomiting	0	2 (6)	2 (4)	7 (13)	3 (3)	14 (5)
General disorders and administration site conditions
Fatigue	3 (7)	1 (3)	9 (17)	1 (2)	5 (4)	19 (6)
Nervous system disorders
Dizziness	5 (11)	2 (6)	12 (23)	18 (32)	21 (19)	58 (19)
Somnolence	2 (4)	2 (6)	6 (12)	7 (13)	3 (3)	20 (7)
Headache	1 (2)	3 (9)	4 (8)	8 (14)	10 (9)	26 (9)
* Three hundred and two (302) patients were included in the safety analysis.

Table 6 lists, by successful dose, adverse events with an overall frequency of ≥ 5% within the total population that occurred after a successful dose had been determined.

Table 6. Adverse Events Which Occurred During Long-Term Treatment at a Frequency of ≥ 5%

System Organ ClassMeDRA preferred term, n (%)	100 mcg (N=19)	200 mcg (N=31)	400 mcg (N=44)	600 mcg (N=48)	800 mcg (N=58)	Total (N=200)
Blood and lymphatic system disorders
Anemia	6 (32)	4 (13)	4 (9)	5 (10)	7 (13)	26 (13)
Neutropenia	0	2 (6)	1 (2)	4 (8)	4 (7)	11 (6)
Gastrointestinal disorders
Nausea	8 (42)	5 (16)	14 (32)	13 (27)	17 (31)	57 (29)
Vomiting	7 (37)	5 (16)	9 (20)	8 (17)	11 (20)	40 (20)
Constipation	5 (26)	4 (13)	5 (11)	4 (8)	6 (11)	24 (12)
Diarrhea	3 (16)	0	4 (9)	3 (6)	5 (9)	15 (8)
Abdominal pain	2 (11)	1 (3)	4 (9)	7 (15)	4 (7)	18 (9)
General disorders and administration site conditions
Edema peripheral	6 (32)	5 (16)	4 (9)	5 (10)	3 (5)	23 (12)
Asthenia	3 (16)	5 (16)	2 (5)	3 (6)	8 (15)	21 (11)
Fatigue	3 (16)	3 (10)	9 (20)	9 (19)	8 (15)	32 (16)
Infections and infestations
Pneumonia	1 (5)	5 (16)	1 (2)	1 (2)	4 (7)	12 (6)
Investigations
Weight decreased	1 (5)	1 (3)	3 (7)	2 (4)	6 (11)	13 (7)
Metabolism and nutrition disorders
Dehydration	4 (21)	0	4 (9)	6 (13)	7 (13)	21 (11)
Anorexia	1 (5)	2 (6)	4 (9)	3 (6)	6 (11)	16 (8)
Hypokalemia	0	2 (6)	0	1 (2)	8 (15)	11 (6)
Musculoskeletal and connective tissue disorders
Back pain	2 (11)	0	2 (5)	3 (6)	2 (4)	9 (5)
Arthralgia	0	1 (3)	3 (7)	4 (8)	3 (5)	11 (6)
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Cancer pain	3 (16)	1 (3)	3 (7)	2 (4)	1 (2)	10 (5)
Nervous system disorders
Dizziness	5 (26)	3 (10)	5 (11)	6 (13)	6 (11)	25 (13)
Headache	2 (11)	1 (3)	4 (9)	5 (10)	8 (15)	20 (10)
Somnolence	0	1 (3)	4 (9)	4 (8)	8 (15)	17 (9)
Psychiatric disorders
Confusional state	3 (16)	1 (3)	2 (5)	3 (6)	5 (9)	14 (7)
Depression	2 (11)	1 (3)	4 (9)	3 (6)	5 (9)	15 (8)
Insomnia	2 (11)	1 (3)	3 (7)	2 (4)	4 (7)	12 (6)
Respiratory, thoracic, and mediastinal disorders
Cough	1 (5)	1 (3)	2 (5)	4 (8)	5 (9)	13 (7)
Dyspnea	1 (5)	6 (19)	0	7 (15)	4 (7)	18 (9)

In addition, a small number of patients (n=11) with Grade 1 mucositis were included in clinical trials designed to support the safety of FENTORA. There was no evidence of excess toxicity in this subset of patients.

The duration of exposure to FENTORA varied greatly, and included open-label and double-blind studies. The frequencies listed below represent the ≥ 1% of patients from three clinical trials (titration and post-titration periods combined) who experienced that event while receiving FENTORA. Events are classified by system organ class.

Adverse Events ( ≥ 1%)

Blood and Lymphatic System Disorders: Anemia, Neutropenia, Thrombocytopenia, Leukopenia

Cardiac Disorders:

Tachycardia

Gastrointestinal Disorders:

Nausea, Vomiting, Constipation, Abdominal Pain, Diarrhea, Stomatitis, Dry Mouth, Dyspepsia, Upper Abdominal Pain, Abdominal Distension, Dysphagia, Gingival Pain, Stomach Discomfort, Gastroesophageal Reflux Disease, Glossodynia, Mouth Ulceration

General Disorders and Administration Site Conditions:

Fatigue, Edema Peripheral, Asthenia, Pyrexia, Application Site Pain, Application Site Ulcer, Chest Pain, Chills, Application Site Irritation, Edema, Mucosal Inflammation, Pain

Hepatobiliary Disorders:

Jaundice

Infections and Infestations:

Pneumonia, Oral Candidiasis, Urinary Tract Infection, Cellulitis, Nasopharyngitis, Sinusitis, Upper Respiratory Tract Infection, Influenza, Tooth Abscess

Injury, Poisoning and Procedural Complications:

Fall, Spinal Compression Fracture

Investigations:

Decreased Weight, Decreased Hemoglobin, Increased Blood Glucose, Decreased Hematocrit, Decreased Platelet Count

Metabolism and Nutrition Disorders:

Dehydration, Anorexia, Hypokalemia, Decreased Appetite, Hypoalbuminemia, Hypercalcemia, Hypomagnesemia, Hyponatremia, Reduced Oral Intake

Musculoskeletal and Connective Tissue Disorders:

Arthralgia, Back Pain, Pain in Extremity, Myalgia, Chest Wall Pain, Muscle Spasms, Neck Pain, Shoulder Pain

Nervous System Disorders:

Dizziness, Headache, Somnolence, Hypoesthesia, Dysgeusia, Lethargy, Peripheral Neuropathy, Paresthesia, Balance Disorder, Migraine, Neuropathy

Psychiatric Disorders:

Confusional State, Depression, Insomnia, Anxiety, Disorientation, Euphoric Mood, Hallucination, Nervousness

Renal and Urinary Disorders:

Renal Failure

Respiratory, Thoracic and Mediastinal Disorders:

Dyspnea, Cough, Pharyngolaryngeal Pain, Exertional Dyspnea, Pleural Effusion, Decreased Breathing Sounds, Wheezing

Skin and Subcutaneous Tissue Disorders:

Pruritus, Rash, Hyperhidrosis, Cold Sweat

Vascular Disorders:

Hypertension, Hypotension, Pallor, Deep Vein Thrombosis

See WARNINGS.

