Table 1

Alfentanil buccal, sublingual or nasal

Alfentanil buccal, sublingual or nasal
What is it?Strong opioid analgesic—CD schedule 2 drug
Mechanism of actionOpioid having central agonist effect
Dose10%–16% of the total CSCI dose hourly prn
Time to onset of effect5 min17
FormulationNasal spray with attachment for buccal/SL use (5 mg/5 mL) bottle available as special order from Torbay Hospital Manufacturing Unit Tel: 01803 664 707. Each ‘spray’ delivers 0.14 mL=140 μg alfentanil
Injection preparation given via buccal, sublingual or nasal route. Two strengths available, 500 μg/mL and 5 mg/mL
IndicationModerate to severe pain for the management of breakthrough, incident or procedural pain when eGFR <20
Common adverse effectsApnoea; chills; fatigue; hypertension; movement disorders; muscle rigidity; procedural complications16
ContraindicationsAvoid or use a reduced dose in hepatic failure17
LicencingNasal spray is an unlicensed product
Injection is licensed but a transmucosal route is ‘off label’
BenefitsRapidity of onset of action
Ease of nasal administration
RisksPrescribing/administration error
Lack of familiarity with drug
Lay carer administration
Lack of availability
Unrecognised hepatic failure
CostSpecial—price on application
  • CD - Controlled Drug

  • CSCI - continuous subcutaneous infusion; SL - sublingual; eGFR - estimated Glomerular Filtration Rate