Rethink Dosing Flexibility
INDIVIDUALIZE TREATMENT AND TITRATE TO THE OPTIMAL DOSE1
BELBUCA® 12-hour Dosing for Consistent Relief1
NOT ACTUAL SIZE
Broad range of 7 dosage strengths1
Individualize treatment and titrate up to the lowest dose that provides adequate analgesia and minimizes adverse reactions. Patients in both the BELBUCA® and the placebo groups of the clinical trials were allowed to receive rescue medications to minimize opioid withdrawal symptoms and/or breakthrough pain.
Why do the films vary in size?
- If the dose of medication increased proportionately with the sizes of the films, the lowest dose would be too small for handling, and the largest dose would be too big to apply comfortably2
- Instead, 2 formulations of BELBUCA® were optimized to deliver buprenorphine via buccal films that are conducive to everyday use3
Open label titration phase:
Patients were titrated every 4 to 8 days and reached their optimal dose, on average, within 25 days4-6*
Patients randomized to BELBUCA®: dose distribution at end of open-label titration phase4
Optimal dose was defined as a dose of medication that5:
- Patients found satisfactory for both analgesia and tolerability (preferable without the need for rescue medication) and no more than 1 dose of 5/325 mg hydrocodone/acetaminophen (HC/APAP) per day (1 or 2 tablets per dose)
- Patients were willing to continue at the same dose for the 12-week double-blind treatment phase
*In the clinical trial, average time to reach optimal dose was 24.5 days in the open-label titration phase6
For opioid-experienced patients, taper the total daily opioid dose to 30 mg Oral MSE or less1
- When transitioning opioid-experienced patients, start by tapering their current opioid dose to no more than 30 mg morphine sulfate equivalent (MSE) daily1
- There is a potential for buprenorphine to precipitate withdrawal in patients who are already on opioids1
- There are no established conversion ratios defined by clinical trials for conversion from other opioids to BELBUCA®
Determine the appropriate STARTING DOSE based on the patient’s total daily opioid dose prior to taper1
†All patients should be titrated no more frequently than every 4 days, and dosed in q12h intervals.1
‡Opioid-naive and opioid-intolerant patients: Begin at 75 mcg QD or q12h for at least 4 days; increase to 150 mcg q12h.1
NOTE: Only dose up to 450 mcg q12h were studied in opioid-naïve patients.1
Monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of initiating therapy and following dosage increases with BELBUCA®, and adjust the dosage accordingly. Close monitoring is of particular importance when converting from methadone to other opioid agonists, including BELBUCA®. The ratio between methadone and other opioid agonists may vary widely as a function of previous dose exposure. Methadone has a long half-life and can accumulate in the plasma.1
TITRATION EXAMPLE SCRIPT
Starting dose will range from 75 mcg once daily or every 12 hours to 300 mcg every 12 hours depending on the patient’s prior opioid experience and risk for abuse potential.1
Titration should occur every 4 to 8 days, based on the pharmacokinetic profile and time to reach steady-state plasma levels.1 Prescribe enough films based on the patient’s titration schedule.
Consider your titration plan when determining the appropriate amount of films to prescribe.
MAINTENANCE EXAMPLE SCRIPT
Optimal dose will vary based on the patient’s prior opioid experience, analgesic needs, and tolerance to adverse events.1
After titration to an optimal dose, prescribe enough films based on your follow-up plan.
BELBUCA® is Schedule III and can be refilled up to 5 times during 6 months before patients would require a new prescription depending on state or local regulations.1,9,10 If you prefer follow up with patients more frequently, consider prescribing a lower number of refills.
Remember to monitor and periodically reassess patients as they begin and throughout treatment with BELBUCA®.1 Examples only. Please refer to the full Prescribing Information to determine appropriate dosing.
BELBUCA® (buprenorphine) buccal film is indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.
Limitations of Use
- Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with long-acting opioid formulations, reserve BELBUCA® for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain.
- BELBUCA® is not indicated as an as-needed (prn) analgesic.
BELBUCA® is contraindicated in patients with significant respiratory depression; acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment; known or suspected gastrointestinal obstruction, including paralytic ileus; and hypersensitivity (e.g., anaphylaxis) to buprenorphine.
