Fentanyl Patch

Not being a hospice nurse, though have used the patch in orthopedics and not seen a problem. I am assuming her vital signs are more stable not increased BP/HR etc. and respirations fine? It may help to talk to the pharmacist having a list of all her meds to make sure there is no untoward interaction with all of them, what does the doctor say?

http://www.duragesic.com/duragesic/

I have had this reaction with the patch. I am not a big fan of those patches.

Yes, I too have seen this reaction to a Fentenyl patch. I suggest you

stop the patch and see if the patient perks up. The 12 mcg patch is

equivalent to approx. 40-55 mg of morphine/day.

Best wishes!

maybe the pt is catching up on all the sleep they hadnt been getting??

but that does seem to be a rather big leap....how about roxanol....or is there a prob with diversion in ther household?

We use MS gel, 20 mg/ml alot. It can be applied routinely as well as PRN. The pt is only absorbing about 1/2 of that and it is easy to titrate up and down. I am wondering if this pt has had a dramatic decline however and that is why you are seeing the increase in pain, and now in sedation.

Also, I have been told that it takes up to 14 days to get maximum effects of Fentanyl patch.

I have to say, I'm not used to seeing people who are opiate naive on fentanyl -- it's too hard to titrate. As someone suggested, unless they have a morphine allergy I'd start w/a morphine solute (doesn't even have to be at the strength of roxanol). If they are allergic, you could go with a liquid Oxycontin.

And I also was wondering if this a sign of a terminal decline -- the sedation and loss of appetite.

I don't usually see these symptoms more than 2-3 days after starting a patch or any narcotic for that matter. It could be a sign of the decline, usually sedation is the sign of too much med but everyone has their own reaction. I would usually go from Tylenol to a prn narcotic before going to a long acting one first, then base it on how much prn the patient uses. I have had this same issue before and the care giver reacted in the same way, we try until we get it right and certainly want to control pain. Don't be haard on yourself for caring.:redpinkhe

Thanks for all the support. Things were better today. Pt is very comfortable. Eating less than two weeks ago but VS stable and caregiver seems tolerate at this point. I truly felt that roxanol would have been better but I could bet my life on it that the caregiver would not have given it. Very old world and old school.

Afraid of the M word.

Again, thanks all!:heartbeat

I suspect her reduced appetite and increased lethargy is also due to decline more than the patch. But next time you could try low-dose Roxanol for a few days and see how the pt does prior to starting a patch, which is hard to titrate. I might have tried this lady on Roxanol 5 mg BID (like, 9 am and 5 pm, continuing the tylenol), or if she can swallow it, percocet liquid 5/325 5 ml q4 or q6 while awake, d/c the tylenol, prior to starting the patch.

Tylenol 3 mg to fentanyl 12 mcg is NOT big leap, in my opinion.

BTW, it's the fentanyl 25 mcg that's equivalent to 45 mg of morphine a day. Not the 12 mcg, which is equal to half that.

I suspect her reduced appetite and increased lethargy is also due to decline more than the patch. But next time you could try low-dose Roxanol for a few days and see how the pt does prior to starting a patch, which is hard to titrate. I might have tried this lady on Roxanol 5 mg BID (like, 9 am and 5 pm, continuing the tylenol), or if she can swallow it, percocet liquid 5/325 5 ml q4 or q6 while awake, d/c the tylenol, prior to starting the patch.

Tylenol 3 mg to fentanyl 12 mcg is NOT big leap, in my opinion.

BTW, it's the fentanyl 25 mcg that's equivalent to 45 mg of morphine a day. Not the 12 mcg, which is equal to half that.

I guess by big leap I meant that if the person is opiate naive, then going to something that you can't titrate is a bit of a leap. But the OP then explained that she was concerned that the family CG wouldn't administer, so it makes a certain sense to go that route.

Not to be disagreeable, but not wanting anyone to be misinformed. You

may wish to check with yor pharmacist/MD for equivalency of morphine

with fentenyl 12 mcg. Best wishes!

I suspect her reduced appetite and increased lethargy is also due to decline more than the patch. But next time you could try low-dose Roxanol for a few days and see how the pt does prior to starting a patch, which is hard to titrate. I might have tried this lady on Roxanol 5 mg BID (like, 9 am and 5 pm, continuing the tylenol), or if she can swallow it, percocet liquid 5/325 5 ml q4 or q6 while awake, d/c the tylenol, prior to starting the patch.

Tylenol 3 mg to fentanyl 12 mcg is NOT big leap, in my opinion.

BTW, it's the fentanyl 25 mcg that's equivalent to 45 mg of morphine a day. Not the 12 mcg, which is equal to half that.

Step 1 - Calculate the 24 hr morphine dose: 3 mg/hr x 24 hrs = 72 mg IV morphine/24 hrs;

Step 2 - Convert the IV dose to the equianalgesic oral morphine dose using a ratio of:

1 mg IV = 3 mg oral; thus 72 mg IV = 216 mg po/24 hours;

Step 3 Convert the oral morphine dose to transdermal fentanyl. There are two methods:

Other teaching points about transdermal fentanyl:

• Start at the lowest patch dose - 12 mcg/hour - in an opioid naïve patient; there is no maximum dose.
  
• Therapeutic blood levels are not reached for 13-24 hours after patch application, and fentanyl will be continue to be released into the blood for at least 24 hours after patch removal.
  
• Opioid withdrawal symptoms can occur during dose conversions--care must be taken to avoid this by use of breakthrough opioids or other dosing systems.
  
• Some patients will need to have their patches changed every 48 hours.
  
• The recommended upward dose titration interval is no more frequently than every 72 hours.
  
• Place patches on non-irradiated, hairless skin.
  
• Direct heat applied over the patch can increase drug absorption with increased toxic effects.
  
• There are no clinical data that cachectic patients have reduced efficacy due to loss of subcutaneous fat.