Discarded patches have the potential to be misused. Phoenixa twostep approach to converting patients from intravenous fentanyl to transdermal patches can prevent occurrence of breakthrough pain episodes. Twostep titration weans patients from iv to patch fentanyl. The half life of the two drugs needs to be considered when converting so that the patient does not experience breakthrough pain or receive too much opiate during the conversion period. Methadone, fentanyl lozenges and neuraxial opioids are not included in this table due to their complex and variable pharmacokinetics. The cii rate was decreased by 50% 6 hours after application of the fentanyl. A 25 microgramhour fentanyl patch is equivalent to about 60mg to 90mg of oral morphine in 24 hours. Transdermal fentanyl patches were designed to provide. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediaterelease opioids and should prescribe no greater quantity than needed for the expected duration. Converting to transdermal fentanyl palliative care.
If 2 extra doses of 15 mg sc morphine are required over the previous 24 hours, the initial syringe driver prescription will. While this makes the conversion relatively easy, patches tend to be left on longer than needed. Converting to transdermal fentanyl palliative care network of. Select opioid morphine po morphine sc morphine iv oxycodone po oxycodone sc iv hydromorphone po hydromorphone sc iv buprenorphine sl buprenorphine td buprenorphine sc iv fentanyl td fentanyl sc iv alfentanyl sc iv sufentanyl sc iv codeine po tramadol po tapentadol po. Conversions to and from fentanyl transdermal are notoriously tricky, requiring knowledge of the published conversion data, general opioid pharmacology, and a generous dose of common sense. Frail or elderly patients may need lower doses and slower titration. After six hours, the dose of intravenous fentanyl was decreased 50 percent, and after 12 hours the iv drug was discontinued. Quickwhat dose of duragesic patch fentanyl transdermal is equianalgesic to a 3 mghr morphine drip. Use the dosing and conversion chart for opioid analgesics to calculate the equivalent total daily morphine dose. Equivalent doses are based on the 24 hour dose of fentanyl or buprenorphine received from a patch. If at any time the patient develops symptoms of withdrawal, return to the previous rate and consider giving an iv bolus of fentanyl. What are the steps for converting from morphine or. Advice should be sought from the palliative care team.
A safe and effective method for converting patients from transdermal. Equianalgesic chart changes in italics ui health care. Efficacy and safety of a sixhour continuous overlap. Changing an oral or iv opioid to transdermal fentanyl 1. Fentanyl patches are another option, but are expensive and difficult to titrate. Conversion from morphine or equivalent to fentanyl transdermal. Canadian guideline for safe and effective use of opioids. The patches are designed to be worn for three days before being replaced. Dilaudid hydrolmorphone and fentanyl are narcotic opioid drugs used to manage of severe chronic pain, for example cancerrelated pain. Caution should be used in older adults or patients with cachexiafentanyl is lipid soluble and requires subcutaneous fat for proper absorption. Dosage use only when converting another opioid to fentanyl patch. In all patients, a transdermal patch delivering fentanyl at a rate equivalent to that of the final continuous iv infusion was applied. The fentanyl patch comes in multiples of 25 micrograms.
Fentanyl patches need to be disposed of carefully because a significant amount of fentanyl is left in the patch after three days. Use appropriate opioid for situation or care setting. Patient on 50 microgramshour fentanyl patch, unable to take prn oral opioid and in last days of life. In renal impairment gfr fentanyl and buprenorphine patches. Initial dose based on previous 24hour opioid requirement consult product literature, for evaluating analgesic efficacy and dose increments, see under chronic intractable pain not currently treated with a strong opioid analgesic, for conversion from long term oral morphine to transdermal fentanyl, see pain management with opioids under. In acute pain the conversion of morphine to fentanyl is 1. In the case example above, 216 mg of oral morphine per day is approximately equianalgesic to the 100 mcghr fentanyl patch. Opioid equianalgesic dose chart equianalgesic dose drug iv imsq poslpr onset of action t12 h duration comments mg mg morphine avinza, embeda, kadian, ms. Do not begin a patient on a fentanyl transdermal patch as their first opioida small number of patients may require a 48hour dosing interval. A withdrawal syndrome may also occur when switching to fentanyl, which responds to tapering doses of the previous opioid. Conversion of intrathecal opioids to fentanyl in chronic. Converting from oral morphine to fentanyl transdermal patch. Use of iv fentanyl is restricted to oncology, burn service, palliative care, intensive care. Enter 24hour total doses below, then click the convert button to display 24hour equianalgesic doses.