IMPORTANT SAFETY INFORMATION about BELBUCA®
WARNING: ADDICTION, ABUSE, AND MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL EXPOSURE; AND NEONATAL OPIOID WITHDRAWAL SYNDROME; AND RISKS FROM CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS
Addiction, Abuse, and Misuse
BELBUCA® exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient’s risk prior to prescribing BELBUCA® and monitor patients regularly for the development of these behaviors and conditions.
Life-Threatening Respiratory Depression
Serious, life-threatening, or fatal respiratory depression may occur with use of BELBUCA®. Monitor for respiratory depression, especially during initiation of BELBUCA® or following a dose increase. Misuse or abuse of BELBUCA® by chewing, swallowing, snorting, or injecting buprenorphine extracted from the buccal film will result in the uncontrolled delivery of buprenorphine and pose a significant risk of overdose and death.
Accidental exposure to even one dose of BELBUCA®, especially by children, can result in a fatal overdose of buprenorphine.
Neonatal Opioid Withdrawal Syndrome
Prolonged use of BELBUCA® during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life threatening if not recognized and treated and requires management according to protocols developed by neonatology experts. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available.
Risks From Concomitant Use With Benzodiazepines Or Other CNS Depressants
Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing for use in patients for whom alternative treatment options are inadequate, limit dosages and durations to the minimum required, and follow patients for signs and symptoms of respiratory depression and sedation.
WARNINGS AND PRECAUTIONS
Addiction, Abuse, and Misuse
- BELBUCA® contains buprenorphine, a Schedule III controlled substance. As an opioid, BELBUCA® exposes users to the risks of addiction, abuse, and misuse. Although the risk of addiction in any individual is unknown, it can occur in patients appropriately prescribed BELBUCA® and in those who obtain the drug illicitly. Addiction can occur at recommended doses and if the drug is misused or abused.
- Assess each patient’s risk for opioid addiction, abuse, or misuse prior to prescribing BELBUCA® and monitor all patients receiving BELBUCA® for the development of these behaviors and conditions. Risks are increased in patients with a personal or family history of substance abuse (including drug or alcohol abuse or addiction) or mental illness (e.g., major depression). The potential for these risks should not, however, prevent the proper management of pain in any given patient. Patients at increased risk may be prescribed opioids such as BELBUCA®, but use in such patients necessitates intensive counseling about the risks and proper use of BELBUCA®, along with intensive monitoring for signs of addiction, abuse, or misuse.
- Abuse or misuse of BELBUCA® by swallowing may cause choking, overdose, and death.
- Opioids are sought by drug abusers and people with addiction disorders and are subject to criminal diversion. Consider these risks when prescribing or dispensing BELBUCA®. Strategies to reduce the risk include prescribing the drug in the smallest appropriate quantity and advising the patient on the proper disposal of unused drug.
Life-Threatening Respiratory Depression
- Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death.
- While serious, life-threatening or fatal respiratory depression can occur at any time during the use of BELBUCA®; the risk is greatest during initiation of therapy or following a dosage increase. Monitor patients closely for respiratory depression when initiating therapy with BELBUCA®and following dosage increases.
- To reduce the risk of respiratory depression, proper dosing and titration of BELBUCA® are essential. Overestimating the dose of BELBUCA® when converting patients from another opioid product may result in fatal overdose with the first dose.
- Accidental exposure to BELBUCA®, especially in children, can result in respiratory depression and death due to an overdose of buprenorphine.
Neonatal Opioid Withdrawal Syndrome
- Prolonged use of BELBUCA® during pregnancy can result in withdrawal in the neonate. Neonatal opioid withdrawal syndrome, unlike opioid withdrawal syndrome in adults, may be life threatening if not recognized and treated and requires management according to protocols developed by neonatology experts. Observe newborns for signs of neonatal opioid withdrawal syndrome and manage accordingly. Advise pregnant women using opioids for a prolonged period of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available.
Risks due to Interactions with Benzodiazepines or Other Central Nervous System Depressants
- Profound sedation, respiratory depression, coma, and death may result from the concomitant use of BELBUCA® with benzodiazepines or other CNS depressants (e.g., non-benzodiazepine sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, other opioids, alcohol). Because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate.
