Morphine IR | 2.5–5 mg orally every 4–8 h |
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Morphine syrup useful for initiating and titrating lowest doses in the elderly -
In renal dysfunction, use reduced dose or avoid use if impairment is severe (active metabolites M3G and M6G can accumulate and cause toxicity)8,14,15 -
Brand choices vary in available dosage strengths and in cost9,16 -
Some CR capsule products (M-Eslon, Kadian) can be sprinkled onto food
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Morphine CR (most given every 12 h, eg, MS Contin, MOS SR, M-Eslon; Kadian given every 24 h) | 10 mg orally every 12 h (this dose is for M-Eslon only) 15 mg orally every 12 h 10–20 mg orally every 24 h |
Hydromorphone IR | 0.5–1mg orally every 4–8 h |
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A low dose of IR given every 8–12 h might often be adequate in the frail elderly -
Might cause less constipation and sedation than morphine -
More costly -
Some CR capsule products (Hydromorph Contin) can be sprinkled onto food
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Hydromorphone CR (Contin given every 12 h; Jurnista given every 24 h) | 3 mg orally every 12 h 4 mg orally every 24 h |
Oxycodone, with or without acetaminophen | 2.5–5 mg orally every 4–8 h (most tablets scored; allows for lower dose or titration by half tablets) |
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Metabolized by CYP 2D6*; use with caution in renal or hepatic dysfunction, as plasma concentrations might increase up to 50% -
Also a κ agonist -
Might cause less constipation and sedation than morphine -
More costly -
CR formulation has a biphasic release (approximately 38% initial release, and approximately 62% delayed release); inability to titrate the IR component separately might be problematic in some patients, triggering subtle, early opioid withdrawal
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Oxycodone CR | 5–10 mg orally every 12 h |
Fentanyl patch | 12–25 μg/h every 72 h |
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High potency; not for opioid-naïve patients or those with poor response to codeine -
Overdose risk: heat absorption, effect, and risk; CYP 3A4 inhibitors† risk -
Onset delayed by 12–24 h -
Allow ≥ 6 d before increasing dose -
Relatively high cost
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