Palliative Care Guidelines - NHS Lanarkshire

Palliative Care Guidelines: Fentanyl patchesFentanyl patches in the last days of life1. If a patient is semi-conscious or close to death, continue the fentanyl patch, changing it every72 hours.2. If a new, opioid responsive pain develops, use subcutaneous morphine as required forbreakthrough pain. Use the conversion chart to calculate the dose of morphine.3. After 24 hours, the breakthrough doses of morphine given in that period can be totalled andthis dose of morphine administered as a SC infusion in a syringe driver or pump over the next24 hours in addition to the fentanyl patch.Dose Conversions• All opioid dose conversions are approximate.• Round the dose down if the patient is pain free or frail; round up if the patient has pain and isless unwell or younger.• Reduce the dose by up to 30% when changing opioid if the patient is opioid toxic, frail orelderly and re-titrate.• Reduce the dose by up to 30% when converting from fentanyl back to morphine or anotheropioid and re-titrate.• Patients should be monitored closely so that the dose can be adjusted if necessary.• Manufacturers of the various formulations of fentanyl have issued different recommendationsfor dose conversion, as have drug regulatory bodies.• Fentanyl is approximately 100-150 times more potent than oral morphine; this table provides aguide to dose conversions, but if in doubt seek advice.Immediate release oralmorphine 1Fentanyl patch dose(micrograms/hour)24 hour oral morphine dose5-10mg 12 30-60mg10-15mg 25 60-90mg15-20mg 37 90-120mg20-30mg 50 120-180mg30-40mg 62 180-240mg40-50mg 75 240-300mg50-60mg 87 300-360mg60mg 100 360mg1Assuming use of about 1/6 th of the 24hour oral morphine dose.• Converting from fentanyl given by IV infusion or via a PCA device.• Calculate the hourly dose of fentanyl (micrograms/ hour)• Prescribe the patch strength closest to this dose (micrograms/ hour)• Continue the IV fentanyl for the first 12 hours after the patch is applied.© NHS Lothian Issue date: January 2009 Review date: March 20123