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Transdermal pain management

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Presentation on theme: "Transdermal pain management"— 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 How transdermal fentanyl works How to use transdermal fentanyl
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 Mechanism of action µ-opioid receptor
fentanyl seletive opiods attenuate pain through mechanisms mediated by the mu receptor at the cellular level. The mu receptor acheivs this in 2 ways: decreasing intracellular cyclic AMP and inhibiting neuronal firing y decreasing membrane excitability

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

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 fentanyl Compounded 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 Opionds achieve their effect b yactivitating membrane bound receptors. The mu-reeptor is the major site for most medically-relevant opiod narcotics, just as fentanyl. Mu

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 Johns Hopkins opioid program –
Resources Johns Hopkins opioid program – Ken Latta, BS, RPh – Manager, Duke Compounding Facility

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