MEPERIDINE HYDROCHLORIDE 
Pronounciation
- (meh-PER-ih-deen hy-droh-KLOR-eyed)
Trade Name(s)
- Demerol, Demerol HCl, Meperidine HCl PF
MEPERIDINE HYDROCHLORIDE
Pronounciation
Trade Name(s)
Individualize dose, taking into account the patient’s severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse. Use lowest effective dose for the shortest duration consistent with the patient’s treatment goals.
50 to 150 mg IM or SC every 3 to 4 hours as needed for pain. If IV administration is required, dosage should be decreased and the injection made very slowly, preferably using a diluted solution.
15 to 35 mg/hr; see Precautions.
1 to 10 mg/mL dilution is usually used. Titrate under the direct observation and control of the anesthesiologist. Dose dependent on premedication, type of anesthesia, type and duration of procedure, and patient’s condition.
Treatment or prevention of shaking chills (unlabeled):
12.5 to 50 mg.
1.1 to 1.8 mg/kg/dose IM or SC; see comments under Usual Dose and Maternal/Child.
Reduced dose may be required in the elderly or debilitated, in hepatic or renal disease, or in numerous other disease states; see Precautions. ■ Doses appropriate for the general population may cause serious respiratory depression in vulnerable patients. ■ Increase doses as required if analgesia is inadequate, tolerance develops, or pain severity increases. The first sign of tolerance is usually a reduced duration of effect. ■ Decrease dose by 25% to 50% when administered concomitantly with phenothiazines and other centrally acting medications (e.g., sedatives). ■ See Drug/Lab Interactions.
May be given undiluted; however, further dilution with 5 mL of SWFI, NS, or other IV solutions to facilitate titration is appropriate; see chart on inside back cover.
No data available from manufacturer.
Before use, store at CRT protected from light. Do not freeze.
Compatibility information not available from manufacturer. Other sources suggest specific compatibilities dependent on concentration and manufacturer; consult a pharmacist.
A single dose over 4 to 5 minutes. Frequently titrated according to symptom relief and respiratory rate. Rapid IV administration increases the possibility of hypotension and respiratory depression.
A synthetic opioid agonist similar to morphine. Has multiple actions; the most prominent involve the CNS and organs composed of smooth muscle. Principal actions of therapeutic value are analgesia and sedation. A parenteral dose of meperidine 60 to 80 mg is approximately equivalent in analgesic effect to 10 mg of morphine. Onset of action occurs in about 5 minutes and lasts for about 2 to 3 hours. Metabolized to an active, toxic metabolite (normeperidine) in the liver. The half-life of meperidine is 2 to 5 hours. The half-life of normeperidine is 15 to 30 hours. This extended half-life may lead to cumulative effects. Excreted in the urine. Crosses the placental barrier. Secreted in breast milk.
Management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. ■ Preoperative medication. ■ Support of anesthesia. ■ Obstetric analgesia.
Treatment or prevention of shaking chills (rigors) caused by some medications (e.g., amphotericin B [all formulations], aldesleukin [Proleukin]). ■ Treatment of postoperative shivering.
Because of the risk of addiction, abuse, and misuse, even at recommended doses, reserve meperidine for use in patients for whom alternative treatment options (e.g., nonopioid analgesics or opioid combination products):
Meperidine should not be used for treatment of chronic pain. Prolonged use may increase the risk of toxicity (e.g., seizures) from accumulation of the meperidine metabolite normeperidine.
Significant respiratory depression. ■ Acute or severe bronchial asthma in the absence of resuscitation equipment or in unmonitored settings. ■ Known or suspected GI obstruction, including paralytic ileus. ■ Hypersensitivity to meperidine. ■ Patients who have received MAO inhibitors (e.g., selegiline [Eldepryl]) in the previous 14 days.
