Skip to main content
  1. Right Decisions
  2. Scottish Palliative Care Guidelines
  3. Back
  4. Medicine information
  5. Alfentanil
Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

Alfentanil

Red – For medicines normally initiated and used under specialist guidance

Introduction

Description: Potent opioid, rapid onset and short duration of action.

Third-line opioid: only for use with specialist advice.

Caution: Do not confuse with Fentanyl. Fentanyl is four times more potent than alfentanil. 

Preparations

Tables are best viewed in landscape mode on mobile devices

Injection

1mg in 2ml
5mg in 10ml (not routinely used)

5mg in 1ml (high strength)

Ampoules
  • Used as a subcutaneous infusion or sublingually. (The ampoules can be opened and administered sublingually ⴕ).
  • A high concentration preparation (5mg in 1ml) can be ordered.

Caution with high strength preparation; refer to local policy for its use.

Sublingual/
buccal spray

5mg/5ml (1 metered dose = 140 micrograms)

5ml spray

Pharmacist can order spray on a named patient basis if advised by a palliative care specialist (check local NHS board for availability).

 

Indications

  • Third-line injectable opioid for moderate to severe opioid responsive pain in patients unable to tolerate morphine, diamorphine or oxycodone due to persistent side effects (for example sedation, confusion, hallucinations, itch). Refer to Pain management, Choosing and changing opioids guidelines.
  • Injectable analgesic for moderate to severe, opioid responsive pain in patients with Stage 4 to 5 chronic kidney disease (eGFR less than 20ml/min) although specialists may recommend earlier, or severe acute renal impairment.
  • Episodic/incident pain:
    • pain often related to a particular event (for example movement, dressing changes); sudden in onset, can be severe, but may not last long
    • different from breakthrough pain occurring when the dose of regular analgesic has worn off
    • assessed and treated independently of the regimen used to manage any continuous/background pain. 

 

Cautions

  • Liver impairment: reduced clearance.
    Dose reduction of 30 to 50% may be necessary.
  • Renal impairment: no dose reduction needed.
    Not removed by dialysis.

Drug interactions

  • Hepatic metabolism is reduced by grapefruit juice and a number of medications, for example fluconazole, QTclarithromycin, QTerythromycin: refer to British National Formulary (BNF).
  • Alcohol and central nervous system depressants increase side effects
  • Anticonvulsants may reduce its effect. Refer to BNF.

Side effects

Similar to other opioids: nausea, dizziness, sedation, delirium, rarely respiratory depression.

 

Dose and administration

  1. Alfentanil for moderate to severe opioid responsive pain
    • Continuous subcutaneous infusion in a CME T34 syringe pump over 24 hours.
    • Stability and compatibility – refer to CME T34 syringe pump compatibility tables.
    • Titrate on the advice of a specialist.
    • Prescribe doses of over 1000micrograms in milligrams (mg).
    • Prescribe 1/6th to 1/10th of the 24 hour dose hourly for breakthrough pain as alfentanil has a very short duration of action. The same dose can be given subcutaneously or sublingually. Sometimes other opioids with a longer duration of action are used for breakthrough pain.  If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review.  If more than 6 doses are required in 24 hours seek advice or review.

  2. Alfentanil for episodic/ incident pain
    • Starting dose: 100micrograms.
    • Give a dose five minutes before an event likely to cause pain, for example, a painful dressing change; repeat if needed.
    • Increase dose according to response.  This dose is titrated independently of the background dose.
    • Give by subcutaneous injection or sublingually at the same dose.
    • Consider an alfentanil spray if the patient is being discharged home (check local health board for availability).

 

Dose conversions

Alfentanil is approximately (≈) 30 times more potent than oral morphine.

Tables are best viewed in landscape mode on mobile devices

Oral morphine 30mg

≈ subcutaneous alfentanil 1mg (1000micrograms)

Subcutaneous morphine 15mg

≈ subcutaneous alfentanil 1mg (1000micrograms)

Subcutaneous diamorphine 10mg

≈ subcutaneous alfentanil 1mg (1000micrograms)

Oral oxycodone 15mg

≈ subcutaneous alfentanil 1mg (1000micrograms)

Subcutaneous oxycodone 7.5mg

≈ subcutaneous alfentanil 1mg (1000micrograms)

 

A patient whose pain is controlled on a subcutaneous alfentanil infusion can be converted to a fentanyl patch. Apply the patch and stop the infusion 12 hours later. Seek advice for dose conversions as cross titration may be necessary.

  • Dose conversions should be conservative and doses rounded down.
  • Monitor the patient carefully so that the dose can be adjusted if necessary.
  • If the patient has opioid toxicity, reduce dose by approximately 1/3rd when changing opioid (refer to Choosing and changing opioids guideline).

 

Practice points

  • The community pharmacist, GP and community nurse should be informed as preparations may not be readily available.
  • The unscheduled care service should be informed that the patient is receiving this third-line opioid.
  • Alfentanil can be prescribed by the patient’s GP for the indications listed in liaison with local palliative care specialists.

 

Resources

Professional
Royal Pharmaceutical Society. Palliative Drugs. 2018 [cited 2018 Oct 02]; Available from: http://www.palliativedrugs.com/.

 

References

Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):497-504.

Urch CE, Carr S, Minton O. A retrospective review of the use of alfentanil in a hospital palliative care setting. Palliat Med. 2004;18(6):516-9.