Demerol (Meperidine) for Pain Management
Meperidine should generally be avoided as a first-line analgesic and is no longer recommended for routine pain management due to significant safety concerns, particularly neurotoxicity from its metabolite normeperidine, multiple drug interactions, and lack of superiority over safer alternatives. 1
Major Contraindications and Safety Concerns
Meperidine is absolutely contraindicated in patients with renal insufficiency (GFR <30 mL/min/1.73 m²) and end-stage renal disease due to accumulation of normeperidine, an active metabolite that can cause seizures and CNS toxicity 1
The medication has significant serotonergic effects that increase toxicity risk when combined with other serotonergic medications, including SSRIs, SNRIs, and MAO inhibitors 1, 2
Meperidine may aggravate preexisting convulsions and can cause seizures even in individuals without a history of convulsive disorders when doses are escalated 2
The drug should be used with extreme caution in patients with supraventricular tachycardias due to vagolytic action that may significantly increase ventricular response rate 2
Clinical Context Where Meperidine Is Sometimes Used
The FDA approves meperidine for relief of moderate to severe pain 2, but this approval predates modern understanding of its risks
For severe migraine headaches, meperidine is sometimes used as a rescue medication when other treatments fail, though it should be avoided for chronic daily headaches due to dependency and rebound headache risks 3
Historical use for biliary colic and pancreatitis has been debunked—clinical evidence shows meperidine has no advantage over other opioids for these conditions 4
Superior Alternatives
For moderate to severe pain, use morphine, hydromorphone, oxycodone, or fentanyl instead, which provide more reliable analgesia with better safety profiles 1
For patients with renal impairment specifically, fentanyl, sufentanil, or methadone (under experienced supervision) are preferred as they have no active metabolites 1
For acute migraine management, consider triptans, NSAIDs (including parenteral ketorolac), or dihydroergotamine before resorting to opioids 3
For neuropathic pain, first-line agents include gabapentinoids (gabapentin, pregabalin) or antidepressants (duloxetine, nortriptyline), not opioids 3, 5
Important Drug Interactions
Acyclovir increases plasma concentrations of meperidine and normeperidine 2
Cimetidine reduces clearance and increases normeperidine formation 2
Phenytoin enhances hepatic metabolism of meperidine but increases normeperidine concentrations—concomitant use should be avoided 2
Ritonavir increases meperidine plasma concentrations—concomitant use should be avoided 2
Mixed agonist/antagonist opioids (pentazocine, nalbuphine, butorphanol, buprenorphine) may reduce meperidine's analgesic effect or precipitate withdrawal 2
Clinical Pharmacology Limitations
Meperidine has poor oral bioavailability, requiring parenteral administration 6
Analgesic effects last only 3-4 hours with parenteral administration, shorter than many alternatives 6
Despite patient and physician preference in some settings, controlled trials rarely demonstrate superior analgesic efficacy compared to alternative parenteral pain medications 6
Common Pitfalls to Avoid
Do not use meperidine for chronic pain management due to risks of tolerance, physical dependence, and normeperidine accumulation 2, 4
Do not combine with alcohol or other CNS depressants unless specifically ordered, as dangerous additive effects may occur 2
Do not abruptly discontinue after prolonged use (more than a few weeks)—taper the dose to avoid precipitating withdrawal symptoms 2
Avoid using meperidine when safer alternatives like morphine or hydromorphone are available and appropriate 1, 4