Reduce dosing when combined with benzodiazepines combination increases risk of respiratory compromise fentanyl iv 0. An equianalgesic chart is a conversion chart that lists equivalent doses of analgesics drugs used to relieve pain. Duragesic fentanyl transdermal dosing, indications. In an inpatient setting, rescue doses can be provided iv every 1530 minutes.
More aggressive dosing of tdfe is required in this patient population using a 100. If problems with adhesion of the fentanyl transdermal system patch occur, the edges of the patch may be taped with first aid tape. Fentanyl patches need to be disposed of carefully because a significant amount of fentanyl is left in the patch after three days. Fentanyl transdermal patches have recently been associated with a number of serious adverse events and deaths nationwide. 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. Quickwhat dose of duragesic patch fentanyl transdermal is equianalgesic to a 3 mghr morphine drip. Abstral fentanyl dose, indications, adverse effects.
Initiating schedule iii, 7day butrans in opioidexperienced patients starting the right patient at the right dose of butrans. At maximum concentration fentanyl td produces drug levels approximately equal to those attained by intravenous infusion at the same rate per hour. For patients with a current fentanyl transmucosal lozenge of 200 mcg or 400 mcg, initiate fentanyl sublingual spray subsysr at 100 mcg. Fentanyl transdermal system tds informational summary. Dosing considerations with transdermal formulations of fentanyl and buprenorphine for the treatment of cancer pain. Conversion ratios in many equianalgesic dosing tables do not apply to repeated doses of opioids. Oral rescue doses can be offered as needed over the normal dosing interval of the drug typically every 4 hours. Transdermal and parenteral fentanyl dosage calculations and conversions objectives after reading this chapter and completing all practice problems, the participant will be able to. Difficult to titrate during procedural sedation due to slower onset and longer duration of action. Fencino doses should be individualised based upon the status of the patient and should be assessed at regular intervals after application. Transdermal and parenteral fentanyl dosage calculations. The equianalgesic chart indicates that 20 mg of oral oxycodone is equal to 30 mg of oral morphine.
Opioid equianalgesic dose chart equianalgesic dose. Overestimating the dose when converting patients from another opiate can result in a fatal overdose with the first dose. Equianalgesic chart changes in italics ui health care. Actiq, fentora fentanyl transmucosal dosing, indications. Fentanyl transdermal system fentanyl transdermal system.
Fentanyl transdermal system fentanyl transdermal system for. Accuracy in equianalgesic dosing journal of pain and. In the case example above, 216 mg of oral morphine per day is approximately equianalgesic to the 100 mcghr fentanyl patch. Dosage titration of the new opioid should be completed slowly and with frequent monitoring. Quickwhat dose of the transdermal fentanyl patch duragesica is equianalgesic to a 3 mghr morphine continuous infusion. Converting to transdermal fentanyl palliative care network. Examples of determining the appropriate initial fentanyl patch size. Due to incomplete crosstolerance, it is recommended that the initial dose is 5075 % of the equianalgesic dose based on the ayonrinde method above. For these reasons fentanyl td should not be used for acute. Each butrans patch is intended to be worn for 7 days.
Transdermal and parenteral fentanyl dosage calculations and. Cyp 3a4 inhibitors amiodarone, azoles, antiretrovirals, erythromycin, clarithromycin, diltiazem, verapamil, maois, etc can lead. 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. Effects of patch last for 18 24 hours after the patch is removed. Converting to transdermal fentanyl palliative care network of. Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals.
In clinical trials, these ranges of daily oral morphine doses were used as a basis for conversion to duragesic. Conversions to and from duragesic are notoriously tricky, requiring knowledge of the published conversion data, general opioid pharmacology and a generous dose of common sense. As stated above, because equianalgesic tables are inherently inaccurate, the availability of breakthrough doses is paramount. Patients considered opioidtolerant are those taking, for one week or longer, at least 60 mg oral. Some experts use this conversion in cancer patients. The methadone conversion table indicates that a conversion factor for a domed. Product labeling for hydromorphone recommends a starting dose of 0. Dosing considerations with transdermal formulations of. Meperidine is nota recommended drug in a palliative care setting and is to be avoided. See fentanyl information below for initiating patch and patch to po dosing. Fentanyl patches durogesic for chronic pain nps medicinewise. Round up to and begin treatment with transdermal fentanyl using a patch size of 50 gh.
Jun 28, 2007 equianalgesic dosing tables are available in the package insert for assistance. Do not remove the fentanyl transdermal system patch from the blister until you are ready to use it see figure f. An alternative algorithm for dosing transdermal fentanyl for. Recommend an appropriate dose of transdermal fentanyl when. Equianalgesic dose conversion between benzomorphans e. Equianalgesic dosing of opioids for pain management. 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. This is especially important for fentanyl and methadone conversions. Equianalgesic dosing charts in etherapeutic guidelines or product information mims. Oral modifiedrelease opioid products for chronic pain management. 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.
Transdermal patch should be used only in opioid tolerant patients. Patients considered opioid tolerant are those who are taking 60 mg of oral morphineday, 25 mcg of transdermal fentanylhour, 30 mg of oxycodone daily, 8 mg of oral hydromorphone daily, or an equianalgesic dose of another opioid for a week or longer. Oral modifiedrelease opioid products for chronic pain. Fentanyl patch conversions package insert recommendations. Iv use even at low doses and when given very slowly may cause marked decrease in. Use the morphine to fentanyl equivalents chart to determine the equianalgesic dose of transdermal fentanyl. Fentanyl accumulates to form a depot in the skin below the. The transdermal patch is a longacting formulation with a delayed onset of effect initially and a prolonged duration of action. Evaluation and comparison of online equianalgesic opioid. 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.
