Dosing and uses of Demerol, pethidine (meperidine)
Adult dosage forms and strengths
syrup: Schedule II
- 50mg/5mL
tablet: Schedule II
- 50mg
- 100mg
injectable solution: Schedule II
- 25mg/mL
- 50mg/mL
- 75mg/mL
- 100mg/mL
Pain
Meperidine is not recommended as a first choice analgesic by The American Pain Society and ISMP (2007); if no other options, limit use in acute pain to ≤48hr; doses should not exceed 600 mg/24hr; oral route is not recommended for treatment of acute or chronic pain
Pain: 50-150 mg PO/IM/SC q3-4hr PRN; adjust dose based degree of response
Preoperatively: 50-150 mg IM/SC q3-4hr PRn
Continuous infusion: 15-35 mg/hr
Obstetrical analgesia: 50-100 mg IM/SC; repeated q1-3hr PRn
Dosing Modifications
Renal impairment: Avoid use
Hepatic impairment: Consider lower initial dose intially; increased opioid effect possible in cirrhosis
Pediatric dosage forms and strengths
syrup: Schedule II
- 50mg/5mL
tablet: Schedule II
- 50mg
- 100mg
injectable solution: Schedule II
- 25mg/mL
- 50mg/mL
- 75mg/mL
- 100mg/mL
Pain
Meperidine is not recommended as a first choice analgesic by The American Pain Society and ISMP (2007); if no other options, limit use in acute pain to ≤48hr; doses should not exceed 600 mg/24hr; oral route is not recommended for treatment of acute or chronic pain
1-1.8 mg/kg PO/IM/SC q3-4hr PRN; individual dose not to exceed 100 mg
Preoperatively: 1.1-2.2 mg/kg IM/SC 30-90 minutes before initiation of anesthesia
Geriatric dosage forms and strengths
Pain
50 mg PO q4hr or 25 mg IM q4hr; treatment for acute pain should be limited to 1-2 doses
Dosing Considerations
Not drug of choice in elderly patients, because of accumulation of metabolite normeperidine, causing increased central nervous system (CNS) effects
Reduce total daily dose in elderly patients
Demerol, pethidine (meperidine) adverse (side) effects
Frequency not defined
Agitation
Angina
Bradycardia
Cardiac arrest
Coma
Constipation
Dizziness
Dry mouth
Dysphoria
Euphoria
Faintness
Hypotension
Mental clouding or depression
Myocardial infarction
Nausea
Nervousness
Palpitation
Physical and psychological dependence
Pruritus, urticaria
QT-interval prolongation
Respiratory arrest
Respiratory/circulatory depression
Restlessness
Sedation
Seizures
Severe cardiac arrhythmias
Shock
ST-segment elevation
Sweating, flushing, warmness of face/neck/upper thorax
Syncope
Tachycardia
Urinary retention
Visual disturbances
Vomiting
Weakness
Warnings
Contraindications
Hypersensitivity to drug or component of the formulation
Severe respiratory insufficiency
Within 14 days of taking MAO inhibitors; if linezolid or IV methylene blue (MAOIs) must be administered, discontinue serotonergic drug immediately and monitor for CNS toxicity; may resume 24 hr after last linezolid or methylene blue dose, or after 2 weeks of monitoring, whichever comes first
Cautions
Potential for tolerance and drug dependence
Caution in acute abdominal conditions (may obscure diagnosis or clinical course of patient), pseudomembranous colitis, toxin-mediated diarrhea
Narrow therapeutic index in certain patient populations, particularly in combination with CNS-depressant drugs
Cardiac arrhythmias, drug abuse or dependence, emotional lability, gallbladder disease, head injury, increased intracranial pressure, benign prostatic hyperplasia, hepatic or renal impairment, seizures with epilepsy, urethral stricture, urinary tract surgery
Use with caution in following conditions: Sickle cell anemia; pheochromocytoma; acute alcoholism; adrenocortical insufficiency (eg, Addison disease); CNS depression or coma; delirium tremens; debilitated patients; kyphoscoliosis associated with respiratory depression; myxedema or hypothyroidism; prostatic hypertrophy or urethral stricture; head trauma; billiary tract impairment; severe impairment of hepatic, pulmonary, or renal function; toxic psychosis
Interaction with mixed agonist/antagonist opioid analgesics (eg, pentazocine, nalbuphine, butorphanol, buprenorphine) may precipitate withdrawal symptoms
May cause less smooth muscle spasm and constipation than equipotent doses of morphine
Chronic high-dose therapy or administration to patients with renal impairment may result in accumulation of active metabolite normeperidine, leading to agitation and seizures
Pregnancy and lactation
Pregnancy category: B; use for prolonged periods or near term not established
Lactation: Drug excreted in breast milk
Pregnancy categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA: Information not available.
