Initiating Treatment with Transdermal Opioids

Guidance on dosing for fentanyl and buprenorphine patches.

FENTANYL

  • The initial dose of transdermal fentanyl should be selected according to the patient’s previous 24 hr opioid requirement (calculated as morphine equivalent).
  • Opioid-naive patients should be titrated with low doses of short-acting opioids, then started on a 25 microgram/hr patch (Fencino, Matrifen, Mezolar and Victanyl SPCs recommend starting patients on a patch with a release rate of 12–12.5 microgram/hr).
  • Patients naive to strong opioids should be started on a 25 microgram/hr patch.
  • Previous analgesic therapy should be phased out gradually from the time of the first patch application until analgesic efficacy with the fentanyl patch is attained.
  • Recommended dose conversions from oral morphine to transdermal fentanyl as they appear in the relevant Summaries of Product Characteristics (SPCs) are included below.
PATIENTS STABILISED ON A STRONG OPIOID OVER SEVERAL WEEKS
Oral morphine dose per 24 hr (mg)Transdermal fentanyl dose (microgram/hr)
<44 12 (Durogesic, Fencino, Matrifen, Mezolar, Opiodur) or 25 (OsmanilVictanyl)
45–89 12 (Durogesic, Fencino, MatrifenMezolar) or 25 (Opiodur, Osmanil, Victanyl)
90–134 25 or 37.5 (Victanyl)
135–179 50 (all except Mezolar) or 37.5 (Mezolar)
180–224 50
225–314 75
315–404 100
405–494 125
495–584 150
585–674 175
675–764 200
765–854 225
855–944 250
945–1034 275
1035–1124 300
HIGHLY OPIOID-TOLERANT PATIENTS ON STABLE AND WELL TOLERATED OPIOID THERAPY FOR A LONG PERIOD
Oral morphine dose per 24 hr (mg) Transdermal fentanyl dose (microgram/hr)
<44 12 (Durogesic, Matrifen, Osmanil)
45–89 25 (Durogesic, Matrifen, Osmanil)
<60 12 (Fencino, Mezolar, OpiodurVictanyl)
60–89 25 (Fencino, Fentalis, Mezolar, OpiodurVictanyl)
90–119 50 (all except Mezolar) or 37.5 (Mezolar)
120–149 50
150–209 75
210–269 100
270–329 125
330–389 150
390–449 175
450–509 200
510–569 225
570629 250
630689 275
690749 300

An alternative way to calculate the initial dose of fentanyl is to multiply the 24 hr morphine dose in mg by 10 to obtain 24 hr fentanyl dose in microgram. Then divide answer by 24 to obtain microgram/hr patch strength.1
eg, daily morphine dose 300mg x 10 = daily fentanyl dose 3000 microgram. When divided by 24 this equates to 125 microgram/hr.

BUPRENORPHINE

Transtec patches
Available as 35 microgram/hr, 52.5 microgram/hr, 70 microgram/hr, changed twice weekly.

  • No previous analgesia and patients switching from weak opioid or non-opioid analgesics: initiate treatment with 35 microgram/hr patch.
  • Switching from strong opioids: initiate treatment with 35 microgram/hr patch and titrate individually.
  • Higher daily doses of strong opioid (approx 120mg oral morphine): initiate treatment with 52.5 microgram/hr patch.
  • Previous analgesics (with the exception of transdermal opioids) should be given at the same dose during the first 12 hr after switching to Transtec and appropriate rescue medication given on demand in the following 12 hr.
  • Short-acting supplemental analgesics should be used during titration as required.

Bupeaze patches, Hapoctasin patches
Available as 35 microgram/hr, 52.5 microgram/hr, 70 microgram/hr, changed every 3 days (Hapoctasin) or every 4 days (Bupeaze).

  • Opioid-naive patients: initiate treatment with 35 microgram/hr patch.
  • Patients switching from weak opioid or non-opioid analgesics: initiate treatment with 35 microgram/hr patch.
  • Switching from strong opioids: initiate treatment with 35 microgram/hr patch and titrate individually.
  • Higher daily doses of strong opioid (approx 120mg oral morphine): initiate treatment with 52.5 microgram/hr patch.
  • Previous analgesics (with the exception of transdermal opioids) should be given at the same dose during the first 12 hr after switching to Bupeaze or Hapoctasin and appropriate rescue medication given on demand in the following 12 hr.
  • Short-acting supplemental analgesics should be used during titration as required.

Butec patches, BuTrans patches, Reletrans patches
Available as 5 microgram/hr, 10 microgram/hr, 15 microgram/hr, 20 microgram/hr, changed every 7 days.

  • All patients: initiate treatment with 5 microgram/hr patch and titrate as necessary (min 3 days after initial dose).
  • Short-acting supplemental analgesics should be used during initiation and titration as required.

Panitaz patches, Sevodyne patches
Available as 5 microgram/hr, 10 microgram/hr, 20 microgram/hr, changed every 7 days.

  • All patients: initiate treatment with 5 microgram/hr patch and titrate as necessary (min 3 days after initial dose).
  • Short-acting supplemental analgesics should be used during initiation and titration as required.

 References
1. Twycross R, Wilcock A, Howard P. Palliative Care Formulary. 5th ed. Nottingham: Palliativedrugs.com Ltd, 2014. 

Recommended dosages taken from Summaries of Product Characteristics [accessed August 2016].


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