Abstral 200 mikrogram Resoriblett, sublingual

Sverige - svenska - Läkemedelsverket (Medical Products Agency)

Bipacksedel Bipacksedel (PIL)


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Aktiva substanser:
Tillgänglig från:
Medartuum AB
INN (International namn):
fentanyl citrate
200 mikrogram
Resoriblett, sublingual
mannitol Hjälpämne; fentanylcitrat 314,2 mikrog Aktiv substans
Receptbelagda typ:
Förpacknings: Blister, 30 resoribletter
Bemyndigande status:
Tillstånd datum:

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Package leaflet: Information for the patient

Abstral 100 microgram sublingual tablets

Abstral 200 microgram sublingual tablets

Abstral 300 microgram sublingual tablets

Abstral 400 microgram sublingual tablets

Abstral 600 microgram sublingual tablets

Abstral 800 microgram sublingual tablets


Read all of this leaflet carefully before you start taking this medicine because it contains

important information for you.

Keep this leaflet. You may need to read it again.

If you have any further questions, ask your doctor or pharmacist.

This medicine has been prescribed for you only. Do not pass it on to others. It may harm them,

even if their signs of illness are the same as yours.

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side

effects not listed in this leaflet. See section 4.

What is in this leaflet

What Abstral is and what it is used for

What you need to know before you take Abstral

How to take Abstral

Possible side effects

How to store Abstral

Contents of the pack and other information


What Abstral is and what it is used for


is a treatment for adults

who must already regularly be taking strong pain-relieving

medicine (opioids)

for their persistent cancer pain, but require treatment for their breakthrough pain.

If you are not sure, talk to your doctor.

Breakthrough pain is pain which occurs suddenly, even though you have taken or used your usual

opioid pain-relieving medicine.

The active substance in Abstral sublingual tablets is fentanyl. Fentanyl belongs to a group of strong

pain-relieving medicines called opioids.


What you need to know before you take Abstral

Do not take Abstral

if you are allergic to fentanyl or any of the other ingredients of this medicine (listed in section 6)

if you have severe breathing problems

if you are not regularly using a prescribed opioid medicine (e.g codeine, fentanyl,

hydromorphone, morphine, oxycodone, pethidine), every day on a regular schedule, for at least

a week, to control your persistent pain. If you have not been using these medicines you must not

use Abstral because it may increase the risk that breathing could become dangerously slow

and/or shallow, or even stop

if you suffer from short-term pain other than breakthrough pain

if you are being treated with medicines containing sodium oxybate

Warnings and precautions

Talk to your doctor or pharmacist before taking Abstral if you have, or have recently had, any of the

following, as your doctor will need to take account of these when prescribing your dose:

a head injury, because Abstral may cover up the extent of the injury

breathing problems or suffer from myasthenia gravis (a condition characterised by muscle


if you have problems with your heart especially slow heart rate

low blood pressure

liver or kidney disease, as this may require your doctor to more carefully adjust your dose

a brain tumour and/or raised intracranial pressure (an increase of pressure in the brain which

causes severe headache, nausea/vomiting and blurred vision)

mouth wounds or mucositis (swelling and redness of the inside of the mouth)

if you take antidepressants or antipsychotics please refer to the section ‘Other medicines and


if you have ever developed adrenal insufficiency or lack of sex hormones (androgen deficiency)

with opioid use

When taking Abstral, inform your doctor or dentist that you are taking this medicine, if:

you are to have any surgery

you experience pain or increased sensitivity to pain (hyperalgesia) which does not respond to a

higher dosage of your medicine as prescribed by your doctor

you experience a combination of the following symptoms: nausea, vomiting, anorexia, fatigue,

weakness, dizziness and low blood pressure. Together these symptoms may be a sign of a

potentially life-threatening condition called adrenal insufficiency, a condition in which the

adrenal glands do not produce enough hormones

Your doctor may need to check you more closely if:

you or anyone in your family have ever abused or been dependent on alcohol, prescription

medicines or illegal drugs (“addiction”)

you are a smoker

you have ever had problems with your mood (depression, anxiety or a personality disorder) or

have been treated by a psychiatrist for other mental illnesses

Repeated use of Abstral may lead to dependence and abuse which may result in life-threatening

overdose. If you have concern that you may become dependent on Abstral, it is important that you

consult your doctor.

Sleep-related breathing disorders

Abstral can cause sleep-related breathing disorders such as sleep apnoea (breathing pauses during

sleep) and sleep related hypoxemia (low oxygen level in the blood). The symptoms can include

breathing pauses during sleep, night awakening due to shortness of breath, difficulties in maintaining

sleep or excessive drowsiness during the day. If you or another person observe these symptoms,

contact your doctor. A dose reduction may be considered by your doctor.

Other medicines and Abstral

Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines

(other than your regular opioid pain-relieving medicine).

Some medicines may increase or decrease the effects of Abstral. Therefore if you start, change the

dose of, or stop therapy with the following medication tell your doctor as they may need to adjust your

dose of Abstral:

Certain types of antifungal medicines containing e.g. ketoconazole or itraconazole (used to treat

fungal infections).

Certain types of antibiotic medicines called macrolides, containing e.g. erythromycin (used to

treat infections).

Certain types of antiviral medicines called protease inhibitors, containing e.g. ritonavir (used to

treat infections caused by viruses).

Rifampin or rifabutin (medicines used to treat bacterial infections).

Carbamazepine, phenytoin or phenobarbital (medicines used to treat convulsions/fits).