Pharmacology of Demerol, pethidine (meperidine)
Mechanism of action
Narcotic agonist-analgesic of opiate receptors; inhibits ascending pain pathways, thus altering response to pain; produces analgesia, respiratory depression, and sedation
Absorption
Bioavailability: 50-60%; hepatic impairment, 80-90%
Onset: Rapid
Duration: PO/SC, 2-4 hr
Peak plasma time: SC, 40-60 min; IM, 30-50 min
Distribution
Protein bound: 65-75%
Metabolism
Metabolized in liver via hydrolysis, partial conjugation with glucuronic acid, N-demethylation
Metabolites: Meperidinic acid, normeperidine (active)
Elimination
Half-life: 2.5-4 hr (adults); 7-11 hr (liver disease)
Excretion: Urine (primarily)
Administration
IV Incompatibilities
Additive: Aminophylline, amobarbital, floxacillin, furosemide, heparin, morphine, phenobarbital, phenytoin, sodium bicarbonate(?)
Syringe: Heparin, morphine, pentobarbitaL
Y-site: Acyclovir(?), allopurinol, amphotericin B cholesteryl sulfate, cefepime, cefoperazone, doxorubicin, furosemide (may be compatible at lower concentrations), idarubicin, imipenem-cilastatin, minocycline, nafcillin(?)
Not specified: Diazepam
IV Compatibilities
Solution: Most common solvents
Additive: Cefazolin, dobutamine, metoclopramide, ondansetron, scopolamine, triflupromazine, verapamiL
Syringe: Atropine, butorphanol, chlorpromazine, cimetidine, dimenhydrinate, diphenhydramine, droperidol, fentanyl, glycopyrrolate, hydroxyzine, ketamine, metoclopramide, midazolam, ondansetron, papaveretum, pentazocine, pentazocine with perphenazine, perphenazine, prochlorperazine, promazine, promethazine, promethazine with atropine, ranitidine, scopolamine
Y-site: Amifostine, amikacin, ampicillin, ampicillin-sulbactam, atenolol, aztreonam, bivalirudin, bumetanide, cefamandole, cefazolin, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftizoxime, ceftriaxone, cefuroxime, chloramphenicol, cisatracurium, cladribine, clindamycin, dexamethasone, dexmedetomidine, diltiazem, diphenhydramine, dobutamine, docetaxel, dopamine, doxycycline, droperidol, erythromycin, etoposide phosphate, famotidine, fenoldopam, filgrastim, fluconazole, fludarabine, gatifloxacin, gemcitabine, gentamicin, granisetron, heparin, 6% hetastarch in lactated electrolyte injection (Hextend), hydrocortisone, insulin, kanamycin, labetalol, lidocaine, linezolid, magnesium sulfate, melphalan, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, ondansetron, oxacillin, oxytocin, paclitaxel, penicillin G, piperacillin, piperacillin-tazobactam, potassium chloride, propofol, propranolol, ranitidine, remifentanyl, sargramostim, teniposide, thiotepa, ticarcillin, ticarcillin-clavulanate, tobramycin, trimethoprim, vancomycin, verapamil, vinorelbine
Not specified: Epinephrine
IV/IM Administration
IM: Inject into large muscle mass; when repeated injection is needed, IM is preferred to SC
IV injection: Inject 10 mg/mL very slowly; opiate antagonist and facilities for administration of oxygen and control of respiration should be available during and immediately after administration
Continuous IV infusion: 15-35 mg/hr
Drug has been injected or infused epidurally