Meperidine exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient’s risk before prescribing meperidine, and monitor all patients regularly for the development of these behaviors and conditions. Strategies to reduce the risk of diversion or misuse should be used by health care facilities that use this and other controlled substances. ■ See prescribing information for further discussion regarding abuse, addiction, physical dependence, and tolerance. ■ Serious, life-threatening, or fatal respiratory depression may occur with the use of meperidine. Adequate facilities should be available for monitoring and ventilation. An opioid antagonist (e.g., naloxone), emergency drugs, resuscitative and intubation equipment, and oxygen should be readily available. ■ Use of meperidine as a first-line analgesic for pain is discouraged due to its short duration of action and the risk of accumulation of its toxic metabolite, normeperidine. Accumulation of normeperidine may increase the risk of toxicity (e.g., seizures). If its use in acute pain (in patients without renal or CNS disease) cannot be avoided, the American Pain Society and ISMP recommend limiting treatment to 48 hours or less and not exceeding 600 mg/24 hr. ■ Use with extreme caution in patients with COPD, cor pulmonale, a substantially decreased respiratory reserve, hypercapnia, hypoxia, or pre-existing respiratory depression; these patients are at increased risk for decreased respiratory drive, including apnea, even at recommended doses. Consider using nonopioid analgesics, or administer under careful medical supervision at the lowest effective dose. ■ Use with caution and reduce initial doses in elderly, cachectic, or debilitated patients and in patients with severe impairment of hepatic, pulmonary, or renal function. Consider using nonopioid analgesics. ■ Cases of serotonin syndrome have been reported during concomitant use of meperidine with serotonergic drugs. ■ Use caution in patients with head injury, brain tumors, or increased intracranial pressure. Respiratory depression may cause increased PCO2, cerebral vasodilation, and increased intracranial pressure. Clinical course of head injury may be obscured. Avoid use in patients with impaired consciousness or coma. ■ Cases of adrenal insufficiency have been reported with opioid use, more often after more than 1 month of use. If adrenal insufficiency is diagnosed, treat with physiologic replacement doses of corticosteroids and wean the patient off the opioid to allow adrenal function to recover. Another opioid may be tried, because some cases reported use of a different opioid without recurrence of adrenal insufficiency. ■ Use with caution in patients with biliary tract disease, including acute pancreatitis; may cause spasm of the sphincter of Oddi and diminish biliary and pancreatic secretions. ■ May increase the frequency of seizures in patients with a convulsive disorder and may induce or aggravate seizures in some clinical settings. Prolonged meperidine use may increase the risk of seizures from the accumulation of the meperidine metabolite normeperidine. ■ May cause severe hypotension in postoperative patients or in any patient whose ability to maintain blood pressure has been compromised by depleted blood volume or concomitant administration of drugs that can cause hypotension (e.g., anesthetics, phenothiazines). In patients with circulatory shock, meperidine-induced vasodilation may further reduce cardiac output and blood pressure. Use should be avoided. ■ Meperidine may provoke hypertension in patients with pheochromocytoma. ■ Use with caution in patients with atrial flutter and other supraventricular tachycardias; may produce a significant increase in ventricular response rate due to a possible vagolytic action. ■ Do not abruptly discontinue meperidine in a patient who is physically dependent; dose must be tapered gradually. ■ See Drug/Lab Interactions.
Monitor for respiratory depression, especially during initiation of therapy (within the first 24 to 72 hours) or after a dose increase. Oxygen, naloxone, and equipment to establish and maintain an airway must be available. ■ Assess baseline pain, reassess after administration of meperidine, and adjust dose or interval as required. ■ Monitor vital signs and oxygenation and observe patient frequently. ■ Keep patient supine; orthostatic hypotension and fainting may occur; less likely with continuous low doses, but observe closely during ambulation. ■ Monitor patients who may be susceptible to the intracranial effects of CO2 retention for increasing intracranial pressure and signs of sedation and respiratory depression. ■ Monitor patients with biliary tract disease for worsening of symptoms. ■ Monitor patients with a history of seizure disorders for worsening seizure control. ■ With use, the active metabolite normeperidine may accumulate to toxic levels; will lower seizure threshold. ■ Monitor for S/S of serotonin syndrome (e.g., mental status changes [e.g., agitation, coma, hallucinations], autonomic instability [e.g., hyperthermia, labile blood pressure, tachycardia], neuromuscular aberrations [e.g., hyperreflexia, incoordination, rigidity], and/or GI symptoms [e.g., diarrhea, nausea, vomiting]). Onset of symptoms may occur within hours to days of concomitant use of opioids with serotonergic drugs ■ Uncontrolled pain causes sleep deprivation, decreases pain threshold, and increases pain. When pain is finally controlled, expect the patient to sleep more until recovery from sleep deprivation. ■ Laxatives with or without stool softeners may be required to avoid constipation and fecal impaction. Maintain adequate hydration. ■ Monitor patients regularly for the development of opioid addiction, abuse, and misuse.
