The emr pcc grants permission to reproduce parts of this publication for clinical and educational use only, provided that the eastern metropolitan region palliative. Frail or elderly patients may need lower doses and slower titration. If fentanyl tp was used as the basic prescribed drug, fentanyl was given orally or in suppository form in a dose equivalent to 16 to 14 of the basic prescribed. Fentanyl transdermal patch duragesic is a prescription medication used to treat severe chronic pain such as cancer. Withdrawal symptoms, drug interactions, dosage, and pregnancy and breastfeeding safety are provided. A withdrawal syndrome may also occur when switching to fentanyl, which responds to tapering doses of the previous opioid. Converting from oral morphine to fentanyl transdermal patch. You will probably need to take a fasteracting narcotic by mouth to relieve pain during the first few days of using fentanyl skin patch.
Equivalent doses and conversion ratios obtained with the expression of daily dose of morphine injection mgdaily delivered dose of fentanyl patch mg were determined from the relationship. Fencino doses should be individualised based upon the status of the patient and should be assessed at regular intervals after application. If switching because of possible opioidinduced hyperalgesia, the calculated equivalent dose should be. Opioid conversion and brand availability in canada michael g. How should conversion from oral morphine to fentanyl patches be. Apr 21, 2020 conversion from morphine or equivalent to fentanyl transdermal. Practical management of opioid rotation and equianalgesia ncbi. Conversion tables show that the oral to parenteral ratio for morphine is 3.
Dose equivalents and changing opioids faculty of pain. Based on estimated 24hour equivalent oral morphine dose, look up the recommended fentanyl patch dose in table 2 below. Each patients risk should be assessed prior to prescribing sandoz fentanyl patch, and all patients should be monitored regularly for the development of these behaviours or conditions see warnings and precautions. The 50, 75, and 100 mcghr patches should only be used in patients already on and tolerant to opioid therapy. Here is a table of substance dosage and potency, related to 10 mg of intravenously administered morphine. Fentanyl patch 100mcghour 360mg morphine 24 hours consider dose reduction of 20% a. This opioid dose equivalence table is intended for comparison of different opioid and opioid formulations in individual patients or in patient cohorts. For each 25 mcghr fentanyl transdermal patch, a dose of hysingla er 20 mg every 24 hours represents a conservative initial dose. Always ensure that an old patch has been removed before a new patch is applied. A 25 microgramhour fentanyl patch is equivalent to about 60mg to 90mg of oral morphine in 24 hours. Published equianalgesic ratios are considered crude estimates at best and therefore it is imperative that careful consideration is given to individualizing the dose of the selected opioid.
Transdermal and parenteral fentanyl dosage calculations and. Convert from morphine equivalent dose to methadone equivalent dose using conversion ratio. Equianalgesic chart doses listed are equivalent to 10 mg of parenteral morphine. Based on this estimated 24hour equivalent oral morphine dose, work out the recommended fentanyl patch dose. The initial dose of sandoz fentanyl patch should be obtained or calculated from the conversion tables see dosage and administration, and must not be higher than that dose which is equivalent to the total dose of opioids the patient is receiving at the time of the switch to the patch. Initial fentanyl transdermal dosage use only when converting another opioid to fentanyl patch. Use of this table for conversion from fentanyl to other opioids can overestimate the dose of the new agent and may result in an overdosage. This dose may be excessive when used in the opioid naive or the elderly.
Buprenorphine patch takes 3 days to achieve its steady state. It may be 812h or longer after putting on the first patch before pain relief is experienced. Opioid oral morphine milligram equivalent mme conversion. Treatment of cancer pain with transdermal fentanyl the. Fentanyl patch converter globalrph conversion from. The opioid doses shown in the table below are therapeutically equivalent doses. Methadone dosing guidelines iowa medicaid drug utilization. Convert to equivalent dose of fentanyl by dividing total 24 hour oral dose by 100. Dose conversion in opioid rotation from continuous. Agreed to dose of 280mg morphine daily in 2 divided doses 140mg morphine sr twice daily 4. Each duragesic patch may be worn continuously for 72 hours. On opioid rotation from continuous intravenous infusion of fentanyl fentanyl civ to fentanyl transdermal patch fentanyl tp, dose conversion can be based on the bioavailability of fentanyl tp because the active ingredient is the same. Doses of transdermal fentanyl used after opioid rotation were expressed.
