Transcript Fentanyl transdermal patch Morphine oral

Dr Pauline Kane
Registrar in Palliative Medicine
Beaumont Hospital
17th Sept 2009
Overview
 Transdermal opioid patches
 Used for stable chronic pain
 Frequently cancer pain is not stable pain
 Transmucosal opioids
 Short acting opioids
 Breakthrough cancer pain
 New drugs
Indications for Transdermal Opioid
Patch
 Indication: Chronic pain
 Cannot take oral medications
 Nausea, Vomiting
 Mucositis
 Mouth ulcers
 Dysphagia
 Difficulty taking tablets
 Poor compliance
 Cognitive impairment
 Elderly
Transdermal route
 Avoidance of hepatic first pass metabolism
 Continuous pain relief
 Improves patient compliance with treatment
 Constant drug delivery providing a more stable plasma
concentration without peaks
 Ease of administration despite nausea, vomiting and
difficulties swallowing
 Absorption independent of food or fluid intake
Transdermal Patches
Fentanyl patch
 Durogesic
 Matrifen
 Replace patch every 72 hours
Why fentanyl?
 Fentanyl citrate
 Absorbed easily through skin
 Low risk for skin irritation
 100 times more potent than morphine
 Less constipating
 Less nausea and vomiting
Using Fentanyl Patch
 Apply patch to dry, flat, non-hairy skin on torso or
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upper arm
Press firmly in place with the hand for 30 seconds to
ensure good contact
Replace patch every 72 hours
Rotate patch sites
Avoid same site for several days
Wait 24 hours before evaluating pain relief
Fentanyl transdermal patch
Matrix Patch
Fentanyl Patch
Fentanyl transdermal patch
 Equivalence chart – Lasts 72 hours
Fentanyl transdermal patch
Morphine oral equivalent in 24
hours
12mcg/hr
45mg oral morphine in 24 hours
25mcg/hr
90mg oral morphine in 24 hours
50mcg/hr
180mg oral morphine in 24 hours
75mcg/hr
270mg oral morphine in 24 hours
100mcg/hr
360mg oral morphine in 24 hours
Other users of fentanyl patches
Buprenorphine Transdermal Patch
 Butrans – lower strength opioid patch
 Replace patch every 7 days
 Transtec – higher strength opioid patch
 Replace patch every 3 days
Butrans Transdermal Patch
 Indication:
 Moderate pain unresponsive to non-opioid analgesics
 Apply to dry, non-hairy skin on torso or upper arm
 Replace patch every 7 days
 Rotate patch site
 Avoid using same area for 3 weeks
 Level of pain relief should not be assessed until patch
is on for 3 days
Buprenorphine transdermal patch
Equivalence chart: Lasts 7 days
Buprenorphine transdermal patch
Butrans
Morphine oral equivalent in 24
hours
5mcg/hr
7mg oral morphine in 24 hours
10mcg/hr
14mg oral morphine in 24 hours
15mcg/hr
21mg oral morphine in 24 hours
20mcg/hr
28mg oral morphine in 24 hours
Transtec transdermal patch
 Indication:
 Moderate to severe pain
 Severe pain unresponsive to non-opioid analgesics
 Apply patch every 3 days
 Rotate patches
 Avoid same area for at least 6 days
 Only evaluate pain relief after patch is on for at least 24
hours
Buprenorphine transdermal patch
Equivalence chart:Lasts 72 hours/3 days
Buprenorphine transdermal patch
Transtec
Morphine oral equivalent in 24
hours
35mcg/hr
30-60mg oral morphine in 24 hours
52.5mcg/hr
60-90mg oral morphine in 24 hours
70mcg/hr
90-120mg oral morphine in 24 hours
Buprenorphine transdermal patch
 Rates of absorption increase if skin is warm and
dilated
 Safe to use in patients with renal impairment
 Not removed in haemodialysis
 Smaller starting doses are advised in hepatic
impairment – highly protein bound drug
 More persistent erythema than with fentanyl patches
 Can cause pruritus
Transdermal Opioid Patches
 Important to remember that the patches contain a
significant dose of morphine
 In patients who are opioid naïve
 Commence at lowest dose
 Remember buprenorphine 5mcg/hr patch = morphine
7mg/24 hours orally
