Use the morphine to fentanyl equivalents chart to determine the equianalgesic dose of transdermal fentanyl. Equianalgesic doses need to be calculated when switching from one drug to another. Unlike other as needed medications, fentanyl transdermal patch has a strict dosing. Oct 15, 2019 patients considered opioidtolerant are those taking, for one week or longer, at least 60 mg oral morphine per day, 25 mcg transdermal fentanyl per hour, 30 mg oral oxycodone per day, 8 mg oral hydromorphone per day, 25 mg oral oxymorphone per day, 60 mg oral hydrocodone per day, or an equianalgesic dose of another opioid. Due to the risk of respiratory depression, the transdermal patch is for use in opioidtolerant patients only. Aug 12, 2019 durogesic dtrans doses should be individualised based upon the status of the patient and should be assessed at regular intervals after application. Overestimating the dose when converting patients from another opiate can result in a fatal overdose with the first dose. Dosing considerations with transdermal formulations of. Cyp 3a4 inhibitors amiodarone, azoles, antiretrovirals, erythromycin, clarithromycin, diltiazem, verapamil, maois, etc can lead.
Oxycodone is the preferred drug in this case as it is renally safer than morphine. Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals. Clinicians refer to equianalgesic dosing charts to compare opioid regimens between oral and parenteral routes and. Fentanyl transdermal system is indicated for the management of pain in opioidtolerant patients, severe enough to require daily, aroundtheclock, longterm opioid treatment and for which alternative treatment options are inadequate patients considered opioidtolerant are those who are taking, for one week or longer, at least 60 mg of morphine. Do not increase the duragesic dose for the first time until at least 3 days after the initial application. Fentanyl patches need to be disposed of carefully because a significant amount of fentanyl is left in the patch after three days. Highdose fentanyl patch for cancer pain american board of.
Jan 06, 2017 examples of accidental exposure include transfer of a fentanyl transdermal system from an adults body to a child while hugging, sharing the same bed as the patient, accidental sitting on a patch and possible accidental exposure of a caregivers skin to the medication in the patch while applying or removing the patch. The amount of residual drug in the patients system must be accounted for. See fentanyl information below for initiating patch and patch to po dosing. Oral rescue doses can be offered as needed over the normal dosing interval of the drug typically every 4 hours. Most of the above oral opioids are available as generics.
Fentanyl patch use in nonopioid tolerant patients has resulted in fatal respiratory depression. Transdermal and parenteral fentanyl dosage calculations. Dosage use only when converting another opioid to fentanyl patch. Meperidine is nota recommended drug in a palliative care setting and is to be avoided. Currently, there are no empirical studies converting fentanyl to morphine. Tables of this general type are also available for nsaids, benzodiazepines, depressants, stimulants, anticholinergics. Appendix a equianalgesic conversion for morphine and fentanyl transdermal patch appendix b medications used in palliative care for pain management for additional guidance on pain management, see also the bc interprofessional palliative symptom management. The phenomena of incomplete cross tolerance appears to play a larger role, especially in patients with increasing intensity of pain and with those on relatively higher doses of analgesic. You wish to convert the therapy to transdermal fentanyl. Use of iv fentanyl is restricted to oncology, burn service, palliative care, intensive care units or based on recommendation by the pain service. The patches are designed to deliver approximately 12, 25, 50, 75, and 100 mcgh fentanyl to the systemic circulation, which represent about 0.
Ability to edit equianalgesic conversion factors if necessary in order to reflect any changes in the literature. Fentanyl transdermal system fentanyl transdermal system for. The fentanyl patch is indicated for the management of pain in opioidtolerant patients, severe enough to require daily, aroundtheclock, longterm opioid treatment and for which alternative treatment options are inadequate patients considered opioidtolerant are those who are taking, for one week or longer, at least 60 mg of morphine daily, or at least 30 mg of oral oxycodone. Equianalgesic dosing tables are available in the package insert for assistance. For these reasons fentanyl td should not be used for acute. Fentanyl patch conversions package insert recommendations fentanyl patch dosing determination based on current11 jun 2017 using the table below, the equivalent dose of fentanyl patch would be 25 mcg. Round up or down based on patient factors and available patch sizes. Nov 20, 2019 patients considered opioidtolerant are those taking, for one week or longer, at least 60 mg oral morphine per day, 25 mcg transdermal fentanyl per hour, 30 mg oral oxycodone per day, 8 mg oral hydromorphone per day, 25 mg oral oxymorphone per day, 60 mg oral hydrocodone per day, or an equianalgesic dose of another opioid. Fentanyl cii sublimaze duragesic patch for opioid tolerant patients only transdermal o. Titrate the dose based on the daily dose of supplemental opioid analgesics required by the patient on the second or third day of the initial application.
Opioid equianalgesic dose chart equianalgesic dose. Initiating schedule iii, 7day butrans in opioidexperienced patients starting the right patient at the right dose of butrans. Do not initiate treatment with duragesic in opioid nontolerant patients see contraindications 4 the recommended starting dose when converting from other opioids to duragesic is intended to minimize the potential for overdosing patients with the first dose. Tdfe and tdbu formulations offer safe and effective therapeutic options in the treatment of cancer pain.
Discarded patches have the potential to be misused. Converting to transdermal fentanyl palliative care. Patients considered opioidtolerant are those taking, for one week or longer, at least 60 mg oral morphine per day, 25 mcg transdermal fentanyl per hour, 30 mg oral oxycodone per day, 8 mg oral hydromorphone per day, 25 mg oral oxymorphone per day, 60 mg oral hydrocodone per day, or an equianalgesic dose of another opioid. Converting to transdermal fentanyl palliative care network. Fentanyl patch converter globalrph conversion from other opioid patch conversion an alternative algorithm for dosing transdermal fentanyl an alternative algorithm for dosing transdermal fentanyl. Abstral fentanyl dose, indications, adverse effects. Fentanyl patch conversions package insert recommendations. There are many opioids and many formulations available e. Equianalgesic charts are used for calculation of an equivalent dose a dose which would offer an equal amount of analgesia between different analgesics. Examples of determining the appropriate initial fentanyl patch size.
In clinical trials, these ranges of daily oral morphine doses were used as a basis for conversion to duragesic. Equianalgesic dosing of opioids for pain management. Schedule 8 schedule 11 medication management points to consider when prescribing and using the transdermal opioid patches transdermal fentanyl patch. Principles of opioid management fraser health authority. Transdermal and parenteral fentanyl dosage calculations and conversions objectives after reading this chapter and completing all practice problems, the participant will be able to. Pharmacological profiles and opioid conversion tables who fentanyl patch converter globalrph conversion from other opioid patch conversion an alternative algorithm for dosing transdermal fentanyl an alternative algorithm for dosing transdermal fentanyl.
Administering this dose orally would require a large amount of tablets to be taken daily, which makes opioid rotation uncomfortable. An equianalgesic chart is a conversion chart that lists equivalent doses of analgesics drugs used to relieve pain. For frail elderly patients, use more conservative conversion or a lower strength patch e. A 33% dose reduction from the calculated dose of 100 mg is equal to 67 mg of oral morphine per day. Some experts use this conversion in cancer patients. Opiate equianalgesic dosing chart committee 1nn s of age. Durogesic dtrans 12 mcghr transdermal patch summary of. Convert the calculated 24 hour equianalgesic dose of oral morphine to the 24 hour equianalgesic dose of the new opioid. Fentanyl transdermal patch duragesic is a prescription medication used to treat severe chronic pain such as cancer. Butrans is for transdermal use on intact skin only.
Transdermal and parenteral fentanyl dosage calculations and. Durogesic dtrans doses should be individualised based upon the status of the patient and should be assessed at regular intervals after application. Fentanyl transdermal patch is a prescription medication thats used to treat chronic pain in opioidtolerant people. Multiincident analysis a multiincident analysis on. Iv use even at low doses and when given very slowly may cause marked decrease in. The table is based on oral dosing for chronic noncancer pain. The hydromorphone is equianalgesic to a dose of 96 mgd of oral morphine. Quickwhat dose of the transdermal fentanyl patch duragesica is equianalgesic to a 3 mghr morphine continuous infusion. Use the dosing and conversion chart for opioid analgesics to calculate the equivalent total daily morphine dose. In the case example above, 216 mg of oral morphine per day is approximately equianalgesic to the 100 mcghr fentanyl patch. Recommend an appropriate dose of transdermal fentanyl when. Equianalgesic chart changes in italics ui health care.
Transdermal patch should be used only in opioid tolerant patients. Jun 28, 2007 equianalgesic dosing tables are available in the package insert for assistance. Not apply when switching from fentanyl patch to morphine use extreme caution. Appropriate transdermal system dosage adjustments should be based on the daily dose of supplementary opioids, using the ratio of 45 mgday of oral morphine to a 12. Some contain small numbers of patients, involve single doses and use patients with limited opioid exposure. During the last decade, fentanyl patch transdermal therapeutic system tts has been introduced to the arsenal of opioids for cancer pain control. Dosing considerations with transdermal formulations of fentanyl and buprenorphine for the treatment of cancer pain.
