Belbucca TID?

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agolden1

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Didn't get a ton of exposure to belbucca in fellowship, but want to use it more in my practice.

Have a patient who had previously been on methadone at roughly 120 MME who was rotated off of it to morphine and titrated down to about 60 MME by an NP at a different pain clinic locally. Patient didn't endorse great benefit from the morphine at any time she was on it, so I offered a rotation to belbucca. Currently on 150mcg BID dosing. She's getting good relief, but notes it isn't lasting got 12 hours. Typically about 7-9 hours of benefit.

In this situation, do folks normally just go to a TID dose, or increase to 300 mcg BID? I don't see much published about TID dosing...

Thanks!
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I’m amazed 150 mcg is cutting it quite frankly. Honestly, if they feel 300 mcg total daily is providing some relief, just switch to a 15 mcg per hd Butrans, can increase to a 20 mcg if not enough.


Never do TID Belbuca, won’t get approved, but I do titrate up to TID suboxone tabs, typically half a 2 mg tab BID of TID.
 
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It comes in a box of 60 so you can’t dispense 90
 
dipriMAN said:
I’m amazed 150 mcg is cutting it quite frankly. Honestly, if they feel 300 mcg total daily is providing some relief, just switch to a 15 mcg per hd Butrans, can increase to a 20 mcg if not enough.


Never do TID Belbuca, won’t get approved, but I do titrate up to TID suboxone tabs, typically half a 2 mg tab BID of TID.
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She did a butrans before and didn’t like it,

Started lower with the belbucca due to unfamiliarity and based on the prescribers recommendations. Will increase though and see how she does.

She’s very happy so far though minus the time length issue.
 
agolden1 said:
She did a butrans before and didn’t like it,

Started lower with the belbucca due to unfamiliarity and based on the prescribers recommendations. Will increase though and see how she does.

She’s very happy so far though minus the time length issue.
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Interesting. I’ve seen more sweating and nausea with Belbuca compared to Butrans. Also, I’ve had a few people with dental caries. Has made me a bit less enthusiastic about Belbuca.
 
I have a handful of people on TID belbucca. You could order a bigger size and have them cut the films. I am somewhat surprised that the 150 BID was getting benefit in your patient, however I have had a couple of cases where the conversion seemed off with a much lower dosing of bupe and I suspect that OIH was possibly at play, as they felt markedly improved.
 
dipriMAN said:
Interesting. I’ve seen more sweating and nausea with Belbuca compared to Butrans. Also, I’ve had a few people with dental caries. Has made me a bit less enthusiastic about Belbuca.
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Will keep an eye out for the sweating and nausea in the future. Discussed and documented risks of dental carries and advised good dental hygiene....
 
lobelsteve said:
Anyone have patients say it doesn't stay in cheek? Sticks to fingers and teeth. Had bad rash from patch. Getting great relief, but thinks it should be easier to apply.
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I have. The rash from the butrans patch can be often circumvented with flonase application to the skin first. The stickiness and handling can be an issue and I wish it was easier to use too.
 
kstarm said:
I have a handful of people on TID belbucca. You could order a bigger size and have them cut the films. I am somewhat surprised that the 150 BID was getting benefit in your patient, however I have had a couple of cases where the conversion seemed off with a much lower dosing of bupe and I suspect that OIH was possibly at play, as they felt markedly improved.
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wow. no issues with medication absorption if patch is cut?
 
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lobelsteve said:
Anyone have patients say it doesn't stay in cheek? Sticks to fingers and teeth. Had bad rash from patch. Getting great relief, but thinks it should be easier to apply.
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I see it all the time. Complaints from some patients that the different dosages are different sizes, and some are harder than others to handle. Most of my patients hate the Belbuca compared to Butrans, but the psychological aspect of using it twice daily as compared to slapping a patch in and forgetting about it for a week seems to help some people, and of course some people need more than the 20 mcg Butrans and need Belbuca.
 
kstarm said:
Not cutting butrans, cutting belbucca films
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Echo this. You can cut the morning film and use the second half in the afternoon, full in the PM if needed.

agolden1 said:
In this situation, do folks normally just go to a TID dose, or increase to 300 mcg BID? I don't see much published about TID dosing...
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Just as a rough frame of reference from the study/website, most patients were north of 300 mcg BID dosing

1670297789813.png


For the 120 MME range, you're looking at a likely target of 600 - 900 mcg BID
For the 60 MME range, 300-450 mcg may be a reasonable goal.

In your patient's case, I would titrate them to 300 mcg BID.
 
Orin said:
Echo this. You can cut the morning film and use the second half in the afternoon, full in the PM if needed.


Just as a rough frame of reference from the study/website, most patients were north of 300 mcg BID dosing

View attachment 362882

For the 120 MME range, you're looking at a likely target of 600 - 900 mcg BID
For the 60 MME range, 300-450 mcg may be a reasonable goal.

In your patient's case, I would titrate them to 300 mcg BID.
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Agree with the change to 300. Surprised by this graph. I don’t have anyone above 300mcg.
 
lobelsteve said:
Anyone have patients say it doesn't stay in cheek? Sticks to fingers and teeth. Had bad rash from patch. Getting great relief, but thinks it should be easier to apply.
Click to expand...

I have. Seems worse in smokers and anyone on anticholinergics. I even got a call from a pharmacist asking if I could just put the patient back on hydrocodone.
 
jwalker12 said:
Recently spoke with our local belbucca rep? any real adverse effects? are you guys being cautious in liver dysfunction or prolonged qt?
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No issues for clinically meaningful changes with QTc with bupe (and actually the data for methadone doesn't suggest there is any clinically meaningful change in QTc either). I do not know what you mean by "real" adverse effects. People get side effects with it like other medications. I haven't seen anything I felt was dangerous though.
 
I'm sure you guys know already this but in case anyone who reads this didn't-- you can tape around the perimeter of a butrans patch but you should not tape over the center(drug delivering portion) otherwise it'll inadvertently increase absorption.
 
Similar question with Butrans: can you dose it every 5 days instead of weekly? I do have several patients who find it works for them but wears off. I know the pharmacy is resistant to opening boxes, so can only be dispensed in multiples of 4.
 
drrosenrosen said:
Similar question with Butrans: can you dose it every 5 days instead of weekly? I do have several patients who find it works for them but wears off. I know the pharmacy is resistant to opening boxes, so can only be dispensed in multiples of 4.
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You could try a mail order pharmacy. I’m assuming they ship from a few centralized warehouses so maybe they don’t care as much.
 
drrosenrosen said:
Similar question with Butrans: can you dose it every 5 days instead of weekly? I do have several patients who find it works for them but wears off. I know the pharmacy is resistant to opening boxes, so can only be dispensed in multiples of 4.
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better yet is to cut the dose in half (not the patch) and use 1 patch twice weekly. so 1 patch monday-monday, 1 patch thursday-thursday.
 
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