Herbal medicines containing St John’s wort (

Hypericum perforatum).

Medicines containing alcohol.

Medicines called monoamine-oxidase (MAO) inhibitors, which are used for severe depression.

and Parkinson’s disease. Tell your doctor if you have taken this type of medicine within the last

two weeks.

Certain types of strong pain killers, called partial agonist/antagonists e.g. buprenorphine,

nalbuphine and pentazocine (medicines for treatment of pain). You could experience symptoms

of withdrawal syndrome (nausea, vomiting, diarrhoea, anxiety, chills, tremor, and sweating)

while using these medicines.

Abstral may add to the effect of medicines that make you feel sleepy (sedative medicines), including:


strong pain-relieving medicines

(opioid-type medicines e.g. for pain and cough)

general anaesthetics (used to make you sleep during operations)

muscle relaxants

sleeping tablets

medicines used to treat



anxiety (such as benzodiazepines e.g. diazepam) and psychosis

medicines containing clonidine (used to treat high blood pressure)

Use of Abstral at the same time as medicines that make you feel sleepy (sedative medicines), such as

benzodiazepines, increases the risk of drowsiness, difficulties in breathing (respiratory depression),

coma and may be life-threatening. Because of this, use of Abstral together with sedative medicines

should only be considered when other treatment options are not possible.

However, if your doctor does prescribe Abstral together with sedative medicines, the dose and

duration of treatment should be limited by your doctor.

Please tell your doctor about all sedative medicines you are taking, and follow your doctor’s dose

recommendation closely. It could be helpful to inform friends or relatives to be aware of the signs and

symptoms stated above. Contact your doctor when experiencing such symptoms.

The risk of certain other side effects increases if you are taking medicines such as certain

antidepressants or antipsychotics. Abstral may interact with these medicines and you may experience

mental status changes (e.g. agitation, hallucinations, coma), and other effects such as body temperature

above 38°C, increase in heart rate, unstable blood pressure, and exaggeration of reflexes, muscular

rigidity, lack of coordination and/or gastrointestinal symptoms (e.g. nausea, vomiting, diarrhoea).

Your doctor will tell you whether Abstral is suitable for you.

Abstral with food, drink and alcohol

Abstral can make some people feel drowsy. Do not consume alcohol without consulting your doctor

as it might make you feel more drowsy than usual.

Do not drink grapefruit juice while you are prescribed Abstral treatment as it may increase the side

effects of Abstral.

Pregnancy and breast-feeding

You must not use Abstral during pregnancy unless you have been specifically told to by your doctor.

Fentanyl can get into breast milk and may cause side effects in the breast-fed infant. Do not use

Abstral if you are breast-feeding. You should not start breast-feeding until at least 5 days after the last

dose of Abstral.

Ask your doctor or pharmacist for advice before taking any medicine when pregnant or breast-feeding.

Driving and using machines

Abstral may impair your mental and/or physical ability to perform potentially hazardous tasks such as

driving or operating machinery.

If you feel dizzy, sleepy or have blurred vision when you take Abstral, do not drive or use machinery.

Abstral contains sodium

This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially ‘sodium-



How to take Abstral

Before taking Abstral for the first time your doctor will explain how Abstral should be taken to

effectively treat your breakthrough pain.

Always take this medicine exactly as your doctor has told you. Check with your doctor or pharmacist

if you are not sure.

This product should ONLY be used by you according to your doctor’s instructions. It should not be

used by anyone else as it could present a SERIOUS risk to their health, especially in children.

Abstral is a different type of medication from other medicines you may have used to treat your

breakthrough pain.

You must always use the dose of Abstral as prescribed by your doctor

– this

may be a different dose from that which you have used with other medicines for breakthrough pain.

Starting Treatment – Finding the most appropriate dose

For Abstral to work successfully, your doctor will need to identify the most appropriate dose for

treating your breakthrough pain. Abstral is available in a range of strengths. You may need to try

different strengths of Abstral over a number of episodes of breakthrough pain to find the most

appropriate dose. Your doctor will help you do this and will work with you to find the best dose to use.

If you do not get adequate pain relief from one dose your doctor may ask you to take an extra dose to

treat an episode of breakthrough pain.

Do not take a second dose

unless your doctor tells you to

, as this may result in overdose.

Sometimes your doctor may advise you to take a dose which consists of more than one tablet at a time.

Only do this if directed by your doctor.

Wait at least 2 hours from taking your last dose before treating your next episode of breakthrough pain

with Abstral.

Continuing Treatment - Once you have found the most appropriate dose

Once you and your doctor have found a dose of Abstral that controls your breakthrough pain you

should take this dose no more than four times a day.

A dose of Abstral may consist of more than

one tablet.

Wait at least 2 hours from taking your last dose before treating your next episode of breakthrough pain

with Abstral.

If you think that the dose of Abstral that you are using is not controlling your breakthrough pain

satisfactorily tell your doctor, as he may need to adjust your dose.

You must not change your dose of Abstral unless directed by your doctor.

Taking the medicine

Abstral should be used sublingually, which means that the tablet should be placed under the tongue

where it dissolves rapidly in order to allow fentanyl to be absorbed across the lining of the mouth.

Once absorbed, fentanyl starts to work to relieve pain.

When you get an episode of breakthrough pain, take the dose advised by your doctor as follows:

If your mouth is dry, take a sip of water to moisten it. Spit out or swallow the water.

Remove the tablet(s) from the blister pack immediately before use as follows:

Separate one of the blister squares from the pack by tearing along the dotted

lines/perforations (keep the remaining blister squares together).

