10 to 20     : Use small doses, e.g. 2.5–5 mg and extended dosing intervals. Titrate according to response
<10           : Use small doses, e.g. 1.25–2.5 mg and extended dosing intervals. Titrate according to response
DOSE IN PATIENTS UNDERGOING RENAL REPLACEMENT THERAPIES
CAPD                :Not dialysed. Dose as in GFR <10 mL/min
HD                     :Dialysed – active metabolite removed significantly. Dose as in GFR <10 mL/min
HDF/high flux   :Dialysed – active metabolite removed significantly. Dose as in GFR <10 mL/min
CAV/VVHD      :Dialysed. Dose as in GFR=10–20 mL/min
IMPORTANT DRUG INTERACTIONS
Potentially hazardous interactions with other drugs
Antidepressants: possible CNS excitation or depression with MAOIs – avoid concomitant use, and for 2 weeks after stopping MAOI; possible CNS excitation or depression with moclobemide; increased sedative effects with tricyclics
Antivirals: concentration possibly increased by ritonavirSodium oxybate: enhanced effect of sodium oxybate – avoid concomitant use
ADMINISTRATION
Reconstition
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Route
Oral, SC, IM, IV, PR
Rate of Administration
2 mg/minute. (Titrate according to response)
Comments
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OTHER INFORMATION
Extreme caution with all opiates in patients with impaired renal functionPotential accumulation of morphine-6- glucuronide (a renally excreted active metabolite, more potent than morphine) and morphine-3-glucuronide. Half-life of morphine-6-glucuronide is increased from 3–5 hours in normal renal function to about 50 hours in ERFENSURE NALOXONE READILY AVAILABLESome units avoid slow release oral preparations as any side effects may be prolonged.