Avoid alcohol or other CNS depressants (e.g., barbiturates, benzodiazepines [e.g., diazepam (Valium)]). Review all medications for interactions. ■ May cause blurred vision, dizziness, or drowsiness; use caution in tasks that require alertness. ■ Request assistance with ambulation. ■ Promptly report unrelieved pain or unacceptable side effects. ■ Promptly report S/S of serotonin syndrome. ■ May result in severe constipation. Scheduled bowel regimen recommended. ■ May result in addiction, abuse, and misuse, even when taken as recommended.
Not recommended for use during pregnancy or before labor when other analgesic techniques are more appropriate. ■ Use during delivery may cause depression of respiration and psychophysiologic effects in the newborn. May also prolong labor by reducing the strength, duration, and frequency of contractions (this effect is not consistent). Closely monitor neonates exposed to meperidine during labor and delivery for signs of excessive sedation and respiratory depression. ■ Prolonged use of meperidine during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life threatening if not recognized and treated. Infants born to mothers receiving meperidine during pregnancy should be monitored closely and treated for neonatal opioid withdrawal syndrome, if indicated. See literature for treatment protocols.■ Use caution with breast-feeding. Monitor infants exposed to meperidine through breast milk for excess sedation and respiratory depression. Withdrawal symptoms can occur in breast-fed infants when maternal administration of an opioid analgesic is stopped or when breast-feeding is stopped. ■ Safety and effectiveness of meperidine in pediatric patients has not been established. Consider risk versus benefit before use in neonates or young infants. Rate of elimination is slower in neonates and young infants compared to older pediatric patients or adults. May be more sensitive to effects (e.g., respiratory depression).
See Dose Adjustments and Precautions. ■ May be more sensitive to effects (e.g., respiratory depression, CNS depression, constipation, urinary retention). Respiratory depression is the chief risk for elderly patients treated with opioids. ■ Lower doses may provide effective analgesia. ■ Consider age-related organ impairment.
Concomitant use of meperidine withmonoamine oxidase (MAO) inhibitors(e.g., selegiline [Eldepryl], phenelzine [Nardil], tranylcypromine [Parnate], linezolid [Zyvox]) can result in coma, severe respiratory depression, cyanosis, and hypotension; seeContraindications. Severe and unpredictable potentiation of MAO inhibitors has been reported. MAO inhibitor interactions may manifest as serotonin syndrome or opioid toxicity (e.g., respiratory depression, coma). ■ Concomitant use of meperidine with benzodiazepines (e.g., diazepam [Valium], midazolam [Versed]) and other CNS depressants (e.g., sedative/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, other opioids, alcohol) may result in profound sedation, respiratory depression, coma, and death. Hypotension can also occur. Reserve concomitant use for patients for whom alternative treatment options are inadequate. Limit dose and duration of treatment to the minimum required, and monitor patients carefully for S/S of respiratory depression and sedation.■ Use caution with concomitant use of meperidine and CYP3A4 or CYP2B6 inhibitors (e.g., macrolide antibiotics [e.g., erythromycin (Erythrocin)], azole antifungals [e.g., ketoconazole (Nizoral)], and protease inhibitors [e.g., ritonavir (Norvir)]) or when discontinuing a CYP3A4 or CYP2B6 inducer (e.g., rifampin [Rifadin], carbamazepine [Tegretol], phenytoin [Dilantin]) in an meperidine-treated patient. May increase plasma concentration of meperidine, increase or prolong opioid adverse effects, and cause potentially fatal respiratory depression. Dose reduction may be indicated. ■ Alternatively, concomitant use of meperidine with CYP3A4 or CYP2B6 inducers or discontinuation of a CYP3A4 or CYP2B6 inhibitor could result in lower than expected meperidine plasma concentration and decreased efficacy. An increase