Fentanyl is metabolized mainly via the human cytochrome P450 3A4 isoenzyme system (CYP3A4); therefore potential interactions may occur when FENTORA is given concurrently with agents that affect CYP3A4 activity. The concomitant use of FENTORA with strong CYP3A4 inhibitors (e.g., ritonavir, ketoconazole, itraconazole, troleandomycin, clarithromycin, nelfinavir, and nefazadone) or moderate CYP3A4 inhibitors (e.g., amprenavir, aprepitant, diltiazem, erythromycin, fluconazole, fosamprenavir, and verapamil) may result in increased fentanyl plasma concentrations, potentially causing serious adverse drug effects including fatal respiratory depression. Patients receiving FENTORA concomitantly with moderate or strong CYP3A4 inhibitors should be carefully monitored for an extended period of time. Dosage increase should be done conservatively. (See PHARMACOKINETICS, Drug Interactions and DOSAGE AND ADMINISTRATION.)

Grapefruit and grapefruit juice decrease CYP3A4 activity, increasing blood concentrations of fentanyl, thus should be avoided.

Drugs that induce cytochrome P450 3A4 activity may have the opposite effects.

Concomitant use of FENTORA with an MAO inhibitor, or within 14 days of discontinuation, is not recommended.

See BOXED WARNING

The concomitant use of other CNS depressants, including other opioids, sedatives or hypnotics, general anesthetics, phenothiazines, tranquilizers, skeletal muscle relaxants, sedating antihistamines, potent inhibitors of cytochrome P450 3A4 isoform (e.g., erythromycin, ketoconazole, and certain protease inhibitors), and alcoholic beverages may produce increased depressant effects. Hypoventilation, hypotension, and profound sedation may occur.

FENTORA is not recommended for use in patients who have received MAO inhibitors within 14 days, because severe and unpredictable potentiation by MAO inhibitors has been reported with opioid analgesics.

Pediatric Use: The safety and efficacy of FENTORA have not been established in pediatric patients below the age of 18 years.

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 tablets out of the reach of children. (See SAFETY AND HANDLING, PRECAUTIONS, and MEDICATION GUIDE for specific patient instructions.)

Drug Abuse, Addiction and Diversion of Opioids

FENTORA contains fentanyl, a mu-opioid agonist and a Schedule II controlled substance with high potential for abuse similar to hydromorphone, methadone, morphine, oxycodone, and oxymorphone. Fentanyl can be abused and is subject to misuse, and criminal diversion.

Concerns about abuse, addiction, and diversion should not prevent the proper management of pain. However, all patients treated with opioids require careful monitoring for signs of abuse and addiction, since use of opioid analgesic products carries the risk of addiction even under appropriate medical use.

Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Drug addiction is a treatable disease, utilizing a multidisciplinary approach, but relapse is common.

“Drug-seeking” behavior is very common in addicts and drug abusers.

Abuse and addiction are separate and distinct from physical dependence and tolerance. Physicians should be aware that addiction may not be accompanied by concurrent tolerance and symptoms of physical dependence in all addicts. In addition, abuse of opioids can occur in the absence of addiction and is characterized by misuse for non-medical purposes, often in combination with other psychoactive substances. Since FENTORA tablets may be diverted for non-medical use, careful record keeping of prescribing information, including quantity, frequency, and renewal requests is strongly advised.

Proper assessment of patients, proper prescribing practices, periodic re-evaluation of therapy, and proper dispensing and storage are appropriate measures that help to limit abuse of opioid drugs.

FENTORA should be handled appropriately to minimize the risk of diversion, including restriction of access and accounting procedures as appropriate to the clinical setting and as required by law.

Healthcare professionals should contact their State Professional Licensing Board, or State Controlled Substances Authority for information on how to prevent and detect abuse or diversion of this product.

Physical Dependence and Withdrawal

The administration of FENTORA should be guided by the response of the patient. Physical dependence, per se, is not ordinarily a concern when one is treating a patient with cancer and chronic pain, and fear of tolerance and physical dependence should not deter using doses that adequately relieve the pain.

Opioid analgesics may cause physical dependence. Physical dependence results in withdrawal symptoms in patients who abruptly discontinue the drug. Withdrawal also may be precipitated through the administration of drugs with opioid antagonist activity, e.g., naloxone, nalmefene, or mixed agonist/antagonist analgesics (pentazocine, butorphanol, buprenorphine, nalbuphine).

Physical dependence usually does not occur to a clinically significant degree until after several weeks of continued opioid usage. Tolerance, in which increasingly larger doses are required in order to produce the same degree of analgesia, is initially manifested by a shortened duration of analgesic effect, and subsequently, by decreases in the intensity of analgesia.

Respiratory Depression

Respiratory depression is the chief hazard of opioid agonists, including fentanyl, the active ingredient in FENTORA. Respiratory depression is more likely to occur in patients with underlying respiratory disorders and elderly or debilitated patients, usually following large initial doses 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.

General

The extent of fentanyl absorption with different formulations of transmucosal delivery systems can be substantially different; therefore, the same dose of fentanyl in two different formulations should not be viewed as equivalent. Therefore, caution must be exercised when switching patients from one product to another. (See DOSAGE AND ADMINISTRATION.)

For patients not previously using oral transmucosal fentanyl citrate, the initial dose of FENTORA should be 100 mcg. Each patient should be individually titrated to provide adequate analgesia while minimizing side effects.

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). Patients taking FENTORA should be warned of these dangers and should be counseled accordingly.

The use of concomitant CNS active drugs requires special patient care and observation. (See WARNINGS.)

Chronic Pulmonary Disease

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

Head Injuries and Increased Intracranial Pressure

FENTORA should only be administered 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 and should be used only if clinically warranted.

Application Site Reactions

In clinical trials, 10% of all patients exposed to FENTORA reported application site reactions. These reactions ranged from paresthesia to ulceration and bleeding. Application site reactions occurring in ≥ 1% of patients were pain (4%), ulcer (3%), and irritation (3%). Application site reactions tended to occur early in treatment, were self-limited and only resulted in treatment discontinuation for 2% of patients.

Cardiac Disease

Intravenous fentanyl may produce bradycardia. Therefore, FENTORA should be used with caution in patients with bradyarrhythmias.

