What is the recommended oxycodone dosing for children, including immediate‑release oral dose per kilogram, maximum single and 24‑hour limits, and guidance on extended‑release use?

Pediatric Oxycodone Dosing

Oxycodone immediate-release should be dosed at 0.05–0.2 mg/kg per dose orally every 4–6 hours in children, with a maximum single dose not exceeding 5–10 mg depending on age and opioid tolerance, and extended-release formulations are generally not recommended for routine pediatric use.

Immediate-Release Oral Dosing

Standard weight-based dosing:

• Start at 0.05–0.1 mg/kg per dose orally every 4–6 hours for opioid-naive children 1
• May titrate up to 0.2 mg/kg per dose for severe pain or burn injuries that often require larger or more frequent doses 1
• Maximum single dose should not exceed 5 mg in younger children or 10 mg in adolescents to minimize risk of respiratory depression 1

Dosing intervals and duration:

• Administer every 4–6 hours as needed for pain control 1
• The immediate-release formulation has an onset of action within 1 hour and duration of approximately 3–4 hours 2
• Stable plasma levels are reached within 24 hours, making titration more predictable than morphine 2

Maximum Daily Limits

24-hour dosing caps:

• Total daily dose should be carefully monitored and individualized based on pain severity and patient response 1
• Higher doses may be necessary in patients with opioid tolerance, but this requires close monitoring for respiratory depression 1
• Burn pain often requires larger or more frequent doses than standard recommendations 1

Extended-Release Formulations

Pediatric considerations:

• Extended-release oxycodone (OxyContin) is not routinely recommended for children due to limited safety and efficacy data in pediatric populations 2
• If extended-release formulations are considered in adolescents, tablets must be swallowed whole and never broken, chewed, or crushed to avoid rapid release and potential overdose 2
• The controlled-release formulation has a 12-hour duration of action with an onset at 1 hour 2

Special Populations and Adjustments

Hepatic and renal impairment:

• No dose reduction is needed in moderate hepatic or renal failure, though caution is warranted 2
• Oxycodone is primarily metabolized in the liver to oxymorphone (potent analgesic) and noroxycodone (weak analgesic), with excretion via kidneys 2
• Plasma half-life is 3–5 hours, which is half that of morphine, allowing for more predictable titration 2

Elderly patients:

• No routine dose reduction is required in elderly patients, but start at the lower end of the dosing range 2

Safety and Monitoring

Common adverse effects:

• Nausea, constipation, and drowsiness are the most common side effects 2
• Oxycodone causes somewhat less nausea, hallucinations, and pruritus compared to morphine 2
• Histamine release may cause flushing, itching, and hypotension, particularly in unstable cardiac or trauma patients 1

Respiratory monitoring:

• There is an increased incidence of apnea when oxycodone is combined with other sedative agents such as benzodiazepines 1
• Monitor oxygen saturation continuously and be prepared to provide respiratory support 1
• Fentanyl may be preferred over oxycodone in hemodynamically unstable patients due to less histamine release 1

Clinical Pearls

Bioavailability and administration:

• Oral bioavailability ranges from 60–87%, which is higher than morphine 2, 3
• No food interference with absorption 2
• Plasma protein binding is 45% 2

Equivalence considerations:

• Oxycodone-to-morphine equivalence ratio is approximately 1:1.5–2 for cancer pain treatment 2
• Long-term administration may be associated with less toxicity compared to morphine 2

Combination therapy:

• Oxycodone combined with acetaminophen offers synergistic analgesia at lower individual drug doses 4
• This combination has an opioid-sparing effect and may be useful for moderate-to-severe pain in children who do not respond to NSAIDs or acetaminophen alone 4