- Fentanyl is a strong opioid available in a patch formulation for transdermal administration for chronic cancer pain
Contraindications:
- Opioid-naïve patients
- Sensitivity to fentanyl or silicone medical adhesive
- Relative contraindication – where rapid dose titration is required
- Severe respiratory depression
Side effects
The most common side effects with transdermal administration are:
- Local skin irritation
- Nausea is a common problem (around 30%) during the first few days of treatment. If it occurs, haloperidol and/or metoclopramide are suitable antiemetics
(See chapter: Nausea and Vomiting)
Guidance for initiation
- Generally, consider only if already established on an opioid equivalent to i.e., 30 – 60 mg morphine/24 hours
- For patients already taking opioids the appropriate starting dose of transdermal fentanyl should be calculated from the previous total daily opioid dose using the dose equivalence table (see section: Approximate equivalent doses of transdermal opioids)
- See table on page 40 for suggested time intervals between commencing new patch and stopping prior morphine
- If initiating oral opioids is not possible, and transdermal fentanyl is considered to be the only appropriate treatment e.g. loss of oral route, severe renal impairment, the lowest starting dose (ie 12 micrograms/hour; equivalent to 30 mg morphine/24 hours) should be used. Patients must be closely monitored, as the potential for serious or life-threatening hypoventilation exists even at the lowest dose of transdermal fentanyl in opioid naïve patients
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 it takes 12-24 hours to reach peak concentrations after patch applications and then effective analgesic concentrations may not be achieved till 72 hours, therefore do not increase patch doses day by day
- Patches are changed every 72 hours in most patients
- In a small minority of patients, they may need changing 48 hourly, due to increased pain/reduced analgesic effect occurring prior to 72 hours
- Remove patch(es) before applying new one(s) to a different site
- 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 PRN. 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 PRN. 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 available P.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. PRN. 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.