Table 10.
Opioid agonist in patients with cirrhosis976
| Opioid agonist | Brand name | Impairment in metabolism | Dose adjustment for cirrhotic patients | Onset of action | Duration of action | Phase I metabolism | Phase II metabolism |
|---|---|---|---|---|---|---|---|
| Morphine | Morphine 5/10/30/100 mg | Decreased intrinsic hepatic clearance (reduction in the enzyme activity or intrahepatic shunting) | Dosing interval should be increased 1.5- to 2-fold in cirrhotic patients. | 5 minutes (IV) | 3–7 hours | None | Glucuronidation via UGT2B7 |
| The dose should also be reduced. | 15 minutes (IM) | ||||||
| 20 minutes (oral) | |||||||
| Oxycodone, semi-synthetic m-opioid agonist | Oxycontin CR 10 mg | Decreased intrinsic hepatic clearance (reduction in the enzyme activity or intrahepatic shunting) | Oral oxycodone should be initiated at lower doses. | 10–30 minutes (IR, oral) | 3–6 hours (IR) | CYP3A4 | None |
| IR codon 10 mg | 1 hour (CR, oral) | 10–12 hours (CR) | CYP2D6 | ||||
| IR codon 5 mg | |||||||
| Oxynorm inj 10 mg | |||||||
| Oxynorm inj 20 mg | |||||||
| Targin CR 5/2.5 mg | |||||||
| Targin CR 10/5 mg | |||||||
| Targin CR 20/10 mg | |||||||
| Targin CR 40/20 mg | |||||||
| Hydromorphone, semi-synthetic opioid | Dilid 2 mg | Possible decreases in the metabolizing capacity of conjugating enzymes | A reduction of dose with standard interval is necessary. | 15–30 minutes | 4–5 hours | None | Glucuronidation via UGT2B7 |
| Jurnista PR 8 mg | It should be avoided in patients with hepatorenal syndrome due to accumulation of the neuroexcitatory metabolite. | ||||||
| Jurnista SR 4 mg | |||||||
| Fentanyl, synthetic opioid from the phenylpiperidine class | Fentanyl 50/100/500/1,000 mcg | Affected by changes in hepatic blood flow | It is a first-choice opioid in patients with hepatorenal syndrome, but dose reduction might be necessary to avoid accumulation. | 5 minutes (SL or IV) | 30–60 minutes (IV) | CYP3A4 | None |
| Abstral SL tab 100/200 mcg | 6–7 hours (IN) | ||||||
| Actiq 200/400 mcg | 20–27 hours (TD) | ||||||
| Matrifen patch 12/25/50/100 mcg | 2–13 hours (SL/buccal) | ||||||
| Instanyl nasal spray 50/100 mcg | |||||||
| Durogesic D-trans 25/50/100 mcg |
IV, intravenous; IM, intramuscular; CR, controlled-release; IR, immediate-release; inj, injection; PR, prolonged-release; SR, sustained-release; SL, sublingual; IN, intranasal; TD, transdermal.