This will be a clinical decision based on patient specific factors and patients should be monitored. Both drugs work the same way in the body to relieve pain. Converting to transdermal fentanyl palliative care. Rescue doses of oral or intravenous morphine, using the equivalent of one sixth of the daily dose, were provided. The size of the breakthrough dose should be 515 % of the patients 24hour baseline dose. A 25 ugh patch is approximately equal to 50 to 75 mg of oral morphine over 24 h. Sandoz fentanyl patch poses risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. These should be used in conjunction with the summary of product characteristics for the fentanyl patch being used. Methadone and tramadol, morphine dose equivalence not reliably. Canadian guideline for safe and effective use of opioids for chronic noncancer pain. The stronger the dose, the larger the patch, as more area of skin needs to be covered to ensure that more of the drug is being absorbed over the same period of time. In the case example above, 216 mg of oral morphine per day is approximately equianalgesic to the 100 mcghr fentanyl patch.
For frail elderly patients, use more conservative conversion or a lower strength patch e. Yes, sometimes it is necessary to apply more than one patch. The drug reservoir contains the appropriate amount of fentanyl base depending on the patch size. The following doses and conversion factors are a guideline only and each patient must be assessed on an individual basis. An alternative algorithm for dosing transdermal fentanyl. Iv use even at low doses and when given very slowly may cause marked decrease in blood pressure. If not using morphine, convert this to a 24 hour oral morphine equivalent dose. Opioid conversion ratios guide to palliative care practice. Comparative doses of oral morphine and transdermal fentanyl are given in tables 1 and 2. Fentanyl duragesic patches come in six different sizes and doses, including. For fasttracking and early extubation following major surgery, total fentanyl doses are limited to 10 to 15 mcgkg. Equianalgesic chart changes in italics ui health care. Scottish palliative care guidelines fentanyl patches.
The patches are designed to deliver approximately 12, 25, 50, 75, and 100 mcgh fentanyl to the systemic circulation, which represent about 0. Doses should be increased or decreased by 2550% of the current 24hour dose. The dose of the initial fentanyl patch is based on the morphine equivalent daily dose currently used by the patient. Each 2 mg po morphine approximately equivalent to 1 mcghr fentanyl patch e. Calculate the total 24hour morphine dose or morphine equivalent. Rapid switching between transdermal fentanyl and methadone in. The dose conversion ratio of morphine injection to fentanyl patch was different at the low doses and high doses of morphine.
Patients who are taking a daily dose of morphine that is not exactly equivalent to a particular fentanyl patch strength, will need to be changed to a patch which is either slightly less or slightly more potent than the morphine dose. The mme conversion factor for fentanyl patches is based on the assumption that one milligram of parenteral fentanyl is equivalent to 100 milligrams of oral morphine and that one patch delivers the dispensed micrograms per hour over a 24 hour day. Practical management of opioid rotation and equianalgesia. Read the medication guide and, if available, the instructions for use provided by your pharmacist before you start using. Patients who are opioid tolerant are those receiving, for 1 week or longer, at least 60 mgday morphine, 25 mcgday transdermal fentanyl, 30 mgday po oxycodone, 8 mgday po hydromorphone, 25 mgday po oxymorphone, 60 mgday po hydrocodone, or an equianalgesic dose of another opioid.
Conversion ratios in many equianalgesic dosing tables do not apply to repeated doses of opioids. Select microgram per hour dose of transdermal fentanyl based on. The recommended upward dose titration interval is every 72 hours. The fentanyl will continue to be effective for 24 hours after the patch is removed as a part of the drug is already depot in the adipose tissue. Jannsen, the manufacturer of fentanyl patches, suggests a more conservative dosing schedule in converting to.
