• Starting Dose: The initial dose of Fentanyl should be 100 mcg.
• Re-dosing patients within a single episode:  Dosing may be repeate once during a single episode of breakthrough pain if pain is not adequately relieve by one Fentanyl dose. Re-dosing may occur 30 minutes after the start of administration of Fentanyl and the same dosage strength should be use.
• Increasing the dose:  Titration should be initiate using multiples of the 100 mcg Fentanyl tablet. Patients require to titrate above 100 mcg can be instructe to use two 100 mcg tablets (one on each side of the mouth in the buccal cavity). If this dose is not successful in controlling the breakthrough pain episode, the patient may be instructe to place two 100 mcg tablets on each side of the mouth in the buccal cavity (total of four 100 mcg tablets). Titrate above 400 mcg by 200 mcg increments bearing in mind using more than 4 tablets simultaneously has not been studie and it is important to minimize the number of strengths available to patients at any time to prevent confusion and possible overdose. To reduce the risk of overdose during titration, patients should have only one strength of Fentanyl tablet.available at any one time.
• Dosage Adjustment: Generally, the dose of Fentanyl should be increase when patients require more than one dose per breakthrough pain episode for several consecutive episodes.

Injection

• Fentanyl injection can be administere intravenously either as a bolus or by infusion & by intramuscular route also. The dose of fentanyl should be individualize according to age, body weight, physical status, underlying pathological condition, use of other drugs and type of surgery and anesthesia.

• Doses in excess of 200mcg are for use in anesthesia only. As a premedicant, 1-2 ml fentanyl may be given intramuscularly 45 minutes before induction of anesthesia. After IV administration in unpremedicate adult patients, 2ml fentanyl may be expecte to provide sufficient analgesia for 10-20 minutes in surgical procedures involving low pain intensity. 10 ml fentanyl injecte as a bolus gives analgesia lasting about one hour. The analgesia produce is sufficient for surgery involving moderately painful procedures. Giving a dose of 50mcglkg fentanyl will provide intense analgesia for some four to six hours, for intensely stimulating surgery.

• Fentanyl may also be given as an infusion. In ventilate patients, a loading dose of fentanyl may be given as a fast infusion of approximately 1 mcg/kg/min for the first 10 minutes followe by an infusion of approximately 0.1 mcg/kg/min. Alternatively the loading dose of fentanyl may be given as a bolus. Infusion rates should be titrate to individual patient response; lower infusion rates may be adequate. Unless it is planne to ventilate post operatively, the infusion should be terminate at about 40 minutes before the end of surgery.

• Lower infusion rates, e.g. 0.05-0.08 mcg/kg/min. are necessary if spontaneous ventilation .is to be maintaine. Higher infusion rates (up to 3 mcg/kg/min) have been use in cardiac surgery. Fentanyl is chemically incompatible with the induction agents thiopentone & methohexitone because of wide differences in pH

• Use in elderly and debilitate patients: It is wise to reduce the dosage in the elderly and debilitate patients. The effect of the initial dose should be taken into account in determining supplemental doses.

Transdermal
Intractable chronic pain:

• Adult: Patches deliver fentanyl in doses that range from: 12-100 mcg/hr. Doses should be individually titrate base on previous use of opioids.
• Opioid-naive patients: Initially, ≤25 mcg/hr; it is recommende to initially titrate w/ low doses of short-acting opioids before starting fentanyl patches.
• Patients receiving a strong opioid analgesic: Initial dose should be based on the previous 24-hr opioid requirements. During transfer to fentanyl patches, previous opioid treatment should be phased out gradually. If patient requires doses >100 mcg/hr, >1 patch may be use; consider alternative or additional therapy if doses >300 mcg/hr are require. Replace patch every 72 hr and apply the new patch to a different site; avoid using the same area of skin for a few days.
• Elderly: Dose reduction may be neede.

How Long Does It Take to Work?

The effects of fentanyl citrate usually occur within minutes of administration and can last for up to several hours. The duration of effect depends on the dose and the individual’s metabolism.

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