Peel back the edge of the foil where the arrow is shown and gently remove the tablet. Do

not try to push Abstral sublingual tablets through the foil top, as this will damage them.

Place the tablet under your tongue as far back as you can and let it dissolve completely.

Abstral will dissolve rapidly under the tongue and be absorbed in order to provide pain relief. It

is therefore important that you do not suck, chew or swallow the tablet.

You should not drink or eat anything until the tablet has completely dissolved under your


If you take more Abstral than you should

remove any remaining tablets from your mouth

tell your carer or another person what has happened

you or your carer should immediately contact your doctor, pharmacist or local hospital and

discuss what action to take

while waiting for the doctor, keep the person awake by talking to or shaking her/him now and


Symptoms of overdose include:

extreme drowsiness

slow, shallow breathing


If these occur, seek emergency medical help immediately.

If you think someone has taken Abstral by accident seek emergency medical help immediately.

If you stop taking Abstral

You should discontinue Abstral when you no longer have any breakthrough pain. You must however

continue to take your usual opioid pain-relieving medicine to treat your persistent cancer pain as

advised by your doctor. You may experience withdrawal symptoms similar to the possible side effects

of Abstral when discontinuing Abstral. If you experience withdrawal symptoms or if you are

concerned about your pain relief you should contact your doctor. Your doctor will evaluate if you need

medicine to reduce or eliminate the withdrawal symptoms.

If you have any further questions on the use of this medicine, ask your doctor or pharmacist.


Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them.

If you start to feel unusually or extremely sleepy or your breathing becomes slow or shallow, you

or your carer should immediately contact your doctor or local hospital for emergency help (see

also section 3 “If you take more Abstral than you should”).

Very common side effects (may affect more than 1 in 10 people) include:


Common side effects (may affect up to 1 in 10 people) include:

dizziness, headache, excessive sleepiness

breathlessness/shortness of breath

inflammation inside the mouth, vomiting, constipation, dry mouth

sweating, weary/tired/lack of energy

Uncommon side effects (may affect up to 1 in 100 people) include:

allergic reaction, trembling/shaking, disturbed or blurred vision, fast or slow heart beat, low

blood pressure, memory loss

depression, suspicious thoughts/ feeling afraid for no reason, feeling confused, feeling

disorientated, feeling anxious/unhappy/restless, feeling unusually happy/healthy, mood swings

feeling full all the time, stomach-ache, indigestion

mouth ulcers, problems with tongue, pain in mouth or throat, tightness in throat, lip or gum


loss of appetite, loss of or change in sense of smell/taste

difficulty sleeping or disturbed sleep, disturbance in attention/easily distracted, lack of

energy/weakness/loss of strength

abnormality in skin, rash, itchiness, night sweats, decreased sensitivity to touch, bruising easily

joint pain or stiffness, stiffness in muscles

drug withdrawal symptoms (

may manifest by the occurrence of the following side effects:

nausea, vomiting, diarrhoea, anxiety, chills, tremor, and sweating

), accidental overdose, in

males an inability to get and/or keep an erection, feeling generally unwell

Side effects of frequency not known: (frequency cannot be estimated from the available data)

swollen tongue, severe breathing problems, fall, flushing, feeling very warm, diarrhoea,

convulsion (fits), swelling of arms or legs, seeing or hearing things that are not really there

(hallucinations), fever, drug dependence (addiction), drug abuse, reduced level or loss of

consciousness, itchy rash and delirium (symptoms may include a combination of agitation,

restlessness, disorientation, confusion, fear, seeing or hearing things that are not really there,

sleep disturbance, nightmares)

Prolonged treatment with fentanyl during pregnancy may cause withdrawal symptoms in the newborn

which can be life-threatening (see section 2).

Reporting of side effects

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects

not listed in this leaflet.

You can also report side effects directly via the national reporting system listed below. By reporting

side effects you can help provide more information on the safety of this medicine.

To be completed nationally.


How to store Abstral

The pain-relieving medicine in Abstral is very strong and could be life-threatening if taken

accidentally by a child. Abstral must be kept out of the sight and reach of children.

Do not use this medicine after the expiry date which is stated on the blister after EXP. The expiry date

refers to the last day of that month.

Do not store above 25°C.

Store in the original blister in order to protect from moisture.

It is recommended to keep Abstral in a locked storage space.

Any unused product should be taken, if possible, to your pharmacist to be disposed of safely. Do not

throw away any medicines via wastewater or household waste. These measures will help protect the



Contents of the pack and other information

What Abstral


The active substance is fentanyl. One sublingual tablet contains:

100 micrograms fentanyl (as citrate)

200 micrograms fentanyl (as citrate)

300 micrograms fentanyl (as citrate)

400 micrograms fentanyl (as citrate)

600 micrograms fentanyl (as citrate)

800 micrograms fentanyl (as citrate)

The other ingredients are mannitol (E421), silicified microcrystalline cellulose, croscarmellose sodium

and magnesium stearate.

What Abstral looks like and contents of the pack

Abstral is a small white sublingual tablet to be inserted under the tongue. It comes in a range of

different strengths and shapes. Your doctor will prescribe the strength (shape) and number of tablets

suitable for you.

The 100 microgram tablet is a white round tablet

The 200 microgram tablet is a white oval-shaped tablet

The 300 microgram tablet is a white triangle-shaped tablet

The 400 microgram tablet is a white diamond-shaped tablet

The 600 microgram tablet is a white “D”-shaped tablet

The 800 microgram tablet is a white capsule-shaped tablet

Abstral tablets are contained in blisters, available in cartons of 10 or 30 tablets.

