Formulary
Alfentanil: Indications, Dosing, Side Effects and Interactions
Alfentanil clinical drug profile including indications, dosing, side effects, cautions and interactions.
MedNext Academy | 6 min read
Alfentanil: Indications, Dosing, Side Effects and Interactions
Alfentanil clinical drug profile including indications, dosing, side effects, cautions and interactions.
Indications and dose
**Spontaneous respiration: analgesia and enhancement of anaesthesia**
- **Adult** (By Intravenous Injection): for short procedures Initially up to 500 micrograms, dose to be administered over 30 seconds; supplemental doses 250 micrograms.
**Assisted ventilation: analgesia and enhancement of anaesthesia**
- **Adult** (By Intravenous Injection): for short procedures Initially 30-50 micrograms/kg, supplemental doses 15 micrograms/kg.
**Assisted ventilation: analgesia and enhancement of anaesthesia during maintenance of anaesthesia**
- **Adult** (By Intravenous Infusion): for longer procedures Initially 50-100 micrograms/kg, dose to be administered over 10 minutes or as a bolus, followed by maintenance 30-60 micrograms/kg/hour.
**Assisted ventilation: analgesia and suppression of respiratory activity during intensive care**
- **Adult** (By Intravenous Infusion): for up to 4 days Initially 2 mg/hour, adjusted according to response; usual dose 0.5-10 mg/hour, alternatively initially 5 mg in divided doses, to be administered over 10 minutes; dose used for more rapid initial control, reduce rate of administration if hypotension or bradycardia occur; additional doses of 0.5-1 mg may be given by intravenous injection during short painful procedures.
**Assisted ventilation: analgesia and enhancement of anaesthesia for short procedures for alfentanil**
- **Neonate** (By intravenous injection): Initially 5-20 micrograms/kg, dose to be administered over 30 seconds; supplemental doses up to 10 micrograms/kg.
- **Child** (By intravenous injection): Initially 10-20 micrograms/kg, dose to be administered over 30 seconds; supplemental doses up to 10 micrograms/kg.
**Assisted ventilation: analgesia and enhancement of anaesthesia during maintenance of anaesthesia for longer procedures for alfentanil**
- **Neonate** (By intravenous infusion): Initially 10-50 micrograms/kg, dose to be administered over 10 minutes, followed by 30-60 micrograms/kg/hour.
- **Child** (By intravenous infusion): Initially 50-100 micrograms/kg, dose to be administered over 10 minutes, followed by 30-120 micrograms/kg/hour, usual dose with intravenous anaesthetic, 60 micrograms/kg/hour.
Cautions
Adrenocortical insufficiency (reduced dose is recommended); asthma (avoid during an acute attack); central sleep apnoea; convulsive disorders; current or history of mental health disorder; current or history of substance use disorder; debilitated patients (reduced dose is recommended); diseases of the biliary tract; elderly (reduced dose is recommended); hypotension; hypothyroidism (reduced dose is recommended); impaired respiratory function (avoid in chronic obstructive pulmonary disease); inflammatory bowel disorders; myasthenia gravis; obstructive bowel disorders; prostatic hypertrophy; shock; urethral stenosis Cautions, further information Dependence and addiction Prolonged use of opioid analgesics may lead to drug dependence and addiction, even at therapeutic doses. There is an increased risk in individuals with current or history of substance use disorder or mental health disorders. See also Important safety information . Central sleep apnoea Opioids cause a dose-dependent increased risk of central sleep apnoea, consider total opioid dose reduction. M Palliative care In the control of pain in terminal illness, the cautions listed should not necessarily be a deterrent to the use of opioid analgesics. M Elderly Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria to aid medication reviews (see Prescribing in the elderly for information). Potentially inappropriate: if prescribed a strong , oral , or transdermal opioid (i.e. morphine, oxycodone, fentanyl, buprenorphine, diamorphine, methadone, tramadol, pethidine, pentazocine) as first-line therapy for mild pain (WHO analgesic ladder not observed) if used regularly without concomitant laxative (risk of severe constipation) if prescribed a long-acting (modified-release) opioid without a short-acting (immediate-release) opioid for breakthrough pain (risk of persistence of severe pain) Cautions For alfentanil Cautions, further information Repeated intra-operative doses Repeated intra-operative doses of alfentanil should be given with care since the resulting respiratory depression can persist postoperatively and occasionally it may become apparent for the first time postoperatively when monitoring of the patient might be less intensive. M