 Remember fentanyl 12mcg/hr patch = morphine
40mg/24 hours orally
 Important to check daily that patch is still in place
Cautionary Use of Opioid
Transdermal Patches
 COPD or other medical conditions predisposing to
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respiratory depression eg. Myasthenia gravis
Elderly
Cachetic
Debilitated
Susceptibility to hypercapnia – CO2 retention
 Raised intracranial pressure
 Impaired consciousness
 Coma
 Brain tumour
 Caution in bradyarrhythmias
Precautions
 Lack of appreciation that fentanyl is a strong opioid
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analgesic
Inappropriate use for short-term, intermittent or postoperative pain in opioid naive patients
Lack of patient education re safe use, storage &
disposal
Lack of awareness of signs of overdose
Lack of awareness of increased absorption of opioid if
skin under patch becomes vasodilated eg. Febrile
patients, or by an external heat source eg. Electric
blankets, sauna
Breakthrough Cancer Pain
 Incident pain – predictable
 Voluntary – onset with activity such as walking
 Involuntary – onset with activity such as coughing
 Procedural – onset related to intervention such as
wound dressing
 Spontaneous pain - unpredictable
Breakthrough Cancer Pain
 Rapid onset
 Short duration
 1 min to 2-3 hours
Fentanyl for breakthrough pain
 Indication: Patient has been on long acting opioid
medication of the following strength for chronic
cancer pain for at least a week;
 Oral morphine ≥ 60mg/day
 Transdermal fentanyl ≥ 25mcg/hr
 Oxycodone ≥ 30mg/day
 Oral hydromorphone ≥ 6mg/day
 An equianalgesic dose of another opioid
 Can commence on short acting opioid for
breakthrough pain
Buccal Fentanyl: Actiq
 First transmucosal fentanyl preparation
 ‘Lozenge on a stick’
 Fentanyl in hard sweet matrix
 Lozenge placed inside cheek and moved constantly up
and down, and changed at intervals to other cheek
 Aim to consume lozenge in 15 mins
Transmucosal routes
 Buccal
 Effentora
 Place tablet in upper portion of buccal cavity above
upper rear molar between cheek and gum
 Less permeable
 75% is actually swallowed, reducing bioavailability
 Prolonged contact with mucosa and lozenge –
problematic if inflamed mucosa
Transmucosal routes
 Sublingual
 Abstral
 Place tablet under tongue
 Rapid absorption
 Highly vascularised under the tongue
 Highly permeable
 High bioavailability
Transmucosal:Nasal route
 Nose has surface area of 150-180cm2
 Continuous mucus in nose limits drug uptake to about
15mins
 Rhinitis does not affect it
 Convenient to use in those with nausea, vomiting, dry
mouth syndrome or mucositis
 Nasalfent
 Not reimbursed on GMS
Directions for Use
 Wait 4 hours between doses
 No food/drink while tablet in mouth
 Tablet disintegration takes 15-30 mins
Buccal and Sublingual
Medication
 Do not suck/chew/swallow as this decreases plasma
concentration
 Xerostomia – drink water prior to tablet placement
 Mouth ulcers
 Mucositis
Transmucosal fentanyl citrate
 25% of dose is absorbed rapidly into systemic
circulation
 Pain relief in 5-10 mins
 Remainder is swallowed or absorbed more slowly
 This is subject to hepatic first pass metabolism
 Only 1/3 of this amount is available systemically,
25% of the total dose
Fentanyl for Breakthrough Pain
 Use with caution
 Highly addictive
 Irish Medicines Board have 6 recorded cases of
addiction to Actiq
 Only use for breakthrough pain caused by cancer
Conclusion
 Transdermal patches
 Indication:
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Chronic pain poorly controlled on non-opioid analgesics
 Start on lowest dose in opioid naïve patients
 Transmucosal route
 Indication:
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Only used for breakthrough pain secondary to cancer
 Highly addictive