Page 465 Acute Pain Management

Drug Comments Recommendations References
NB doses must still be
titrated to effect for each
patient
Methadone Methadone and its metabolites Dose adjustment may be AMH, 2008
are excreted in urine and faeces; required in severe renal Davies et al, 1996
in anuric patients it may be impairment Dean, 2004
mostly in faeces Launay‐Vacher et
High protein binding, high al, 2005
volume of distribution and Lugo et al, 2005
moderate water solubility would Mercadante &
suggest that it is likely to be Arcuri, 2004
poorly removed by dialysis Murtagh et al,
2007
Morphine Major metabolites M3G and M6G Dose adjustment AMH, 2008
excreted via kidney and recommended or use Angst et al, 2000
accumulate in renal impairment alternative opioid Craig & Hunter,
M6G is an opioid agonist that 2008
crosses the blood‐brain barrier Davies et al, 1996
slowly; delayed sedation from Dean, 2004
M6G has been reported in renal D'Honneur et al,
failure 1994
Neurotoxicity from accumulation Hanna et al, 1993
of M3G possible Launay‐Vacher et
Oral administration results in al, 2005
proportionally higher metabolite Mercadante &
load Arcuri, 2004
Morphine and its metabolites are Pauli‐Magnus et
al, 1999
cleared by most haemodialysis Richtsmeier et al,
procedures but may not be 1997
significantly affected by
peritoneal dialysis
M6G also removed but slow
diffusion from CNS delays
response
Oxycodone The metabolite oxymorphone is No dose adjustment AMH, 2008
active but plasma levels are required in most patients Dean, 2004
normally negligible and therefore Kalso, 2005
it has an insignificant clinical Lee et al, 2005
effect in patients with normal Riley et al, 2008 CHAPTER 11
renal function
Higher blood concentrations of
oxycodone and metabolites with
moderate to severe renal
impairment; half life significantly
increased in endstage renal
disease
Oxycodone and its metabolites
are dialyzable

Acute pain management: scientific evidence 417