TRANSDERMALPATCHGUIDANCE 3TsFormulary TransdermalPatch Guidelines

General Guidance
Transdermaladministrationisanalternative,(notnecessarilybetter), methodofdrugadministration.Afterthe applicationofanypatchthereisadelayofmanyhoursbeforetherapeuticlevelsofadrugarereached.Also, after removal of a patch, there is a delay of many hours before circulating levels of a drug drop to a sub therapeuticlevel,i.e.thereisaSLOWONSETandSLOWOFFSETofanalgesiaandofsideeffects. Transdermalpatchesareconsiderablymoreexpensivethanoraltherapy. Considerusingpatchesonlywhen: Difficulty/inabilitytoswallow Intractablenauseaandvomiting PoorabsorptionfromGItract,(shortbowel/inflammatoryboweldisease) Persistentexcessivesideeffectsfromoralopiatesduetopeaksinplasmaconcentrations Complianceproblems Painisstableandthereforeanalgesicrequirementisstable AcutepainisanabsolutecontraindicationfortheuseoftheTransdermalRoute. Consider prescribing a course of antiemetic for firstseventotendays due tohighincidence ofnausea and vomiting. Temperatureincrease,(fever,bath,shower,heatpad)mayincreasedeliveryrateofpatchescausingtoxicity andshorteningdurationofaction ofpatch. Buprenorphineisasyntheticopioidagonist/antagonistforuseinmoderatetoseverepainandtransdermally isavailableastwodifferentbrandslowstrengthBuTransandhighstrengthTranstec Buprenorphine(BuTrans)patchesreleasing5g/hr,10g/hrand20g/hr Indications for use: treatment of nonmalignant pain of moderate intensity when an opioid is necessary for obtainingadequateanalgesia. Criteriaforuse:patientswithchronicpain,whohavepreviouslyreceivedweakopiates, (e.g.Codeine,Dihydrocodeine,Tramadol)andrequireatopicalpreparationbutdonotyet requirethelevelofanalgesiaprovidedbymorphineorFentanylpatches.

Butrans patches contain Buprenorphine in a continuous release formulation to be worn for seven consecutivedays. Initiatetreatmentwiththeloweststrengthpatch. Patchesmustbewornforthreedaysuntil maximaleffectattained.Afterthreedaysthedosemaybeincreaseddependingonthepatientsresponseand theneedforcurrenttopupanalgesia;howeveritisrecommendedthatinmostcasesthepatchbechanged after sevendays. This is toachieve pain control whilst at thesame time minimising opioidsideeffects. The decisiontoincreasethepatchstrengthshouldbebasedonthepatientsneedforsupplementalpainreliefand theiranalgesicresponsetopatch.Thedoseshouldbetitratedindividuallytoalevelthatcontrolspainwithno, ortolerablesideeffects.Alargerpatchshouldreplacethecurrentpatchoracombinationofpatchesmaybe worn. No dose adjustment required for renal impairmentorelderly patients but usewithcaution inpatients with hepaticimpairment.

Application Patchesshouldbeappliedtorelativelyhairfree,nonirritated,intactskinonupperouterarm,upperchestor upperback. Ifa hair free site is unavailable, thehairat thesite shouldbecut withscissorsand not shaved. Patchesshouldbeworncontinuouslyforsevendaysincludingduringbathing,showeringetc,ifpatchfallsoffa newpatchshould beapplied.Thesameskinsiteshouldnotbeusedforthreetofourweeksfollowingremoval. Amaximumoftwopatchescanbeappliedatanyonetime. GuidelinesforapproximatedoseequivalentsofBuTranspatchesandotheroralopioidanalgesics Buprenorphine 5g/hr Buprenorphine 10g/hr Buprenorphine patch patch 20g/hrpatch Tramadol Codeine Dihydrocodeine 50mg/day 30 60mg/day 60mg/day 50100mg/day 60120mg/day 60120mg/day 100150mg/day 120180mg/day 120180mg/day

Buprenorphine(Transtec)patchesreleasing35g/hr,52.5g/hrand70g/hr Indicationsforuse:moderatetoseverecancerpainandseverepainunresponsivetononopioidanalgesics. Application Adultsover18,applytodry,nonhairyskinonuppertorso(anyhairsshouldbecutwithscissorsratherthan shaved),removingafternolongerthan 96hours andsitingreplacementpatchonadifferentarea(avoidsame areaforateastsixdays).Forconvenienceofusethepatchescanbechangedtwiceaweekatregularintervals e.g.alwaysonMondaymorningandThursdayevening.Patientsforwhomapatchisappropriateandhavenot previouslyreceivedastrongopioidanalgesicbutwhohaveprogressedthroughsteps1and2oftheWHOpain ladder, www.who.int/entity/cancer/palliative/painladder/en, should be started on the 35g/hr patch. For patients who have received strong opioid analgesia, the dose should be based on previous 24 hour opioid requirement.Seetablebelow. Whenstarting,analgesiceffectshouldnotbeevaluateduntilthepatchhasbeenwornfor24hours(toallow for gradual increase in plasma Buprenorphine concentration). If necessary the dose should be adjusted at intervals of no longer than 96 hours using a patch of the next strength or using two patches of the same strengthappliedatthesametimetoavoidconfusion. Maximumoftwopatchestobeusedatthesametime. Breakthrough(asrequiredprn)dosesofanalternativeanalgesicmayberequired. Afterremovalofapatch,Buprenorphineconcentrationsdecreasegraduallyandsoanalgesiaismaintainedfor acertainamountoftime.Asageneralrule,asubsequentopioidshouldnotbeadministeredwithin24hours ofremovalofpatch.