Dosing for fentanyl patches the initial dose of fentanyl should be the lowest possible dose based on the patients opioid history and current medical status. Effects of patch last for 18 24 hours after the patch is removed. Conversion ratios in many equianalgesic dosing tables do not apply to repeated doses of opioids. Chart a1 fentanyl transdermal patch equianalgesic conversion. Equianalgesic conversion for morphine morphine equivalence table for chronic dosing drug sciv mg po mg comments morphine 10 30a codeine 120 sc only 200 metabolized to morphine fentanyl patch see table below useful when po pr routes not an option fentanyl 0. Evaluation and comparison of online equianalgesic opioid.
Describe the pharmacokinetics of transdermal fentanyl, and variables that can influence dosing. Doses in each column are considered equianalgesic and interchangeable at the. If a patient with chronic pain is on meperidine, convert patient to an equianalgesic dose of one of the other opioids listed in this table. Rapid bolus infusion may lead to chest wall rigidity. Aug 19, 2014 every cancer patient requires individualized dosing of their tdo in order to reduce the risk of subtherapeutic dosing and withdrawal. More aggressive dosing of tdfe is required in this patient population using a 100. Withdrawal symptoms, drug interactions, dosage, and pregnancy and breastfeeding safety are provided. Round up to and begin treatment with transdermal fentanyl using a patch size of 50 gh. An alternative algorithm for dosing transdermal fentanyl for.
Oral modifiedrelease opioid products for chronic pain. Opioidtolerant patients are those who have been taking daily, for a week or longer, at least 60 mg of oral morphine, 30 mg of oral oxycodone, or at least 8 mg of oral hydromorphone or an equianalgesic dose of another opioid. Side effects may include profuse sweating, coughing, nausea, diarrhea, and tearing. Highdose fentanyl patch for cancer pain american board. Equianalgesic dose calculations are a means for selecting the. Patients who are opioid tolerant are those receiving, for 1 week or longer, at least 60 mgday morphine, 25 mcgday transdermal fentanyl, 30 mgday po oxycodone, 8 mgday po hydromorphone, 25 mgday po oxymorphone, 60 mgday po hydrocodone, or an equianalgesic dose of another opioid. Accuracy in equianalgesic dosing journal of pain and. Ongoing, preventable fatal events with fentanyl transdermal. A withdrawal syndrome may also occur when switching to fentanyl, which responds to tapering doses of the previous opioid. Fentanyl transdermal system fentanyl transdermal system. An equianalgesic dose of another opioid the time to maximum concentration is between 29 and 36 hours. At maximum concentration fentanyl td produces drug levels approximately equal to those attained by intravenous infusion at the same rate per hour. Equianalgesic dosing its not just about the math mechele fillman, np pain. Option for converting final out put into an equivalent fentanyl patch strength as long as published guidelines exist for the current dose.
The recommended dosing frequency of longacting morphine ms contin is every 12 hours 2 doses per day. Reduce dosing when combined with benzodiazepines combination increases risk of respiratory compromise fentanyl iv 0. Dosing in renal and hepatic dysfunction fentanyl appears safe for renal dysfunction and in dialysis with dose adjustments as necessary dosing not generally affected in liver failure methadone appears safe for renal dysfunction and in dialysis not advised in severe liver failure codeine, meperidine, propoxyphene are not advised for. Fentanyl patch is a controlled delivery system designed to release a steady amount of medication at a constant rate of mcghour. Changing to a topical dosage form, such as a fentanyl patch, generally requires the use of an immediaterelease dosage form for the first 6 to 12 hours after patch administration, because it. There are few studies that involve patients who have been prescribed strong opioids for more than 3 months. As stated above, because equianalgesic tables are inherently inaccurate, the availability of breakthrough doses is paramount.
Advanced opioid conversion calculator morphine equivalents. Converting to transdermal fentanyl palliative care network of. Published equianalgesic ratios are considered crude estimates at best and therefore it is imperative that careful consideration is given to individualizing the dose of the selected opioid. Canadian guideline for safe and effective use of opioids. The limiting factor for fentanyl patches in high doses is the body surface area. Dose titration during the initial patch application, patients should use shortacting analgesics as needed until efficacy with fentanyl is.
Dosing butrans buprenorphine transdermal system ciii. Duragesic fentanyl transdermal dosing, indications. Cyp 3a4 inhibitors amiodarone, azoles, antiretrovirals, erythromycin. In an inpatient setting, rescue doses can be provided iv every 1530 minutes. Dosage titration of the new opioid should be completed slowly and with frequent monitoring.
Equipotent doses of transdermal fentanyl and transdermal buprenorphine in patients with cancer and noncancer pain. Dose equivalence and switching between opioids specialist. Equianalgesic doses of opioids their use in clinical. Equianalgesic dose conversion between benzomorphans e.