Table 10. Opioid Agonist in Patients with Cirrhosis [976].
| 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. The dose should also be reduced. |
5 minutes (IV) 15 minutes (IM) 20 minutes (oral) |
3–7 hours | None | Glucuronidation via UGT2B7 |
| Oxycodone, semi-synthetic m-opioid agonist | Oxycontin CR 10 mg IR codon 10 mg 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 |
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) 1 hour (CR, oral) |
3–6 hours (IR) 10–12 hours (CR) |
CYP3A4 CYP2D6 |
None |
| Hydromorphone, semi-synthetic opioid | Dilid 2 mg Jurnista PR 8 mg Jurnista SR 4 mg |
Possible decreases in the metabolizing capacity of conjugating enzymes | A reduction of dose with standard interval is necessary. It should be avoided in patients with hepatorenal syndrome due to accumulation of the neuroexcitatory metabolite. |
15–30 minutes | 4–5 hours | None | Glucuronidation via UGT2B7 |
| Fentanyl, synthetic opioid from the phenylpiperidine class | Fentanyl 50/100/500/1000 mcg Abstral SL tab 100/200 mcg Actiq 200/400 mcg Matrifen patch 12/25/50/100 mcg Instanyl nasal spray 50/100 mcg Durogesic D-trans 25/50/100 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) 6–7 hours (IN) 20–27 hours (TD) 2–13 hours (SL/buccal) |
CYP3A4 | None |
IV = intravenous, IM = intramuscular, CR = controlled-release, IR = immediate-release, inj = injection, PR = prolonged-release, SR = sustained-release, SL = sublingual, IN = intranasal, TD = transdermal