Page 93 WHO - Guidelines on the pharmacological treatment of persisting pain in children with medical illness

A2.2.5 Prolonged-release versus immediate-release morphine

Clinical question
In children with persisting pain due to medical illnesses, should prolonged-release morphine be used in
preference to immediate-release morphine to achieve and maintain effective and safe pain control?

Recommendations
8. It is strongly recommended that immediate-release oral morphine formulations be available for the
treatment of persistent pain in children with medical illnesses.
9. It is also recommended that child-appropriate prolonged-release oral dosage forms be available, if
affordable.
Strong recommendations, low quality of evidence

Domains and considerations

Quality of evidence
There is insufficient evidence to support the use of prolonged-release over immediate-release
morphine as a sole agent. The only available evidence is in adults (Annex 4. Evidence retrieval
and appraisal, GRADE Table 10). The Cochrane review found that, in spite of the relevance of this
comparison, only 15 studies of 460 participants compared prolonged-release morphine preparations
with immediate-release morphine (115). None of the trials were large, having a median size of
27 participants (age range: 16–73). The results of these trials show that immediate-release and
modified-release morphine formulations are equivalent for pain relief. Approximately 6% of
participants (adults) in the studies who received morphine (any type) experienced intolerable adverse
effects.
Uncertainty: yes, in relation to children since no studies are available in this age group.

Risks/benefits
Benefits
Immediate-release oral morphine needs to be administered more frequently, but it is always
necessary in the management of episodic or breakthrough pain.
Risks
Adherence to long-term treatment with immediate-release oral morphine may be problematic.
Uncertainty: none.

Values and acceptability
In favour
The panel valued access to immediate-release oral morphine and noted that commercially marketed
prolonged-release oral morphine formulations are sometimes the only products available for
procurement.
Against
None
Uncertainty: none.

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