Not all pack sizes may be marketed.

Marketing Authorisation Holder and Manufacturer:

Marketing Authorisation Holder:

To be completed nationally



Calle Severo Ochoa 13

Leganés, 28914 (Madrid)


Aesica Queenborough Ltd.

North Road



ME11 5EL

United Kingdom

Gedeon Richter Plc.

Gyömrői út 19-21

1103 Budapest


This medicinal product is authorised in the Member States of the EEA under the following



Cyprus, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Netherlands, Norway,

Portugal, Slovenia, Spain, Sweden, UK.


Czech Republic, Estonia, Latvia, Lithuania, Slovak Republic, Romania

This leaflet was last revised in: 27 May 2021

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Abstral 100 microgram sublingual tablets

Abstral 200 microgram sublingual tablets

Abstral 300 microgram sublingual tablets

Abstral 400 microgram sublingual tablets

Abstral 600 microgram sublingual tablets

Abstral 800 microgram sublingual tablets



Each sublingual tablet contains:

100 micrograms fentanyl (as citrate)

200 micrograms fentanyl (as citrate)

300 micrograms fentanyl (as citrate)

400 micrograms fentanyl (as citrate)

600 micrograms fentanyl (as citrate)

800 micrograms fentanyl (as citrate)

For the full list of excipients, see section 6.1.



Sublingual tablet

100 microgram sublingual tablet is a white round tablet

200 microgram sublingual tablet is a white oval-shaped tablet

300 microgram sublingual tablet is a white triangle-shaped tablet

400 microgram sublingual tablet is a white diamond-shaped tablet

600 microgram sublingual tablet is a white “D”-shaped tablet

800 microgram sublingual tablet is a white capsule-shaped tablet




Therapeutic indications

Management of breakthrough pain in adult patients using opioid therapy for chronic cancer pain.

Breakthrough pain is a transient exacerbation of otherwise controlled chronic background pain.


Posology and method of administration

Abstral should only be administered to patients who are considered tolerant to their opioid therapy for

persistent cancer pain. Patients can be considered opioid tolerant if they take at least 60 mg of oral

morphine daily, at least 25 micrograms of transdermal fentanyl per hour, at least 30 mg of oxycodone

daily, at least 8 mg of oral hydromorphone daily or an equianalgesic dose of another opioid for a week

or longer.

Method of administration:

Abstral sublingual tablets should be administered directly under the tongue at the deepest part. Abstral

sublingual tablets should not be swallowed, but allowed to completely dissolve in the sublingual

cavity without chewing or sucking. Patients should be advised not to eat or drink anything until the

sublingual tablet is completely dissolved.

In patients who have a dry mouth water may be used to moisten the buccal mucosa before taking


Dose titration:

The object of dose titration is to identify an optimal maintenance dose for ongoing treatment of

breakthrough pain episodes. This optimal dose should provide adequate analgesia with an acceptable

level of adverse reactions.

The optimal dose of Abstral will be determined by upward titration, on an individual patient basis.

Several doses are available for use during the dose titration phase. The initial dose of Abstral used

should be 100 micrograms, titrating upwards as necessary through the range of available dosage


Patients should be carefully monitored until an optimal dose is reached.

Switching from other fentanyl containing products to Abstral must not occur at a 1:1 ratio because of

different absorption profiles. If patients are switched from another fentanyl containing product, a new

dose titration with Abstral is required.

The following dose regimen is recommended for titration, although in all cases the physician should

take into account the clinical need of the patient, age and concomitant illness.

All patients must start therapy with a single 100 microgram sublingual tablet. If adequate analgesia is

not obtained within 15-30 minutes of administration of a single sublingual tablet, a supplemental

(second) 100 microgram sublingual tablet may be administered. If adequate analgesia is not obtained

within 15-30 minutes of the first dose an increase in dose to the next highest tablet strength should be

considered for the next episode of breakthrough pain (Refer to figure below).

Dose escalation should continue in a stepwise manner until adequate analgesia with tolerable adverse

reactions is achieved. The dose strength for the supplemental (second) sublingual tablet should be

increased from 100 to 200 micrograms at doses of 400 micrograms and higher. This is illustrated in

the schedule below. No more than two (2) doses should be administered for a single episode of

breakthrough pain during this titration phase.


Strength (micrograms) of first sublingual

tablet per episode of breakthrough pain

Strength (micrograms) of supplemental

(second) sublingual tablet to be taken 15-30

minutes after first tablet, if required

If adequate analgesia is achieved at the higher dose, but undesirable effects are considered

unacceptable, an intermediate dose (using the 100 microgram sublingual tablet where appropriate)

may be administered.

During titration, patients can be instructed to use multiples of 100 microgram tablets and/or 200

microgram tablets for any single dose. No more than four (4) tablets should be used at any one time.

The efficacy and safety of doses higher than 800 micrograms have not been evaluated in clinical

studies in patients.

In order to minimise the risk of opioid–related adverse reactions and to identify the appropriate dose, it

is imperative that patients be monitored closely by health professionals during the titration process.

During titration patients should wait at least 2 hours before treating another episode of breakthrough

pain with Abstral.

Starting dose

100 µg

Adequate pain relief achieved within 15-30 minutes?



Take a second tablet

(See table to determine strength

of second tablet)

Increase first tablet to next

higher strength for next

breakthrough pain episode

Use this dose for

subsequent breakthrough

pain episodes

Maintenance therapy:

Once an appropriate dose has been established, which may be more than one tablet, patients should be

maintained on this dose and should limit consumption to a maximum of four Abstral doses per day.

