Limited evidence for intranasal fentanyl in the emergency department and the prehospital setting--a systematic review.

INTRODUCTION The intranasal (IN) mode of application may be a valuable asset in non-invasive pain management. Fentanyl demonstrates pharmacokinetic and pharmacodynamic properties that are desirable in the management of acute pain, and IN fentanyl may be of value in the prehospital setting. The aim of this systematic review was to evaluate the current evidence for the use of IN fentanyl in the emergency department (ED) and prehospital setting. METHOD Reports of trials of IN fentanyl in (ED) and prehospital treatment of pain were systematically sought using the PubMed database, Embase, Google scholar, the Cochrane database and the Cumulative Index to Nursing and Allied Health Literature. RESULTS Twelve studies of IN fentanyl in the (ED) and prehospital setting were included in the final analysis. In the ED, analgesic non-inferiority and superiority were demonstrated when comparing IN fentanyl with intravenous (IV) and intramuscular morphine, respectively. Non-blinded, non-controlled studies demonstrated an analgesic effect of IN fentanyl in patients with moderate and severe pain. In the prehospital setting, both analgesic inferiority and non-inferiority were demonstrated when IN fentanyl was compared with IV morphine. Finally, a significant analgesic effect of IN fentanyl was demonstrated when IN fentanyl was compared with methoxyflurane. CONCLUSION Only limited quality evidence exists for the efficacy of IN fentanyl in the ED and in the prehospital setting, and more double-blinded, randomised, controlled trials are urgently needed to validate the use of IN fentanyl in this context.