Hepatic or Renal Disease

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

Information for Patients and Caregivers

1. Patients and their caregivers must be instructed that children, especially small children, exposed to FENTORA are at high risk of FATAL RESPIRATORY DEPRESSION. Patients and their caregivers must be instructed to keep FENTORA tablets out of the reach of children. (See SAFETY AND HANDLING, WARNINGS, and MEDICATION GUIDE for specific patient instructions.)
2. Patients and their caregivers should be provided a Medication Guide each time FENTORA is dispensed because new information may be available.
3. Patients should be aware that FENTORA contains fentanyl which is a strong pain medication similar to hydromorphone, methadone, morphine, oxycodone, and oxymorphone.
4. Patients should be instructed that the active ingredient in FENTORA, fentanyl, is a drug that some people abuse. FENTORA should be taken only by the patient it was prescribed for, and it should be protected from theft or misuse in the work or home environment.
5. Patients should be instructed that FENTORA tablets are not to be swallowed whole; this will reduce the effectiveness of the medication. They are to be placed between the cheek and gum above a molar tooth and allowed to dissolve. After 30 minutes if remnants of the tablet still remain, patients may swallow it with a glass of water.
6. Patients should be cautioned to talk to their doctor if breakthrough pain is not alleviated or worsens after taking FENTORA.
7. Patients should be cautioned that FENTORA can affect a person's ability to perform activities that require a high level of attention (such as driving or using heavy machinery). Patients taking FENTORA should be warned of these dangers and counseled accordingly.
8. Patients should be warned to not combine FENTORA with alcohol, sleep aids, or tranquilizers except by the orders of the prescribing physician, because dangerous additive effects may occur, resulting in serious injury or death.
9. Female patients should be informed that if they become pregnant or plan to become pregnant during treatment with FENTORA, they should ask their doctor about the effects that FENTORA (or any medicine) may have on them and their unborn children.
10. Patients and caregivers should be advised that if they have been receiving treatment with FENTORA and the medicine is no longer needed they should flush any remaining product down the toilet, and if they then need further assistance, contact Cephalon at 1-800-896-5855.

Disposal of Unopened FENTORA Blister Packages When No Longer Needed

Patients and members of their household must be advised to dispose of any unopened blister packages remaining from a prescription as soon as they are no longer needed.

To dispose of unused FENTORA, remove FENTORA tablets from blister packages and flush down the toilet. Do not flush the FENTORA blister packages or cartons down the toilet. (See SAFETY AND HANDLING.)

Detailed instructions for the proper storage, administration, disposal, and important instructions for managing an overdose of FENTORA are provided in the FENTORA Medication Guide. Patients should be encouraged to read this information in its entirety and be given an opportunity to have their questions answered.

In the event that a caregiver requires additional assistance in disposing of excess unusable tablets that remain in the home after a patient has expired, they should be instructed to call the Cephalon toll-free number (1-800-896-5855) or seek assistance from their local DEA office.

Laboratory Tests

The effects of FENTORA on laboratory tests have not been evaluated.

Carcinogenesis, Mutagenesis, and 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. tymphimurium or E. coli, or the mouse lymphoma mutagenesis assay. Fentanyl citrate was not clastogenic in the in vivo mouse micronucleus assay.

Fentanyl impairs fertility in rats at doses of 30 mcg/kg IV and 160 mcg/kg SC. Conversion to human equivalent doses indicates this is within the range of the human recommended dosing for FENTORA.

Pregnancy - Category C

There are no adequate and well-controlled studies in pregnant women. FENTORA should be used 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 characteristic of neonatal abstinence syndrome in newborn infants. Symptoms of neonatal respiratory or neurological depression were no more frequent than expected in most studies of infants born to women treated acutely during labor with intravenous or epidural fentanyl.

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

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

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 3-times the human dose of 1600 mcg per pain episode on a mg/m² basis). Intravenous administration of fentanyl (10 or 30 mcg/kg) to pregnant female rats from gestation day 6 to 18, was embryo or fetal 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 passes across the placenta to the fetus; therefore FENTORA is not recommended for analgesia during labor and delivery.

Nursing Mothers

Fentanyl is excreted in human milk; therefore FENTORA should not be used in nursing women 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 FENTORA.

Pediatric Use

See WARNINGS.

Geriatric Use

Of the 304 patients with cancer in clinical studies of FENTORA, 69 (23%) were 65 years of age and older.

Patients over the age of 65 years tended to titrate to slightly lower doses than younger patients.

Patients over the age of 65 years reported a slightly higher frequency for some adverse events specifically vomiting, constipation, and abdominal pain. Therefore, caution should be exercised in individually titrating FENTORA in elderly patients to provide adequate efficacy while minimizing risk.

Clinical Presentation

The manifestations of FENTORA overdosage are expected to be similar in nature to intravenous fentanyl and other opioids, and are an extension of its pharmacological actions with the most serious significant effect being hypoventilation. (See CLINICAL PHARMACOLOGY.)

General

Immediate management of opioid overdose includes removal of the FENTORA tablet, if still in the mouth, ensuring a patent airway, physical and verbal stimulation of the patient, and assessment of level of consciousness, as well as ventilatory and circulatory status.

Treatment of Overdosage in the Opioid Non-Tolerant Person

Ventilatory support should be provided, intravenous access obtained, and naloxone or other opioid antagonists should be employed as clinically indicated. The duration of respiratory depression following overdose may be longer than the effects of the opioid antagonist's action (e.g., the half-life of naloxone ranges from 30 to 81 minutes) and repeated administration may be necessary. Consult the package insert of the individual opioid antagonist for details about such use.

Treatment of Overdose in Opioid-Tolerant Patients

Ventilatory support should be provided and intravenous access obtained as clinically indicated. Judicious use of naloxone or another opioid antagonist may be warranted in some instances, but it is associated with the risk of precipitating an acute withdrawal syndrome.

General Considerations for Overdose

Management of severe FENTORA overdose includes: securing a patent airway, assisting or controlling ventilation, establishing intravenous access, and GI decontamination by lavage and/or activated charcoal, once the patient's airway is secure. In the presence of hypoventilation or apnea, ventilation should be assisted or controlled and oxygen administered as indicated.

Patients with overdose should be carefully observed and appropriately managed until their clinical condition is well controlled.

Although muscle rigidity interfering with respiration has not been seen following the use of FENTORA, this is possible with fentanyl and other opioids. If it occurs, it should be managed by the use of assisted or controlled ventilation, by an opioid antagonist, and as a final alternative, by a neuromuscular blocking agent.

Because life-threatening respiratory depression could occur at any dose in opioid non-tolerant patients, FENTORA is contraindicated in the management of acute or postoperative pain. This product must not be used in opioid non-tolerant patients.

FENTORA is contraindicated in patients with known intolerance or hypersensitivity to any of its components or the drug fentanyl.

Pharmacology

Fentanyl is a pure opioid agonist whose principal therapeutic action is analgesia. Other members of the class known as opioid agonists include substances such as morphine, oxycodone, hydromorphone, codeine, and hydrocodone. Pharmacological effects of opioid agonists include anxiolysis, euphoria, feelings of relaxation, respiratory depression, constipation, miosis, cough suppression, and analgesia. Like all pure opioid agonist analgesics, with increasing doses there is increasing analgesia, unlike with mixed agonist/antagonists or non-opioid analgesics, where there is a limit to the analgesic effect with increasing doses. With pure opioid agonist analgesics, there is no defined maximum dose; the ceiling to analgesic effectiveness is imposed only by side effects, the more serious of which may include somnolence and respiratory depression.

