Fentanyl Patch

[Brightonrn1]

We ordered a 12 mcg Fentanyl patch for our bedbound end stage Parkinsons disease and Dementia pt who was taking 3gms of Tylenol daily for generalized pain. she was moaning in pain prior to this change with also increase bp and heart rate.

Has anyone out there seen someone not come around after over a week with the Fentanyl patch? By this I mean, she has a decrease appetite, not as responsive, and generally not the same. Although no further moaning when turned. Caregiver is really upset at me, the nurse, for suggesting this change for the pt.

What have other hospice nurses seen with low dose Fentanyl patches?

[marachne]

I guess this is part of why I have trouble wrapping my head around "converting" from a NSAID to an opiate. You can only estimate even w/i classes of drugs (esp w/fentanyl). And with an older adult, I'm a firm believer in "start low and go slow."

I do understand the decision in this case however.

Fast Fact #2 Converting to/from transdermal fentanyl

Quick--what dose of the fentanyl transdermal system/patch (Duragesic â ) is equianalgesic to a 3 mg/hr morphine continuous infusion? Conversions to and from fentanyl transdermal are notoriously tricky, requiring knowledge of the published conversion data, general opioid pharmacology and a generous dose of common sense.

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:

A. Standard Table: look up fentanyl transdermal in the PDR and find the morphine conversion table which says that 135-224 mg of oral morphine per 24 hours = 50 mcg/hour patch. Note: this range of morphine is very broad which may result in significant under dosing.

B. Alternate Formula: In 2000, Brietbart et al published an alternative method, based on the results of a multi-center trial by Donner et al, that relied on a fixed dose conversion ratio to calculate the fentanyl transdermal dose. Brietbart recommended the ratio of:

2 mg oral morphine = 1 mcg/hour of fentanyl transdermal--rounded to the nearest patch size. In the case example above, 216 mg of oral morphine per 24 hours is approximately equianalgesic to a 100 mcg/hour fentanyl transdermal patch.

Note: using this formula, 25 mcg/hour fentanyl transdermal is roughly equivalent to 50 mg oral morphine/24 hours. This dose may be excessive when used in an opioid naïve patient and/or the elderly.

Key Considerations

1. All equianalgesic ratios/formulas are approximations; clinical judgment is needed when making dose or drug conversions.

2. The risk of sedation/respiratory depression with fentanyl transdermal is probably increased in the elderly or patients with renal impairment due to its long half-life. Thus, choose the lower end of the dosing spectrum.

3. When in doubt, go low and slow with long-acting opioids, using PRN breakthrough doses generously while finding the optimal long-acting/transdermal dosage.

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.

[Allow Mystery]

Recommended Initial Dose Conversion to Duragesic Patch

(Jansen-Ortho 2006) 25 ug patch = 60-134 total oral morphine

daily dose

Many Fentenyl lawsuits out there for overdosing.

Best Wishes!

[Sabby_NC]

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

I agree.

My first thought was that this maybe a disease process decline and not related to the patch at all.

What about gels etc or is the patient still able to swallow meds effectively without pocketing etc?