GuidelinesforapproximatedoseequivalentsofTranstecpatchesandotheropioidanalgesics Pretreatmentwithopioids(mg/24hours) Transtec 35g/hr Weakopioids Codeine Dihydrocodeine Tramadol Strongopioids Morphine,parenteral Morphine,oral Transtec 52.5g/hr Transtec 70g/hr Transtec 2x 70g/hr

180240mg/24hours 120240mg/24hours 150400mg/24hours 1020mg/24hours 3060mg/24hours 30mg/24hours 90mg/24hours 40mg/24hours 120mg/24hours 80mg/24 hours 240mg/24

Fentanylpatches Oralmorphineistheopioidoffirstchoiceformoderatetoseverepain.Withdosetitrationasuitablelevelof analgesia can usually be achieved. For patients unable to take oral morphine alternative analgesia is by injectionorthetransdermalroute. Fentanylpatchesshouldbereservedforpatientswithstablepainwhoarealreadyonstrongopioidsandare unabletotolerateoralmedications. Factorstoconsider Itusuallytakes3648hourstoachievesteadystateplasmaconcentration,duringwhichtimeother analgesiccoverwillberequired Onceapatchhasbeenremoveddrugeliminationoccursslowlyandsignificantbloodlevelspersist foratleast24hours Theyareinappropriateforunstableandacutepain Fatalitiesandlifethreateningadverseeffectshavebeenreportedwithincorrectuseoftransdermal Fentanyl.Patientsshouldbecounselledoncorrectpatchapplicationanddose Fentanylpatchesareavailableas12g/hr,25g/hr,50g/hr,75g/hrand100g/hr. Fentanylpatchesareindicatedforchronicintractablepain(malignantornonmalignant). A25g/hrpatchisequivalenttoapproximately90mgoralmorphine/24hours Application Thepatchisappliedtodry,nonirritated,nonhairyskinontorsoorupperarm.Thepatchshouldberemoved after 72 hoursandsitedonadifferentarea(avoidusingthesameareaforseveraldays). The strength of the initial Fentanyl patch should be based on the patients previous 24 hour opioid requirement and thegeneral condition ofthepatient. Calculate thedose from theconversion chart orseek advice.Allequivalentdosesareapproximate. StartingaFentanylpatch Doseconversions Conversionoforalmorphine/IMMorphinetoFentanylpatch(alldosesareapproximate) Total24houroralmorphinemg 60134 135224 225314 315404 Total24 hourIMMorphinemg 1022 2337 3852 5367 Fentanylpatchg/hour 25 50 75 100

Makesurethepatienttakesanotherregularanalgesicforthefirst12hoursafterthepatchisfirstappliedto allowtheFentanyltoreachtherapeuticlevels. Previousanalgesia Immediaterelease (quickacting)morphine

Apply patch; continue the immediate release opioid4hourlyforthenext12hours Modified release (long acting) 12 hourly Apply patch when the last dose of a 12 hourly, morphine modifiedreleaseopioidisgiven Subcutaneous infusion of morphine or Applythepatchandcontinuetheinfusionforthe diamorphine next12hours,thenstoptheinfusion

An immediate release opioid (e.g. oral morphine or morphine SC) must be available as required for breakthroughpain. Review the Fentanyl patch dose after 72 hours when drug levels should be at a steady state. If the patient showssignsofopioidtoxicity(drowsiness,confusion)reducethedoseandreassessthepain. Ifthepatientstillhaspainwhichisopioidresponsive,titrate theFentanyldosein1225g/hrincrements.It willtake12 24hoursforthenewdosetotakeeffectsogivebreakthroughanalgesiaasrequired. References 1. 7dayBuprenorphinepatchforseverechronicpain,www.nelm.nhs.uk 2. Summaryofproductcharacteristics Transtecpatches.BuTranspatches.NappPharmaceuticals. 3. Accessedvia http://emc.medicines.org.uk 4. Guidelinesfor theuseoftransdermalopioids,CambridgeandHuntingdonpalliativecaregroup, www.arthurrankhouse.nhs.ukfactsheet5. 5. Principlesofpaincontrol.CambridgeandHuntingdonpalliativecaregroup. 6. www.arthurrankhouse.nhs.uk factsheet6. 7. Recommendationsfortheappropriateuseofopioidsforpersistentnoncancerpain http://www.britishpainsociety.org/opioids_doc_2004.pdf 8. Dorothyhouse/WessexpalliativecareHandbook,www.dorothyhouse.co.uk 9. Pharmacologicapproachestopainmanagement,www.endlink.lurie.northwestern.edu 10. Equianalgesicdoses,www.elmmb.nhs.uk 11. Analgesicschapter4.7BNF58,www.bnf.org

Approvedby3TsFormularyWorkingGroup: June2011 ReviewDate: June2014 Numberofpages:4

ThisGuidelinehasbeenadaptedfrom theBCAP: TransdermalPatchGuidance,November2009.