Page 468 Acute Pain Management

Drug Comments Recommendations References
NB doses must still be
titrated to effect for each
patient
Dextro‐ Reduced oxidation leading to Limited data: dose Tegeder et al,
propoxyphene reduced clearance adjustment may be 1999
required
Fentanyl Disposition appears to be Limited data: no dose Tegeder et al,
unaffected adjustment required 1999
Methadone Increased half‐life but limited Limited data: no dose Lugo et al, 2005
significance adjustment required in Novick et al, 1985
chronic stable liver
disease
Morphine Hepatic impairment does not In most patients no dose Kotb et al, 2005
appear to have a significant adjustment required Rudin et al, 2007
effect on morphine
pharmacokinetics; even in
patients with cirrhosis there is a
large hepatic reserve for
glucuronidation
Blood concentrations of
morphine but not morphine
metabolites higher after liver
resection; blood concentrations
also higher in patients with liver
cancer
Increased oral bioavailability of
morphine due to its normal high
first pass metabolism when given
via this route
Oxycodone Decreased oxycodone clearance Limited data: no dose Kalso, 2005
with mild to moderate hepatic adjustment required in Riley et al, 2008
impairment most patients
Pethidine Reduced clearance Limited data: dose Tegeder et al,
adjustment may be 1999
CHAPTER 11 Sufentanil No difference in clearance or No dose adjustment Chauvin et al,
required; use not
recommended
1989
required
elimination
Tegeder et al,
1999
Tramadol
Reduced clearance
Limited data: dose
adjustment may be AMH, 2008
Tegeder et al,
required if impairment is 1999
severe Kotb et al, 2008

420 Acute Pain Management: Scientific Evidence