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Duramorph
morphine sulfate
Black Box Warnings .
Appropriate Use
should only be prescribed by healthcare professionals knowledgeable about opioid use and how to mitigate assoc. risks; epidural and intrathecal use should only be admin. by physicians familiar w/ patient management problems assoc. w/ epidural and intrathecal admin. and should only be given where appropriate monitoring available; reserve opioid analgesics for patients w/ inadequate tx alternatives; proper dosing and titration essential to decr. resp. depression risk
Neuraxial Administration Risk
risk of severe adverse rxns incl. acute or delayed resp. depression up to 24h w/ single-dose epidural or intrathecal admin; observe patients in fully equipped and staffed environment for at least 24h after initial dose
Addiction, Abuse, and Misuse
opioid agonist Schedule II controlled substance w/ 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 w/ recommended use, esp. during tx start or after dose incr; to decr. risk, initiate and titrate dose appropriately; rapid IV admin. may result in overdosing due to 30 min delay in max CNS effect w/ IV admin.
Risks from Concomitant Use w/ Benzodiazepines, CNS Depressants
concomitant opioid use w/ benzodiazepines or other CNS depressants, incl. alcohol, may result in profound sedation, resp. depression, coma, and death; reserve concomitant use for patients w/ inadequate alternative tx options
Neonatal Opioid Withdrawal Syndrome
advise pregnant patients w/ extended opioid use of risk of potentially life-threatening neonatal opioid withdrawal syndrome; ensure tx by neonatology experts avail. at delivery
Adult Dosing .
Dosage forms: INJ
pain, mod-severe
- [SC/IV route]
- Dose: individualize dose SC/IV prn; Start: 2-10 mg/70 kg/dose SC/IV x1; Info: use lowest effective dose, shortest effective tx duration; consider low start dose, titrate slowly in patients 65 yo and older; 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
- [epidural route]
- Dose: individualize dose epidurally prn; Start: 5 mg epidurally x1, then after 1h may give 1-2 mg/dose prn; Max: 10 mg/24h; Info: use lowest effective dose, shortest effective tx duration; consider low start dose, titrate slowly in patients 65 yo and older; 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
- [intrathecal route]
- Dose: 0.2-1 mg intrathecally x1; Info: epidural route preferred to intrathecal route; use lowest effective dose; if additional dose needed, consider alternate route
acute angina, severe (off-label)
- [2-4 mg IV q5-15min prn]
- Info: may give up to 10 mg/dose
dyspnea (off-label)
- [individualize dose SC/IV q30min-4h prn]
- Info: for use in palliative care; start 1.5-3 mg SC/IV q30min-4h prn in opioid-naive patients; individualize dose based on current opioid intake; may incr. dose by up to 50% if inadequate response after 2 doses
renal dosing
- [SC/IV route]
- CrCl 10-50: decr. usual dose by 25%; CrCl <10: avoid use
- HD/PD: avoid use
- [epidural/intrathecal route]
- renal impairment: not defined, caution advised
- HD/PD: not defined, caution advised
hepatic dosing
- [see below]
- cirrhosis: decr. usual start dose, amount not defined; Info: titrate slowly
Peds Dosing .
- Dosage forms: INJ
pain, mod-severe (off-label)
- [intermittent injection, <1 mo]
- Dose: 0.025-0.05 mg/kg/dose SC/IV q6h prn; Info: use lowest effective dose, shortest effective tx duration; 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
- [intermittent injection, 1-6 mo]
- Dose: 0.1 mg/kg/dose SC/IV q6h prn; Info: use lowest effective dose, shortest effective tx duration; 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
- [intermittent injection, 7 mo and older]
- Dose: 0.1-0.2 mg/kg/dose SC/IV q4h prn; Max: 2.5 mg/dose if <13 yo, 10 mg/dose if 13 yo and older; Info: use lowest effective dose, shortest effective tx duration; 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
- [epidural route, 6 mo-12 yo]
- Dose: 0.015-0.05 mg/kg/dose epidurally prn; Max: 0.1 mg/kg/dose epidurally up to 5 mg/24h; Alt: 0.001-0.005 mg/kg/h epidurally prn; Info: use lowest effective dose, shortest effective tx duration; 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
- [SC/IV route]
- CrCl 10-50: decr. usual dose by 25%; CrCl <10: decr. usual dose by 50%; Info: titrate slowly
- HD: decr. usual dose by 50%; supplement after dialysis not defined; PD: decr. usual dose by 50%; supplement not defined; Info: titrate slowly
- [epidural route]
- renal impairment: not defined, caution advised
- HD/PD: not defined, caution advised
hepatic dosing
- [see below]
- cirrhosis: decr. usual start dose, amount not defined; Info: titrate slowly