During the maintenance period patients should wait at least 2 hours before treating another episode of

breakthrough pain with Abstral.

Dose re-adjustment:

If the response (analgesia or adverse reactions) to the titrated Abstral dose markedly changes, an

adjustment of dose may be necessary to ensure that an optimal dose is maintained.

If more than four episodes of breakthrough pain are experienced per day over a period of more than

four consecutive days, then the dose of the long acting opioid used for persistent pain should be re-

evaluated. If the long acting opioid or dose of long acting opioid is changed the Abstral dose should be

re-evaluated and re-titrated as necessary to ensure the patient is on an optimal dose.

It is imperative that any dose re-titration of any analgesic is monitored by a health professional.

In absence of adequate pain control, the possibility of hyperalgesia, tolerance and progression of

underlying disease should be considered (see section 4.4).

Discontinuation of therapy:

Abstral should be discontinued immediately if the patient no longer experiences breakthrough pain

episodes. The treatment for the persistent background pain should be kept as prescribed.

If discontinuation of all opioid therapy is required, the patient must be closely followed by the doctor

in order to avoid the possibility of abrupt withdrawal effects


Use in children and adolescents:

Abstral must not be used in patients less than 18 years of age due to a lack of data on safety and


Use in older people:

Dose titration needs to be approached with particular care and patients observed carefully for signs of

fentanyl toxicity (see section 4.4).

Use in patients with renal and hepatic impairment

Patients with kidney or liver dysfunction should be carefully observed for signs of fentanyl toxicity

during the Abstral titration phase (see section 4.4).



Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Patients without maintenance opioid therapy as there is an increased risk of respiratory depression.

Severe respiratory depression or severe obstructive lung conditions.

Treatment of acute pain other than breakthrough pain.

Patients being treated with medicinal products containing sodium oxybate.


Special warnings and precautions for use

Patients and their carers must be instructed that Abstral contains an active substance in an amount that

can be fatal to a child, and therefore to keep all tablets out of the sight and reach of children.

Due to the potentially serious undesirable effects that can occur when taking an opioid therapy such as

Abstral, patients and their carers should be made fully aware of the importance of taking Abstral

correctly and what action to take should symptoms of overdose occur.

Before Abstral therapy is initiated, it is important that the patient’s long-acting opioid treatment used

to control their persistent pain has been stabilised.

Opioid Use Disorder (abuse and dependence)

Tolerance and physical and/or psychological dependence may develop upon repeated administration

of opioids such as fentanyl. Iatrogenic addiction following therapeutic use of opioids is known to


Repeated use of Abstral may lead to Opioid Use Disorder (OUD). Abuse or intentional misuse of

Abstral may result in overdose and/or death. The risk of developing OUD is increased in patients with

a personal or a family history (parents or siblings) of substance use disorders (including alcohol use

disorder), in current tobacco users or in patients with a personal history of other mental health

disorders (e.g. major depression, anxiety and personality disorders).

Patients will require monitoring for signs of drug-seeking behaviour (e.g. too early requests for refills).

This includes the review of concomitant opioids and psycho-active drugs (like benzodiazepines). For

patients with signs and symptoms of OUD, consultation with an addiction specialist should be


Respiratory Depression

In common with all opioids, there is a risk of clinically significant respiratory depression associated

with the use of Abstral. Particular caution should be exercised during dose titration with Abstral in

patients with chronic obstructive pulmonary disease or other medical conditions predisposing them to

respiratory depression (e.g. myasthenia gravis) because of the risk of further respiratory depression,

which could lead to respiratory failure.

Increased intracranial pressure

Abstral should only be administered with extreme caution in patients who may be particularly

susceptible to the intracranial effects of hyperkapnia, such as those showing evidence of raised

intracranial pressure, reduced consciousness, coma or brain tumours. In patients with head injuries, the

clinical course may be masked by the use of opioids. In such a case, opioids should be used only if

absolutely necessary.


As with other opioids, in case of insufficient pain control in response to an increased dose of fentanyl,

the possibility of opioid-induced hyperalgesia should be considered. A fentanyl dose reduction or

discontinuation of fentanyl treatment or treatment review may be indicated.

Cardiac disease

Fentanyl may produce bradycardia. Fentanyl should be used with caution in patients with previous or

pre-existing bradyarrhythmias.

Elderly, cachectic or debilitated population

Data from intravenous studies with fentanyl suggest that older patients may have reduced clearance, a

prolonged half-life and they may be more sensitive to the active substance than younger patients.

Older, cachectic, or debilitated patients should be observed carefully for signs of fentanyl toxicity and

the dose reduced if necessary.

Impaired hepatic or renal function

Abstral should be administered with caution to patients with liver or kidney dysfunction, especially

during the titration phase. The use of Abstral in patients with hepatic or renal impairment may increase

the bioavailability of fentanyl and decrease its systemic clearance, which could lead to accumulation

and increased and prolonged opioid effects.

Hypovolaemia and hypotension

Care should be taken in treating patients with hypovolaemia and hypotension.

Use in patients with mouth wounds or mucositis

Abstral has not been studied in patients with mouth wounds or mucositis. There may be a risk of

increased systemic drug exposure in such patients and therefore extra caution is recommended during

dose titration.

Abstral withdrawal

There should be no noticeable effects on cessation of treatment with Abstral, but possible symptoms of

withdrawal are anxiety, tremor, sweating, paleness, nausea and vomiting.

