Case Studies (February 2015)

Case 1

JD is a 76-year-old man diagnosed with stage 4 esophageal cancer. Over the past few months, his doctor has successfully managed his chronic cancer pain with extended-release oxycodone (Oxycontin) 30 mg twice daily. He has also been prescribed immediate-release oxycodone (Roxicodone) 15 mg every 4 hours, as needed, for breakthrough pain; he reports taking Roxicodone “nearly all the time.” Due to the progression of his cancer, it has become difficult for JD to swallow pills. His doctor would like to switch him to an extended-release fentanyl transdermal patch (Duragesic).

Is JD a candidate for the fentanyl patch? If so, what strength should be prescribed?

Written by Erica Bernardes, PharmD candidate; Diana M. Sobieraj, PharmD; and Craig I. Coleman, PharmD

Case 2

BM, a 28-year-old woman, is 6 weeks’ pregnant and has no significant medical history. She was recently diagnosed with iron-deficiency anemia, so her doctor would like her to start iron supplementation. She approaches the pharmacy consultation window with an OTC bottle of ferrous sulfate 325 mg. Her doctor instructed her to take 120 mg of iron, but she cannot find that strength.

How should the pharmacist respond?

Written by Erica Bernardes, PharmD candidate; Elizabeth S. Mearns, PharmD; and Craig I. Coleman, PharmD

ANSWERS

Case 1: The extended-release fentanyl transdermal patch is indicated for persistent chronic pain requiring around-the-clock opioid management. Due to the high potency and subsequent risk for respiratory depression with the use of fentanyl patches, they should only be used in patients already receiving opioid therapy and demonstrating opioid tolerance. Opioid tolerance is defined as taking at least 60 mg of morphine daily, 30 mg of oral oxycodone daily, 8 mg of oral hydromorphone daily, or an equianalgesic dose of another opioid for a week or longer. JD has been taking a total of 150 mg of oral oxycodone daily (60 mg of scheduled extended-release oxycodone plus 90 mg of as-needed immediate-release oxycodone) for a few months and is therefore a candidate for the fentanyl patch. When converting from other opioids to the fentanyl patch, it is important to remember that the package insert suggests a conservative initial strength based on the 24-hour amount of opioid currently used by the patient rather than equianalgesic dosing. The estimates are conservative to minimize the potential for overdose with the first dose. Per the package insert, JD’s proper starting dose is the 75 mcg/hr patch. Given the conservative conversion to the fentanyl patch, JD should also continue to receive a fast-acting opioid for breakthrough pain. Fentanyl citrate (Actiq) is an oral transmucosal lozenge with an initial dose of 200 mcg to treat episodes of breakthrough cancer pain. JD should take one 200-mcg lozenge for breakthrough pain, and if the pain is not relieved after 30 minutes, he may take only 1 additional dose for that episode. The dose should be titrated upward until he reaches a dose that provides adequate analgesia from a single Actiq lozenge per breakthrough pain episode. Until this dose is met, no more than 6 lozenges should be dispensed at a time in order to limit the number of units in the home during titration, and all units should be used before increasing to a higher dose in order to prevent confusion and possible overdose. Once a successful dose has been achieved, he should take no more than 4 lozenges daily. If he is experiencing more than 4 breakthrough pain episodes per day, the dose of the fentanyl patch should be reevaluated.

Case 2: For pregnant women with severe iron-deficiency anemia, the World Health Organization Guidelines for Iron Supplementation recommend a total of 120 mg of oral elemental iron per day for 3 months. Many forms of iron supplement preparations are available, and each preparation comes in various amounts of elemental iron, iron salts, and complexes. The 325 mg that BM sees on the bottle of ferrous sulfate does not reflect the amount of elemental iron provided. Each tablet of ferrous sulfate 325 mg contains only 65 mg of elemental iron; therefore, BM should take one 325-mg tablet every 12 hours daily. Iron supplementation should be taken in 2 equally spaced doses to maximize tolerability and increase the percentage of iron absorbed (less iron gets absorbed at higher doses). After completing 3 months of therapeutic supplementation, BM should continue with a preventive supplementation regimen of 60 mg of elemental iron (one 325-mg tablet) daily for 6 months.

Read the answers

Erica Bernardes is a PharmD candidate at the University of Connecticut School of Pharmacy. Dr. Sobieraj is assistant professor of pharmacy practice. Dr. Mearns is a health economics and outcomes research fellow at Hartford Hospital Evidence-Based Practice Center. Dr. Coleman is professor of pharmacy practice, as well as codirector and methods chief at Hartford Hospital Evidence-Based Practice Center, at the University of Connecticut School of Pharmacy.

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