in the dose of meperidine may be required. ■ Serotonin syndrome has been reported with the concomitant use of opioids, including meperidine, and other drugs that affect the serotonergic neurotransmitter system (e.g., selective serotonin reuptake inhibitors [SSRIs], serotonin and norepinephrine reuptake inhibitors [SNRIs], tricyclic antidepressants [TCAs], triptans, 5-HT3 receptor antagonists, mirtazapine, trazodone, tramadol, MAO inhibitors, linezolid, and intravenous methylene blue). Careful observation, particularly during treatment initiation and dose adjustment, is required with concomitant use. ■ Mixed agonist/antagonist analgesics and partial agonists (e.g., buprenorphine [Buprenex], butorphanol [Stadol], nalbuphine, pentazocine [Talwin]) may reduce the analgesic effect of meperidine and/or precipitate withdrawal symptoms. Avoid concomitant use. ■ Meperidine may enhance the neuromuscular blocking action of skeletal muscle relaxants (e.g., cyclobenzaprine [Flexeril], orphenadrine [Norflex]), increasing the degree of respiratory depression. Monitor patient and decrease dose if indicated. ■ Opioids can reduce the efficacy of diuretics by inducing the release of antidiuretic hormone. Increase dose of diuretic if needed. ■ Concomitant use with anticholinergic drugs may increase the risk of urinary retention and/or severe constipation, which may lead to paralytic ileus. ■ Concomitant use of acyclovir (Zovirax) may increase plasma concentrations of meperidine and normeperidine. Monitor for respiratory depression and sedation. ■ Concomitant use of cimetidine (Tagamet) may reduce the clearance and volume of distribution of meperidine and the formation of normeperidine. Monitor for respiratory depression and sedation.
The most common adverse reactions are dizziness, light-headedness, nausea, sedation, sweating, and vomiting. The most serious side effects reported are respiratory depression and, to a lesser degree, circulatory depression. Respiratory arrest, cardiac arrest, and shock have occurred. Other reported adverse reactions include agitation, anaphylaxis, biliary tract spasm, bradycardia, confusion, constipation, convulsions, delirium, dry mouth, flushing, headache, hypersensitivity reactions, hypotension, involuntary muscle movements, mood changes, palpitations, phlebitis, postural hypotension, pruritus, rash, restlessness, syncope, tachycardia, transient hallucinations and disorientation, tremor, urinary retention, urticaria, visual disturbances, and weakness.
Apnea, atypical snoring, bradycardia, cardiac arrest, circulatory depression or collapse, cold and clammy skin, constricted pupils, hypotension (severe), partial or complete airway obstruction, respiratory depression or arrest, skeletal muscle flaccidity, somnolence progressing to stupor or coma, and death.
With increasing severity of minor side effects or onset of any major side effect, discontinue the drug and notify the physician. A patent airway, artificial respiration, oxygen therapy, and other symptomatic treatment must be instituted promptly. Naloxone hydrochloride will reverse cardiovascular, CNS, and respiratory reactions. In patients who are physically dependent on narcotics, use extreme caution to avoid precipitating an acute withdrawal syndrome. If use of an antagonist is needed in a physically dependent patient, begin administration of the antagonist at a lower than usual dose and titrate with care. In all patients, adjust and titrate the dose of a narcotic antagonist to reverse side effects without reversing pain control. Avoid total reversal of pain control. The duration of action of meperidine may exceed the duration of action of naloxone. Monitor patient carefully. Repeat doses of naloxone may be required. IV hydrocortisone or prednisolone and chlorpromazine have been used to treat severe reactions (e.g., hypertension, hyperpyrexia) in patients who inadvertently receive an MAO inhibitor and meperidine. The usefulness and safety of narcotic antagonists in treatment of these reactions is unknown; see Contraindications and Drug/Lab Interactions. Resuscitate as necessary.