Serotonin Syndrome

Caution is advised when Abstral is co-administered with drugs that affect the serotoninergic

neurotransmitter systems.

The development of a potentially life-threatening serotonin syndrome may occur with the concomitant

use of serotonergic drugs such as Selective Serotonin Re-uptake Inhibitors (SSRIs) and Serotonin

Norepinephrine Re-uptake Inhibitors (SNRIs), and with drugs which impair metabolism of serotonin

(including Monoamine Oxidase Inhibitors [MAOIs]). This may occur within the recommended dose.

Serotonin syndrome may include mental-status changes (e.g., agitation, hallucinations, coma),

autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular

abnormalities (e.g., hyperreflexia, incoordination, rigidity), and/or gastrointestinal symptoms (e.g.,

nausea, vomiting, diarrhoea).

If serotonin syndrome is suspected, treatment with Abstral should be discontinued.

Sleep-related breathing disorders

Opioids can cause sleep-related breathing disorders including central sleep apnoea (CSA) and sleep-

related hypoxemia. Opioid use increases the risk of CSA in a dose-dependent fashion. In patients who

present with CSA, consider decreasing the total opioid dosage.

Risk from concomitant use of sedative medicines such as benzodiazepines or related drugs

Concomitant use of Abstral and sedative medicines such as benzodiazepines or related drugs may

result in sedation, respiratory depression, coma and death. Because of these risks, concomitant

prescribing with these sedative medicines should be reserved for patients for whom alternative

treatment options are not possible. If a decision is made to prescribe Abstral concomitantly with

sedative medicines, the lowest effective dose should be used, and the duration of treatment should be

as short as possible.

The patients should be followed closely for signs and symptoms of respiratory depression and

sedation. In this respect, it is strongly recommended to inform patients and their caregivers to be aware

of these symptoms (see section 4.5).

Abstral contains sodium

This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially ‘sodium-



Interaction with other medicinal products and other forms of interaction

Concomitant use of medicinal products containing sodium oxybate and fentanyl is contraindicated (see

section 4.3). Treatment with sodium oxybate should be discontinued before start of treatment with


Fentanyl is metabolised by CYP3A4. Active substances that inhibit CYP3A4 activity such as

macrolide antibiotics (e.g. erythromycin), azole antifungal agents (e.g. ketoconazole, itraconazole) or

certain protease inhibitors (e.g. ritonavir) may increase the bioavailability of fentanyl by decreasing its

systemic clearance, potentially enhancing or prolonging opioid effects. Grapefruit juice is also known

to inhibit CYP3A4. Coadministration with agents that induce CYP3A4 activity such as

antimycobacterials (e.g. rifampin, rifabutin), anticonvulsants (e.g. carbamazepine, phenytoin, and

phenobarbital), herbal products (e.g. St John’s wort (Hypericum perforatum)) may reduce the efficacy

of fentanyl. CYP3A4 inducers exert their effect in a time-dependent manner, and may take at least 2

weeks to reach maximal effect after introduction. Conversely, on discontinuation, CYP3A4 induction

may take at least 2 weeks to decline. Patients receiving fentanyl who stop therapy with, or decrease the

dose of CYP3A4 inducers, may be at risk of increased fentanyl activity or toxicity. Fentanyl should

therefore be given to patients with caution if administered concomitantly with CYP3A4 inhibitors

and/or inducers.

Concomitant use of other CNS depressants, such as other morphine derivatives (analgesics and

antitussives), general anaesthetics, skeletal muscle relaxants, sedative antidepressants, sedative H1

antihistamines, barbiturates, anxiolytics (i.e., benzodiazepines), hypnotics, antipsychotics, clonidine

and related substances may produce increased CNS depressant effects, increased risk of sedation,

respiratory depression, hypotension, coma and death because of additive CNS depressant effect. The

dose and duration of concomitant use should be limited (see section 4.4)..

Alcohol potentiates the sedative effects of morphine-based analgesics, therefore concomitant

administration of alcoholic beverages or medicinal products containing alcohol with Abstral is not


Abstral is not recommended for use in patients who have received monoamine oxidase (MAO)

inhibitors within 14 days because severe and unpredictable potentiation by MAO inhibitors has been

reported with opioid analgesics.

The concomitant use of partial opioid agonists/antagonists (e.g. buprenorphine, nalbuphine,

pentazocine) is not recommended. They have high affinity to opioid receptors with relatively low

intrinsic activity and therefore partially antagonise the analgesic effect of fentanyl and may induce

withdrawal symptoms in opioid dependent patients.

Serotoninergic Drugs

Co-administration of fentanyl with a serotoninergic agent, such as a Selective Serotonin Re-uptake

Inhibitor (SSRI) or a Serotonin Norepinephrine Re-uptake Inhibitor (SNRI) or a Monoamine Oxidase

Inhibitor (MAOI), may increase the risk of serotonin syndrome, a potentially life-threatening



Fertility, pregnancy and lactation

The safety of fentanyl in pregnancy has not been established. Studies in animals have shown

reproductive toxicity, with impaired fertility in rats (see section 5.3). The potential risk for humans is

unknown. Fentanyl should only be used during pregnancy when clearly necessary.

Long-term treatment during pregnancy may cause withdrawal symptoms in the new-born infant.

Fentanyl should not be used during labour and delivery (including caesarean section) since fentanyl

crosses the placenta and may cause respiratory depression in the foetus or in the new-born infant.


