Sensitivity to fentanyl or silicone medical adhesive.
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.
An immediate release opioid preparation should always be available P.R.N. for breakthrough pain.
No further modified release morphine
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.
EITHER
Change to oral opioid
OR
Change to subcutaneous opioid e.g. diamorphine or morphine or oxycodone infusion.
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.
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.
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:
Use the links below for further information about Transdermal Opioids:
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.