Analgesia

The analgesic effects of fentanyl are related to the blood level of the drug, if proper allowance is made for the delay into and out of the CNS (a process with a 3-to-5-minute half-life).

In general, the effective concentration and the concentration at which toxicity occurs increase with increasing tolerance with any and all opioids. The rate of development of tolerance varies widely among individuals. As a result, the dose of FENTORA should be individually titrated to achieve the desired effect. (See DOSAGE AND ADMINISTRATION.)

Central Nervous System

The precise mechanism of the analgesic action is unknown although fentanyl is known to be a mu opioid receptor agonist. Specific CNS opioid receptors for endogenous compounds with opioid-like activity have been identified throughout the brain and spinal cord and play a role in the analgesic effects of this drug.

Fentanyl produces respiratory depression by direct action on brain stem respiratory centers. The respiratory depression involves both a reduction in the responsiveness of the brain stem to increases in carbon dioxide and to electrical stimulation.

Fentanyl depresses the cough reflex by direct effect on the cough center in the medulla. Antitussive effects may occur with doses lower than those usually required for analgesia. Fentanyl causes miosis even in total darkness. Pinpoint pupils are a sign of opioid overdose but are not pathognomonic (e.g., pontine lesions of hemorrhagic or ischemic origin may produce similar findings).

Gastrointestinal System

Fentanyl causes a reduction in motility associated with an increase in smooth muscle tone in the antrum of the stomach and in the duodenum. Digestion of food is delayed in the small intestine and propulsive contractions are decreased. Propulsive peristaltic waves in the colon are decreased, while tone may be increased to the point of spasm resulting in constipation. Other opioid-induced effects may include a reduction in gastric, biliary and pancreatic secretions, spasm of the sphincter of Oddi, and transient elevations in serum amylase.

Cardiovascular System

Fentanyl may produce release of histamine with or without associated peripheral vasodilation. Manifestations of histamine release and/or peripheral vasodilation may include pruritus, flushing, red eyes, sweating, and/or orthostatic hypotension.

Endocrine System

Opioid agonists have been shown to have a variety of effects on the secretion of hormones. Opioids inhibit the secretion of ACTH, cortisol, and luteinizing hormone (LH) in humans. They also stimulate prolactin, growth hormone (GH) secretion, and pancreatic secretion of insulin and glucagon in humans and other species, rats and dogs. Thyroid stimulating hormone (TSH) has been shown to be both inhibited and stimulated by opioids.

Respiratory System

All opioid mu-receptor agonists, including fentanyl, produce dose dependent respiratory depression. The risk of respiratory depression is less in patients receiving chronic opioid therapy who develop tolerance to respiratory depression and other opioid effects. During the titration phase of the clinical trials, somnolence, which may be a precursor to respiratory depression, did increase in patients who were treated with higher doses of another oral transmucosal fentanyl citrate (Actiq). Peak respiratory depressive effects may be seen as early as 15 to 30 minutes from the start of oral transmucosal fentanyl citrate product administration and may persist for several hours.

Serious or fatal respiratory depression can occur even at recommended doses. Fentanyl depresses the cough reflex as a result of its CNS activity. Although not observed with oral transmucosal fentanyl products in clinical trials, fentanyl given rapidly by intravenous injection in large doses may interfere with respiration by causing rigidity in the muscles of respiration. Therefore, physicians and other healthcare providers should be aware of this potential complication.

(See BOXED WARNING, CONTRAINDICATIONS, WARNINGS, PRECAUTIONS, ADVERSE REACTIONS, and OVERDOSAGE for additional information on hypoventilation.)

Pharmacokinetics

Fentanyl exhibits linear pharmacokinetics. Systemic exposure to fentanyl following administration of FENTORA increases linearly in an approximate dose-proportional manner over the 100- to 800-mcg dose range.

Absorption

Following buccal administration of FENTORA, fentanyl is readily absorbed with an absolute bioavailability of 65%. The absorption profile of FENTORA is largely the result of an initial absorption from the buccal mucosa, with peak plasma concentrations following venous sampling generally attained within an hour after buccal administration. Approximately 50% of the total dose administered is absorbed transmucosally and becomes systemically available. The remaining half of the total dose is swallowed and undergoes more prolonged absorption from the gastrointestinal tract.

In a study that compared the absolute and relative bioavailability of FENTORA and Actiq (oral transmucosal fentanyl citrate [OTFC]), the rate and extent of fentanyl absorption were considerably different (approximately 30% greater exposure with FENTORA) (Table 1).

Table 1. Pharmacokinetic Parameters* in Adult Subjects Receiving FENTORA or Actiq (OTFC)

Pharmacokinetic Parameter (mean)	FENTORA 400 mcg	Actiq (OTFC) 400 mcg (adjusted dose)***
Absolute Bioavailability	65% ± 20%	47% ± 10.5%
FractionAbsorbed Transmucosally	48% ± 31.8%	22% ± 17.3%
Tmax (minute) **	46.8 (20-240)	90.8 (35-240)
Cmax (ng/mL)	1.02 ± 0.42	0.63 ± 0.21
AUC0-tmax(nghr/mL)	0.40 ± 0.18	0.14 ± 0.05
AUC0-inf (ng·hr/mL)	6.48 ± 2.98	4.79 ± 1.96
* Based on venous blood samples. ** Data for Tmax presented as median (range). *** Actiq (OTFC) data was dose adjusted (800 mcg to 400 mcg).

Similarly, in another bioavailability study exposure following administration of FENTORA was also greater (approximately 50%) compared to Actiq (OTFC).

Due to differences in drug delivery, measures of exposure (Cmax, AUC_0-tmax, AUC_0-inf) associated with a given dose of fentanyl were substantially greater with FENTORA compared to Actiq (OTFC) (see Figure 1). Therefore, caution must be exercised when switching patients from one product to another. (See DOSAGE AND ADMINISTRATION.) Figure 1 includes an inset which shows the mean plasma concentration versus time profile to 6 hours. The vertical line denotes the median Tmax for FENTORA.

Figure 1. Mean Plasma Concentration Versus Time Profiles Following Single Doses of FENTORA and Actiq (OTFC) in Healthy Subjects

Systemic exposure to fentanyl following administration of FENTORA increases linearly in an approximate dose-proportional manner over the 100- to 800-mcg dose range. Mean pharmacokinetic parameters are presented in Table 2. Mean plasma concentration versus time profiles are presented in Figure 2.

