1.1.2. Buccal Tablets (Fentora®, generic)

Patients prescribed fentanyl buccal tablets for breakthrough pain should begin therapy with an initial dose of 100 mcg, with the exception of those previously treated with fentanyl oral transmucosal lozenges^{2, 7-11}. Dose conversions between fentanyl oral transmucosal lozenges and buccal tablets are summarized in Table 1.

The tablet is placed in the buccal cavity (the space between the upper cheek and rear molar) or under the tongue and should be allowed to dissolve completely over a period of 30 minutes. Tablets should not be split, crushed, chewed or swallowed whole. If there are any tablet pieces remaining after 30 minutes, the patient may swallow them with a glass of water. The same dosage strength may be repeated once during a breakthrough pain episode, administered no sooner than 30 minutes after initiating buccal fentanyl tablet therapy, if pain is not relieved by the first buccal tablet dose. Patients must wait at least 4 hours before administering a fentanyl buccal tablet dose for another episode of breakthrough pain. The fentanyl buccal tablet dose should be increased in patients requiring greater than one breakthrough dose for several consecutive episodes. Patients requiring fentanyl buccal tablet doses higher than 100 mcg should be titrated in multiples of 100 mcg. Patients may receive up to four 100 mcg tablets at one time placed on each side of the mouth in each buccal cavity (2 tablets per side). Fentanyl buccal tablet dosages greater than 400 mcg should be titrated in 200 mcg increments. Doses should be titrated to achieve adequate analgesia with acceptable side effects, but no more than 4 tablets should be used concurrently for a breakthrough episode. Patients should receive only one buccal tablet dosage strength at a time to minimize confusion and the possibility of overdose. If more than four breakthrough pain episodes happen per day, the long-term opiate maintenance dose should be re-evaluated. To discontinue fentanyl buccal tablet use, a downward titration is recommended to minimize potential withdrawal adverse effects.