From the Guidelines
Proton pump inhibitors (PPIs) should be given alongside morphine to prevent gastrointestinal complications, particularly in patients at risk of gastric ulceration or those on prolonged opioid therapy. When administering morphine, it is essential to consider the potential gastrointestinal side effects, including increased gastric acid secretion and delayed gastric emptying, which can raise the risk of peptic ulcer disease 1. Although the provided study focuses on the use of PPIs in patients undergoing intragastric balloon therapy, the underlying principle of preventing gastrointestinal complications applies to patients receiving morphine as well.
Some key points to consider when giving PPIs with morphine include:
- Typical dosing of PPIs, such as omeprazole 20-40mg daily or pantoprazole 40mg daily, for the duration of morphine treatment
- Patients at higher risk of gastric ulceration, such as those with a history of peptic ulcer disease, concurrent NSAIDs, corticosteroids, or anticoagulants, elderly patients, and those requiring higher doses or prolonged courses of morphine therapy
- The mechanism of action of PPIs in reducing acid production and providing gastric protection by irreversibly blocking the hydrogen/potassium ATPase enzyme system in gastric parietal cells.
It is crucial to weigh the benefits of PPI prophylaxis against the potential risks, such as enteric infections, community-acquired pneumonia, increased bone fracture risks, kidney disease, and micronutrient deficiencies, and to use the lowest effective dose, frequency, and duration of PPIs 1.
From the Research
Proton Pump Inhibitors (PPIs) and Morphine
- PPIs are commonly used to prevent gastrointestinal (GI) bleeding in patients taking medications that increase the risk of bleeding, such as aspirin or anticoagulants 2.
- Morphine, an opioid analgesic, can increase the risk of GI bleeding due to its effects on the GI tract, including decreased motility and increased pressure on the sphincter of Oddi 3.
- The use of PPIs in patients taking morphine may be justified to reduce the risk of GI bleeding, especially in those with a history of GI bleeding or other risk factors 4, 5.
Risk Factors for GI Bleeding
- Prior GI event 2
- Use of anticoagulants 2
- Use of nonsteroidal anti-inflammatory drugs (NSAIDs) 5
- Age 5
- Comorbidity 5
Benefits and Risks of PPIs
- PPIs can reduce the risk of GI bleeding in patients taking medications that increase the risk of bleeding 4, 5, 2.
- However, long-term use of PPIs has been associated with an increased risk of cardiovascular adverse effects, such as myocardial infarction and stroke 3.
- Histamine 2 blockers may be an alternative therapeutic option in certain patients, as they have not been found to be associated with increased cardiovascular risk 3.