title: The opioid rotation ratio of strong opioids to transdermal fentanyl in cancer patients.
abstract: BACKGROUND
  Transdermal fentanyl (TDF) is 1 of the most common opioids prescribed to patients with cancer. However, the accurate opioid rotation ratio (ORR) from other opioids to TDF is unknown, and various currently used methods result in wide variation of the ORR. The objective of this study was to determine the ORR of the oral morphine equivalent daily dose (MEDD) to the TDF dose when correcting for the MEDD of breakthrough opioids (the net MEDD) in cancer outpatients.
  
  
  METHODS
  The records of 6790 consecutive patients were reviewed at the authors' supportive care center from 2010 to 2013 to identify those who underwent rotation from other opioids to TDF. Data regarding Edmonton Symptom Assessment Scale scores and MEDDs were collected for patients who returned for a follow-up visit within 5 weeks. Linear regression analysis was used to estimate the ORR between the TDF dose and the net MEDD (the MEDD before opioid rotation [OR] minus the MEDD of the breakthrough opioid used along with TDF after OR).
  
  
  RESULTS
  In total, 129 patients underwent OR from other opioids to TDF. The mean patient age was 56 years, 59% were men, and 88% had advanced cancer. Uncontrolled pain (80%) was the most frequent reason for OR. In 101 patients who underwent OR and had no worsening of pain at follow-up, the median ORR from net MEDD to TDF (in mg per day) was 0.01 (range, -0.02 to 0.04), and the correlation coefficient of the TDF dose to the net MEDD was 0.77 (P < .0001). The ORR was not significantly impacted by body mass index or serum albumin. The ORR of 0.01 suggests that an MEDD of 100 mg is equivalent to 1 mg TDF daily or approximately 40 micrograms per hour of TDF (1000 micrograms/24 hours).
  
  
  CONCLUSIONS
  The median ORR from MEDD to TDF in mg per day was 0.01. These results warrant further studies.
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Akhila
authors.initials: A
authors.lastname: Reddy
authors.affiliation: Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Supakarn
authors.initials: S
authors.lastname: Tayjasanant
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Ali
authors.initials: A
authors.lastname: Haider
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Heung
authors.affiliation: Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Jimin
authors.initials: J
authors.lastname: Wu
authors.affiliation: Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Diane
authors.initials: D
authors.lastname: Liu
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Sriram
authors.initials: S
authors.lastname: Yennurajalingam
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Suresh
authors.initials: S
authors.lastname: Reddy
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Maxine
authors.initials: M
authors.lastname: de la Cruz
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Eden Mae
authors.initials: EM
authors.lastname: Rodriguez
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Jessica
authors.initials: J
authors.lastname: Waletich
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Marieberta
authors.initials: M
authors.lastname: Vidal
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Joseph
authors.initials: J
authors.lastname: Arthur
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Holmes
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Kimmie
authors.initials: K
authors.lastname: Tallie
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Angelique
authors.initials: A
authors.lastname: Wong
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Rony
authors.initials: R
authors.lastname: Dev
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Janet
authors.initials: J
authors.lastname: Williams
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bruera
mesh_terms: D000279:Administration, Cutaneous; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D004334:Drug Administration Schedule; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications* / Q000188:drug therapy; D010146:Pain / Q000188:drug therapy* / Q000209:etiology / Q000517:prevention & control; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D005283:Fentanyl
keywords: cancer pain; cancer patients; conversion ratio; fentanyl transdermal; morphine equivalent daily dose; opioid rotation; supportive care