Transdermal medication patches can offer a non-invasive option of medication delivery for patients who are unable to swallow oral formulations. Several common medications for symptom management in hospice and palliative care are available in the form of transdermal patches (Table 1). Compared to other dosage forms, transdermal patches can offer the benefit of steady, controlled medication delivery and less frequent medication administration, often with fewer adverse effects. Patients and caregivers generally consider patches to be an easy form of medication administration.
Transdermal medication patches deliver medication directly into the bloodstream, bypassing the digestive system. This can increase medication bioavailability by eliminating the “first pass effect,” whereby oral medications undergo various metabolic processes in the gastrointestinal tract and liver that can reduce the active concentration of the medication reaching systemic circulation.
Most transdermal patches deliver medication via a matrix system in which the medication is homogenously dispersed within an adhesive polymer matrix. Drug release occurs as the drug diffuses from the matrix to the skin. Other patches use a reservoir system, in which the drug is contained in a liquid reservoir behind a leak-proof rate-controlling membrane. A few transdermal patches contain medication that incorporates the drug directly into the adhesive layer.
Table 1: Transdermal Patches Used in Hospice
| Medication | Brand Name | Labeled Duration of Application | Labeled Indication(s) |
| Buprenorphine | Butrans® | 7 days | Chronic pain |
| Clonidine | Catapres-TTS® | 7 days | Hypertension |
| Fentanyl | Duragesic® | 3 days | Chronic pain |
| Lidocaine 5% (prescription only)* | Lidoderm® | 12 hours | Postherpetic neuralgia |
| Nicotine | Nicoderm CQ® | Daily | Smoking cessation |
| Nitroglycerin | Nitro-Dur® | 12-14 hours | Angina pectoris |
| Oxybutynin | Oxytrol® | Twice weekly | Overactive bladder |
| Rivastigmine | Exelon® | Daily | Alzheimer’s dementia, Parkinson’s-related dementia |
| Rotigotine | Neupro® | Daily | Parkinson’s disease, restless leg syndrome |
| Scopolamine | Transderm Scop® | 3 days | Motion sickness, post-op nausea/vomiting |
| *Over-the-counter lidocaine patches are considered topical, not transdermal, and may be changed more frequently (See Comparing Prescription and Over-the-counter Lidocaine Patches). | |||
Key Considerations
While transdermal patches offer a convenient, non-oral option for medication delivery, there are several considerations that are important when determining the appropriate patients for their use. These include:
Available Dosages Limited
Patches are available in a limited number of dosages, which can limit the flexibility of dose titration when initiating the medication and tapering when reducing doses or discontinuing.
Delayed Onset of Action
The delivery of medication must first cross through the layers of the skin, then travel into the bloodstream. This means the onset of action of transdermal patch formulations is delayed, sometimes for as long as 12 hours or more.
Lag Periods
Because of the delayed delivery of medication into the bloodstream, it can take longer to stabilize the patient’s dose. Further, when the patch is removed, residual medication that has already been absorbed into the skin continues to enter the blood stream, resulting in a prolonged elimination time. This can result in prolonged adverse effects for patients who aren’t tolerating the medication. It can also affect next-dose timing when patients are being switched from patches to other formulations.
Not Suitable for Acute Symptoms
Transdermal patches are best suited for stable, chronic symptoms due to the delayed onset of action and limited dose flexibility
Higher Cost
Cost of transdermal preparations is generally higher than oral formulations.
Cachexia May Reduce Absorption
Cachexia, a severe wasting syndrome characterized by loss of muscle mass and subcutaneous tissue, often occurs in people at the end of life. Cachexia can cause thinning and water loss of the skin, altering skin permeability, which may impact the absorption of medication from transdermal patches. Studies have shown mixed results regarding the impact of cachexia on transdermal medication pharmacokinetics, thus, the effectiveness of transdermal patches in cachectic patients remains unclear (See Conversion from Transdermal Fentanyl Use to Oral Administration in Cachectic Patients).
Heat Increases Absorption Rate
Exposure to heat can impact the safety and effectiveness of transdermal medication patches. Heat from external sources like heating pads, electric blankets, hot baths, saunas, or outdoor exposure can increase skin temperature and blood flow, leading to faster drug absorption from the patch. This accelerated absorption can result in higher drug levels in the blood stream, increasing the risk of side effects or toxicity and potentially altering the duration of the patch effects. Fever can have the same effects. Cases of serious overdose have been reported with transdermal medications like fentanyl.
Risk of Hyperthermia
Some patches may actually CAUSE hyperthermia due to alterations in the body’s ability to maintain a stable internal temperature. The anticholinergic effects of scopolamine patches can disrupt thermoregulation. The FDA recently issued a warning that the scopolamine patches (often used in hospice for the management of nausea) can increase body temperature and cause heat-related complications, resulting in hospitalization or even death. Most reports of hyperthermia that resulted in serious harm occurred when scopolamine patches were used in children 17 years and younger (an off-label use); hyperthermia occurred within 72 hours after the first application of the patch. Accordingly, the FDA now requires the addition of a new warning to the transdermal scopolamine patch prescribing and patient information about this risk of hyperthermia (See FDA Drug Safety Communication).
Hospice nurses and prescribers should warn patients and caregivers to remove the patch if their body temperature increases or they are not sweating in warm temperatures, and to contact the hospice if they experience side effects such as increased confusion or decreased consciousness.
