From the FDA Drug Label
The majority of patients are adequately maintained with fentanyl transdermal system administered every 72 hours Some patients may not achieve adequate analgesia using this dosing interval and may require systems to be applied every 48 hours rather than every 72 hours. An increase in the fentanyl transdermal system dose should be evaluated before changing dosing intervals in order to maintain patients on a 72-hour regimen Dose Titration The recommended initial fentanyl transdermal system dose based upon the daily oral morphine dose is conservative, and 50% of patients are likely to require a dose increase after initial application of fentanyl transdermal system The initial fentanyl transdermal system dose may be increased after 3 days based on the daily dose of supplemental opioid analgesics required by the patient in the second or third day of the initial application Appropriate dosage increments should be based on the daily dose of supplementary opioids, using the ratio of 45 mg/24 hours of oral morphine to a 12. 5 mcg/hr increase in fentanyl transdermal system dose.
The options for escalating analgesia in patients with severe abdominal pain who have not responded to the first three steps of the World Health Organization (WHO) analgesia ladder include:
- Increasing the dose of the current opioid analgesic, such as fentanyl, after 3 days of initial application
- Changing the dosing interval of the current opioid analgesic, such as from every 72 hours to every 48 hours
- Adding a short-acting analgesic for breakthrough pain
- Considering alternative opioid analgesics, such as morphine or hydromorphone, using equianalgesic dose conversions Key points to consider when escalating analgesia include:
- Dose titration should be based on the daily dose of supplemental opioid analgesics required by the patient
- Appropriate dosage increments should be used to avoid overdosing the patient
- Close monitoring of the patient's pain and adverse effects is necessary when escalating analgesia 1
From the Research
For patients with severe abdominal pain not responding to the first three steps of the WHO analgesia ladder, regional anesthesia techniques, including epidural analgesia with local anesthetics combined with opioids, should be considered as a primary escalation option, as they can provide excellent pain relief, as supported by the most recent and highest quality study 2. When considering escalation options for analgesia in patients with severe abdominal pain, several factors should be taken into account, including the patient's medical history, current medications, and potential side effects.
- Interventional pain management techniques, such as nerve blocks (celiac plexus, splanchnic, or hypogastric plexus blocks), can provide targeted relief by interrupting pain pathways.
- Patient-controlled analgesia (PCA) pumps delivering opioids like morphine, hydromorphone, or fentanyl allow patients to self-administer medication within preset limits, improving pain control while reducing side effects.
- Ketamine infusions at sub-anesthetic doses (0.1-0.5 mg/kg/hr) can be effective for refractory pain through NMDA receptor antagonism.
- Regional anesthesia techniques, including epidural analgesia with local anesthetics (bupivacaine 0.0625-0.125%) combined with opioids, can provide excellent pain relief, as shown in a review of current evidence 2.
- For patients with malignancy-related pain, consider neurolytic procedures or intrathecal drug delivery systems.
- Adjuvant medications like gabapentinoids, antidepressants, or corticosteroids may enhance pain control. These advanced options should be implemented with close monitoring for side effects and regular reassessment of pain control, ideally through a multidisciplinary approach involving pain specialists, as they target different pain mechanisms and can provide relief when conventional approaches fail, as noted in a study on the use of analgesics in patients with acute abdominal pain 3.