Discontinuing transdermal fentanyl

On removal of the patch, it takes approximately 17 hours for serum concentration of fentanyl to reduce by 50%.

Different methods of conversion are practised. The preferred methods A and B according to pain control, are given below:

A. Discontinuing the patch if the patient's pain is controlled either

• Change to oral opioid
  • remove patch and document the time of removal
  • prescribe a starting dose of oral opioid at the approximate equivalent dose (for that patch) to be commenced 12 hours after the time the patch has been removed
  • ensure adequate dose of oral immediate release opioid is available p.r.n. for breakthrough pain
  • OR
    
• change to subcutaneous opioid e.g. diamorphine or morphine or oxycodone infusion:
  • remove patch and document the time of removal
  • prescribe a starting dose of subcutaneous opioid over 24 hours at the approximate equivalent dose (for that patch) to be commenced 12 hours after the time the patch has been removed
  • ensure adequate dose of subcutaneous opioid is available p.r.n. for breakthrough pain

B. Discontinuing the patch if the patient's pain is uncontrolled, consider seeking specialist advice

• consider why the pain was not responding and address any other issues
• consider seeking specialist palliative care advice
• administer an immediate release opioid (e.g. p.r.n. oral morphine or SC opioid). Re-titrate to the patient's requirements
• review the patient regularly during this change over period

If converting a patient with renal failure from transdermal fentanyl to an alternative opioid then seek specialist advice.

Continuing the patch if the patient's pain is uncontrolled:

• add an appropriate increment of opioid by the subcutaneous route whilst continuing the patch
  • in some areas, it is practice to continue with fentanyl patch administration, adding an appropriate dose of opioid via the subcutaneous route. Consult local guidelines

Note (1): in the last days of life it may be acceptable practice in some cases to continue with fentanyl patch administration, adding an appropriate increment of diamorphine by subcutaneous infusion - seek specialist advice in this situation

Reference:

1. West Midlands Palliative Care Physicians (2007). Palliative care - guidelines for the use of drugs in symptom control.
2. West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptom control