User:Amymyu/sandbox

Indications
There are no clinical guidelines outlining the use and implementation of opioid rotation. However, this strategy is commonly used for these various situations: pain not controlled by current opioid, pain controlled but in the presence of intolerable adverse events, pain not controlled despite rapid increase in opioid dose, switching to utilize different alternative routes of administration, or switching due to high cost of current opioid (or other patient-specific cost considerations).

to better control the pain or reduce the adverse effects (cognitive impairment, hallucinations, delirium, myoclonus, nausea, vomiting, constipation, and orthostatic hypotension). Doctors often need to switch from one opioid to another during treatment due to numerous reasons. The reasons for switch or rotation are inadequate pain relief with increasing dose, intolerable side effects, loss of route of administration, and cost. Rotation is used to obtain better analgesic effect that has been compromised by tolerance.

Opioid rotation is performed in the following conditions:

1. Pain intensity is greater than or equal to 4 (numerical scale from 0 to 10), despite the increasing dose of morphine;

2. Patient presents with myoclonus, hallucination or delusion;

3. Nausea and vomiting;

4. Oversedation;

5. Local toxicity;

6. Need for alternative routes;

7. High cost;

8. Non-acceptance by the patient.

The need to change opioid occurs in the following clinical conditions: (a) pain is controlled but the patient experiences intolerable adverse effects; (b) pain is not adequately controlled, but it is impossible to increase the dose due to adverse effects; (c) pain is not adequately controlled by rapid increasing the dose of opioids, although the drug does not produce adverse effects. This last point remains controversial, as further increasing doses could potentially allow achieving the appropriate analgesia. However, a rapid opioid escalation has been recognized as a negative factor for the clinical response.

Opioid dose escalation has yielded intolerable and unmanageable side effects, such as somnolence or mental clouding; Severe pain (often with emerging side effects) continues despite repeated dose escalations; There may be benefit in a switch to a different route of administration (e.g., transdermal rather than oral), or drug or formulation (e.g., a formulation with once-daily dosing); A change in clinical status suggests need for an opioid with different pharmacokinetic properties (e.g., a drug without active metabolites in the setting of progressive renal insufficiency); Cost considerations require a change in therapy.

The goal of opioid rotation is to avoid further unnecessary dose escalation and minimize potential adverse effects. The process begins with the selection of a safe and effective starting dose for the new opioid. The selection of a starting dose must be based on an estimate of the relative potency between the existing opioid and the new one. Potency, which is defined as the dose required to achieve a given effect, differs widely among opioids and among individuals under varying conditions. To rotate effectively from one opioid to another, the new opioid must be started at a dose that will cause neither toxicity nor physiological withdrawal symptoms and will be sufficiently efficacious to achieve meaningful pain relief.

However: opioid rotation could also be a cause of fatalities...

An increasing body of literature suggests that widely used opioid rotation practices, including the use of dose conversion ratios found in equianalgesic tables, may be an important contributor to the increasing incidence of opioid-related fatalities. These errors may be due, in part, not only to inadequate prescriber’s competence but also to proliferation of inconsistent guidelines for opioid rotation, conflation of equianalgesic tables as conversion tables, and limitations inherent in the pubequianalgesic dose tables.