Table 2. Pharmacokinetic Parameters* Following Single 100, 200, 400, and 800 mcg Doses of FENTORA in Healthy Subjects

Pharmacokinetic Parameter (mean±SD)	100 mcg	200 mcg	400 mcg	800 mcg
Cmax(ng/mL)	0.25 ± 0.14	0.40 ± 0.18	0.97 ± 0.53	1.59 ± 0.90
Tmax, minute** (range)	45.0 (25.0 - 181.0)	40.0 (20.0 - 180.0)	35.0 (20.0 - 180.0)	40.0 (25.0 - 180.0)
AUC0-inf(nghr/mL)	0.98 ± 0.37	2.11 ± 1.13	4.72 ± 1.95	9.05 ± 3.72
AUC0-tmax(nghr/mL)	0.09 ± 0.06	0.13 ± 0.09	0.34 ± 0.23	0.52 ± 0.38
T1/2, hr**	2.63 (1.47 - 13.57)	4.43 (1.85 - 20.76)	11.09 (4.63 - 20.59)	11.70 (4.63 - 28.63)
* Based on venous sampling. ** Data for Tmax presented as median (range).

Figure 2. Mean Plasma Concentration Versus Time Profiles Following Single 100, 200, 400, and 800 mcg Doses of FENTORA in Healthy Subjects

Dwell time (defined as the length of time that the tablet takes to fully disintegrate following buccal administration), does not appear to affect early systemic exposure to fentanyl.

The effect of mucositis (Grade 1) on the pharmacokinetic profile of FENTORA was studied in a group of patients with (N = 8) and without mucositis (N = 8) who were otherwise matched. A single 200 mcg tablet was administered, followed by sampling at appropriate intervals. Mean summary statistics (standard deviation in parentheses, expected tmax where range was used) are presented in Table 3.

Table 3. Pharmacokinetic Parameters in Patients with Mucositis

Patient status	Cmax (ng/mL)	tmax (min)	AUC0-tmax (ng·hr/mL)	AUC0-8 (ng·hr/mL)
Mucositis	1.25 ± 0.78	25.0 (15 - 45)	0.21 ± 0.16	2.33 ± 0.93
No mucositis	1.24 ± 0.77	22.5 (10 - 121)	0.25 ± 0.24	1.86 ± 0.86

Distribution

Fentanyl is highly lipophilic. The plasma protein binding of fentanyl is 80-85%. The main binding protein is alpha-1-acid glycoprotein, but both albumin and lipoproteins contribute to some extent. The mean oral volume of distribution at steady state (Vss/F) was 25.4 L/kg.

Metabolism

The metabolic pathways following buccal administration of FENTORA have not been characterized in clinical studies. The progressive decline of fentanyl plasma concentrations results from the uptake of fentanyl in the tissues and biotransformation in the liver. Fentanyl is metabolized in the liver and in the intestinal mucosa to norfentanyl by cytochrome P450 3A4 isoform. In animal studies, norfentanyl was not found to be pharmacologically active. (See PRECAUTIONS: DRUG INTERACTIONS for additional information.)

Elimination

Disposition of fentanyl following buccal administration of FENTORA has not been characterized in a mass balance study. Fentanyl is primarily (more than 90%) eliminated by biotransformation to N-dealkylated and hydroxylated inactive metabolites. Less than 7% of the administered dose is excreted unchanged in the urine, and only about 1% is excreted unchanged in the feces. The metabolites are mainly excreted in the urine, while fecal excretion is less important.

The total plasma clearance of fentanyl following intravenous administration is approximately 42 L/h.

Special Populations

The pharmacokinetics of FENTORA has not been studied in Special Populations.

Race

The pharmacokinetic effects of race with the use of FENTORA have not been systematically evaluated. In studies conducted in healthy Japanese subjects, systemic exposure was generally higher than that observed in US subjects (mean Cmax and AUC values were approximately 50% and 20% higher, respectively). The observed differences were largely attributed to the lower mean weight of the Japanese subjects compared to US subjects (57.4 kg versus 73 kg).

Age

The effect of age on the pharmacokinetics of FENTORA has not been studied.

Gender

Systemic exposure was higher for women than men (mean Cmax and AUC values were approximately 28% and 22% higher, respectively). The observed differences between men and women were largely attributable to differences in weight.

Renal or Hepatic Impairment

The effect of renal or hepatic impairment on the pharmacokinetics of FENTORA has not been studied. Although fentanyl kinetics are known to be altered as a result of hepatic and renal disease due to alterations in metabolic clearance and plasma protein binding, the duration of effect for the initial dose of fentanyl is largely determined by the rate of distribution of the drug.

Diminished metabolic clearance may, therefore, become significant, primarily with repeated dosing or at very high single doses. For these reasons, while it is recommended that FENTORA is titrated to clinical effect for all patients, special care should be taken in patients with severe hepatic or renal disease. (See PRECAUTIONS.)

Drug Interactions

The interaction between ritonavir and fentanyl was investigated in eleven healthy volunteers in a randomized crossover study. Subjects received oral ritonavir or placebo for 3 days. The ritonavir dose was 200 mg tid on Day 1 and 300 mg tid on Day 2 followed by one morning dose of 300 mg on Day 3. On Day 2, fentanyl was given as a single IV dose at 5 mcg/kg two hours after the afternoon dose of oral ritonavir or placebo. Naloxone was administered to counteract the side effects of fentanyl. The results suggested that ritonavir might decrease the clearance of fentanyl by 67%, resulting in a 174% (range 52%-420%) increase in fentanyl AUC0-inf. Coadministration of ritonavir in patients receiving FENTORA has not been studied; however, an increase in fentanyl AUC is expected. (See DOSAGE AND ADMINISTRATION and PRECAUTIONS.)

Clinical Trials

Breakthrough Pain

The efficacy of FENTORA was demonstrated in a double-blind, placebo-controlled, cross-over study in opioid tolerant patients with cancer and breakthrough pain. Patients considered opioid tolerant were those who were taking at least 60 mg of oral morphine/day, at least 25 mcg of transdermal fentanyl/hour, at least 30 mg of oxycodone daily, at least 8 mg of oral hydromorphone daily or an equianalgesic dose of another opioid for a week or longer.

In this trial, patients were titrated in an open-label manner to a successful dose of FENTORA. A successful dose was defined as the dose in which a patient obtained adequate analgesia with tolerable side effects. Patients who identified a successful dose were randomized to a sequence of 10 treatments with 7 being the successful dose of FENTORA and 3 being placebo. Patients used one tablet (either FENTORA or Placebo) per breakthrough pain episode.

Patients assessed pain intensity on a scale that rated the pain as 0=none to 10=worst possible pain. With each episode of breakthrough pain, pain intensity was assessed first and then treatment was administered. Pain intensity (0-10) was measured at 15, 30, 45 and 60 minutes after the start of administration. The sum of differences in pain intensity scores at 15 and 30 minutes from baseline (SPID30) was the primary efficacy measure.