If the decision is made to prescribe a benzodiazepine or other CNS depressant concomitantly with an opioid analgesic, prescribe the lowest effective dosages and minimum durations of concomitant use. Follow patients closely for signs and symptoms of respiratory depression and sedation.
Risk of Life-Threatening Respiratory Depression in Patients with Chronic Pulmonary Disease or in Elderly, Cachectic, or Debilitated Patients
- The use of BELBUCA® in patients with acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment is contraindicated.
- Patients with Chronic Pulmonary Disease: BELBUCA®-treated patients with significant chronic obstructive pulmonary disease or cor pulmonale and those with substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression are at increased risk of decreased respiratory drive, including apnea, even at recommended dosages of BELBUCA®.
- Life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients as they may have altered pharmacokinetics or altered clearance compared with younger, healthier patients.
- Monitor such patients closely, particularly when initiating and titrating BELBUCA® and when BELBUCA® is given concomitantly with other drugs that depress respiration.
- Cases of adrenal insufficiency have been reported with opioid use, more often following greater than one month of use. Presentation of adrenal insufficiency may include non-specific symptoms and signs including nausea, vomiting, anorexia, fatigue, weakness, dizziness, and low blood pressure. If adrenal insufficiency is suspected, confirm the diagnosis with diagnostic testing as soon as possible. If adrenal insufficiency is diagnosed, treat with physiologic replacement doses of corticosteroids. Wean the patient off of the opioid to allow adrenal function to recover and continue corticosteroid treatment until adrenal function recovers. Other opioids may be tried as some cases reported use of a different opioid without recurrence of adrenal insufficiency. The information available does not identify any particular opioids as being more likely to be associated with adrenal insufficiency.
- BELBUCA® has been observed to prolong the QTc interval in some subjects participating in clinical trials. Consider these observations in clinical decisions when prescribing BELBUCA® to patients with hypokalemia, hypomagnesemia, or clinically unstable cardiac disease, including unstable atrial fibrillation, symptomatic bradycardia, unstable congestive heart failure, or active myocardial ischemia. Periodic electrocardiographic (ECG) monitoring is recommended in these patients. Avoid the use of BELBUCA® in patients with a history of Long QT Syndrome (or an immediate family member with this condition) or those taking Class IA antiarrhythmic medications (e.g., quinidine, procainamide, disopyramide) or Class III antiarrhythmic medications (e.g., sotalol, amiodarone, dofetilide) or other medications that prolong the QT interval.
- BELBUCA® may cause severe hypotension, including orthostatic hypotension and syncope, in ambulatory patients. There is an increased risk in patients whose ability to maintain blood pressure has already been compromised by a reduced blood volume or concurrent administration of certain CNS depressant drugs (e.g., phenothiazines or general anesthetics). Monitor these patients for signs of hypotension after initiating or titrating the dosage of BELBUCA®. In patients with circulatory shock, BELBUCA®may cause vasodilation that can further reduce cardiac output and blood pressure. Avoid the use of BELBUCA®in patients with circulatory shock.
Risks of Use in Patients with Increased Intracranial Pressure, Brain Tumors, Head Injury, or Impaired Consciousness
- In patients who may be susceptible to the intracranial effects of CO2 retention (e.g., those with evidence of increased intracranial pressure or brain tumors), BELBUCA® may reduce respiratory drive, and the resultant CO2 retention can further increase intracranial pressure. Monitor such patients for signs of sedation and respiratory depression, particularly when initiating therapy with BELBUCA®.
- Opioids may also obscure the clinical course in a patient with a head injury. Avoid the use of BELBUCA® in patients with impaired consciousness or coma.
- Cases of cytolytic hepatitis and hepatitis with jaundice have been observed in individuals receiving sublingual formulations of buprenorphine for the treatment of opioid dependence, both in clinical trials and in post-marketing adverse events reports. For patients at increased risk of hepatotoxicity (e.g., patients with a history of excessive alcohol intake, intravenous drug abuse or liver disease), obtain baseline liver enzyme levels and monitor periodically during treatment with BELBUCA®.
