BNF for Children 2011-2012

206 4.7.2 Opioid analgesics BNFC 2011–20124 Central nervous systemDF 118 Forte c (Martindale) ATablets, dihydrocodeine tartrate 40 mg, net price 100-tab pack = £11.51. Label: 2DoseSevere pain. By mouthChild 12–18 years 40–80 mg 3 times daily; max. 240 mgdailyModified releaseDHC Continus c (Napp) ATablets, m/r, dihydrocodeine tartrate 60 mg, net price56-tab pack = £5.18; 90 mg, 56-tab pack = £8.66;120 mg, 56-tab pack = £10.89. Label: 2, 25DoseChronic severe pain. By mouthChild 12–18 years 60–120 mg every 12 hoursWith paracetamolSection 4.7.1FENTANYLCautions see notes above; also diabetes mellitus,impaired consciousness, cerebral tumour, myastheniagravis, see also Transdermal Fentanyl, belowContra-indications see notes aboveHepatic impairment see notes aboveRenal impairment see notes abovePregnancy see notes aboveBreast-feeding monitor infant for opioid-inducedside-effectsSide-effects see notes above; also abdominal pain,dyspepsia, diarrhoea, gastro-oesophageal reflux disease,stomatitis, anorexia, hypertension, vasodilatation,dyspnoea, aesthenia, myoclonus, anxiety, tremor,appetite changes, rhinitis, pharyngitis, paraesthesia,application-site reactions; less commonly ileus, flatulence,hypoventilation, impaired concentration,impaired coordination, amnesia, speech disorder,malaise, seizure, pyrexia, thirst, blood disorders(including thrombocytopenia), chills; rarely hiccups,very rarely arrhythmia, apnoea, haemoptysis, ataxia,delusions, bladder painIndication and doseSevere chronic pain. By transdermal routeChild 2–16 years currently treated with strongopioid analgesic, initial dose based on previous 24-hour opioid requirement (consult product literature)Child 16–18 years child not currently treatedwith strong opioid analgesic (but see TransdermalFentanyl, below), one ‘12’ or ‘25 micrograms/hour’patch replaced after 72 hours; child currentlytreated with strong opioid analgesic, initial dosebased on previous 24-hour opioid requirement(consult product literature)Dose adjustment When starting, evaluation of theanalgesic effect should not be made before the systemhas been worn for 24 hours (to allow for the gradualincrease in plasma-fentanyl concentration)—previousanalgesic therapy should be phased out gradually fromtime of first patch application; if necessary dose shouldbe adjusted at 48–72-hour intervals in steps of 12–25 micrograms/hour. More than one patch may be usedat a time (but applied at same time to avoid confusion)—consider additional or alternative analgesic therapy ifdose required exceeds 300 micrograms/hour (important:it may take up to 25 hours for the plasma-fentanylconcentration to decrease by 50%—replacement opioidtherapy should be initiated at a low dose and increasedgradually).Long duration of action In view of the long duration ofaction, children who have had severe side-effects shouldbe monitored for up to 24 hours after patch removalBreakthrough pain and premedication analgesia,see under preparation belowPeri-operative analgesia section 15.1.4.3Conversion (from oral morphine to transdermal fentanyl),see Prescribing in Palliative Care, p. 18Administration For patches, apply to dry, non-irritated,non-irradiated, non-hairy skin on torso or upperarm, removing after 72 hours and siting replacementpatch on a different area (avoid using the same areafor several days).LozengesActiq c (Flynn) 2Lozenge, (with oromucosal applicator), fentanyl (ascitrate) 200 micrograms, net price 3 = £17.52, 30 =£175.16; 400 micrograms, 3 = £17.52, 30 = £175.16;600 micrograms, 3 = £17.52, 30 = £175.16; 800 micrograms,3 = £17.52, 30 = £175.16; 1.2 mg, 3 = £17.52,30 = £175.16; 1.6 mg, 3 = £17.52, 30 = £175.16.Label: 2DoseBreakthrough pain. By transmucosal application (lozenge withoromucosal applicator)Child 16–18 years initially 200 micrograms (over 15minutes) repeated if necessary 15 minutes after first dose(no more than 2 dose units for each pain episode); ifadequate pain relief not achieved with 1 dose unit forconsecutive breakthrough pain episodes, increase thestrength of the dose unit until adequate pain reliefachieved with 4 lozenges or less dailyNote If more than 4 episodes of breakthrough pain eachday, adjust dose of background analgesicPatchesTransdermal fentanylFever or external heat Monitor patients using patchesfor increased side-effects if fever present (increasedabsorption possible); avoid exposing application site toexternal heat, for example a hot bath or sauna (mayalso increase absorption)Respiratory depression Risk of fatal respiratorydepression, particularly in patients not previouslytreated with a strong opioid analgesic; manufacturerrecommends use only in opioid tolerant patientsCounselling Patients and carers should be informedabout safe use, including correct administration anddisposal, strict adherence to dosage instructions, andthe symptoms and signs of opioid overdosage. Patchesshould be removed immediately in case of breathingdifficulties, marked drowsiness, confusion, dizziness, orimpaired speech, and patients and carers should seekprompt medical attention.Prescriptions Prescriptions for fentanyl patches can bewritten to show the strength in terms of the release rate andit is acceptable to write ‘Fentanyl 25 patches’ to prescribepatches that release fentanyl 25 micrograms per hour. Thedosage should be expressed in terms of the interval betweenapplying a patch and replacing it with a new one, e.g. ‘onepatch to be applied every 72 hours’. The total quantity ofpatches should be written in words and figures.Fentanyl (Non-proprietary) 2Patches, self-adhesive, fentanyl, ‘12’ patch (releasingapprox. 12 micrograms/hour for 72 hours), net price 5