Methadone for Analgesia in Children with Life-Limiting Illness: Experience from a Tertiary Children’s Health Service
Abstract
:1. Introduction
2. Methods
3. Results
4. Discussion
5. Conclusions
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Morphine | Fentanyl | Hydromorphone | |
---|---|---|---|
Relative Potency | 1 | 40 | 5 |
Example Doses | 4 mg | 100 mcg | 800 mcg |
Patient | Age | Sex | Weight (kg) | Diagnosis | Prior Opioid/Analgesia | Care Location | Goals of Care | ECG |
---|---|---|---|---|---|---|---|---|
1 | 4 years | F | 19.0 | Relapsed biliary embryonal rhabdomyosarcoma | Hydromorphone | Hospital (ward) | Palliative Care | Yes |
2 | 2 years | M | 12.7 | Haemophagocytic lymphohistiocytosis | Hydromorphone, ketamine | Hospital (ward) | Pain Management | No |
3 | 8 years | F | 27.0 | Relapsed acute lymphoblastic leukaemia | Hydromorphone, ketamine | Hospital (intensive care) | Palliative Care | Yes |
4 | 3 years | M | 14.5 | Metastatic hepatoblastoma | Hydromorphone | Hospital (ward) | Pain Management | No |
5 | 5 years | M | 21.0 | Relapsed acute lymphoblastic leukaemia | Hydromorphone | Home | Palliative Care | No |
6 | 16 months | M | 11.0 | Meningococcal septicaemia with brain injury and four limb amputation | Morphine | Hospital (ward) | Pain Management | No |
7 | 12 years | M | 34.6 | Relapsed pelvic alveolar rhabdomyosarcoma | Hydromorphone | Home | Palliative Care | No |
8 | 9 years | F | 45.9 | Frontotemporal pleomorphic xanthoastrocytoma | Hydromorphone | Hospital (ward) | Pain Management | No |
9 | 16 years | M | 46.0 | Refractory graft versus host disease post bone marrow transplant for acute myeloid leukaemia | Hydromorphone | Hospital (ward) | Palliative Care | No |
10 | 16 years | M | 38.6 | Cerebral palsy with spastic quadriplegia, parental nutrition | Fentanyl patch | Hospital (ward) | Palliative Care | No |
11 | 6 years | F | 20.0 | Low grade sarcoma | Hydromorphone | Hospital (ward) | Pain Management | No |
12 | 5 years | F | 18.0 | Juvenile myelomonocytic leukaemia, graft versus host disease | Hydromorphone, ketamine | Hospital (intensive care) | Pain Management | Yes |
13 | 7 years | F | 25.8 | Epileptic encephalopathy | Oxycodone | Home | Pain Management | No |
14 | 7 years | F | 22.0 | Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries | Morphine | Home | Palliative Care | No |
15 | 15 years | F | 45.0 | Severe veno-occlusive disease and renal impairment post bone marrow transplant for acute lymphoblastic leukaemia | Hydromorphone | Hospital (intensive care) | Pain Management | Yes |
16 | 23 months | M | 15.0 | Bi-lineage leukaemia requiring bone marrow transplant | Hydromorphone | Hospital (intensive care) | Pain Management | Yes |
Pt | Approx. MEDD (PO) | Methadone Starting Dose and Route | Maximal Methadone Dose and Route | Rapid Conversion or Adjuvant | Reason for Rotation to Methadone | Conversion Ratio (PO Morph: PO Meth) | Breakthrough Analgesia | Side Effects or Issues Noted | Outcome |
---|---|---|---|---|---|---|---|---|---|
1 | 504 mg | 5 mg QID PO | 15 mg PO QID. | Rapid conversion | Increasing Drowsiness and Inadequate Analgesia. | 25:1 | Hydromorph PCA IV. | Less drowsy on methadone. Able to start walking again. Withdrawal symptoms. | Died 6 months after commencing methadone. |
Changed to 30 mg IV infusion over 24 h | Changed to meth PCA IV subsequently | ||||||||
2 | 1080 mg | 1 mg nocte NG | 2 mg QID SL | Adjuvant | Loss of central venous access and unable to maintain SC route. | N/A | Hydromorph PCA and ketamine IV | Drowsiness and low respiratory rate requiring doses to be skipped. | Died 3 months after commencing methadone. |
3 | 5400 mg | 15 mg QID PO | 240 mg IV infusion over 24 h | Rapid conversion | Inadequate Analgesia. | 90:1 | Hydromorph PCA IV.Eventually converted to meth PCA IV | Improved Analgesia. | Died one month after commencing methadone. |
