SAN ANTONIO, Tex.–Treatment of breakthrough cancer pain is an important component of care for patients, and nurses should consider various factors when titrating the dose of fentanyl sublingual spray to an effective dose, according to a presentation at ONS 41st Annual Congress.1

“Nurses, physician assistants, and nurse practitioners play a key role in identifying, assessing, and managing breakthrough cancer pain,” said Sheila E. Ayers, BSN, MSN, ACNP-BC.

Breakthrough cancer pain should always be considered in adults with persistent cancer pain, but it can be difficult to manage given its rapid onset, frequency, variability in pain intensity, and short duration. Transmucosal immediate-release formulations of fentanyl are commonly used for breakthrough cancer pain and titrated to a dose that is both effective and minimizes adverse events.

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“Sublingual administration may be advantageous in patients who are unable to tolerate oral medication administration because of nausea, vomiting, or dysphagia, or utilize parenteral administration because of emaciation, reduced venous access, or coagulation-related defects,” Ayers reported.

Because fentanyl sublingual spray was recently approved by the US Food and Drug Administration, clinicians at The West Clinic in Memphis, Tennessee, sought to describe their clinic’s best nursing practices for the titration of this novel formulation.

Phase 3 findings have previously demonstrated that fentanyl sublingual spray significantly reduces pain intensity compared with placebo as quickly as 5 minutes following administration. Although rapid onset is of great importance to patients, identifying an effective dose frequently necessitates individualized dose titration. Therefore, patient education and ongoing communication between the oncology nurse and the patient are important during titration.

For example, ineffectiveness should not be immediately concluded when there is a lack of effect with a particular titration dose; it may instead suggest that the clinician has not yet identified an appropriate dose for that individual patient.

“Increasing the dose without an adequate assessment may accidentally overdose the patient,” Ayers noted.

In addition, oncology nurses should consider patients’ comorbidities, including neuropathies or arthritis. In these instances, nurses should attempt to minimize the number of actuations or the benefit vs risk in those with grade 2 or higher mucositis.

During the titration phase, it is also recommended that nurses conduct telephone follow-up 3 to 5 days following titration initiation.

Ayers concluded: “Keeping in frequent contact with patients, nurses, physician assistants, and nurse practitioners can play a major role in breakthrough cancer pain management by providing patient education and maintaining ongoing communication with patients and/or caregivers to ensure safe, and appropriate use of agents, such as fentanyl sublingual spray.”


1. Ayers S, Parikh N, Cognata Smith C, Tian GG. Nursing considerations for titration of fentanyl sublingual spray to effective dose. Oral presentation at: 2016 Oncology Nursing Society Annual Congress; April 28-May 1, 2016; San Antonio, TX.