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butorphanol nasal
generic
Black Box Warnings .
Appropriate Use
should only be prescribed by healthcare professionals knowledgeable about opioid use and how to mitigate associated risks; reserve opioid analgesics for patients with inadequate tx alternatives; proper dosing and titration essential to decr. respiratory depression risk
Addiction, Abuse, and Misuse
opioid agonist Schedule IV controlled substance with risk of addiction, abuse, and misuse, which can lead to overdose and death; assess opioid abuse or addiction risk prior to prescribing; regularly reassess all patients for misuse, abuse, and addiction
Respiratory Depression
serious, life-threatening, or fatal cases may occur even with recommended use, especially during tx start or after dose incr; to decr. risk, initiate and titrate dose appropriately
Accidental Ingestion
accidental ingestion of even one dose, especially in children, can result in fatal butorphanol overdose
Risks from Concomitant Use with Benzodiazepines, CNS Depressants
concomitant opioid use with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death; reserve concomitant use for patients with inadequate alternative tx options
Neonatal Opioid Withdrawal Syndrome
advise pregnant patients with extended opioid use of risk of potentially life-threatening neonatal opioid withdrawal syndrome; ensure tx by neonatology experts available at delivery
Opioid Analgesic REMS
providers are strongly encouraged to complete risk evaluation and mitigation strategy (REMS)-compliant education program, counsel patients and/or caregivers with each Rx on serious risks, safe use, and importance of reading medication guide
CYP450 3A4 Interaction
concomitant use with CYP450 3A4 inhibitors or D/C of concomitant CYP450 3A4 inducers may incr. butorphanol levels and may cause potentially fatal respiratory depression; monitor patients receiving any concomitant CYP450 3A4 inhibitor or inducer
Adult Dosing .
Dosage forms: SPRAY: 1 mg per actuation
Special Note
- [prescribing info]
- Info: consider prescribing opioid overdose reversal agent (e.g., naloxone, nalmefene), especially if risk of opioid overdose or accidental exposure
pain, moderate-severe
- [1-2 mg intranasally q3-4h prn]
- Start: 1 mg intranasally x1, may repeat in 60-90min, then q3-4h prn; Info: use lowest effective dose, shortest effective tx duration; for elderly patients, start 1 mg intranasally x1, may repeat in 90-120min, then q6h prn; for recumbent patients with severe pain, may give 2 mg intranasally q3-4h prn; give 2 mg dose as 1 actuation in each nostril; taper dose gradually to avoid withdrawal symptoms if D/C tx in physically opioid-dependent patients; search 'opioid taper' for epocrates Opioid Tapering decision tool
renal dosing
- [adjust dose amount]
- renal impairment: start 1 mg intranasally x1, may repeat in 90-120min, then give q6h prn
- HD/PD: not defined
hepatic dosing
- [adjust dose frequency]
- hepatic impairment: start 1 mg intranasally x1, may repeat in 90-120min, then give q6h prn
Peds Dosing .
Peds dosing is currently unavailable or not applicable for this drug.