Letter to the editor: Subcutaneous sufentanil for palliative care patients in a hospital setting

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Palliative Medicine
2008; 22: 89–90
© 2008 SAGE Publications, Los Angeles, London, New Delhi and Singapore 10.1177/0269216307085177
Subcutaneous sufentanil for palliative care
patients in a hospital setting
Sir – Sufentanil is a highly lipophilic synthetic opioid anal-
gesic. It is one of the anilinoperidone analogues in the same
class as fentanyl, alfentanil and remifentanil. These
‘lipophilic opioids’ are more potent than morphine, have a
more rapid onset of action and are shorter acting. Sufentanil
is the most lipid soluble and most potent opioid in the
class. It is normally delivered parenterally, or as a neuraxial
analgesic,
1
but can be delivered via the transmucosal and
intranasal routes.
2,3
Sufentanil has been used for break-
through analgesia in palliative care,
4
but there is limited data
on its use by continuous subcutaneous infusion (CSCI).
5
We
describe our experience in the use of sufentanil delivered by
CSCI to patients with advanced malignant disease in a hos-
pital palliative care setting.
Forty-eight patients who had received sufentanil over a
three-year period were identified through hospital pharmacy
records. Prior to starting sufentanil, all patients had been
receiving other opioids, most commonly fentanyl or mor-
phine. The most common reasons for switching to sufentanil
were CSCI volume limitations, toxicity, renal impairment or
inadequate pain control. The majority of patients had some
degree of renal impairment at the time of opioid rotation to
sufentanil. The effect on pain control following titration was
generally described as favourable, but no formal efficacy or
toxicity measures were undertaken. Many different drugs
including clonazepam, cyclizine, glycopyrrolate, haloperidol,
hyoscine, ketamine, methadone, methotrimeprazine, meto-
clopramide, midazolam and octreotide were used in combina-
tion with sufentanil with no incompatability observed.
The starting dose of sufentanil ranged from 15 to
600 mcg/24 h (median 95 mcg/24 h). The dose of sufentanil
was increased in 50%, decreased in 10% and remained the
same in 38% patients. The median final dose was
130 mcg/24 h (range 15–700 mcg/24 h). Twenty patients
(42%) received sufentanil until death and nine patients
(19%) were discharged to another care setting on sufentanil.
In the patients that remained in hospital, the median duration
of sufentanil infusion was four days (range 1–14 days).
The relative analgesic potency of sufentanil against other
opioids has been assessed in a number of studies. Although
generally said to be ~10 times more potent than fentanyl,
1
other relative fentanyl: sufentanil ratios reported in the liter-
ature across a number of settings range from about 5:1 to
24:1.
5,6
In this series, the median fentanyl: sufentanil conver-
sion ratio in patients previously receiving fentanyl at the
time of conversion was 10:1 (range 2.5:1–20:1). When all
patients are considered and all opioids converted to fentanyl
equivalent doses, the median conversion ratio was 11:1
(range 2.5–24:1). One ‘rule of thumb’ when switching from
morphine to sufentanil is to give 50% of the total daily dose
of oral morphine in mgs as sufentanil in mcgs (ie, 100 mg
oral morphine/day would be converted to 50 mcg sufentanil
given via a CSCI over 24 h). This equates to a fentanyl:
sufentanil ratio of 13:1 and may be too conservative.
Unlike many other opioids, the lipophilic opioids are not
dependent on renal function for elimination and are probably
less efficient at inhibiting bowel transit time than other
opioids that are not as lipid soluble.
7
It is usual practice on
our unit to utilize these opioids in patients with bowel
obstruction or abnormal renal function and/or within the con-
text of opioid rotation. All the lipophilic opioids are known to
accumulate in fat tissue. This results in delayed clearance of
the drug following removal of a transdermal patch or discon-
tinuation of an infusion. We therefore recommend caution
when rotating from sufentanil to another opioid.
An advantage of sufentanil is its relative potency in a con-
centrated volume. The dose of fentanyl that can be given via
a CSCI is limited by dose/volume restrictions. Sufentanil
offers a practical alternative to fentanyl at doses exceeding
750 mcg (ie, 15 mLs) when delivered over 24 h in a standard
Graseby infusion device.
Our experience has been that sufentanil is a useful opioid
when considering opioid rotation, especially in patients with
renal impairment. We have found it safe and effective to use
in a syringe driver in combination with a number of other
drugs commonly delivered by CSCI. This drug is more
expensive than other opioids. We would recommend referral
to specialist palliative care or pain teams rather than routine
use by generalists.
Clare White
Macmillan Specialist Registrar
in Palliative Medicine
Mater Adult Hospital, Brisbane
Letter to the editor
Address for correspondence: Clare White, Macmillan Specialist
Registrar in Palliative Medicine, Royal Group of Hospitals, Belfast,
Northern Ireland.
E-mail: clarewhite100@hotmail.com
Current Address: Clare White, Royal Group of Hospitals, Belfast, UK.
Current Address: Anthony Hall, High Risk Medications & Systems,
Safe Medication Practice Unit, Queensland Health, Brisbane,
Australia.

90 Letter to the editor
Janet Hardy
Director of Palliative Care
Mater Health Services
Brisbane
Alice Boyd
Medical Resident
Mater Adult Hospital
Brisbane
Anthony Hall
Clinical Pharmacist
Palliative Care and Assistant
Director of Pharmacy Mater Health Services
Brisbane
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