Dosing considerations with transdermal formulations of fentanyl and buprenorphine for the treatment of cancer pain

Figures & data

Figure 1 Dosing algorithm for TD-Fe in the cancer patient.

Notes: Adapted from Skaer TL. Transdermal opioids for cancer pain. Health Qual Life Outcomes. 2006;4:24.²² Adapted from Breitbart W, Chandler S, Eagel B, et al. An alternative algorithm for dosing of transdermal fentanyl for cancer-related pain. Oncology (Williston Park). 2000;14(5):695–705.⁴³
Abbreviations: hr, hour; IR, immediate release; TD-Fe, transdermal fentanyl.

Figure 2 Examples of determining the appropriate initial fentanyl patch size.

Notes: Adapted from Skaer TL. Transdermal opioids for cancer pain. Health Qual Life Outcomes. 2006;4:24.²² Adapted from Breitbart W, Chandler S, Eagel B, et al. An alternative algorithm for dosing of transdermal fentanyl for cancer-related pain. Oncology (Williston Park). 2000;14(5):695–705.⁴³
Abbreviation: hr, hour.

Table 1 Recommended dosage conversion rates from morphine to other selected opioids for the treatment of cancer-related pain

Medication	Dosage*	Oral morphine equipotency
Morphine (mg/day)	1 [IM]; 3 [PO]	1:1
Oxycodone (mg/day)	40 [PO]	1.5:1
Hydromorphone (mg/day)	3 [IM]; 15 [PO]	4:1
TD-Fe (μg/hr)	25	100:1
TD-Bu (μg/hr)	35	75–100:1^

Notes:

* All patients must be stabilized on their previous opioid therapy prior to switching. Practitioners should take into account the clinical status of the patient when switching between various opioid medications;

^ non-cancer patients may require more conservative dosing of transdermal buprenorphine using a 100–110:1 equianalgesic ratio.^23,32–38

Abbreviations: IM, intramuscular; PO, oral; TD-Fe, transdermal fentanyl; TD-Bu, transdermal buprenorphine.

Table 2 Significant CYP3A interactions with transdermal opioids

CYP3A inhibitors

Amiodarone^

Chloramphenicol

Cimetidine

Ciprofloxacin

Clarithromycin^

Diltiazem^

Erythromycin^

Fluconazole^

Fluoxetine

Fluvoxamine

Gestodene

Indiavir

Itraconazole^

Ketoconazole^

Mibefradil

Mifepristone

Nefazodone

Nelfinavir

Norfloxacin^

Ritonavirb

Saquinavir

Telithromycin

Verapamil^

Voriconazole^

CYP3A inducers

Carbamazepine

Dexamethasone

Etavirenz

Modafinil

Nevirapine

Oxcarbazepine

Phenobarital

Phenytoin^

Rifabutin

Rifampin^

St John’s wort

Troglitazone^

Notes:

^ Most clinically significant with opioids. Adapted from Overholser BR, Foster DR. Opioid pharmacokinetic drug-drug interactions. Am J Manage Care. 2011;17(Suppl 11): S276–S287.⁵³

Abbreviation: CYP3A, cytochrome P450-3A.

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