Effects of patch last for 18 24 hours after the patch is removed. Patches conversion doses drug name drug dose equivalent oral morphine dose fentanyl 25 patch 25microgramshour 30mg to 4mg24hours fentanyl 50 patch 50 microgramshour 5mg to 224mg24hours fentanyl 75 patch 75 microgramshour 225mg to 314mg24hours fentanyl 100 patch 100 microgramshour 315mg to 404mg24hours transtec 52. John smith, a terminally ill lung cancer patient has pain that is well controlled on morphine sustained action, 90mg every 12 hours. Patients at the authors institution routinely are switched from transdermal to intravenous iv fentanyl using a 1. Convert 180 mg morphine equivalent to fentanyl using table 1 50 mcghr. When converting between certain opioids, the direction of conversion eg, morphine to hydromorphone versus hydromorphone to morphine will produce a different conversion ratio. 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. The fentanyl infusion dose wasdecreased inhalfsix hours after patch application, then completely stopped after 12 hours. Transdermal fentanyl patches should not be initiated in patients with unstable pain. In other words, the conversion factor not accounting for days of use would be 6025 or 2. Longterm opioid use often begins with treatment of acute pain.
One option that i dont like to use is switching patients over to a fentanyl patch. Eight patients initially reported their pain at rest as. For frail elderly patients, use more conservative conversion or a lower strength patch e. 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. Monitor the patient carefully for respiratory depression. Duragesic label page 1 full prescribing information for.
The following doses and conversion factors are a guideline only and each patient must be assessed on an individual basis. Equianalgesic conversion for morphine morphine equivalence table for chronic dosing drug sc iv 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. The conversions given are comparable doses but there is wide patient intervariability relating to opioid conversion. A safe and effective method for converting cancer patients from. Both drugs work the same way in the body to relieve pain. Use the morphine to fentanyl equivalents chart to determine the equianalgesic dose of 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. Converting from fentanyl given by iv infusion or via a pca device. Transdermal fentanyl and buprenorphine patches are prescribed in.
The authors prospectively evaluated 15 consecutive cancer patients during the conversion from iv to transdermal fentanyl. If pain is stable the patient may be considered for conversion to a fentanyl patch. Opioid equianalgesic calculator opioid switching from. In each patient, all transdermal patches were removed, and a continuous infusion ci delivering iv fentanyl. Transdermal and parenteral fentanyl dosage calculations. Calculate the total 24hour morphine dose or morphineequivalent. However, since the fentanyl patch remains in place for 3 days, we have multiplied the conversion factor by 3 2. This should not be confused with the total amount of fentanyl in the patch.
Nomura et al used the same method, but shortened the conversion period to six hours, and the dose was cut in half three hours after patch placement. Transdermal patch should be used only in opioid tolerant patients. Opioid oral morphine milligram equivalent mme conversion. A safe and effective method for converting cancer patients. It fentanyl and conversion from it morphinehydromorphone to it fentanyl have been challenging given the lipophilic nature of fentanyl. Fentanyl patch conversion 25mcghour topically exchanged every 72 hours equivalent to. Opioid conversion table hop16091451 croni ain anaeen tooli calculating total daily doses of opioids is important to appropriately and effectively prescribe, manage, and taper opioid.
Scottish palliative care guidelines fentanyl patches. Injecting fentanyl minimising the risks the patch strength on the label indicates the dosage that the fentanyl patch releases each hour when worn. There are many opioids and many formulations available e. Each 2 mg po morphine approximately equivalent to 1 mcghr fentanyl patch e.
So round up the calculated 5 micrograms dosage of fentanyl to 125 micrograms or a 150 microgram patch depending on whether patients pain is under good control or not. Conversion to methadone is appropriate for opioid use greater than several months, assuming opioids are effective for the patient. Smith is now unable to swallow and so the morphine needs to be converted into a transdermal fentanyl patch. There are differences in the literature regarding opioid conversion ratios. Note this dose should not be decreased further as it is already conservative. Both dilaudid and fentanyl can be habit forming even at prescribed doses. A safe and effective method for converting cancer patients ncbi nih.
Select microgram per hour dose of transdermal fentanyl. Therefore the rough fentanyl equivalent for 270 mg of morphine 5 micrograms of fentanyl hour. These bidirectional differences are not captured in a traditional equianalgesic table. Opioid conversion and brand availability in canada. For delivery rates in excess of 100 mcghour, multiple systems may be used. Residual effects from discontinued longacting formulations should also be assessed before converting a patient to a new opioid. Buprenorphine suboxone is an option if opioid abuse, misuse or extreme opioid tolerance is a. Canadian guideline for safe and effective use of opioids for chronic noncancer pain site map toc back appendix b8. Quickwhat dose of the transdermal fentanyl patch duragesica is equianalgesic to a 3 mghr morphine continuous infusion.
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