Various formulations of oral transmucosal fentanyl for breakthrough cancer pain: an indirect mixed treatment comparison meta-analysis

Objective To compare the efficacy of fentanyl effervescent buccal tablet (FBT), sublingual oral transmucosal fentanyl citrate (ODT) and compressed lozenge oral transmucosal fentanyl citrate (OTFC) for the treatment of breakthrough cancer pain (BTcP).

Methods Randomised, controlled trials of FBT, ODT and OTFC in the treatment of BTcP were identified via a systematic literature review. Pain intensity difference (PID) data were extracted from all eligible studies for all recorded time points. A mixed treatment comparison of these data was undertaken with placebo as the indirect comparator. The primary outcome was improvement in PID during the first 60 min after dosing (15–60 min).

Results There was a 66% probability of FBT producing a greater improvement in PID during the first 60 min after dosing than ODT (mean improvement in PID 0.54) and a 68% probability versus OTFC (mean PID 0.48). ODT and OTFC produced a similar level of pain relief during the 60-min time period (53% probability; mean PID 0.10, in favour of ODT). When data for OTFC versus morphine sulphate immediate release (MSIR) were included, it was found that FBT and ODT both produced better PID scores over the 60-min time period than MSIR (FBT: 68% probability, mean PID 0.75; ODT: 57% probability, mean PID 0.35). The improved outcome for FBT and ODT over MSIR was evident from 15 min after dosing.

Conclusion FBT may have some efficacy advantages over ODT and OTFC and all oral fentanyl preparations appear superior to MSIR in the treatment of BTcP.