1.1.5. Intranasal Spray (Lazanda®)

Fentanyl intranasal spray should be initiated in all patients with a dose of 100 mcg (one spray in one nostril). If adequate analgesia is achieved, this dose will be used to manage future breakthrough pain episodes. If adequate pain relief is not achieved with the 100 mcg dose, titrate the dose upward in a stepwise manner to 200 mcg (2 x 100 mcg – one spray in each nostril), 400 mcg (4 x 100 mg – two sprays in each nostril or 1 x 400 mcg – one spray in one nostril), or 800 mcg (2 x 400 mcg – one spray in each nostril) per dose until adequate analgesia is achieved with minimal adverse effects. Patients must wait at least 2 hours before administering subsequent fentanyl intranasal spray doses. Safety and efficacy of doses greater than 800 mcg have not yet been determined in clinical trials. Once an effective dose has been established, fentanyl intranasal spray should be used to manage no more than four breakthrough episodes per day. If adequate analgesia is not achieved within 30 minutes of a fentanyl intranasal spray dose or a breakthrough pain episode occurs before the next fentanyl intranasal spray dose (i.e., within 2 hours of a fentanyl intranasal spray dose), a rescue medication may be utilized as dictated by the patient’s health care provider. If more than four breakthrough pain episodes happen per day, long-term opiate maintenance doses should be re-evaluated. To discontinue fentanyl intranasal spray use, a downward titration is recommended to minimize potential withdrawal adverse effects^{5, 7-11}.