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]:
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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: |
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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. |
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