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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 associated risks; epidural and intrathecal use should only be administered by physicians familiar with patient management problems associated with epidural and intrathecal administration and should only be given where appropriate monitoring available; reserve opioid analgesics for patients with inadequate tx alternatives; proper dosing and titration essential to decr. respiratory depression risk
Neuraxial Administration Risk
risk of severe adverse reactions including acute or delayed respiratory depression up to 24h with single-dose epidural or intrathecal administration; 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 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; rapid IV administration may result in overdosing due to 30 min delay in max CNS effect with IV administration
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
Adult Dosing .
Dosage forms: INJ
pain, moderate-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, moderate-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