Fentanyl passes into breast milk and may cause sedation and respiratory depression in the breast-fed

child. Fentanyl should not be used by breastfeeding women and breastfeeding should not be restarted

until at least 5 days after the last administration of fentanyl.


Effects on ability to drive and use machines

No studies on the effects on the ability to drive and use machines have been performed with Abstral.

However, opioid analgesics are known to impair the mental or physical ability to perform potentially

hazardous tasks such as driving or operating machinery. Patients should be advised not to drive or

operate machinery if they become dizzy or drowsy or experience blurred or double vision while taking



Undesirable effects

Undesirable effects typical of opioids are to be expected with Abstral; they tend to decrease in

intensity with continued use. The most serious potential adverse reactions associated with opioid use

are respiratory depression (which could lead to respiratory arrest), hypotension and shock.

The clinical trials of Abstral were designed to evaluate safety and efficacy in treating patients with

breakthrough cancer pain; all patients were taking concomitant opioids, such as sustained-release

morphine, sustained-release oxycodone or transdermal fentanyl, for their persistent pain. Therefore, it

is not possible to definitively separate the effects of Abstral alone.

The most frequently observed adverse reactions with Abstral include typical opioid adverse reactions,

such as nausea, constipation, somnolence and headache.

Tabulated Summary of Adverse Reactions with Abstral and/or other fentanyl-containing compounds:

The following adverse reactions have been reported with Abstral

and/or other fentanyl-containing


during clinical studies and from post-marketing experience. They are listed below by

system organ class and frequency (very common

1/10; common

1/100 to < 1/10; uncommon

1/1,000 to <1/100; not known (cannot be estimated from available data)). Within each frequency

grouping, undesirable effects are presented in order of decreasing seriousness.

System Organ Class

Adverse Reaction by Frequency

Very common



1/100 to < 1/10


1/1,000 to <1/100

Not known (cannot

be estimated from

available data)

Immune system



Metabolism and

nutrition disorders


Decreased appetite

Psychiatric disorders



Confusional state


Mental status changes


Euphoric mood


Emotional lability

Disturbance in attention



Drug dependence


Drug abuse


System Organ Class

Adverse Reaction by Frequency

Very common



1/100 to < 1/10


1/1,000 to <1/100

Not known (cannot

be estimated from

available data)

Nervous system











Sleep disorder


Depressed level of


Loss of


Eye disorders

Vision blurred

Cardiac disorders



Vascular disorders



thoracic and




Oropharyngeal pain

Throat tightness









Dry mouth

Mouth ulceration

Gingival ulceration

Lip ulceration

Impaired gastric emptying

Abdominal pain


Stomach discomfort

Tongue disorder

Aphthous stomatitis

Swollen tongue


Skin and

subcutaneous tissue



Skin lesion


Pruritus allergic


Night sweats

Increased tendency to



Musculoskeletal and

connective tissue



Musculoskeletal stiffness

Joint stiffness

Reproductive system

and breast disorders

Erectile dysfunction

General disorders

and administration

site conditions


*Drug withdrawal






Peripheral oedema





Injury, poisoning

and procedural


Accidental overdose


opioid withdrawal symptoms such as nausea, vomiting, diarrhoea, anxiety, chills, tremor, and sweating have

been observed with transmucosal fentanyl

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It

allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare

professionals are asked to report any suspected adverse reactions via the national reporting system

listed below:

To be completed nationally



The symptoms of fentanyl overdose are an extension of its pharmacological actions, the most serious

effect being respiratory depression, which may lead to respiratory arrest. Coma is also known to occur.

Management of opioid overdose in the immediate term includes removal of any remaining Abstral

sublingual tablets from the mouth, physical and verbal stimulation of the patient and an assessment of

the level of consciousness. A patent airway should be established and maintained. If necessary, an

oropharyngeal airway or endotracheal tube should be inserted, oxygen administered and mechanical

ventilation initiated, as appropriate. Adequate body temperature and parenteral fluid intake should be


For the treatment of accidental overdose in opioid-naïve individuals, naloxone or other opioid

antagonists should be used as clinically indicated and in accordance with their Summary of Product

Characteristics. Repeated administration of the opioid antagonist may be necessary if the duration of

respiratory depression is prolonged.

Care should be taken when using naloxone or other opioid antagonists to treat overdose in opioid-

maintained patients, due to the risk of precipitating an acute withdrawal syndrome.

If severe or persistent hypotension occurs, hypovolaemia should be considered, and the condition

should be managed with appropriate parenteral fluid therapy.

Muscle rigidity interfering with respiration has been reported with fentanyl and other opioids. In this

situation, endotracheal intubation, assisted ventilation and administration of opioid antagonists as well

as muscle relaxants may be requested.

Cases of Cheyne Stokes respiration have been observed in case of fentanyl overdose, particularly in

patients with history of heart failure.




Pharmacodynamic properties

Pharmacotherapeutic group: Analgesics; Opioids; Phenylpiperidine derivatives.

ATC code: N02AB03

Fentanyl is a potent µ-opioid analgesic with rapid onset of analgesia and short duration of action.

Fentanyl is approximately 100-fold more potent than morphine as an analgesic. Secondary effects of

fentanyl on central nervous system (CNS), respiratory and gastro-intestinal function are typical of

opioid analgesics and are considered to be class effects. These can include respiratory depression,

bradycardia, hypothermia, constipation, miosis, physical dependence and euphoria.

