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GUIDELINES FOR THE USE OF TRANSDERMAL FENTANYL

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					              GUIDELINES FOR THE USE OF TRANSDERMAL FENTANYL

   In the majority of patients with opioid sensitive pain, the drug of choice will be morphine
    sulphate, titrated according to response and then converted to a modified release
    preparation.

   Transdermal fentanyl is for use in patients with stable pain. It should not be used for titration
    against rapidly escalating pain.

   Fentanyl is a second line opioid whose use should be limited to the following situations:
     Patients who have been taking at least 60 mg of morphine daily for at least a week and in
       whom one or more of the following apply:
        Patients with renal impairment.
        Patients with extreme dysphagia or an inability to swallow.
        Patients who are intolerant of morphine sulphate.
        Where there are concerns regarding gastrointestinal absorption of opioid drugs.

   Never use transdermal fentanyl patches in opioid naïve patients, as this may lead to dangerous
    respiratory depression.

   Fentanyl should not be used as an alternative to discussing the use of opioids with patients, or in
    those patients who claim to be morphine phobic.

   When considering the use of transdermal fentanyl it may be appropriate to discuss the patient’s
    requirements with the Palliative Care Team.

Starting a patch

   The starting dose of transdermal fentanyl is calculated on the basis of the oral morphine
    sulphate equivalent dose as listed in the conversion chart below.

   Continue to administer oral morphine sulphate for 12 hours after applying the first patch, ie:
     Immediate release morphine sulphate 4 hourly for 12 hours, or
     the final dose of modified release morphine sulphate, taken at the same time as applying the
       first patch.
     For breakthrough pain, prescribe immediate release morphine sulphate equivalent to the 4
       hourly dose. This may be required for the first 24-48 hours of transdermal fentanyl use.

4 hourly morphine sulphate           Equivalent 12 hourly dose of           Transdermal Fentanyl
                                       morphine sulphate ie bd                dose per 72 hours
          10 mg                             30 mg )                             25 mcg/hr
          15 mg                             45 mg )
          20 mg                             60 mg )                             50 mcg/hr
          30 mg                             90 mg )
          40 mg                            120 mg )                             75 mcg/hr
          50 mg                            150 mg )
          60 mg                            180 mg                              100 mcg/hr
          70 mg                            210 mg )                            125 mcg/hr
          80 mg                            240 mg )
          90 mg                            270 mg )                            150 mcg/hr
         100 mg                            300 mg )
Dose titration

   It will take up to 72 hours for a steady state of fentanyl to be achieved. Titration, in 12-25 mcg
    per hour steps, if required, should take place no more frequently than every 72 hours.
   For full prescribing information please refer to the Summary of Product Characteristics for
    transdermal fentanyl or the BNF.
   The usual breakthrough analgesia for patients on transdermal fentanyl will be oral immediate
    release morphine sulphate.
   The use of oral transmucosal fentanyl citrate lozenges (Actiq®) should be discussed with the
    Palliative Care Team.

Matrix or reservoir preparation

There are currently 2 different formulations, a reservoir gel and a drug matrix. Only the matrix
formulation has the 12 mcg per hour titration/initiation patch.

The Royal Pharmaceutical Society advises that all non-parenteral opioids are prescribed by
proprietary name.

If a change in formulation is made, the patient should be monitored closely for signs of opioid
toxicity or conversely, of poor pain control.

Conversion from oral opioids to transdermal fentanyl

Once a patient’s opioid requirements (using immediate release or modified release morphine
sulphate) have been steady for 3-5 days, conversion to fentanyl can be carried out using the above
guidelines.

Conversion from other opioids to transdermal fentanyl
Always contact the Palliative Care Team, hospice, or pharmacy for advice.

It must be remembered that the conversion chart offers guidance when commencing
transdermal fentanyl. Different principles will apply when converting from transdermal
fentanyl to other opioids and this conversion chart cannot be used.

Discontinuation of transdermal fentanyl

   Discontinuation of transdermal fentanyl is not straightforward, primarily because of the
    intradermal reservoir of drug which remains following removal of the patch.
   Caution must be exercised, since the addition of alternative opioids may result in significant
    respiratory depression.
   For advice on discontinuing fentanyl and using another opioid, always contact the Palliative
    Care Team, or hospice out-of-hours.

Use of transdermal fentanyl in the terminal phase

It is recommended that for the control of pain in the terminal phase, that transdermal fentanyl be
continued. If necessary, a syringe driver with additional opioid analgesia can be used. Because of
significant renal impairment in the terminal phase, the use of charts to convert transdermal fentanyl
to subcutaneous morphine or diamorphine can result in potentially fatal overdose.

For advice on concomitant syringe driver and transdermal fentanyl medication at the end-of-
life, always contact the Palliative Care Team or hospice including out-of-hours.
Palliative Care Team, CRH Ext: 2700               Palliative Care Team, HRI Ext: 2965
Overgate Hospice 01422 379151                     Kirkwood Hospice 01484 557900
                                                                                     Review November 2008

				
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