Sixty five percent of patients who entered the study achieved a successful dose during the titration phase. The distribution of successful doses is shown in Table 4. The median dose was 400 mcg.

Table 4. Successful Dose of FENTORA Following Initial Titration

FENTORA Dose	(N=80) n(%)
100 mcg	13 (16)
200 mcg	11 (14)
400 mcg	21 (26)
600 mcg	10 (13)
800 mcg	25 (31)

The LS mean (SE) SPID30 for FENTORA-treated episodes was 3.0 (0.12) while for placebo-treated episodes it was 1.8 (0.18) (p < 0.0001).

Figure 3. Mean Pain Intensity Difference (PID) at Each Time Point During the Double-Blind Treatment Period

Medication Guide

FENTORA™
(fen-tor-a)CII
(fentanyl buccal tablet)
100 mcg, 200 mcg, 300 mcg, 400 mcg, 600 mcg, 800 mcg

IMPORTANT: Keep FENTORA in a safe place away from children. Accidental use by a child is a medical emergency and can result in death. If a child accidentally takes FENTORA, get emergency help right away.

Read the Medication Guide that comes with FENTORA before you start taking it and each time you get a new prescription. There may be new information. This Medication Guide does not take the place of talking to your doctor about your medical condition or your treatment. Share this important information with members of your household.

What is the most important information I should know about FENTORA?

1. FENTORA can cause life-threatening breathing problems which can lead to death:

• if it is used by anyone who is not already taking other opioid pain medicines and their body is not used to these medicines (not opioid tolerant)
• if it is not used exactly as prescribed

2. Your doctor will prescribe a starting dose of FENTORA that is different than other fentanyl containing medicines you may have been taking. Do not substitute FENTORA for other fentanyl medicines, including Actiq, without talking with your doctor.

What is FENTORA?

• FENTORA is a prescription medicine that contains the medicine fentanyl.
  FENTORA is a federally controlled substance (CII) because it is a strong opioid pain medicine that can be abused by people who abuse prescription medicines or street drugs.
• FENTORA is used to treat breakthrough pain in adult patients with cancer (18 years of age and older) who are already taking other opioid pain medicines for their constant (around-the-clock) cancer pain. FENTORA is started only after you have been taking other opioid pain medicines and your body has gotten used to them (you are opioid tolerant). Do not use FENTORA if you are not opioid tolerant.
• You must stay under your doctor's care while taking FENTORA.
• FENTORA must not be used for short-term pain from injuries and surgery.
• FENTORA should be placed in the mouth, against your gum and allowed to dissolve. You may feel a gentle bubbling sensation between your cheek and gum as the tablet dissolves. FENTORA is not meant to be chewed or swallowed.
• Prevent theft and misuse. Keep FENTORA in a safe place to protect it from being
• stolen since it can be a target for people who abuse narcotic medicines or street drugs.
• Never give FENTORA to anyone else, even if they have the same symptoms you have. It may harm them and even cause death.
• Selling or giving away this medicine is against the law.

Who should not take FENTORA?

Do Not Take FENTORA if you:

• are not already taking other opioid pain medicines for your constant (around-the-clock) cancer pain. Never use FENTORA for short-term pain from injuries and surgery.
• are allergic to anything in FENTORA. The active ingredient is fentanyl. See the end of this Medication Guide for a complete list of ingredients in FENTORA.

What should I tell my doctor before starting FENTORA?

Tell your doctor about all of your medical and mental problems, especially the ones listed below:

• Trouble breathing or lung problems such as asthma, wheezing, or shortness of breath
• A head injury or brain problem
• Liver or kidney problems
• Seizures (convulsions or fits)
• Slow heart rate or other heart problems
• Low blood pressure
• Mental problems including major depression or hallucinations (seeing or hearing things that are not there)
• A past or present drinking problem or alcoholism, or a family history of this problem
• A past or present drug abuse or addiction problem, or a family history of this problem

Tell your doctor if you are:

• pregnant or planning to become pregnant. FENTORA may harm your unborn baby.
• breast feeding. FENTORA passes through your breast milk, and it can cause serious harm to your baby. You should not use FENTORA while breast feeding.

Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. Some medicines may cause serious or life-threatening medical problems when taken with FENTORA. Sometimes, the doses of certain medicines and FENTORA need to be changed if used together. Do not take any medicine while using FENTORA until you have talked to your doctor. Your doctor will tell you if it is safe to take other medicines while you are using FENTORA. Be especially careful about taking other medicines that make you sleepy such as other pain medicines, anti-depressant medicines, sleeping pills, anxiety medicines, antihistamines, or tranquilizers.

Know the medicines you take. Keep a list of them to show your doctor and pharmacist.

How should I use FENTORA?

• Use FENTORA exactly as prescribed. Do not take FENTORA more often than prescribed. Talk to your doctor about your pain. Your doctor can decide if your dose of FENTORA needs to be changed.
• FENTORA comes packaged in a blister card. Do not open the blister until ready to use. Separate one of the blister units from the blister card by tearing apart at the perforations. Bend the blister unit along the line where indicated. Peel back foil on blister pack to expose tablet.
• DO NOT push the tablet through the foil on the blister pack because this could damage the tablet.
• Once removed from the blister pack, FENTORA must be used right away.
• Place a FENTORA tablet in your mouth above a rear molar tooth between the upper cheek and gum and leave in place until the tablet is dissolved. This generally takes between 14 to 25 minutes. After 30 minutes if there is any tablet left, swallow it with a glass of water. If you cannot take the medicine in this manner, tell your doctor who will advise you what to do. Do not split the tablet.
• Do not bite, chew or suck FENTORA tablets. If you do so, you will swallow more of the medicine and get less relief for your breakthrough cancer pain.
• If you begin to feel dizzy, sick to your stomach, or very sleepy before the tablet is completely dissolved, rinse your mouth with water and spit the remaining pieces of the tablet into a sink or toilet right away. Rinse the sink or flush the toilet to dispose of any remaining tablet pieces.
• If you have more than 4 episodes of breakthrough cancer pain per day, talk to your doctor. The dose of around-the-clock pain medicine may need to be adjusted.
• If you take too much FENTORA or overdose, call 911 for emergency help.

What should I avoid while taking FENTORA?

• Do not drive, operate heavy machinery, or do other dangerous activities until you know how FENTORA affects how alert you are. FENTORA can make you sleepy. Ask your doctor when it is okay to do these activities.
• Do not drink alcohol while using FENTORA. It can increase your chance of getting dangerous side effects.
• Do not take any medicine while using FENTORA until you have talked to your doctor. Your doctor will tell you if it is safe to take other medicines while you are using FENTORA. Be especially careful about taking other medicines that make you sleepy such as other pain medicines, anti-depressant medicines, sleeping pills, anxiety medicines, antihistamines, or tranquilizers.

What are the possible or reasonably likely side effects of FENTORA?

• Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Call your doctor or get emergency medical help right away if you:

• have trouble breathing
• have extreme drowsiness with slowed breathing
• have slow, shallow breathing (little chest movement with breathing)
• feel faint, very dizzy, confused, or have unusual symptoms

These can be symptoms that you have taken too much (overdose) FENTORA or the dose is too high for you. These symptoms may lead to serious problems or death if not treated right away.

• FENTORA can cause pain or sores at the application site (on your gum or the inside of your cheek). Tell your doctor if this is a problem for you.
• FENTORA can cause your blood pressure to drop. This can make you feel dizzy if you get up too fast from sitting or lying down.
• FENTORA can cause physical dependence. Do not stop taking FENTORA or any other opioid without talking to your doctor. You could become sick with uncomfortable withdrawal symptoms because your body has become used to these medicines. Physical dependence is not the same as drug addiction.
• There is a chance of abuse or addiction with FENTORA. The chance is higher if you are or have been addicted to or abused other medications, street drugs, or alcohol, or if you have a history of mental problems.

The most common side effects of FENTORA are nausea, vomiting, dizziness, sleepiness, headache, and constipation. Constipation (not often enough or hard bowel movements) is a very common side effect of pain medicines (opioids) including FENTORA and is unlikely to go away without treatment. Talk to your doctor about dietary changes, and the use of laxatives (medicines to treat constipation) and stool softeners to prevent or treat constipation while taking FENTORA.

Talk to your doctor about any side effects that bother you or that do not go away.

These are not all the possible side effects of FENTORA. For a complete list, ask your doctor.

How should I store FENTORA?

• Keep FENTORA in a safe and secure place away from children and from anyone for whom it has not been prescribed. Accidental use by a child is a medical emergency and can result in death. If a child accidentally takes FENTORA, get emergency help right away.
• FENTORA is supplied in single sealed child-resistant blister packages.
• Store FENTORA at room temperature, 59o to 86oF (15o to 30oC) until ready to use.
• Always keep FENTORA in a secure place to protect from theft.

How should I dispose of unopened FENTORA tablets when they are no longer needed?

• Dispose of any unopened FENTORA tablets remaining from a prescription as soon as they are no longer needed.
• To dispose of unused FENTORA, remove FENTORA tablets from blister packages and flush down the toilet. Do not flush the FENTORA blister packages or cartons down the toilet.
• If you need help with disposal of FENTORA, call Cephalon, Inc., at 1-800-896-5855.

General Information About the Safe and Effective Use of FENTORA

Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Use FENTORA only for the purpose for which it was prescribed. Do not give FENTORA to other people, even if they have the same symptoms you have. FENTORA can harm other people and even cause death. Sharing FENTORA is against the law.

This Medication Guide summarizes the most important information about FENTORA. If you would like more information, talk with your doctor. You can ask your pharmacist or doctor for information about FENTORA that is written for healthcare professionals. You can also call Cephalon, Inc., at 1-800-896-5855.

What are the ingredients of FENTORA?

Active Ingredient: fentanyl citrate

Inactive Ingredients: mannitol, sodium starch glycolate, sodium bicarbonate, sodium carbonate, citric acid, and magnesium stearate.

This Medication Guide has been approved by the U.S. Food and Drug Administration.

IMPORTANT NOTE: This is a summary and does not contain all possible information about this product. For complete information about this product or your specific health needs, ask your health care professional. Always seek the advice of your health care professional if you have any questions about this product or your medical condition. This information is not intended as individual medical advice and does not substitute for the knowledge and judgment of your health care professional. This information does not contain any assurances that this product is safe, effective, or appropriate for you.

FENTANYL TABLET (CANCER PAIN ONLY) - BUCCAL

(FEN-tuh-nill)

COMMON BRAND NAME(S): Fentora

WARNING: This medication should be used only to treat sudden (breakthrough) cancer pain in people who are already using and are able to tolerate moderate-to-large amounts of strong narcotic pain medications (e.g., morphine). Fentanyl must not be used in people who do not regularly take narcotic pain relievers because it can cause them to have very serious (possibly fatal) breathing problems (e.g., very slow and shallow breathing).

Do not use this medication for short-term pain (e.g., from surgery).

This medication can be fatal if taken by a child. Keep this and all other medications out of reach of children. When the medication is no longer needed, properly discard all of the unused medication as directed by the Medication Guide. Consult your doctor or pharmacist if you have any questions.

Different brands of this medication deliver different amounts of medication. Do not switch brands without your doctor's permission and directions.

Tell your doctor or pharmacist of all medications that you may use, especially of drugs affecting liver enzymes that remove fentanyl from your body (See also Drug Interactions section). Your doctor may want to monitor you more closely or change the dosage of your fentanyl if you are on certain interacting drugs. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.

USES: See also Warning section.

This medication is used to treat moderate-to-severe sudden (breakthrough) cancer pain. It acts on certain centers in the brain to give you pain relief. This medication is a narcotic pain reliever (opiate-type).

HOW TO USE: See also Warning section.

Read the Medication Guide provided by your pharmacist before you start using fentanyl and each time you get a refill. Learn all usage and disposal instructions. If you have any questions, consult your doctor or pharmacist.

Take fentanyl as directed by your doctor. Just before using, open the blister pack unit as instructed. Do not push the tablet through the foil of the blister pack because doing so may damage the tablet. Use the medication right away. Do not break, bite, chew, or suck on the medication or swallow the medication whole. Put the medication in your mouth above a back tooth between your cheek and gums, and leave it in place until it is dissolved. The medication usually takes up to 25 minutes to fully dissolve. If there is still some medication left after 30 minutes, swallow it with a glass of water.

If a second dose is needed, wait 30 minutes after starting the first dose. Do not use more than 2 doses for an attack of pain. You must wait at least 4 hours before using this medication again for a later pain attack.

The dosage is based on your medical condition and response to treatment. Pain medications work best if they are used as the first signs of pain occur. If you wait until the pain has worsened, the medication may not work as well.

If you start to have side effects (e.g., dizziness, stomach upset, extreme drowsiness), rinse your mouth with water and spit the medication into a toilet or sink. Rinse the sink or flush the toilet afterwards to remove any remaining medication.

You should also continue to take your long-acting narcotic medication for ongoing pain as directed by your doctor. Also follow your doctor's or pharmacist's instructions for safely using non-narcotic pain relievers (e.g., naproxen, ibuprofen). Ask your doctor or pharmacist if you have any questions.

This medication may cause dependence, especially if it has been used regularly for an extended time or if it has been used in high doses. In such cases, withdrawal reactions (e.g., restlessness, watery eyes, twitching, widened pupils) may occur if you suddenly stop this drug. To prevent withdrawal reactions when stopping extended, regular treatment with this drug, gradually reduce the dosage as directed. Consult your doctor or pharmacist for more details, and report any withdrawal reactions immediately.

