What is Morphine sulfate (Extended release)?
Morphine sulfate (Extended release) are indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.
Morphine Sulfate Extended-Release Tablets are for oral use and contain morphine sulfate, an agonist at the mu-opioid receptor.
Each tablet contains the following inactive ingredients common to all strengths: cetostearyl alcohol, hydroxyethyl cellulose, hypromellose, magnesium stearate, polyethylene glycol, talc, and titanium dioxide.
The tablet strengths describe the amount of morphine per tablet as the pentahydrated sulfate salt (morphine sulfate).
The 15 mg tablets also contain: lactose monohydrate, polysorbate 80
The 30 mg tablets also contain: lactose monohydrate, polysorbate 80
The 60 mg tablets also contain: hydroxypropyl cellulose, lactose monohydrate
The 100 mg tablets also contain: black iron oxide
The 200 mg tablets also contain: hydroxypropyl cellulose
Morphine sulfat is an odorless, white, crystalline powder with a bitter taste. It has a solubility of 1 in 21 parts of water and 1 in 1000 parts of alcohol, but is practically insoluble in chloroform or ether. The octanol: water partition coefficient of morphine is 1.42 at physiologic pH and the pKb is 7.9 for the tertiary nitrogen (mostly ionized at pH 7.4).
Limitations Of Use
Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the the greater risks of overdose and death with extended-release opioid formulations, reserve morphine sulfat extended-release tablets for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain.
Morphine sulfate extended-release tablets are not indicated as an as-needed (prn) analgesic.
Dosage and administration
Morphine extended-release tablets should be prescribed only by healthcare professionals who are knowledgeable in the use of potent opioids for the management of chronic pain.
Initiate the dosing regimen for each patient individually, taking into account the patient’s prior analgesic treatment experience and risk factors for addiction, abuse, and misuse. Monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of initiating therapy with morphine sulfate extended-release tablets.
Morphine sulfate extended-release tablets must be taken whole. Crushing, chewing, or dissolving morphine sulfate extended-release tablets will result in uncontrolled delivery of morphine and can lead to overdose or death.
Use Of Morphine Sulfate Extended-Release Tablets As The First Opioid Analgesic
Initiate treatment with morphine sulfate extended-release tablets with 15 mg tablets orally every 8 or 12 hours.
Use Of Morphine Sulfate Extended-Release Tablets In Patients Who Are Not Opioid Tolerant
The starting dose for patients, who are not opioid-tolerant, is morphine sulfate extended-release tablets 15 mg orally every 12 hours. Patients who are opioid-tolerant are those receiving, for one week or longer, at least 60 mg oral morphine per day, 25 mcg transdermal fentanyl per hour, 30 mg oral oxycodone per day, 8 mg oral hydromorphone per day, 25 mg oral oxymorphone per day, or an equianalgesic dose of another opioid.
Use of higher starting doses in patients who are not opioid tolerant may cause fatal respiratory depression.
Conversion From Other Oral Morphine To Morphine Sulfate Extended-Release Tablets
Patients receiving other oral morphine formulations may be converted to morphine sulfate extendedrelease tablets by administering one-half of the patient’s 24-hour requirement as morphine sulfate extended-release tablets on an every-12-hour schedule or by administering one-third of the patient’s daily requirement as morphine sulfate extended-release tablets on an every-8-hour schedule.
Conversion From Other Opioids To Morphine Sulfate Extended-Release Tablets
There are no established conversion ratios for conversion from other opioids to morphine sulfate extended-release tablets defined by clinical trials. Discontinue all other around-the-clock opioid drugs when morphine sulfate extended-release tablets therapy is initiated and initiate dosing using morphine sulfate extended-release tablets 15 mg orally every 8 to 12 hours.
It is safer to underestimate a patient’s 24-hour oral morphine requirements and provide rescue medication (e.g., immediate-release morphine) than to overestimate the 24-hour oral morphine requirements and manage an adverse reaction. While useful tables of opioid equivalents are readily available, there is substantial inter-patient variability in the relative potency of different opioid drugs and products.
Conversion From Parenteral Morphine Or Other Opioids (Parenteral Or Oral) To Morphine Sulfate Extended- Release Tablets
When converting from parenteral morphine or other non-morphine opioids (parenteral or oral) to morphine sulfate extended-release tablets, consider the following general points:
Parenteral to oral morphine ratio: Between 2 to 6 mg of oral morphine may be required to provide analgesia equivalent to 1 mg of parenteral morphine. Typically, a dose of morphine that is approximately three times the previous daily parenteral morphine requirement is sufficient.
Other parenteral or oral non-morphine opioids to oral morphine sulfate: Specific recommendations are not available because of a lack of systematic evidence for these types of analgesic substitutions. Published relative potency data are available, but such ratios are approximations. In general, begin with half of the estimated daily morphine requirement as the initial dose, managing inadequate analgesia by supplementation with immediate-release morphine.
Side Effect of Morphine sulfate (Extended release)
The following serious adverse reactions are described elsewhere in the labeling:
Addiction, Abuse, and Misuse
Life-Threatening Respiratory Depression
Neonatal Opioid Withdrawal Syndrome
Interactions with Other CNS Depressants
Clinical Trial Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
Morphine sulfate extended-release tablets may increase the risk of serious adverse reactions such as those observed with other opioid analgesics, including respiratory depression, apnea, respiratory arrest, circulatory depression, hypotension, or shock
Most Frequently Observed Reactions
In clinical trials, the most common adverse reactions with morphine sulfate extended-release tablets were constipation, dizziness, sedation, nausea, vomiting, sweating, dysphoria, and euphoric mood.
Some of these effects seem to be more prominent in ambulatory patients and in those not experiencing severe pain.
Less Frequently Observed Reactions
Cardiovascular disorders: tachycardia, bradycardia, palpitations
Eye disorders: visual impairment, vision blurred, diplopia, miosis
Gastrointestinal disorders: dry mouth, diarrhea, abdominal pain, constipation, dyspepsia
General disorders and administration site conditions: chills, feeling abnormal, edema, edema peripheral, weakness
Hepatobiliary disorders: biliary colic
Metabolism and nutrition disorders: anorexia
Musculoskeletal and connective tissue disorders: muscle rigidity, muscle twitching
Nervous system disorders: presyncope, syncope, headache, tremor, uncoordinated muscle movements, convulsion, intracranial pressure increased, taste alteration, paresthesia, nystagmus
Psychiatric disorders: agitation, mood altered, anxiety, depression, abnormal dreams, hallucination, disorientation, insomnia
Renal and urinary disorders: urinary retention, urinary hesitation, antidiuretic effects
Reproductive system and breast disorders: reduced libido and/or potency
Respiratory, thoracic and mediastinal disorders: laryngospasm
Skin and subcutaneous tissue disorders: pruritus, urticaria, rash
Vascular disorders: flushing, hypotension, hypertension