Butorphanol prevents morphine-induced pruritus without increasing pain and other side effects: a systematic review of randomized controlled trials

Abstract

Purpose Pruritus is a frequent adverse event after administration of morphine. Butorphanol has been used to prevent morphine-induced pruritus, but its efficacy is still controversial. The aim of this systematic review was to evaluate the efficacy of using butorphanol to prevent morphine-induced pruritus. Source We searched PubMed, Cochrane Library, EMBASE, and China's BioMedical Disc for full reports of randomized controlled trials that compared the use of butorphanol with either placebo or no treatment for preventing morphineinduced pruritus. The number of patients experiencing pruritus or other side effects was analyzed using relative risk (RR) with 95% confidence intervals (CI). Principal findings Sixteen trials (795 patients) were analyzed. Continuous intravenous and epidural butorphanol reduced pruritus with RR 0.22 (95% CI 0.10 to 0.45) and RR 0.24 (95% CI 0.16 to 0.36), respectively. Use of epidural butorphanol decreased the number of patients requesting rescue treatment for pruritus (RR 0.57; 95% CI 0.41 to 0.81). Butorphanol decreased postoperative pain intensity at four, eight, and 12 hr with standardized mean differences of -0.29 (95% CI -0.52 to -0.05), -0.30 (95% CI -0.56 to -0.04), and -0.23 (95% CI -0.46 to -0.01), respectively. Epidural but not intravenous butorphanol reduced postoperative nausea and vomiting (PONV) (RR 0.35; 95% CI 0.19 to 0.66). Butorphanol did not increase respiratory depression (RR 0.71; 95% CI 0.31 to 1.63), somnolence (RR 0.71; 95% CI 0.22 to 2.37), or dizziness (RR 2.45; 95% CI 0.35 to 17.14). Conclusion Butorphanol administered with morphine may be an effective strategy for preventing morphineinduced pruritus as it decreases pain intensity and PONV without increasing other side effects. Thus, it can be recommended for preventing morphine-induced pruritus during the perioperative period. RésuméObjectif Le prurit est un effet secondaire néfaste fréquent après l'administration de morphine. Le butorphanol a été utilisé pour prévenir le prurit induit par la morphine, mais son efficacité est encore controversée. L'objectif de cette revue méthodique était d'évaluer l'efficacité du butorphanol pour prévenir le prurit induit par la morphine.

Targeting multiple opioid receptors – improved analgesics with reduced side effects?

“…These data indicated that nalfurafine can be used for long‐term treatment of intractable pruritus with minimal concern regarding the risk of dependence (Nakao et al , ). All other mixed μ/κ receptor agonists in clinical use, such as butorphanol, nalbuphine and pentazocine, alleviate morphine‐induced pruritus; however, only butorphanol is used to treat chronic pruritus (Du et al , ). Dihydroetorphine is one of the most potent analgesic opioids known, with up to 12‐fold higher potency than morphine.…”

Neuraxial Opioid-Induced Itch and Its Pharmacological Antagonism

“…Nevertheless, several studies have shown a decreased incidence of pruritus without other side effects when butorphanol was administered with morphine epidurally in pediatric patients (Bailey et al 1994; Gunter et al 2000; Lawhorn et al 1995; Lawhorn and Brown 1994). A recent systematic review also indicates the potential benefits of using butorphanol to prevent neuraxial morphine-induced itch and decrease pain intensity and postoperative nausea and vomiting without increasing other side effects (Du et al 2013). Importantly, a pharmacological study demonstrates that butorphanol’s partial agonist actions at both MOP and KOP sites contribute to its antipruritic actions, i.e., low-efficacy ligands antagonize high-efficacy ligand’s action in producing itch sensation (Lee et al 2007).…”

Why do Pain Physicians Not Routinely Use Mixed Opioids for the Prevention of Neuraxial Opioid-induced Pruritus?

“…Pentazocine also had a lower pruritus recurrence rate [20]. A recent systematic review on the effectiveness of butorphanol included 16 trials, and 795 patients were analyzed [21]. Butorphanol reduced opioidinduced pruritus either by intravenous or epidural routes with an RR of 0.22 (95% CI 0.10 to 0.45) and RR 0.24 (95% CI 0.16 to 0.36), respectively.…”