Though very unlikely, abnormal drug-seeking behavior (addiction) is possible with this medication. To lessen the risk of becoming addicted, do not increase your dose, take it more frequently, or take it for a longer time than prescribed. Properly stop the medication when so directed.

When used for an extended period, this medication may not work as well and may require different dosing. Talk with your doctor if this medication stops working well.

Avoid eating grapefruit or drinking grapefruit juice while being treated with this medication unless your doctor instructs you otherwise. Grapefruit can increase the amount of certain medications in your bloodstream. Consult your doctor or pharmacist for more details.

Tell your doctor if your pain persists or worsens, if you are using this medication more than 4 times per day, or if you are consistently using 2 doses of medication for each attack of pain.

SIDE EFFECTS: Nausea, vomiting, constipation, dry mouth, lightheadedness, dizziness, drowsiness, or headache may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.

To prevent constipation, maintain a diet adequate in fiber, drink plenty of water, and exercise. If you become constipated while using this drug, consult your pharmacist for help with selecting a laxative (e.g., stimulant-type with stool softener).

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur: slow/shallow breathing, pain/numbness/ulcer/bleeding at the area where you placed the medication (e.g., on your gums or inner cheek), fainting, mental/mood changes (e.g., depression, anxiety, confusion), slow/fast/irregular heartbeat, muscle spasms, weakness, tiredness, tingling of the hands/feet, swelling of the ankles/feet, signs of infection (e.g., fever, persistent sore throat), easy bruising/bleeding, pain/redness/swelling of arms or legs, severe stomach/abdominal pain, change in the amount of urine.

Tell your doctor immediately if this rare but very serious side effect occurs: seizures.

A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including: rash, itching, swelling, severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

Contact your doctor for medical advice about side effects. The following numbers do not provide medical advice, but in the US you may report side effects to the Food and Drug Administration (FDA) at 1-800-FDA-1088. In Canada, you may call Health Canada at 1-866-234-2345.

PRECAUTIONS: Before taking fentanyl, tell your doctor or pharmacist if you are allergic to it; or to other narcotic pain medications (e.g., morphine); or if you have any other allergies.

This medication should not be used if you have certain medical conditions. Before using this medicine, consult your doctor or pharmacist if you have: severe breathing problems (e.g., respiratory depression), certain bowel diseases (e.g., paralytic ileus, infectious diarrhea), intoxication with medications that depress the nervous system or your breathing (CNS/respiratory depressants such as alcohol or tranquilizers/sedatives).

Before using this medication, tell your doctor or pharmacist your medical history, especially of: mouth sores, lung diseases (e.g., chronic obstructive pulmonary disease-COPD, hypoxia, hypercapnia), gallbladder disease, brain disorders (e.g., seizures, head injury, tumor, increased intracranial pressure), kidney disease, liver disease, heart problems (e.g., slow/irregular heartbeat), personal or family history of regular use/abuse of drugs/alcohol, underactive thyroid (hypothyroidism), difficulty urinating (e.g., due to enlarged prostate or urethral stricture), mental/mood disorders (e.g., toxic psychosis), adrenal gland problem (e.g., Addison's disease), disease of the pancreas (e.g., pancreatitis), a certain spinal problem (kyphoscoliosis), intestinal diseases (e.g., colitis), recent bowel/abdominal surgery.

This drug may make you dizzy or drowsy. Use caution while driving, using machinery, or taking part in any other activity that requires alertness. Avoid alcoholic beverages because they may increase the risk of side effects.

Before having surgery, tell your doctor or dentist that you are using this medication.

To lower your risk of dizziness and lightheadedness, get up slowly when rising from a sitting or lying position.

Caution is advised when using this drug in the elderly because they may be more sensitive to its effects, especially slow/shallow breathing, constipation, and drowsiness.

During pregnancy, this medication should be used only when clearly needed. Using it for long periods or in high doses near the expected delivery date is not recommended because of possible harm to the unborn baby. Discuss the risks and benefits with your doctor. Infants born to mothers who have used this type of medication for an extended time may have withdrawal symptoms such as irritability, abnormal/persistent crying, vomiting, or diarrhea. Tell your doctor immediately if you notice any of these symptoms in your newborn.

This drug passes into breast milk and could have undesirable effects on a nursing infant. Therefore, breast-feeding is not recommended while using this drug. Consult your doctor before breast-feeding.

DRUG INTERACTIONS: Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.

This drug should not be used with the following medications because very serious interactions may occur: MAO inhibitors (e.g., furazolidone, isocarboxazid, linezolid, moclobemide, phenelzine, procarbazine, selegiline, tranylcypromine, rasagiline), naltrexone, sibutramine.

If you are currently using any of these medications listed above, tell your doctor or pharmacist before starting fentanyl. Avoid taking MAO inhibitors within 2 weeks before, during, and after treatment with this medication.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: antihistamines (e.g., diphenhydramine, meclizine), antispasmodics (e.g., atropine, dicyclomine), blood pressure medications (e.g., "water pills"/diuretics such as hydrochlorothiazide), drugs affecting liver enzymes that remove fentanyl from your body (such as azole antifungals including itraconazole/ ketoconazole, macrolide antibiotics including erythromycin/ troleandomycin, cimetidine, nefazodone, HIV protease inhibitors such as nelfinavir/ritonavir, calcium channel blockers such as diltiazem/verapamil, rifamycins including rifabutin, St. John's wort, certain anti-seizure medicines including carbamazepine), other medications for pain (e.g., pentazocine, nalbuphine, codeine).

Tell your doctor or pharmacist if you also take drugs that cause drowsiness such as: anti-seizure drugs (e.g., phenytoin), medicine for sleep or anxiety (e.g., alprazolam, diazepam, zolpidem), muscle relaxants, phenothiazines (e.g., prochlorperazine, chlorpromazine), psychiatric medicines (e.g., risperidone, amitriptyline, trazodone).

Check the labels on all your medicines (e.g., cough-and-cold products) because they may contain ingredients that may cause drowsiness. Ask your pharmacist about using those products safely.

This medication may interfere with certain laboratory tests (including amylase and lipase levels), possibly causing false test results. Make sure laboratory personnel and all your doctors know you use this drug.

This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US National Poison Hotline at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: slow/shallow breathing, slow heartbeat, severe dizziness.

NOTES: Do not share this medication with others. It is against the law and the medication may cause harm to others.

This medication has been prescribed for your current condition only. Do not use it later for another condition unless told to do so by your doctor. A different medication may be necessary in that case.

MISSED DOSE: Not applicable.

STORAGE: Store at room temperature between 68-77 degrees F (20-25 degrees C) away from moisture. Do not freeze. Brief storage between 59-86 degrees F (15-30 degrees C) is permitted. Do not store in the bathroom. Keep all medicines away from children and pets.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. For more information, read the Medication Guide. Also, consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

Information last revised July 2008 Copyright(c) 2008 First DataBank, Inc.