1 / 21

Transdermal pain management

Transdermal pain management. Yousuf Zafar, MD Duke Cancer Care Research Program. Case. 68yo woman with pancreatic cancer Abdominal pain controlled with 30mg Oxycontin q12hr Interested in decreasing number of pills, and heard about “pain patch” Started on 25mcg transdermal fentanyl

taylor
Download Presentation

Transdermal pain management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Transdermal pain management Yousuf Zafar, MD Duke Cancer Care Research Program

  2. Case • 68yo woman with pancreatic cancer • Abdominal pain controlled with 30mg Oxycontin q12hr • Interested in decreasing number of pills, and heard about “pain patch” • Started on 25mcg transdermal fentanyl • Two days later, her pain is unbearable • Switched back to oral analgesics

  3. Outline • How transdermal fentanyl works • How to use transdermal fentanyl • Moving beyond transdermal fentanyl

  4. Mechanism of action Muijsers RBR, Wagstaff AJ. Drugs 2001

  5. fentanyl Mechanism of actionµ-opioid receptor µ µ µ

  6. Advantages of transdermal pain management • Useful for patients who are unable to swallow or patients experiencing nausea/vomiting • Useful for patients with poor IV access • Constant plasma concentrations • First-pass metabolism is avoided Muijsers RBR, Wagstaff AJ. Drugs 2001

  7. First-pass effect

  8. First-pass effect

  9. Dosing transdermal fentanyl • Calculate previous 24hr analgesic requirements • Convert to oral morphine dose • Convert 24hr oral morphine dose to transdermal fentanyl dose • Titrate every 3 days until pain is controlled • May take up to 6 days to achieve steady-state concentrations • Continue breakthrough medication

  10. Examples • Patient 1: 30mg Oxycontin q12hr = 60mg/day • 60mg x 1.5 = 90mg/day oral morphine • Oral morphine:transdermal fentanyl = 2:1 • 45mcg/hr fentanyl ≈ 50mcg/hr fentanyl q72hr Skaer TL. Health Quality Life Outcomes 2006

  11. Johns Hopkins Opioid Program hopweb.org

  12. Examples • Patient 2: 20mg/day oral hydromorphone, inadequate pain relief • Morphine:hydromorphone = 4:1 • 80mg/day oral morphine • 2 morphine:1 fentanyl = 40mcg/hr • Inadequate pain control, so round up to 50mcg/hr

  13. Patch application considerations • Clean, dry skin • Clipped (not shaved) hair • After placing, hold in place for 30 seconds • Rub the top of patch for 3 minutes • Alternate patch sites • Avoid heating pads/electric blankets as heat can increase rate of release Skaer TL. Health Quality Life Outcomes 2006

  14. Disadvantage to transdermal fentanyl use • Delayed onset of pain control. • Delay for dosage adjustments to take effect • Patch size and skin surface area availability Muijsers RBR, Wagstaff AJ. Drugs 2001

  15. Beyond fentanylCompounded transdermals • Compounding – preparation of medication for a specific patient • Useful for preparing administration routes not readily available • Must be prepared by accredited compounding pharmacy Latta KS. J Pain Pall Care Pharm 2002

  16. Topical morphine • Not extensively studied • Primarily used for cutaneous pain from tumor infiltrating skin • Painful ulcers • Limited stability in topical formulations Donnelly S et al. Supp Care Cancer 2002

  17. Transdermal lidocaine and amitriptyline • Amitriptyline: tricyclic antidepressant used for neuropathic pain • Study compared topical amitriptyline to topical lidocaine or placebo for neuropathic pain • 35 patients • Topical lidocaine reduced pain intensity compared to placebo minimally • Amitriptyline was ineffective Ho KY et al. Clin J Pain 2008

  18. Potential transdermal compounded drugs • Topical hydromorphone • Swish-and-spit hydromorphone • Rectal lidocaine • Ativan, benadryl, Haldol, Reglan (ABHR) cream for nausea

  19. Fentanyl via transdermal iontophoresis • Patient-controlled transdermal system • Allows for delivery of charged molecules across intact skin using electric current • On-demand button delivers fentanyl • Studies have shown PCTS to be comparable to morphine PCA • No IV interruptions/alarms, catheter-related problems • Fewer gaps in analgesia Polomano RC et al. J PeriAnesthesia Nurs 2008

  20. Conclusions • Transdermal fentanyl is a useful alternative to PO/IV opioid analgesics • Monitor patients during titration period to ensure adequate pain control • Think outside the box – consult compounding pharmacist for patients with special pain control needs

  21. Resources • Johns Hopkins opioid program – hopweb.org • Ken Latta, BS, RPh – Manager, Duke Compounding Facilitylatta001@mc.duke.edu

More Related