Microsoft word - fentanyl patch version 8review date october 2010.doc
Guidelines on the use of Transdermal Fentanyl Patch Indications Fentanyl is a strong opioid which may be used in the management of cancer pain. Fentanyl patches may be suitable in patients who have:
Intolerable side effects with oral morphine e.g. intractable constipation and vomiting (despite appropriate antiemetics) and hallucinations (despite haloperidol).
Renal impairment as morphine may accumulate
Contra-indications
NOT suitable for patients who need rapid titration of their medication for severe uncontrolled pain.
NOT suitable for pain which has not responded to morphine.
Side effects Side effects are similar to morphine, although a fentanyl patch is generally less constipating and causes less nausea and vomiting.
Haloperidol 1.5mg at night orally should control fentanyl induced nausea.
Patients should be warned that fentanyl may cause daytime drowsiness.
About 10% of patients experience opioid withdrawal when changing from morphine to fentanyl. Symptoms are “flu” like (e.g. lethargy, nausea, sweating, diarrhoea and shivering) and can be controlled with rescue doses of morphine.
Dose of Fentanyl Patches
FIVE strengths available – 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr & 100mcg/hr.
The patches are usually changed every 72 hours, although occasionally very thin patients may need their patch replacing every 48 hours to obtain adequate control.
The strength of patch should not usually be increased more often than every 3 days, and usually in increments of 6 , 12 or 25 micrograms dependent on the current patch strength & the patient’s medical condition. Be cautious in renal impairment.
If a patient gets confused or experiences hallucinations with a fentanyl patch the dose may need decreasing. If by reducing the dose the patient is alert but not pain controlled an alternative opioid may need to be considered. Contact the Palliative Care Team for advice.
Starting fentanyl patches Steady state plasma concentrations of fentanyl are achieved only after 36-48 hours. In the first 3 days of treatment, and particularly the first 24 hours, the patient may need regular doses of a fast acting opiate (e.g. Oramorph or Oxynorm) for breakthrough pain. Rescue doses of morphine should be equivalent to the dose of 4 hourly morphine for the strength of patch being used. Note: In patients with renal impairment fentanyl appears to be better tolerated than morphine but still may accumulate & cause side effects so dose cautiously. Table 1 Patients on weak opioids
Start on fentanyl 6 to 12mcg /hr every 72 hours
**for a dose of 6mcg use half a 12mcg patch**
Use table 2 overleaf to calculate the dose of fentanyl [Alternatively divide the 24 hour oral morphine dose (in mg) by 3.0 or 3.6 to determine fentanyl dose (in mcg/hr). Divide by 3.0 for morphine doses less than 250mg and by 3.6 for morphine doses 250mg or more)]
If converting from 4 hourly morphine (ie Oramorph) continue to give regular doses for 12 hours after applying the first patch.
If converting from 12 hourly morphine (i.e. Zomorph or MST) apply the first fentanyl patch at the same time as giving last dose of morphine.
Use table 2 overleaf to calculate the dose of fentanyl [Alternatively convert s/c dose to oral morphine 30mg s/c morphine = 20mg s/c diamorphine = 60mg oral morphine Then convert oral morphine to fentanyl by dividing by 3.0 or 3.6 as above]
Maintain the syringe driver for about 12 hours after applying the first patch.
Owner: Selby & York Palliative Care Team & Pharmacy Group Date of Issue : 2002 (version 8 8/2008) Review Date: 10/2010 Approved by : Drug & Therapeutics Committee Fentanyl patch(M)professional 1
Total oral Total s/c Total s/c Fentanyl Break through morphine diamorphine morphine Immediate (mg every (mg /24 hr) (mg /24 hr) every 72 hr Immediate diamorphine morphine release oral (micrograms/ release oral Oxycodone morphine (mg every (mg every (Oxynorm) (Oramorph) (mg every 4hr) (mg every 4 hr)
Note a) If converting from fentanyl patch to alfentanil s/c , s/c alfentanil dose is 1/10th of s/c diamorphine dose) (i.e diamorphine 30mg s/c = alfentanil 3mg s/c) b) If converting to Oxycodone injection (OxyNorm) the dose is half the s/c morphine dose Discontinuing Fentanyl patches, changing to oral morphine or changing to a syringe driver If a patch is removed and not replaced significant blood levels may persist for 24 hours or longer (it takes about 17 hours for the concentration of fentanyl in the plasma to half). Changing to oral morphine As a general guide, remove the patch and 12 hours later give the first dose of modified release oral morphine (Zomorph, MST). Ensure that immediate release oral morphine is prescribed for rescue doses. Monitor the patient closely for signs of opioid excess (e.g increased sedation). Changing to sc morphine/diamorphine infusion (Patients with GFR < 30mL/min may need alfentanil instead. Seek advice) As a general guide, in the terminal phase leave the patch in situ and top up with subcutaneous morphine/diamorphine in a syringe driver. Initially use 1/5th to 1/6th of the patch (micrograms/hr) dose as morphine/diamorphine (mg) s/c over 24 hours and titrate up as necessary. Remember that the breakthrough” when required” dose should be calculated by taking account of both the morphine/diamorphine in the syringe driver and the fentanyl patch. e.g Patient on fentanyl patch 50mcg – Leave patch on & add morphine s/c over 24hrs in syringe driver From table 50mcg patch equiv to 75mg morphine over 24hr (range 70-90mg) Dose morphine in s.driver 4 hrly prn dose of morphine
15mg (i.e 1/6th of 85mg i.e 75mg equivalent as patch & 10mg prn in syringe driver)
Practical points and advice for patients – Applying patches and destroying patches
Apply to clean, dry, non-inflamed, non-irradiated, hairless skin on the upper arm or trunk. Body hair may be clipped, but do not shave. Some patients may need a semi permeable dressing (e.g. Tegaderm) to ensure adherence.
Patients can bathe or shower (with care) whilst wearing fentanyl patches, but the water should not be too hot. A new patch should not be applied immediately after a bath or shower, or immediately after using creams, talc or soap on the skin.
Always remove the old patch before applying a new one and rotate the site of application.
Fentanyl patches are “matrix patches” which experience has shown can be cut in half (although this is unlicensed). For accuracy cut the patches diagonally.
Heat (e.g. hot baths, electric blankets, hot water bottle) should NEVER be applied over the top of the patch as it may enhance the absorption of fentanyl. Pyrexia may also increase absorption.
After removal fold patches in half so that the adhesive side sticks together and discard in a sharps container (in hospital) or safely in the waste bin (patients at home).
For further information contact Palliative Care Team (ext 5835) or Pharmacy Medicines Info. (ext 5960).
Owner: Selby & York Palliative Care Team & Pharmacy Group Date of Issue : 2002 (version 8 8/2008) Review Date: 10/2010 Approved by : Drug & Therapeutics Committee Fentanyl patch(M)professional 2
• Need to have designated staff for duties– mental health ‘Champion’, clinical and• There are certain steps to consider…– Handling the screens (copying, handing out)– Scoring the screens– Communicating to the physician– Orchestrating disposition, talking to family– Following up on compliance– Proper reimbursement• Discussion of treatment options• Evaluate for potent
Bartter’s, Gitelman’s, and Liddle’s Key Points: 1. These syndromes are rare, so it’s important to rule out more common causes (ie diuretics, prescribed or 2. Consider these syndromes when pt has hypokalemic metabolic alkalosis and is chloride re sistant (high urinary 3. Bartter’s is like “lasix”, Gitelman’s is like “thiazide”, and Liddle’s is like “hyper-aldo”. 4.
Guidelines on the use of Transdermal Fentanyl Patch