Opioids may influence the hypothalamic-pituitary-adrenal or –gonadal axes. Some changes that can be

seen include an increase in serum prolactin, and decreases in plasma cortisol and testosterone. Clinical

signs and symptoms may be manifest from these hormonal changes.

The analgesic effects of fentanyl are related to the blood level of the active substance; in opioid-naïve

patients, minimum effective analgesic serum concentrations of fentanyl range from 0.3-1.2 ng/ml,

while blood levels of 10-20 ng/ml produce surgical anaesthesia and profound respiratory depression.

In patients with chronic cancer pain on stable maintenance doses of opioids, statistically significant

improvement in pain intensity difference was seen with Abstral versus placebo from 10 minutes after

administration onwards (see figure 1 below) , with a significantly lower need for rescue analgesic


Figure 1 Mean Pain Intensity Difference from baseline (± SE) for Abstral Compared with Placebo

(measured by a 0-10 Lickert scale)

The safety and efficacy of Abstral have been evaluated in patients taking the drug at the onset of the

breakthrough pain episode. Preemptive use of Abstral for predictable pain episodes was not

investigated in the clinical trials.

Fentanyl, in common with all µ-opioid receptor agonists, produces dose dependent respiratory

depression. This risk is higher in opioid-naïve subjects than in patients experiencing severe pain or

receiving chronic opioid therapy. Long-term treatment with opioids typically leads to development of

tolerance to their secondary effects.

While opioids generally increase the tone of urinary tract smooth muscle, the net effect tends to be

variable, in some cases producing urinary urgency, in others, difficulty in urination.

Opioids increase the tone and decrease the propulsive contractions of the smooth muscle of the

gastrointestinal tract leading to a prolongation in gastrointestinal transit time, which may be

responsible for the constipating effect of fentanyl.


Pharmacokinetic properties

Fentanyl is a highly lipophilic drug absorbed very rapidly through the oral mucosa and more slowly

through the gastrointestinal tract. Orally administered fentanyl undergoes pronounced hepatic and

intestinal first pass effects.

Abstral is a quick dissolving sublingual tablet formulation. Rapid absorption of fentanyl occurs over

about 30 minutes following administration of Abstral. The absolute bioavailability of Abstral has been

Mean Pain Intensity Difference

Time (min)







Mean Pain Intensity Difference

calculated to be 54 %. Mean maximal plasma concentrations of fentanyl range from 0.2 to 1.3 ng/ml

(after administration of 100 to 800 µg Abstral) and are reached within 22.5 to 240 minutes.

About 80-85% of fentanyl is bound by plasma proteins, mainly

1-glycoprotein and to a lesser extent

albumin and lipoprotein. The volume of distribution of fentanyl at steady state is about 3-6 l/kg.

Fentanyl is metabolised primarily via CYP3A4 to a number of pharmacologically inactive metabolites,

including norfentanyl. Within 72 hours of intravenous fentanyl administration around 75% of the dose

is excreted into the urine, mostly as metabolites, with less than 10% as unchanged drug. About 9% of

the dose is recovered in the faeces, primarily as metabolites. Total plasma clearance of fentanyl is

about 0.5 l/h/kg.

After Abstral administration, the main elimination half-life of fentanyl is about 7 hours (range 3-12.5

hours) and the terminal half-life is about 20 hours (range 11.5-25 hours).

The pharmacokinetics of Abstral have been shown to be dose proportional over the dose range of 100

to 800 µg. Pharmacokinetic studies have shown that multiple tablets are bioequivalent to single tablets

of the equivalent dose.

Renal/hepatic impairment

Impaired hepatic or renal function could cause increased serum concentrations. Older, cachectic or

generally impaired patients may have a lower fentanyl clearance, which could cause a longer terminal

half-life for the compound (see sections 4.2 and 4.4).


Preclinical safety data

Safety pharmacology and repeated dose toxicity data reveal no special hazard for humans that is not

already covered by other sections of this SPC. Animal studies have shown reduced fertility and

increased mortality in rat foetuses. Teratogenic effects have, however, not been demonstrated.

Mutagenicity testing in bacteria and in rodents yielded negative results. Like other opioids fentanyl

showed mutagenic effects

in vitro

in mammalian cells. A mutagenic risk with therapeutic use seems

unlikely since effects were induced only at very high concentrations.

Carcinogenicity studies (26-week dermal alternative bioassay in Tg.AC transgenic mice; two-year

subcutaneous carcinogenicity study in rats) with fentanyl did not reveal any findings indicative of

oncogenic potential. Evaluation of brain slides from the carcinogenicity study in rats revealed brain

lesions in animals administered high doses of fentanyl citrate. The relevance of these findings to

humans is unknown.




List of excipients

Mannitol (E421)

Silicified microcrystalline cellulose

Croscarmellose sodium

Magnesium stearate



Not applicable.


Shelf life

2 years


Special precautions for storage

Do not store above 25°C.

Store in the original blister package in order to protect from moisture.


Nature and contents of container

Abstral sublingual tablets are packaged in child resistant blisters of OPA/Aluminium/PVC pockets

with paper/polyester/Aluminium lidding contained in a cardboard outer carton. The packaging is

colour-coded for each Abstral sublingual tablet strength.

Pack size: Packs of 10 or 30 sublingual tablets. Not all pack sizes may be marketed.


Special precautions for disposal

Waste material should be disposed of safely. Patients/carers should be encouraged to return any

unused product to the Pharmacy, where it should be disposed of in accordance with national and local




To be completed nationally



To be completed nationally



Date of first authorisation: 29-02-2008

Date of latest renewal: 28-02-2013



27 May 2021

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