Fentanyl patch converter globalrph conversion from other opioid patch conversion an alternative algorithm for dosing transdermal fentanyl an alternative algorithm for dosing transdermal fentanyl. Fentanyl cii sublimaze duragesic patch for opioid tolerant patients only transdermal o. Equipotent doses of transdermal fentanyl and transdermal buprenorphine in patients with cancer and noncancer pain. Fentanyl transdermal patch is a prescription medication thats used to treat chronic pain in opioidtolerant people.
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. For frail elderly patients, use more conservative conversion or a lower strength patch e. An equianalgesic dose of another opioid the time to maximum concentration is between 29 and 36 hours. Equianalgesic dose calculations are a means for selecting the. Describe the pharmacokinetics of transdermal fentanyl, and variables that can influence dosing.
Oxycodone is the preferred drug in this case as it is renally safer than morphine. Tables of this general type are also available for nsaids, benzodiazepines, depressants, stimulants, anticholinergics. Read the medication guide and, if available, the instructions for use provided by your pharmacist before you start using. Patients considered opioid tolerant are those who are taking 60 mg of oral morphineday, 25 mcg of transdermal fentanyl hour, 30 mg of oxycodone daily, 8 mg of oral hydromorphone daily, or an equianalgesic dose of another opioid for a week or longer. Fencino 12 microgramshour transdermal patch summary of. 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. Equianalgesic dosing tables are available in the package insert for assistance. Equianalgesic dose ratios are only approximations and do not account for genetic factors.
Dose titration during the initial patch application, patients should use shortacting analgesics as needed until efficacy with fentanyl is. Use of iv fentanyl is restricted to oncology, burn service, palliative care, intensive care units or based on recommendation by the pain service. Clinicians should use the fentanyl patch only if they are familiar with the prescribing information. 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. Dosage use only when converting another opioid to fentanyl patch. The next patch is applied to a different skin site after removal of the previous transdermal system. Fentanyl transdermal patch duragesic is a prescription medication used to treat severe chronic pain such as cancer. This is based on studies converting from morphine to fentanyl.
Not apply when switching from fentanyl patch to morphine use extreme caution. You wish to convert the therapy to transdermal fentanyl. Parenteral hydromorphone is 20 times as potent as oral morphine. Fold and tear at slit, or cut at slit taking care not to cut the patch. 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. Opiate equianalgesic dosing chart committee 1nn s of age. Side effects may include profuse sweating, coughing, nausea, diarrhea, and tearing. Highdose fentanyl patch for cancer pain american board. Use the dosing and conversion chart for opioid analgesics to calculate the equivalent total daily morphine dose. Advanced opioid conversion calculator morphine equivalents. Equianalgesic charts are used for calculation of an equivalent dose a dose which would offer an equal amount of analgesia between different analgesics. 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. Avoid nsaids in renal dysfunction, pud, chf, and if equianalgesic dose recommended starting dose for adults dose for children 6 mo. Withdrawal symptoms, drug interactions, dosage, and pregnancy and breastfeeding safety are provided.
Cyp 3a4 inhibitors amiodarone, azoles, antiretrovirals, erythromycin. Fentanyl transdermal system contains fentanyl, an opioid agonist, and 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. Discarded patches have the potential to be misused. Fentanyl patch use in nonopioid tolerant patients has resulted in fatal respiratory depression.
A withdrawal syndrome may also occur when switching to fentanyl, which responds to tapering doses of the previous opioid. Tdfe and tdbu formulations offer safe and effective therapeutic options in the treatment of cancer pain. 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. Schedule 8 schedule 11 medication management points to consider when prescribing and using the transdermal opioid patches transdermal fentanyl patch. The patches are designed to deliver approximately 12, 25, 50, 75, and 100 mcgh fentanyl to the systemic circulation, which represent about 0. Butrans is for transdermal use on intact skin only. Converting to transdermal fentanyl palliative care. 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. Round up or down based on patient factors and available patch sizes. Fentanyl transdermal patch dosing and safety information paper. Codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine. The hydromorphone is equianalgesic to a dose of 96 mgd of oral morphine. Each fentanyl transdermal system patch is sealed in its own protective blister.
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. Dosing butrans buprenorphine transdermal system ciii. Equianalgesic dosing its not just about the math mechele fillman, np pain. Clinicians refer to equianalgesic dosing charts to compare opioid regimens between oral and parenteral routes and. An alternative algorithm for dosing transdermal fentanyl. Currently, there are no empirical studies converting fentanyl to morphine.
Aug 19, 2014 every cancer patient requires individualized dosing of their tdo in order to reduce the risk of subtherapeutic dosing and withdrawal. Ongoing, preventable fatal events with fentanyl transdermal. Special care must be used when dosing this drug in buccal form. Each fentanyl transdermal system patch may be worn continuously for 72 hours.
The amount of residual drug in the patients system must be accounted for. Due to the risk of respiratory depression, the transdermal patch is for use in opioidtolerant patients only. 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. The patients current dose of 240 mg per day of oral oxycodone is equal to 360 mg per day of oral morphine. Convert the calculated 24 hour equianalgesic dose of oral morphine to the 24 hour equianalgesic dose of the new opioid.
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