Nalbuphine and slow release morphine

Clinically significant drug–drug interactions involving opioid analgesics used for pain treatment in patients with cancer: a systematic review

“… 11 , 12 Seven papers reported DDIs causing impairment of pain control and/or opioid withdrawal. 15 – 17 , 24 , 27 , 28 , 33 Finally, in three publications, other symptoms believed to be associated with opioid-related DDIs were reported: hypertension, 13 hypotension, 24 vomiting, 24 sweating, 24 ventricular tachycardia/torsades de pointes. 41 …”

“…Four publications report DDIs associated with opioids of minor current clinical relevance: propoxyphene, dextro-propoxyphene, and nalbuphine. 11 , 12 , 15 , 16 …”

“…DDIs involving opioids can cause acute exacerbations of pain, or withdrawal symptoms ( Table 2 ). In the identified cases, these symptoms resulted from the addition of an opioid with a mixed agonist–antagonist effect (nalbuphine), 15 , 16 and increased or decreased metabolism of an opioid due to the coadministration of a CYP3A4 inducer (rifampin) 27 , 28 or inhibitor (cyclosporine) 33 or cessation of CYP3A4 inhibition (voriconazole) 24 ( Table 3 ). Nalbuphine, which is an agonist at kappa opioid receptors and an antagonist at mu opioid receptors, 48 reverses the analgesic effect of mu opioid agonists when used concomitantly.…”

Preventing glass injuries in the emergency department

“…2 The dose of midazolam should be reduced in elderly patients and in those with considerable comorbidity. Although reversal of midazolam is possible with flumazenil (Anexate-R), this may be associated with patients experiencing arhythmias, hypertension and even convulsions.…”

“…Indeed, hyperlactataemia is most important in assessing any patient with sepsis, and ignoring it could easily lead to underestimation of the severity of illness in a patient with sepsis. 2 It may therefore prove to be far harder to implement these guidelines than was originally envisaged, especially with accident and emergency departments under increasing pressure to meet targets. Education will obviously play a key part; it is evident that there is a disparity between the evidence-based practice we strive for and the daily clinical practice we undertake.…”