Oct 15, 2019 duragesic should not be used if the pouch seal is broken or if the patch is cut or damaged. Converting to transdermal fentanyl palliative care network of. Morphine equivalent dose med opioid conversions globalrph. Discarded patches have the potential to be misused. Equianalgesic dose ratios for fentanyl vs other opioids or routes in. All doses expressed in mg per day with exception of fentanyl transdermal. Patients who are opioid tolerant are those receiving, for 1 week or longer, at least 60 mgday morphine, 25 mcgday transdermal fentanyl, 30 mgday po oxycodone, 8 mgday po hydromorphone, 25. Divide the calculated 24 hour dose of fentanyl by 24 to calculate the hourly dose of fentanyl. Caution should be used in older adults or patients with cachexiafentanyl is lipid soluble and requires subcutaneous fat for proper absorption. Dilaudid hydrolmorphone and fentanyl are narcotic opioid drugs used to manage of severe chronic pain, for example cancerrelated pain. The amount of residual drug in the patients system must be accounted for. These data are presented to allow conversion between different opioids and different administration routes.
Duragesic fentanyl transdermal dosing, indications. Similarly, in patients who were switched from oral methadone to tts fentanyl, the patch was applied immediately after the last dose of methadone. John smith, a terminally ill lung cancer patient has pain that is well controlled on morphine sustained action, 90mg every 12 hours. The opioid rotation ratio of strong opioids to transdermal. Opioid conversion factor convert to mmes duration hours dose equivalent morphine sulfate 30mg codeine 0. Caution is required if opioid dose equivalence tables are used to guide opioid switching, as the administration of a calculated equivalent dose of the replacement opioid may lead to. A patient should be receiving at least 60mg of oral morphine equivalents per day or 25 to 50 micrograms transdermal fentanyl per hour, if transmucosal fentanyl is to be considered for breakthrough pain. While the present study suggested that in opioid rotation from low dose, 50. Original research dose conversion ratio for continuous. In an inpatient setting, rescue doses can be provided iv every 1530 minutes.
We used the equianalgesic chart from wikipedia to build the opioid conversion calculator. Senior dosage ages 65 years and older the kidneys of older adults may not work. Talk to your doctor about the risks of using fentanyl transdermal patch. The transdermal system is pressed firmly in place with the palm of the hand for 30 seconds, making sure the contact is complete, especially around the edges.
Equivalent doses and conversion ratios obtained with the expression of daily dose of morphine injection mgdaily delivered dose of fentanyl patch mg were. Fentanyl dosage increase guideline is based on the daily dose of supplementary oral morphine. The patient should avoid exposure to excessive heat e. Dosage titration of the new opioid should be completed slowly and with frequent monitoring. Select microgram per hour dose of transdermal fentanyl based on table 2. Equianalgesic dose ratios are only approximations and do not account for. Oral rescue doses can be offered as needed over the normal dosing interval of the drug typically every 4 hours. This dose is not possible to provide in slowrelease morphine preparation c. Smith is now unable to swallow and so the morphine needs to be converted into a transdermal fentanyl patch. The conversion ratios are approximate and are intended as a guide only. An old patch can continue to release the drug and cause an overdose.
A guide to equivalent doses for opioid drugs this is to be used as a guide rather than a set of definitive equivalences. Gently wipe area once or twice with slightly dampened gauze to remove loose hair. If the patch is stopped it may take 12h or longer before the effect of the fentanyl wears off. Advanced opioid conversion calculator morphine equivalents. Patches conversion doses drug name drug dose equivalent oral morphine dose fentanyl 25 patch 25microgramshour 30mg to 4mg24hours fentanyl 50 patch 50 microgramshour 5mg to 224mg24hours fentanyl 75 patch 75 microgramshour 225mg to 314mg24hours fentanyl 100 patch 100 microgramshour 315mg to 404mg24hours transtec 52. Influence of serum albumin levels during opioid rotation. Canadian guideline for safe and effective use of opioids. Opioid conversion ratios guide to palliative care practice 2016 352016 2016. Quickwhat dose of the transdermal fentanyl patch duragesica is. Advice should be sought from the palliative care team.
Proper conversion is dependent upon a variety of factors drug dosage. The web page will automatically calculate the total morphine equivalents per day. Fentanyl transdermal patch is a prescription medication thats used to treat chronic pain in opioidtolerant people. Nov 22, 2019 discontinuing fentanyl infusion 30 to 60 minutes prior to the end of surgery will usually allow adequate ventilation upon emergence from anesthesia. Opioid converter morphine equivalent calculator omni. Side effects may include profuse sweating, coughing, nausea, diarrhea, and tearing.
