Palliative Care Guidelines - NHS Lanarkshire

Palliative Care Guidelines: AlfentanilDose & AdministrationAlfentanil for episodic/ incident pain• Starting dose: 100-250 micrograms.• Give a dose five minutes before an event likely to cause pain; repeat if needed• Increase dose up to 500 micrograms according to response.• Give by subcutaneous injection or sublingually. The dose is the same.• Consider an alfentanil spray if the patient is being discharged home.Dose Conversions• Alfentanil is approximately thirty times more potent than oral morphineOral morphine 30mgSubcutaneous morphine 15mgSubcutaneous diamorphine 10mgOral oxycodone 15mgSubcutaneous oxycodone 7.5mg≈ subcutaneous alfentanil 1mg (1000 micrograms)≈ subcutaneous alfentanil 1mg (1000 micrograms)≈ subcutaneous alfentanil 1mg (1000 micrograms)≈ subcutaneous alfentanil 1mg (1000 micrograms)≈ subcutaneous alfentanil 1mg (1000 micrograms)• Alfentanil is approximately four times less potent than fentanyl.A patient whose pain is controlled on a subcutaneous alfentanil infusion can be converted to afentanyl patch. Apply the patch and stop the infusion 12 hours later.Alfentanil SC 24 hourinfusion doseAlfentanil SC hourly asrequired doseFentanyl patch dose givenover 72 hours500 micrograms 100-200 micrograms Do not use a patch1 mg (1000 micrograms) 200-250 micrograms 12 micrograms / hour2mg- 3 mg 300-500 micrograms 25 micrograms / hour3mg- 4mg 500 micrograms 37 micrograms / hour4mg- 5mg Seek advice 50 micrograms / hour6mg- 7mg Seek advice 62 micrograms / hour8mg Seek advice 75 micrograms / hour• As with all opioid conversions, these are approximate doses.• Dose conversions should be conservative and doses rounded down.• Monitor the patient carefully so that the dose can be adjusted if necessary.• If the patient has opioid toxicity, reduce dose by 1/3 rd when changing opioid.(See: Choosing & Changing opioids)ResourcesProfessionalPalliative Care Drug Information online: http://www.palliativedrugs.comPatientPatient leaflet on website: AlfentanilDischarge planning/ Community use:• The community pharmacist, GP, and community nurse should be informed.• The unscheduled care service should be informed that the patient is receiving this third line opioid.• The Community Pharmacy Palliative Care Network stocks a limited supply of alfentanil injectionfor emergency use.• Alfentanil can be prescribed by the patient’s GP for the indications listed in liaison with localpalliative care specialists.Key references1. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Management 2004:25(5): 497-5042. Urch CE, Carr S, Minton O. A retrospective review of the use of alfentanil in a hospital palliative care setting.Palliative Medicine 2004; 18:516-92 Issue date: January 2009 Review date: March 2012 © NHS Lothian