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Guidelines for opioid rotation

Guidelines for opioid rotation
Step 1:
Consider opioid rotation as a strategy to address the scenario of poor opioid responsiveness following dose titration.
The decision about the drug to which the patient is switched is empirical, based on prior experience of the patient and physician, availability, cost, and other factors.
When the new drug is selected, calculate the equianalgesic dose from an equianalgesic dose table.
If switching to any opioid other than methadone or fentanyl, identify an "automatic dose reduction window" equal to a reduction of 25 to 50% below the calculated equianalgesic dose.
If switching to methadone, expert recommendations are available for the appropriate conversion ratio[2]:
  • For patients receiving <60 mg oral morphine per day or equivalent (OME), the initial methadone dose should be no more than 7.5 mg oral methadone daily (eg, 2.5 mg three times daily).
  • For patients receiving 60 to 199 mg OMEs and <65 years of age, use a 10:1 conversion (ie, 10 mg OME:1 mg oral methadone).
  • For patients receiving ≥200 mg OME and/or patients >65 years of age, use a 20:1 conversion (ie, 20 mg OME:1 mg oral methadone).
  • These and other guidelines also recommend converting to a methadone dose no greater than 30 to 40 mg per day, regardless of the previous opioid dose[1].
If switching to transdermal fentanyl, do not do an automatic dose reduction and use the calculated equianalgesic dose included in the FDA-approved manufacturer's labeling for these formulations.
Select a dose closer to the lower boundary (25% reduction) or the upper boundary (50% reduction) of the "automatic dose reduction window" on the basis of a clinical judgment that the equianalgesic dose table is relatively more or less applicable, respectively, to the specific characteristics of the opioid regimen or patient:
  • Select a dose closer to the upper boundary (50% reduction) of the reduction if the patient is receiving a relatively high dose of the current opioid regimen, is of Asian descent, or is elderly or medically frail.
  • Select a dose closer to the lower boundary (25% reduction) of the reduction if the patient does not have these characteristics or is undergoing a switch to a different route of systemic drug administration using the same drug.
Step 2:
After the initial doses, assess response and titrate the dose of the new opioid regimen to optimize outcomes. If switching to methadone, the dose should not be increased before five to seven days, and should not be increased by more than 5 mg per day up to 30 to 40 mg per day, and then can be increased by 10 mg per day (after five to seven days)[2].
If a supplemental "rescue dose" is used for titration, calculate this at 5 to 15% of the total daily opioid dose and administer at an appropriate interval; an exception are the oral transmucosal fentanyl formulations, which should be initiated at one of the lower available doses irrespective of the baseline opioid dose.
EKG: electrocardiogram; FDA: Food and Drug Administration.
References:
  1. Chou R, Cruciani RA, Feillen DA, et al. Methadone safety: a clinical practice guideline for the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society J Pain 2014; 15:321.
  2. McPherson ML, Walker KA, Davis MP, et al. Safe and appropriate use of methadone in hospice and palliative care: Expert consensus white paper. J Pain Symptom Manage 2019; 57:635.
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