What is a safe starting dose of oxycodone (OxyContin) long-acting for a 100-year-old patient with compression fractures, currently on short-acting opioids (prn) for comfort care?

From the Guidelines

For a 100-year-old comfort care patient with compression fractures who is already on short-acting PRN opioids, a safe starting dose of long-acting oxycodone would be 10mg every 12 hours, as this approach aligns with the principle of starting opioids at the lowest possible effective dosage, especially in elderly patients 1. This recommendation is based on the CDC clinical practice guideline for prescribing opioids for pain, which emphasizes the importance of using the lowest effective dose, particularly for patients aged ≥65 years, due to their potentially smaller therapeutic window between safe dosages and dosages associated with respiratory depression and overdose 1. When initiating long-acting opioids, it is crucial to calculate the total daily opioid requirement based on the patient's current short-acting opioid use over 24 hours and then convert approximately 50-75% of this amount to the long-acting formulation, as suggested by the guideline 1. Key considerations include:

• Monitoring the patient closely for side effects, including sedation, confusion, respiratory depression, and constipation, which are more common and potentially more severe in very elderly patients.
• Maintaining access to short-acting opioids for breakthrough pain, typically at 10-15% of the total daily long-acting dose.
• Considering prophylactic stool softeners and laxatives to prevent opioid-induced constipation. Given the patient's advanced age and the context of comfort care, the focus should be on pain control and quality of life, with an emphasis on minimizing adverse effects by using the lowest effective dose, as supported by the guideline's recommendations for cautious opioid prescribing 1.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

Dosage and Administation: 2. 1 Important Dosage and Administration Instructions Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals [see Warnings and Precautions (5)] Initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse [see Warnings and Precautions (5. 1)] .

1. 2 Initial Dosage Use of Oxycodone Hydrochloride Tablets as the First Opioid Analgesic Initiate treatment with oxycodone hydrochloride tablets in a dosing range of 5 to 15 mg every 4 to 6 hours as needed for pain.

The safe starting dose of oxycodone (OxyContin) long-acting for a 100-year-old patient with compression fractures, currently on short-acting opioids (prn) for comfort care, cannot be directly determined from the provided information.

• The label provides guidance on initiating treatment with oxycodone hydrochloride tablets, but it does not specifically address the conversion to long-acting oxycodone or the unique considerations for a 100-year-old patient.
• Key considerations for determining the initial dose include the patient's severity of pain, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse.
• Given the lack of direct information, a conservative approach is advised, and the patient's dosage should be individually titrated to a dose that provides adequate analgesia and minimizes adverse reactions 2.

From the Research

Safe Starting Dose of Oxycodone for a 100-year-old Patient

• The provided studies do not directly address the safe starting dose of oxycodone (OxyContin) long-acting for a 100-year-old patient with compression fractures, currently on short-acting opioids (prn) for comfort care.
• However, a study from 2005 3 compared the efficacies of oxycodone and hydrocodone for the treatment of acute pain associated with fractures, and found that treatment with acetaminophen and either oxycodone (5 mg orally) or hydrocodone (5 mg orally) resulted in pain relief among patients with acute fractures.
• Another study from 2015 4 found that immediate- and short-term pain effects of diclofenac and tramadol were demonstrated, whereas non-significant effects were found for oxycodone and tapentadol in a placebo-controlled trial.
• A review from 2017 5 discussed current treatment strategies for compression fractures, including conservative pain management and vertebral augmentation, but did not provide specific guidance on the safe starting dose of oxycodone for elderly patients.
• A study from 2020 6 described the use of kyphoplasty for the treatment of osteoporotic vertebral compression fractures in an elderly patient, but did not address the use of oxycodone.
• A study from 2021 7 explored fracture outcomes with tapentadol or oxycodone, but did not provide information on the safe starting dose of oxycodone for elderly patients.

Considerations for Oxycodone Dosage

• When determining the safe starting dose of oxycodone for a 100-year-old patient, it is essential to consider the patient's individual characteristics, such as their medical history, current medications, and renal function.
• The patient's current use of short-acting opioids (prn) for comfort care should also be taken into account when determining the starting dose of oxycodone.
• It is crucial to monitor the patient closely for signs of opioid toxicity, such as respiratory depression, and to adjust the dose accordingly.