title: The intravenous to oral relative milligram potency ratio of morphine during chronic dosing in cancer pain.
abstract: Morphine (M) is the opioid analgesic of choice for severe cancer pain. The IV to PO M equipotent switch ratio (CR) is controversial. We designed this prospective observational cohort to confirm the efficacy and safety of M IV to PO CR of 1:3. Consecutive cancer patients admitted to an inpatient palliative medicine unit were screened for inclusion. Pain was managed by palliative medicine specialists. They were blinded to the patient data collected, and the calculated CR. The switch was considered successful if the following criteria were met: (1) Pain adequately controlled: pain rated as none or mild (2) Number of RD less than 4 (for non incident pain) per 24 hours (3) No limiting side effects. We used Day 3 ATC M dose for CR calculations. The major outcome measures were the IV : PO CR ratio, morphine doses (mg/day), pain severity, number of PRN doses, and day 1 and day 3side effects. Descriptive statistics were used to report mean, median, standard deviation and range of different variables. Two hundred and fifty six consecutive admissions were screened, and 106 were eligible for the study. Sixty two underwent a successful M route switch and were included in this analysis. A ratio of 1:3 was safely implemented over a wide M dose range. About 80% were successfully switched with a calculated CR of 1:3. 20% required an oral M dose adjustment after route switch either to better pain control or reduce side effects with a resultant higher (e.g. 1:4) or lower (e.g. 1:2) calculated potency ratios respectively. A potency ratio of 1:3 was safe as evaluated by common M side-effects, the dose also easy to calculate. The 1: 3 M IV to PO relative milligram potency ratio appears correct and practical for most patients over a wide M dose range.
authors.affiliation: The Harry R Horvitz Center for Palliative Medicine, Cleveland, OH 44195, USA.
authors.forename: Wael
authors.initials: W
authors.lastname: Lasheen
authors.forename: Declan
authors.initials: D
authors.lastname: Walsh
authors.forename: Fade
authors.initials: F
authors.lastname: Mahmoud
authors.forename: Nabeel
authors.initials: N
authors.lastname: Sarhill
authors.forename: Nilo
authors.initials: N
authors.lastname: Rivera
authors.forename: Mellar
authors.initials: M
authors.lastname: Davis
authors.forename: Ruth
authors.initials: R
authors.lastname: Lagman
authors.forename: Susan
authors.initials: S
authors.lastname: Legrand
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects / Q000493:pharmacokinetics*; D002908:Chronic Disease; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage* / Q000009:adverse effects / Q000493:pharmacokinetics*; D009369:Neoplasms / Q000150:complications* / Q000378:metabolism*; D010146:Pain / Q000188:drug therapy* / Q000209:etiology / Q000378:metabolism; D010147:Pain Measurement / Q000187:drug effects; D010166:Palliative Care / Q000379:methods; D011446:Prospective Studies; D016037:Single-Blind Method; D013810:Therapeutic Equivalency; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid; D009020:Morphine