Risk of Overdose in Patients With Moderate or Severe Hepatic Impairment
- In a pharmacokinetic study of subjects dosed with buprenorphine sublingual tablets, buprenorphine plasma levels were found to be higher and the half-life was found to be longer in subjects with moderate and severe hepatic impairment but not in subjects with mild hepatic impairment. For patients with severe hepatic impairment, a dose adjustment is recommended, and patients with moderate or severe hepatic impairment should be monitored for signs and symptoms of toxicity or overdose caused by increased levels of buprenorphine.
- Cases of acute and chronic hypersensitivity to buprenorphine have been reported both in clinical trials and in post-marketing experience. The most common signs and symptoms include rashes, hives, and pruritus. Cases of bronchospasm, angioneurotic edema, and anaphylactic shock have been reported.
Risk of Use in Patients with Gastrointestinal Conditions
- BELBUCA® is contraindicated in patients with known or suspected gastrointestinal obstruction, including paralytic ileus.
- BELBUCA® may cause spasm of the sphincter of Oddi. Opioids may cause increases in the serum amylase. Monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms.
Increased Risk of Seizures in Patients with Seizure Disorders
- The buprenorphine in BELBUCA® may increase the frequency of seizures in patients with seizure disorders and may increase the risk of seizures occurring in other clinical settings associated with seizures. Monitor patients with a history of seizure disorders for worsened seizure control during BELBUCA® therapy.
Risks of Use in Cancer Patients with Oral Mucositis
- Cancer patients with oral mucositis may absorb buprenorphine more rapidly than intended and are likely to experience transiently higher plasma levels of the opioid. A dose reduction is recommended in these patients. Monitor carefully for signs and symptoms of toxicity or overdose caused by increased levels of buprenorphine.
Risks of Driving and Operating Machinery
- BELBUCA® may impair the mental and physical abilities needed to perform potentially hazardous activities such as driving a car or operating machinery. Warn patients not to drive or operate dangerous machinery unless they are tolerant to side effects of BELBUCA® and know how they will react to the medication.
- The most common adverse reactions (≥5%) reported by patients treated with BELBUCA® in the clinical trials were nausea, constipation, headache, vomiting, fatigue, dizziness, somnolence, diarrhea, dry mouth, and upper respiratory tract infection.
Intended for healthcare professionals of the United States of America only.
REFERENCES: 1. BELBUCA® (Prescribing Information). Raleigh, NC: BioDelivery Sciences International, Inc.; December 2016. 2. Data on file, DOF-BL-20. BioDelivery Sciences International, Inc.; 2016. 3. Data on file, DOF-BL-03. BioDelivery Sciences International, Inc.; 2015. 4. Gimbel J, Spierings ELH, Katz N, Xiang Q, Tzanis E, Finn A. Efficacy and tolerability of buccal buprenorphine in opioid-experienced patients with moderate to severe chronic low back pain: results of a phase 3, enriched enrollment, randomized withdrawal study. Pain. 2016;157(11):2517-2526. 5. Data on file, DOF-BL-01. BioDelivery Sciences International, Inc.; 2016. 6. Data on file, DOF-BL-11. BioDelivery Sciences International, Inc.; 2016. 7. Therapeutic Research Center. Equianalgesic dosing of opioids for pain management. New Hampshire Medical Society website. https://www.nhms.org/sites/default/files/Pdfs/Opioid-Comparison-Chart-Prescriber-Letter-2012.pdf. Published 2012. Accessed May 9, 2017. 8. McPherson ML. Transdermal and parenteral fentanyl dosage calculations and conversions. In: McPherson ML, ed. Demystifying Opioid Conversion Calculations: A Guide to Effective Dosing. 1st ed. Bethesda, MD: AHSP; 2009:83-106. 9. Drug Enforcement Administration. Questions & Answers – Prescriptions. US Department of Justice website. https://www.deadiversion.usdoj.gov/faq/prescriptions.htm. Accessed May 9, 2017. 10. Drug Enforcement Administration. Controlled Substances – by CSA Schedule. US Department of Justice website.