CLINICAL GUIDELINES FOR #Opioid ROUTE CONVERSION AND ROTATION

Reference: Opioid Equianalgesic Tables: Are They All Equally Dangerous? Philip E. Shaheen, Declan Walsh, Wael Lasheen, Mellar P. Davis and Ruth L. Lagman (Journal of Pain and Symptom Management, Vol. 38 No. 3 September 2009)

👄Rotation of an opioid, secondary to uncontrolled pain requires equianalgesic doses.

👄If you are rotating an opioid secondary to toxicity, it  requires a dose 30% 50% lower than the equivalent dose of the second opioid. This is because of incomplete analgesic cross-tolerance.

👄Thirty percent of patients who are on opioids need an alternative route, as in severe nausea or mucositis. 

👄Once toxicity occurs, before doing rotation, consider treating side effects, lowering the dose of the current opioid(if pain is controlled), and use of adjuvant analgesics. 

👄Whenever we start or titrate opioid dose, always  consider the pharmacokinetic alterations due to age, comorbid conditions, gender, other simultaneously administered medications, and organ failure etc

👄Opioids that are partial agonists have less analgesia per dose increment at higher doses than full agonists or opioids with high intrinsic efficacy (e.g., methadone); therefore, equianalgesic ratios will change with dose. 

👄Rotating to a new opioid before reaching steady-state of the first opioid is pharmacologically meaningless.

👄Rotation in the setting of organ dysfunction is dangerous even if we use  the recommended doses from equianalgesic tables. 

👄Note that, opioids may worsen intestinal colic. Dexamethasone, glycopyrrolate, or octreotide are better options for such pains. 

👄Opioid-induced toxicity takes some time to resolve. If symptoms related to toxicity are persisting after rotation, it can be because of slow clearance of the first opioid and not the new opioid. 

👄Be cautious while rotating between short and long-acting opioids and do it in a careful way, so as to avoid withdrawal or overdosing.

#pharmacology , #anesthesia , #PainAndPalliativeCare , #OpioidRotation , #CriticalCare , #pharmacy , #PainPhysician , #anaesthesia