Palliative Care Guidelines - NHS Lanarkshire

Palliative Care Guidelines: Fentanyl patchesStarting a fentanyl patch (continued)4. Make sure the patient takes another regular opioid for the first 12 hours after the patch is firstapplied to allow the fentanyl to reach therapeutic levels:Immediate release (quick acting)morphine or oxycodoneModified release (long acting) 12 hourlymorphine or oxycodoneSubcutaneous infusion of morphine,diamorphine, oxycodone or alfentanilApply patch; continue the immediate releaseopioid 4 hourly for the next 12 hours.Apply patch when the last dose of a 12hourly, modified release opioid is given.Apply the patch and continue the infusionfor the next 12 hours, then stop the infusion.5. An immediate release opioid (e.g. oral morphine or morphine SC) must be available 1-2 hourly,as required, for breakthrough pain or to treat any opioid withdrawal symptoms (diarrhoea,abdominal pain, nausea, sweating). These can occur during the fentanyl initiation period due tothe variable time to reach steady state. The correct 4 hourly equivalent dose should be used.6. Change the patches every third day (72 hours) at about the same time.7. Fentanyl is often less constipating than morphine; half dose of any laxative and titrate.Adjusting the fentanyl patch doseReview the fentanyl patch dose after 72 hours; drug levels will be at steady state.a) If the patient shows signs of opioid toxicity (drowsiness, confusion), reduce the dose andreassess the pain. Seek advice.b) If the patient still has pain which is opioid responsive, titrate the fentanyl dose in12-25microgram/hour increments depending on the patch type in use. Remember toinclude the breakthrough doses used. It will take 12-24 hours for the new dose to takeeffect so give breakthrough analgesia at the correct dose, as required.Changing fentanyl patches to another opioidFentanyl accumulates in the skin under the patch. It can persist for up to 24 hours after patchremoval. Patients should be monitored carefully for signs of opioid toxicity for 24-48 hours iffentanyl is changed to another opioid.1. Remove the fentanyl patch; prescribe an immediate release opioid, 1-2 hourly, as required, forthe first 24 hours.2. Calculate the opioid dose by converting from fentanyl to immediate release oral morphineusing the conversion chart. Reduce the dose by 1/3 rd .3. To convert to any other immediate release opioid, refer to Choosing & changing opioids.Seek advice if in doubt.Example of an initial dose calculation when discontinuing a fentanyl patchFentanyl patch dose Oral morphine dose Subcutaneous morphine dose50 micrograms/ hr x 72 hrs 20 mg, 1-2 hourly 10mg, 1-2 hourlyRemember that all opioid conversions are approximate; monitor the patient.4. After 24 hours, review the doses used and prescribe a regular, 4 hourly dose of immediaterelease opioid in addition to the correct as required dose.5. Titrate the patient’s opioid requirements for at least 48 hours before converting to a modifiedrelease (long acting) opioid or a subcutaneous opioid infusion.2 Issue date: January 2009 Review date: March 2012 © NHS Lothian