Question for Pharmacist Steve

[satchelle]

Hello,

You have helped me in the past so I thought maybe you might have some thoughts on this:

I was just discharged from the hosp after an 8 day stay for a flare up of the chronic pancreatitis. I went by my PM office on my way home to get my RX. As you know the insurance will no longer cover the Actiq so my PM tried upping the base dose of the fentanyl patch that I get.

I was used to taking 100mcg of the patch as well as Actiq 600mcg 4x a day and Actiq 800 mcg 4 x a day. I also had dilaudid 2mg Q4 hrs as needed.

Now since hospitalization the PM cont to have me on the dilaudid 2mg Q 4 hrs, and has increased the fentayl patch to 125-150 mcg Q 48 hrs. Thats it!

In the hosp I was on the PCA pump and my settings were Dilaudid 1 mg/hour basal rate as well as every 6 minutes I could get an additional 0.5mg. As well as I could figure this was getting me about 6mg an hour which would be 24 mg every 4 hours. Now I can get 2 mg every 4 hours as well as 125-150mcg of fentanyl continuosly. Also in the hospital I was getting the fentanyl patch at 100 mcg Q 48 hours. They did a very quick weaning of the PCA (12 hrs) before I was discharged.

Now that I have been home for 3 days I am in agony. I was d/c'd on a Friday night so unable to call the office for any adjustments. They told me to give it at least a couple of days to see how it goes. To top it all off they had a PA filling in at the office who was clueless about my history.

I'm not a pharmacist but this seems a little extreme to try and be able to get comfortable from this in a 48 hour time frame. I plan to call bright and early in the morning, but I don't want to get stuck again having to wait 48 hours to give it a chance to work. What in your opinion would be a reasonable conversion giving what all I had been on to what I am currently getting now. I don't seem to be having any withdrawl type symptoms or problems, just the pain issue is about to do me in.

Any help would be appreciated, even those who are not pharmacist Steve. I know there are many knowledgable folks out there.

Thanks so much for your help

Satch

[satchelle]

for pharmacist Steve or anyone else who might have some good ideas!!!


Thanks

Satch

[Pharmacist.steve]

changing strengths of Fentanyl patches can take up to 14 days for the blood levels to stablize.. 50% of the increase should happen in the first 72 hrs. Basically the only two options are to let the patient suffer thru it or give them some oral B/T meds and allow them to dose as needed to get to an acceptable level of pain management while the fentanyl stablizes... Not all docs are comfortable with the second option.

Not knowing how much increased pain the flare up of the chronic pancreatitis caused.. which hopefully has now pulled back... trying to get from where you started and what was given to you during the flare and to where you should be now .. would be nothing more than a bad educated guess.

My guess is that you are going to have to be re-titrated.. using a dose of fentanyl patches for 14 days or so and using short acting opiates for break thru as needed.. then up the fentanyl patch dose and start all over again until you get to a fentanyl dose that manages your pain with B/T meds at a minimum