NUCYNTA ER
Clinical safety rating
cautionComprehensive clinical and safety monograph for NUCYNTA ER (NUCYNTA ER).
Tapentadol is a mu-opioid receptor agonist and norepinephrine reuptake inhibitor, providing analgesic effects through opioid receptor activation and modulation of descending pain pathways.
| Metabolism | Primarily hepatic via glucuronidation (UGT1A9, UGT2B7) and to a lesser extent via CYP2C9 and CYP2C19; tapentadol-O-glucuronide is the major inactive metabolite. |
| Excretion | Renal: 99% (tapentadol and glucuronide conjugates); Fecal: <1%; unchanged tapentadol: <5%. |
| Half-life | Terminal elimination half-life: 4.1 hours (range 3.3–4.7 h) after single oral dose; steady state: 4.4 h. No clinically relevant accumulation. |
| Protein binding | Approximately 80% bound; primarily to albumin and alpha-1 acid glycoprotein. |
| Volume of Distribution | 540 L (equivalent to ~7.7 L/kg for 70 kg); indicates extensive tissue distribution. |
| Bioavailability | Oral (ER): 32% (due to first-pass metabolism); absolute bioavailability of immediate-release tapentadol is 32% as well. |
| Onset of Action | Oral (extended-release): Analgesic effect begins within 1 hour, with peak effect at 4–6 hours. |
| Duration of Action | Oral (extended-release): Approximately 12 hours (due to ER formulation); dosing interval is every 12 hours. |
| Molecular Weight | 221.34 |
100 mg orally every 12 hours, titrated from 50 mg every 12 hours; maximum 200 mg every 12 hours.
| Dosage form | TABLET, EXTENDED RELEASE |
| Renal impairment | CrCl 30-90 mL/min: no adjustment; CrCl <30 mL/min: not recommended; end-stage renal disease: contraindicated. |
| Liver impairment | Child-Pugh A: no adjustment; Child-Pugh B: not recommended; Child-Pugh C: contraindicated. |
| Pediatric use | Not approved for pediatric use; safety and efficacy not established. |
| Geriatric use | Initiate at 50 mg every 12 hours; titrate cautiously; monitor for respiratory depression and cognitive impairment. |
| 1st trimester | Limited human data; animal studies show increased risk of neural tube defects at high doses. Avoid use unless benefit outweighs risk. |
| 2nd trimester | Use with caution; may cause fetal opioid dependence. Monitor for withdrawal in neonates. |
| 3rd trimester | Prolonged use may cause neonatal opioid withdrawal syndrome. Avoid in late pregnancy, especially near term. |
Clinical note
Comprehensive clinical and safety monograph for NUCYNTA ER (NUCYNTA ER).
| Placental transfer | Tapentadol crosses the placenta; detected in fetal plasma at concentrations similar to maternal plasma. |
| Breastfeeding | Tapentadol is excreted into breast milk in low concentrations. Use with caution; monitor infant for sedation, respiratory depression, and withdrawal symptoms. Consider alternative analgesics. |
| Lactation Rating | L3 (Moderately Safe) |
| Teratogenic Risk | Prolonged use of opioids during pregnancy can result in neonatal opioid withdrawal syndrome. There is insufficient data on NUCYNTA ER (tapentadol) specifically for teratogenic risk; however, based on other opioids and animal studies, there may be an increased risk of neural tube defects and other malformations with first-trimester exposure. Second and third-trimester exposure may lead to fetal dependence and withdrawal. Use only if benefit outweighs risk. |
| Fetal Monitoring | Monitor maternal vital signs, especially respiratory rate, sedation, and bowel function. Assess for signs of fetal distress via fetal heart rate monitoring during prolonged use. In neonates, monitor for neonatal opioid withdrawal syndrome (NOWS) using standardized scoring tools for at least 48 hours after delivery if maternal use was chronic. |
| Fertility Effects | Opioids, including tapentadol, may alter reproductive hormone levels and can cause menstrual irregularities in women and decreased libido in both sexes. There is limited specific data for NUCYNTA ER; however, chronic use may impair fertility. It is recommended to discuss reproductive goals if long-term therapy is planned. |
■ FDA Black Box Warning
Risk of addiction, abuse, and misuse; life-threatening respiratory depression; accidental ingestion causing fatal overdose in children; neonatal opioid withdrawal syndrome with prolonged use during pregnancy; concomitant use with benzodiazepines or CNS depressants may cause profound sedation, respiratory depression, coma, and death.
| Serious Effects |
Significant respiratory depressionAcute or severe bronchial asthmaKnown or suspected gastrointestinal obstruction, including paralytic ileusHypersensitivity to tapentadol or any component of the formulationConcurrent use of monoamine oxidase inhibitors (MAOIs) or within 14 days of discontinuation
| Precautions | Risk of respiratory depression, especially in elderly or debilitated patients; risk of hypotension and syncope; risk of serotonin syndrome when co-administered with serotonergic drugs; risk of adrenal insufficiency; risk of severe hypotension including orthostatic hypotension; risk of seizures in patients with seizure disorders; risk of withdrawal if abruptly discontinued; not for use in patients with significant respiratory depression, acute or severe bronchial asthma, or known or suspected gastrointestinal obstruction including paralytic ileus. |
| Food/Dietary | Avoid grapefruit and grapefruit juice may increase tapentadol levels. Avoid alcohol as it increases CNS depression and risk of respiratory depression. No specific food restrictions beyond moderation. |
| Clinical Pearls | NUCYNTA ER (tapentadol) is a Schedule II controlled substance with mu-opioid agonist and norepinephrine reuptake inhibitor activity. Extended-release formulation is not interchangeable with immediate-release on a mg-per-mg basis. Do not crush, chew, or dissolve tablets. Use with caution in patients with severe renal or hepatic impairment; contraindicated in severe hepatic impairment. Monitor for respiratory depression, especially at initiation and dose escalation. Avoid use with MAOIs or within 14 days; serotonergic drugs increase risk of serotonin syndrome. |
| Patient Advice | Swallow tablets whole; do not crush, chew, or dissolve. · Avoid alcohol and other CNS depressants (e.g., benzodiazepines, sedatives). · May cause drowsiness or dizziness; avoid driving until response is known. · Do not stop abruptly; withdrawal symptoms may occur. Taper under medical supervision. · Store securely out of reach of children; dispose of unused medication via take-back programs. |
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