What does it mean to give the last dose of scheduled hydromorphone (Hydromorphone) in place of the fentanyl (Fentanyl) 12 microgram (mcg) patch when initiating fentanyl patch therapy for chronic pain management?

From the Guidelines

When initiating fentanyl patch therapy for chronic pain management, it is recommended to give the last dose of scheduled hydromorphone in place of the fentanyl 12 microgram (mcg) patch to ensure a smooth transition and minimize the risk of undertreating pain or causing opioid overdose. This approach is supported by the CDC clinical practice guideline for prescribing opioids for pain, which emphasizes the importance of careful dosing and transitioning between opioids to minimize the risk of overdose and other adverse events 1.

Key Considerations

• The fentanyl patch takes approximately 12-24 hours to reach therapeutic blood levels, and giving the last dose of hydromorphone concurrently with patch application provides pain coverage during this initial period 1.
• The overlap strategy prevents a gap in pain control that could occur if hydromorphone were stopped before the fentanyl became effective.
• The relatively low starting dose of fentanyl (12 mcg/hour) helps reduce the risk of respiratory depression during this transition period when both medications are present in the system.
• Clinicians should use caution when prescribing ER/LA opioids, such as fentanyl, and consider the potential for increased overdose risk, especially in patients with renal or hepatic dysfunction 1.

Clinical Evidence

• A fair-quality study demonstrated a higher risk for overdose among patients treated with ER/LA opioids than among those treated with immediate-release opioids, especially within the first 2 weeks of therapy 1.
• The CDC guideline recommends that ER/LA opioids be reserved for management of pain severe enough to require daily, around-the-clock, long-term opioid treatment when alternative treatment options are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain 1.

Recommendations

• Clinicians should not treat acute pain with ER/LA opioids or initiate opioid treatment for subacute or chronic pain with ER/LA opioids, and clinicians should not prescribe ER/LA opioids for intermittent use 1.
• When changing to an ER/LA opioid for a patient previously receiving a different immediate-release opioid, clinicians should consult product labeling and reduce total daily dosage to account for incomplete opioid cross-tolerance 1.

From the FDA Drug Label

Fentanyl transdermal system is ONLY for use in patients who are already tolerant to opioid therapy of comparable potency. The efficacy of fentanyl transdermal system 12 mcg/hr as an initiating dose has not been determined In addition, patients who are not opioid-tolerant have experienced hypoventilation and death during use of fentanyl transdermal system. To convert patients from oral or parenteral opioids to fentanyl transdermal system, use Table C: TABLE C* DOSE CONVERSION GUIDELINES Current AnalgesicDaily Dosage (mg/d) Oral hydromorphone 8-17 17.1-28 28.1-39 39.1-51 IV hydromorphone 1.5-3.4 3.5-5.6 5.7-7. 9 8-10 Recommended Fentanyl Transdermal System Dose 25 mcg/hr50 mcg/hr75 mcg/hr100 mcg/hr

Giving the last dose of scheduled hydromorphone in place of the fentanyl 12 microgram (mcg) patch when initiating fentanyl patch therapy for chronic pain management is not directly addressed in the provided drug label.

• The label provides guidelines for converting patients from other opioids, including hydromorphone, to fentanyl transdermal system using Table C.
• However, it does not explicitly state what it means to give the last dose of scheduled hydromorphone in place of the fentanyl 12 mcg patch.
• The label emphasizes the importance of using fentanyl transdermal system only in patients who are opioid-tolerant and provides guidelines for dose conversion and titration.
• It is essential to follow the recommended guidelines and consult the label or a healthcare professional for specific guidance on initiating fentanyl patch therapy 2.

From the Research

Initiating Fentanyl Patch Therapy

When initiating fentanyl patch therapy for chronic pain management, giving the last dose of scheduled hydromorphone in place of the fentanyl 12 microgram (mcg) patch is a strategy that may be considered.

Rationale

• The rationale behind this approach is to minimize the risk of opioid-induced respiratory depression, which is a significant concern with fentanyl due to its high potency 3, 4.
• Fentanyl has been shown to have a greater risk of causing respiratory depression compared to other opioids, such as hydromorphone 3.
• Hydromorphone, on the other hand, is considered a safer alternative to fentanyl, with a lower risk of abuse and respiratory depression 3, 5.

Considerations

• When switching from hydromorphone to fentanyl, it is essential to consider the equipotent doses of each medication to avoid overdose and respiratory depression 4.
• The use of fentanyl patches, in particular, requires careful consideration of the patient's medical history, including renal function and the presence of central nervous system depressants, which can increase the risk of respiratory depression 6, 7.
• Close monitoring of the patient's respiratory function and adjustment of the opioid dose as needed are crucial to preventing life-threatening respiratory depression 6, 7.