4 | 12 mg | 1.5 mg QID PO | 3 mg TDS PO. Changed to Fentanyl patch | Rapid conversion | Side effects with morphine—inadequate analgesia and itch. Methadone only alternative slow release opioid that comes as elixir. | 2:1 | Hydromorph NCA | Unsteadiness attributed to methadone. | Died 3 months after ceasing methadone. |
5 | 6000 mg | 150 mg SC infusion over 24 h | 150 mg SC infusion over 24 h | Rapid conversion | Inadequate Analgesia. | 20:1 | Meth SC | Improved analgesia. | Died 7 days after commencing methadone. |
6 | 96 mg | 5.5 mg QID NG | 5.5 mg QID NG | Rapid conversion | Irritability. | 4.4:1 | Morph NCA IV | Withdrawal symptoms. | Weaned off methadone. Alive. |
7 | 9000 mg | 180 mg SC infusion over 24 h | 324 mg daily SC infusion | Rapid conversion | Inadequate Analgesia. | 25:1 | Meth SC | Improved analgesia. | Died 30 h after methadone rotation. |
8 | 648 mg | 15 mg QID PO | 15 mg QID PO | Rapid conversion | Inadequate Analgesia. | 10.8:1 | Hydromorph PCA IV | No significant improvement in analgesia. | Weaned off methadone. Alive. |
9 | 10,800 mg | 36 mg IV infusion over 24 h | 600 mg IV infusion over 24 h | Rapid conversion | Myoclonus. | 150:1 | Meth PCA IV | Less mycolonus. | Died 4 days after methadone rotation. |
10 | 288 mg | 1 mg IV NOCTE | 10 mg QID SL | Adjuvant. Gradual conversion to methadone | Inadequate analgesia. | N/A | NCA fentanyl IV | Improved analgesia. | Weaning Methadone. Alive. |
11 | 30 mg | 0.5 mg QIDPO | 2.5 mg TDS PO | Rapid conversion | Inadequate analgesia. Methadone syrup available as elixir. | 15:1 | PCA hydromorph IV | Improved analgesia. Episode of drowsiness and reduced RR (did not require naloxone). | Able to wean methadone. Alive. |
12 | 1080 mg | 1 mg IV NOCTE | 10 mg QID SL | Adjuvant for one week, then total conversion to methadone | Inadequate analgesia. Seizures (neurotoxicity) possibly due to hydromorphone. | N/A | NCA hydromorph IV | Improved analgesia. No further seizures. | Weaned off methadone. Alive. |
13 | Not on regular opioid, but having PRN codeine | 2 mg BD PO | 4 mg QID PO | Commenced as primary pain management (de novo) at 0.1 mg/kg bd | Complex pain. Neuropathic pain. | Dose based on weight | PRN oxycodone PO | No improvement. | Weaned off methadone. Alive. |
14 | 120 mg | 1 mg at night for 1 day and then 3 mg QID SL | 10 mg QID SL | Initially adjuvant and then rapid conversion | Neurotoxicity. Severe dysponea. Chest pain. Required elixir. | 10:1 | PRN morph PO | Less confusion. Improved analgesia and less dyspnoea. | Alive. |
15 | 1068 mg | 36 mg IV infusion over 24 h | 72 mg IV infusion over 24 h | Rapid conversion | Inadequate Analgesia. Agitation. | 15:1 | Meth NCA IV | Improved analgesia and sedation. | Died 16 days after methadone rotation. |
16 | 21 mg | 0.5 mg TDS PO | 0.5 mg TDS PO | Rapid conversion | Available as elixir. Experienced pruritis with morphine. | 14:1 | PRN meth PO | Stable analgesia. | Weaned methadone. Died 3 weeks after methadone ceased. |
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Mott, C.; Sarpal, A.; Moss, K.; Herbert, A. Methadone for Analgesia in Children with Life-Limiting Illness: Experience from a Tertiary Children’s Health Service. Children 2018, 5, 86. https://doi.org/10.3390/children5070086
Mott C, Sarpal A, Moss K, Herbert A. Methadone for Analgesia in Children with Life-Limiting Illness: Experience from a Tertiary Children’s Health Service. Children. 2018; 5(7):86. https://doi.org/10.3390/children5070086
Chicago/Turabian StyleMott, Christine, Amrita Sarpal, Krista Moss, and Anthony Herbert. 2018. "Methadone for Analgesia in Children with Life-Limiting Illness: Experience from a Tertiary Children’s Health Service" Children 5, no. 7: 86. https://doi.org/10.3390/children5070086