Dangers for Patients with Altered Mental Status
Caution is advised in using patches in patients with altered mental status, who might remove the patch and try to chew or consume it. This can lead to rapid absorption of medication and choking. If patches are used in patients with altered mental status, consider placing the patch on the upper back to minimize the risk of self-removal. Since lidocaine patches must be placed at the site of pain, they may need to be avoided in patients with altered mental status if the site of pain is in a location where the patient could remove the patch.
Common Questions About Patch Administration
Can Transdermal Patches Be Cut?
In general, the FDA advises against cutting transdermal patches, as this can lead to improper dosing and potential health risks. Patches are designed to deliver a specific amount of medication over a set period and cutting them can disrupt this controlled release. In some cases, cutting a patch can result in a large, rapid release of medication, potentially leading to an overdose, particularly with potent drugs like fentanyl.
Lidocaine patches are an exception to this advisement. These patches can be cut into smaller pieces without affecting medication delivery.
Can Transdermal Dose Be Decreased by Partially Occluding the Patch?
Due to the inability to ensure the safe delivery of medication via a partially occluded transdermal patch, it is generally not recommended to try to alter the patch strength in this manner.
What If the Transdermal Patch Won’t Stick?
For the types of patches commonly used in hospice care, first aid tape can be applied to the edges of the patch if the patch does not adhere well to the skin. If adherence problems persist, the patch may be covered with a transparent adhesive dressing. If a patch falls off, the best practice is to replace it with a new patch, rotating sites (for scopolamine, apply behind the other ear), and noting the date and time for changing the patch.
How to Manage Skin Irritation?
A topical steroid can help reduce skin irritation/inflammation from transdermal patches. To avoid patch adhesion issues that may occur when using steroid creams, some hospice nurses report good results from using steroid nasal sprays, (such as fluticasone), spraying this on the skin and allowing it to dry prior to patch application.
Disposal Recommendations/Concerns
A fentanyl patch may still contain more than half of the labeled amount of fentanyl after three days of use, which is enough to cause serious harm from accidental exposure or diversion. Used patches should NOT be placed in household trash. For households with municipal sewage, the FDA recommends any opioid-containing patch (fentanyl, buprenorphine) be folded in half with the sticky sides together then flushed down the toilet. However, in homes with septic systems, or other on-site waste management, alternative disposal methods may be preferred due to the risks of blocking these systems with the non-biodegradable materials found in patches.
Other patch medications should be disposed as follows:
- Fold the sticky sides together and place them in a sturdy container, preferably with a child-resistant cap.
- Do not put a folded patch directly into the trashcan. Whatever container is used to dispose of patches should be removed/discarded from the home frequently.
To learn more, visit: US Food and Drug Administration (FDA) – Disposal of Unused Medicines: What You Should Know.
Patient/Caregiver Education: Transdermal Patch Best Practices
*Lidocaine patches should always be placed at the site of pain |
Switching from Transdermal Patch to Other Formulations
There are several considerations for switching from transdermal patches to other forms of medication administration (e.g. oral, subcutaneous):
- Patch strengths are not all labeled the same. Some are labeled in milligrams per hour or micrograms per hour, and others are labeled per 24 hours. This is an important consideration when determining the patient’s total daily dose when switching to other dosage forms.
- There is residual absorption of medication when a patch is removed, impacting next-dose timing. The best practice is to consult with a pharmacist for guidance in making changes from patches to other forms of medication administration.
- Enclara clients may access several resources for specific transdermal medications and for patient/caregiver education.
Further Reading
- A Primer on the Use of Buprenorphine for Pain Management in Hospice
- Conversion from Transdermal Fentanyl Use to Oral Administration in Cachectic Patients
- Comparing Prescription and Over-the-counter Lidocaine Patches
Enclara clients may access the following resources via E3 Pro:
- Transdermal Fentanyl Fact Sheet
- Determining Appropriate Use of Fentanyl Patches
- Buprenorphine Quick Facts
- Applying a Transdermal Patch: A Patient & Caregiver Guide
- Anticholinergics and Terminal Secretions: Best Practices at End of Life
DOWNLOAD A COPY OF THIS ARTICLE
Click here to download a copy of this month’s article to share with your colleagues or to keep for personal reference.
References
- Clinical Resource, Characteristics of Transdermal Patches (United States). Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. November 2024.
- Wong, Won Fen, et al. “Recent advancement of medical patch for transdermal drug delivery.” Medicina 59.4 (2023): 778.
- Carlini, Andrea, et al. “Transdermal Fentanyl in Patients with Cachexia—A Scoping Review.” Cancers 16.17 (2024): 3094.
- U.S. Food & Drug Administration (FDA). FDA Drug Safety Communication. FDA adds warning about serious risk of heat-related complications with antinausea patch Transderm Scōp (scopolamine transdermal system). June 18, 2025. Link.
- U.S. Food & Drug Administration. Disposal of Unused Medicines: What You Should Know. Oct 31, 2024. Link.
- Institute for Safe Medication Practices (ISMP). Fentanyl patch fatalities linked to “bystander apathy”: we all have a role in prevention! ISMP Medication Safety Alert. 2013 Aug. Retrieved from the World Wide Web August 30, 2013. Available at: Link.
- Fentanyl transdermal system package insert. Webster Groves, MO: SpecGx LLC; 2024 Jan.