What are the steps for converting from morphine or. There is no direct conversion ratio between morphine. This calculator is intended for calculating the morphine equivalent dose med dose for a patient taking one or more opioid medications. Opioid conversion calculator for morphine equivalents. How should conversion from oral morphine to fentanyl. For patients with a current fentanyl transmucosal lozenge of 200 mcg or 400 mcg, initiate fentanyl buccal dose fentoral r at 100 mcg.
Fencino 12 microgramshour transdermal patch summary of. Opioid conversion ratios guide to palliative care practice 2016. You may also need another narcotic while your dose of fentanyl is being adjusted, and to relieve any breakthrough pain that occurs later on. Fentanyl may also cause severe, possibly fatal, breathing problems. As stated above, because equianalgesic tables are inherently inaccurate, the availability of breakthrough doses is paramount. Dose conversion in opioid rotation from continuous intravenous.
Kawano et al examined dose conversion ratios in patients undergoing opioid rotation from morphine injection continuous iv administration miv to transdermal fentanyl patches in a prospective observational study of 45 patients with chronic pain of cancer origin. Oct 29, 2018 kato et al published in 2004 the results of their retrospective observational study of 144 patients with chronic pain of cancer origin and with difficulty tolerating oral morphine, undergoing rotation to fentanyl patch. Convert to equivalent dose of fentanyl by dividing total 24 hour oral dose by 100 parenteral fentanyl is 100 times more potent than oral morphine 180 mg 100 1. The dose to be administered should be clearly prescribed.
Fentanyl has a risk for abuse and addiction, which can lead to overdose and death. Doses should be titrated according to individual response. Equianalgesic opioid conversion ratios for patients previously receiving other. Oral morphine milligram equivalent conversion tablei updated 8162017 opioid strength in mg except where noted mme conversion factor buprenorphine, transdermal patch mcghr 12. If in any doubt double check with the prescriber or pharmacist. Schedule 8 schedule 11 medication management points to consider when prescribing and using the transdermal opioid patches transdermal fentanyl patch. It should not be used to determine doses when converting a patient from one opioid to another. Fentanyl patches need to be disposed of carefully because a significant amount of fentanyl is left in the patch after three days. Conversion from morphine or equivalent to fentanyl transdermal.
Fentanyl tolerance in the treatment of cancer pain. A dose reduction of at least 50% is recommended when switching at high doses eg, oral morphine or equivalent doses of 500mg24 hours or more, in elderly or frail patients. Converting to transdermal fentanyl palliative care network. Follow the patient closely during conversion from transdermal fentanyl to hysingla er, as there is limited experience with this conversion. Provide 100% of expected med morphine equivalents in long acting form, as well as 15% prn option for breakthrough pain with dosing interval comparable to medication half life q34h for oral meds, and retitrate daily. Fentanyl transdermal patch has not been established as safe or effective for use in children younger than 2 years. After application of the fentanyl patch peak plasma levels are achieved 24 hours significant plasma levels occur in 12 to 16 hours.
This calculator, which is based roughly on information provided by janssen pharmaceuticals inc. Drug name drug dose equivalent oral morphine dose fentanyl 25 patch 25micrograms hour 30mg to 4mg 24hours fentanyl 50 patch 50 micrograms hour 5mg to 224mg 24hours fentanyl 75 patch 75 micrograms hour 225mg to 314mg 24hours. During the initial 18 hours following application of the patch, the patient should be instructed to take at least 15 mg 25% of 60 mg of oxycodone until steadystate serum fentanyl levels are. Dosing for fentanyl patches the initial dose of fentanyl should be the lowest possible dose based on the patients opioid history and current medical status. Both dilaudid and fentanyl can be habit forming even at prescribed doses. Further notes regarding dose equivalence are presented below the table. For patients on opioids other than oral morphine, please use the following chart to calculate. It usually includes information on the dosage, relative potency, and halflives, compared to morphine.
The median opioid rotation ratio orr from the morphine equivalent daily dose medd to transdermal fentanyl tdf in mg per day is 0. Fentanyl patch protocol ventura county, california. It is crucial to appreciate that conversion ratios are never more than. The starting point for dose reduction from the calculated equianalgesic dose is around 2550%. Influence of serum albumin levels during opioid rotation from morphine or oxycodone to fentanyl for cancer pain.
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