Contraindications
Acute respiratory depression; comatose patients; head injury (opioid analgesics interfere with pupillary responses vital for neurological assessment); raised intracranial pressure (opioid analgesics interfere with pupillary responses vital for neurological assessment); risk of paralytic ileus
Side effects
Common or very common Arrhythmias; confusion; constipation; dizziness; drowsiness; dry mouth; euphoric mood; flushing; hallucination; headache; hyperhidrosis; hypotension (with high doses); miosis; nausea (more common on initiation); palpitations; respiratory depression (with high doses); skin reactions; urinary retention; vertigo; visual impairment; vomiting (more common on initiation); withdrawal syndrome Uncommon Drug dependence; dysphoria; seizure Side-effects, further information Respiratory depression Respiratory depression is a major concern with opioid analgesics and it may be treated by artificial ventilation or be reversed by naloxone. Dependence, addiction, and withdrawal Long term use of opioids in non-malignant pain (longer than 3 months) carries an increased risk of dependence and addiction, even at therapeutic doses. At the end of treatment the dosage should be tapered slowly to reduce the risk of withdrawal effects; tapering from a high dose may take weeks or months. See also Important safety information . Overdose Opioids (narcotic analgesics) cause coma, respiratory depression, and pinpoint pupils. For details on the management of poisoning, see Opioids, under Emergency treatment of poisoning and consider the specific antidote, naloxone hydrochloride. Side-effects For alfentanil Common or very common Apnoea; chills; fatigue; hypertension; movement disorders; muscle rigidity; procedural complications Uncommon Coma; hiccups; hypercapnia; pain; post procedural complications; respiratory disorders Rare or very rare Agitation; crying; epistaxis; vascular pain Frequency not known Cardiac arrest; cough; fever; loss of consciousness Side-effects, further information Alfentanil can cause muscle rigidity, particularly of the chest wall or jaw; this can be managed by the use of neuromuscular blocking drugs.
Interactions
**Severe interactions:**
- Administration of IV parecoxib 40 mg had no significant effect on the pharmacokinetics of either IV fentanyl or IV alfentanil (CYP3A4 substrates).
- Closely monitor when Duvyzat is used in combination with orally administered CYP3A4 sensitive substrates (e.g., alfentanil, tacrolimus, sirolimus, lovastatin, simvastatin, indinavir, sildenafil,...
**Other interactions (16):**
- Analgesics/Anaesthetics (Alfentanil, Fentanyl, Methadone): Coadministration of fluconazole may cause decreased clearance of alfentanil, fentanyl or methadone and subsequent increased or prolonged...
- Alfentanil Co-administration of etomidate with alfentanil has been reported to decrease the terminal half-life of etomidate to approximately 29 minutes.
- Therefore, caution should be exercised when mifepristone is administered with drugs that are CYP3A4 substrates and have narrow therapeutic range, such as cyclosporine, tacrolimus, sirolimus,...
- If necessary, their dosage should be reduced and, where appropriate, plasma levels monitored: Drugs subject to metabolism by CYP2C9 (see Section 4.4 Special warnings and precautions for use); Oral...
- Specific studies have shown that there are no interactions when ondansetron is administered with alcohol, temazepam, furosemide, alfentanil, tramadol, morphine, lidocaine, propofol and thiopental.
- Opioids such as alfentanil and sufentanil, when combined with sevoflurane, may lead to a synergistic fall in heart rate, blood pressure and respiratory rate.
Pregnancy
Respiratory depression and withdrawal symptoms can occur in the neonate if opioid analgesics are used during delivery; also gastric stasis and inhalation pneumonia has been reported in the mother if opioid analgesics are used during labour.
Breast feeding
Present in milk-withhold breast-feeding for 24 hours.
Hepatic impairment
Manufacturer advises caution. Dose adjustments Manufacturer advises dose reduction and cautious titration.
Renal impairment
Use with caution and titrate carefully (risk of increased and prolonged effects). M Dose adjustments Dose reduction may be required in renal failure. M
Medicinal forms
Solution
Clinical governance
**Author:** MedNext Clinical Team. **Clinical reviewer:** Dr Shameer Deen, MBBS, MS, MRCS. **Sources:** BNF, Indian Pharmacopoeia, CIMS India. **Correction:** Report errors at support@mednext.academy.
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