- Fentanyl is a strong opioid, available in a patch applied to the skin, for transdermal administration over 72 hours for chronic cancer pain.
- Both matrix and reservoir patch formulations are available.
- Patches should be prescribed by their brand name or specify ‘matrix’ or ‘reservoir’ to avoid confusion.
Contraindications:
Sensitivity to fentanyl or silicone medical adhesive.
Initial dose
Is a common problem (for around 30%) during the first few days of treatment. If it occurs, haloperidol or metoclopramide are suitable anti-emetics. (See Nausea and Vomiting).
Generally, the transdermal route is not recommended in opioid-naïve patients. Alternative routes of administration (oral, parenteral) should be considered. To prevent overdose it is recommended that opioid-naïve patients receive low doses of immediate-release opioids (eg, morphine, hydromorphone, oxycodone, tramadol, and codeine) that are to be titrated until an analgesic dosage equivalent to transdermal fentanyl with a release rate of 12 micrograms/hour or 25 micrograms/hour is attained. Patients can then switch to Transdermal Fentanyl patches.
In the circumstance in which commencing with oral opioids is not considered possible and transdermal fentanyl is considered to be the only appropriate treatment option for opioid-naïve patients, only the lowest starting dose (ie, 12 micrograms/hour) should be considered. In such circumstances, the patient must be closely monitored. The potential for serious or life-threatening hypoventilation exists even if the lowest dose of transdermal fentanyl is used in initiating therapy in opioid-naïve patients.
In patients currently taking opioid analgesics, the starting dose of transdermal fentanyl should be based on the daily dose of the prior opioid. To calculate the appropriate starting dose of transdermal fentanyl, convert from the oral opioid dose using the table.
Patch Application
- Patch should be applied to dry non-hairy non-irritated, non-irradiated skin on torso or upper arm. Replacement patch should be sited on a different area. Avoid previous area for several days.
- After application of the first patch, plasma levels rise for 24 hours, analgesic levels are reached by 6-12 hours and a steady state is reached by the time of application of the second patch.
- The patch should be replaced every 72 hours.
- When converting doses greater than 100 micrograms per hour fentanyl seek specialist palliative care advice.
Starting fentanyl patches, converting from oral morphine
An immediate release opioid preparation should always be available P.R.N. for breakthrough pain.
No further modified release morphine
Switching to an alternative opioid from transdermal fentanyl
Before removing an opioid patch and changing to an alternative opioid consider carefully the reasons for doing this.
Carrying out this conversion correctly can be challenging and it is advisable to seek specialist palliative care advice.
On removal of the patch, it takes approximately 17 hours for serum concentration of fentanyl to reduce by 50% and this must be considered when converting. Different methods of conversion are practised. REVIEW the patient regularly during the changeover period.
If converting a patient with renal failure from transdermal fentanyl to an alternative opioid, always seek specialist advice.
Switching to alternative opioid when patient’s pain is controlled:
EITHER
Change to oral opioid
- Remove patch and document the time of removal.
- Prescribe a starting dose of oral opioid at the approximate equivalent dose (for that patch) to be commenced 12 hours after the time the patch has been removed.
- Ensure adequate dose of oral immediate release opioid is available P.R.N. for breakthrough pain.
OR
Change to subcutaneous opioid e.g. diamorphine or morphine or oxycodone infusion.
- Remove patch and document the time of removal.
- Prescribe a starting dose of subcutaneous opioid over 24 hours at the approximate equivalent dose (for that patch) to be commenced 12 hours after the time the patch has been removed.
- Ensure adequate dose of subcutaneous opioid is availableP.R.N. for breakthrough pain.
Discontinuing the patch if the patient’s pain is uncontrolled
Consider why the pain was not responding and address any other issues.
Consider seeking specialist palliative care advice.
Administer an immediate release opioid (e.g.P.R.N. oral morphine or SC opioid). Re-titrate new analgesics to the patient’s requirements.
Continuing the patch if the patient’s pain is uncontrolled:
In some areas, it is best practice to continue with fentanyl patch administration, adding an appropriate dose of opioid via the subcutaneous route. Consult local guidelines.
Transdermal fentanyl patch preparations:
It is advised that transdermal opioid patches should be prescribed by their brand name where possible.
For approximate equivalent doses see table
Two different transdermal formulations are currently available, reservoir and matrix:
- Reservoir patch e.g. Fentalis® and Tilofyl® fentanyl is contained within a reservoir and the release of fentanyl is controlled by a rate limiting membrane.
- Matrix patch e.g. Durogesic D-Trans® and Matrifen® the fentanyl is easily formulated throughout a drug-in-adhesive matrix and the release of fentanyl is controlled by the physical characteristics of the matrix.
Use the links below for further information about Transdermal Opioids:
Disclaimer
This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.