Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review

Abstract

Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R = 0.71, B 876 mL/min, K 16.3 kg) and alfentanil (R = 0.70, B 420 mL/min, K 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.

Individual variations in fentanyl pharmacokinetics and pharmacodynamics in preterm infants

“…The doses were generally very high in the included studies. The authors concluded that preterm and term infants showed lower clearance and protein binding, but that much larger studies must be made to get reliable data .…”

Extrapolation of Drug Clearance in Children ≤ 2 Years of Age from Empirical Models Using Data from Children (> 2 Years) and Adults

“…A recent study [6] indicated that a sigmoidal E max model can be used to describe the body weight versus clearance data across the observations. This study evaluated the predictive performance of a sigmoidal E max model for ten drugs.…”

Ten Years of Fentanyl-like Drugs: a Technical-analytical Review

“…1 Their adverse effects are related to dose, which include respiratory depression, sedation, nausea, vomiting, constipation, pruritus, physical dependence, the risk of addiction, bradycardia, and skeletal muscle rigidity. 2,3 Immediately after their introduction into the market as drugs for the treatment of pain, there was a significant increase in abuse, off-label and illicit uses. [4][5][6] Besides a series of illicit fentanyls (Fig.…”