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Opioid switching – are conversion tables still up to date?

Conversion factors for Transtec® need to be revised

Aachen, Germany, 15 December, 2006. Switching between different

opioids is frequently used in patients with chronic pain either to improve
pain relief, or as a way of reducing adverse effects. Determining the
correct dosage of each opioid relies on the use of conversion tables
which reflect the potency of each drug. As a result of recent experimental
and clinical studies it has been realised that previous estimates of the
®
potency of Transtec may be too low.

Conversion tables can only provide a rough guide to indicate the required dose
of the alternative drug as the response of individuals to different analgesics
varies and is unpredictable. Clinicians need to make a comprehensive
evaluation of the individual patient rather than relying on mathematical
calculations alone. No equianalgesic table is totally reliable and the fact that
different tables sometimes display different equivalencies leads to questioning
their validity.

New data suggest that transdermal buprenorphine is more potent than

previously suggested

Recent studies have challenged traditional conversion ratios. The equipotency

ratio for transdermal buprenorphine to oral morphine has previously been
established as being 1:75, while that for transdermal fentanyl to oral morphine
has been shown to be 1:100.

Recent results from a study of patients with chronic cancer and non-cancer
pain1 have suggested that a conversion factor for transdermal buprenorphine
vs oral morphine of 1:100 to 1:115 may be more appropriate, virtually indicating
®
equiptency for Transtec and transdermal fentanyl.

A further study of patients switching from high dose morphine to transdermal

buprenorphine2 found 80% of patients previously treated with ≥ 120 mg/day
oral morphine achieved satisfactory pain relief when switched to the 52.5μg/h
®
Transtec patch. This patch provides 1.2 mg of buprenorphine per day further
confirming the new equipotency ratio of 1:100.

Contact: Anke Krüger-Hellwig

Phone: +49 241 569-2858, Fax: +49 241 569-1486, anke.krueger-hellwig@grunenthal.com
Grünenthal GmbH, 52099 Aachen, Germany, www.grunenthal.com
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The equianalgesic effect of transdermal buprenorphine and transdermal

fentanyl has been demonstrated using an experimental pain model in humans3.
This randomised, double-blind, placebo controlled study demonstrated that
both drugs given alone at the same dosage induced the same analgesic effect.
A combination of both opioids resulted in an additive analgesic effect.
®
The higher than expected potency of Transtec may in part be explained by the
unique pharmacological profile of buprenorphine. Unlike some other opioids,
buprenorphine shows good efficacy in neuropathic pain which may explain why
®
Transtec shows potent analgesia in clinical practice in mixed pain states. In
addition, buprenorphine has an antihyperalgesic profile, in contrast to some
opioids that can unexpectedly even provoke hyperalgesia3.
These findings indicate that values given in opioid conversion tables for the
potency of transdermal buprenorphine should be revised.

About conversion tables

Conversion tables are used as a rough guide to determine equipotent dosage
and ensure that different opioids can be successfully used, either together or
consecutively. The accuracy of these tables may be questionable since they
may not be capable of reflecting the multitude of factors, e.g. type of pain,
individual response, co-morbidities, concomitant drugs and others which must
be considered when treating patients with chronic pain. In case of opioid switch
each patient has to be considered individually and it is usually recommended to
start with a comparably low dose and to titrate up to the optimal dose
(maximum effect with minimum of side effects) in order to ensure safe and
optimal pain relief.

About Grünenthal
Grünenthal researches, develops and produces high therapeutic value
medicines and markets them throughout the world. Grünenthal is an expert in
drugs for pain therapy and gynecology and a leader in the field of intelligent,
user-friendly drug delivery technologies. Grünenthal is an independent, family-
owned company with a long history of international co-operations. The
company was founded in 1946 and has its headquarters in Germany. We
supply our markets from seven production sites around the world and have
affiliates in 27 countries. Grünenthal employs about 1,900 people in Germany
and about 4,700 world-wide. Sales in 2005 amounted to approximately 777
million Euro.

Contact: Anke Krüger-Hellwig

Phone: +49 241 569-2858, Fax: +49 241 569-1486, anke.krueger-hellwig@grunenthal.com
Grünenthal GmbH, 52099 Aachen, Germany, www.grunenthal.com
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References

1
Sittl R., Likar R., Poulsen Nautrup B.: Equipotent doses of transdermal fentanyl
and transdermal buprenorphine in cancer and non-cancer patients: results of a
retrospective cohort study. Clin Ther. 2005 ; 27 (2): 225-237.
2
Sittl R.: Transdermal buprenorphine in cancer pain and palliative care.
Palliative Medicine 2006 ; 20; Supplement 1: s25-s30.
3
Tröster A., Singler B., Sittl R., et al: Quantification of the analgesic and anti-
hyperalgesic effects of buprenorphine and fentanyl in a healthy volunteer
model of electrically evoked pain. Poster presentation at the 3rd WIP Congress,
Barcelona 2004.

Contact: Anke Krüger-Hellwig

Phone: +49 241 569-2858, Fax: +49 241 569-1486, anke.krueger-hellwig@grunenthal.com
Grünenthal GmbH, 52099 Aachen, Germany, www.grunenthal.com