What are the dosing regimens for Morphine (opioid analgesic) oral extended-release (ER) tablets?

From the Guidelines

Morphine extended-release (ER) oral tablets are typically initiated at 15 mg every 12 hours for opioid-naive patients with moderate to severe chronic pain requiring around-the-clock analgesia. The dose may be adjusted every 1-2 days based on pain control and tolerability, usually increasing by 15-30 mg per day 1. Most patients achieve adequate pain control with 30-120 mg twice daily, though some may require higher doses. Elderly patients or those with renal or hepatic impairment should start at lower doses, often 15 mg once daily. When converting from immediate-release morphine, the same total daily dose can be used but divided into two doses. For patients switching from other opioids, appropriate conversion factors must be applied with a 25-50% dose reduction for cross-tolerance.

Key Considerations

• Morphine ER tablets should be swallowed whole, never crushed or chewed, as this destroys the extended-release mechanism and can cause potentially fatal rapid absorption.
• Patients should be monitored for respiratory depression, constipation, and other opioid side effects, with appropriate prophylactic measures like scheduled laxatives.
• Regular reassessment of pain control, function, and side effects is essential for optimal dosing.
• The optimal route of administration of morphine is by mouth, with two types of formulation required: immediate release (for dose titration) and controlled release (for maintenance treatment) 1.

Dosing Adjustments

• If pain returns consistently before the next regular dose is due, the regular dose should be increased.
• In general, immediate release morphine does not need to be given more often than every four hours and controlled release morphine more often than every 12 hours 1.
• A double dose at bedtime is a simple and effective way of avoiding being woken by pain for patients receiving immediate release morphine every four hours.

Alternative Routes

• If patients are unable to take drugs orally, the preferred alternative routes are subcutaneous and rectal 1.
• The bioavailability of morphine by rectal and oral routes is the same, and the duration of analgesia is also the same, with a relative potency ratio of oral morphine to rectally administered morphine of 1:1 1.

From the FDA Drug Label

Initiate treatment with morphine sulfate tablets in a dosing range of 15 mg to 30 mg every 4 hours as needed for pain Conversion from morphine sulfate tablets to the same total daily dose of an extended-release formulation could lead to excessive sedation at peak serum levels Individually titrate morphine sulfate tablets to a dose that provides adequate analgesia and minimizes adverse reactions

The dosing regimens for Morphine oral extended-release (ER) tablets are not explicitly stated in the provided text. However, the text does provide information on the dosing of morphine sulfate tablets, which can be used as a reference for converting to extended-release formulations.

• The initial dosage for opioid-naïve or opioid-non-tolerant patients is 15 mg to 30 mg every 4 hours as needed for pain.
• When converting from morphine sulfate tablets to extended-release formulations, the same total amount of morphine sulfate is available, but the extended duration of release may lead to excessive sedation at peak serum levels.
• The dosage should be individually titrated to provide adequate analgesia and minimize adverse reactions 2.

From the Research

Dosing Regimens for Morphine Oral Extended-Release (ER) Tablets

• The dosing regimens for Morphine oral extended-release (ER) tablets are not explicitly stated in the provided studies, but we can gather information about the general use of morphine in chronic pain management 3, 4, 5, 6, 7.
• A study on the efficacy and safety of once-daily extended-release hydrocodone in individuals previously receiving ER morphine for chronic pain found that patients were titrated to a once-daily dose of hydrocodone 20,40,60,80, or 120 mg for a 45-day period 5.
• Another study compared the clinical efficacy and safety of once-daily dosing of a novel, prolonged-release oral morphine tablet with twice-daily dosing of a standard controlled-release morphine tablet in patients with cancer pain, but did not provide specific dosing regimens for the ER tablets 7.
• The European Association for Palliative Care recommends a starting dose of 5 mg of normal-release morphine sulfate oral solution every 4 hours in opioid-naive patients or 10 mg in patients already being treated with "weak" opioids, but this is for normal-release morphine, not ER tablets 4.
• A study on the assessment of extended-release opioid analgesics for the treatment of chronic pain discusses the advantages of ER opioids, including extended periods of time during which drug plasma levels are within the therapeutic range and decreased peak-to-trough fluctuations, but does not provide specific dosing regimens for morphine ER tablets 6.