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Cautious use and optimal dose of morphine for relieving malignant pain in a complex patient with multiple comorbidities
  1. Vinod Kumar1,
  2. Rakesh Garg1,
  3. Nishkarsh Gupta2,
  4. Sachidanand Jee Bharati1
  1. 1Department of Anaesthesiology, Intensive Care and Pain Medicine, All India Institute of Medical Sciences, New Delhi, India
  2. 2All India Institute of Medical Sciences, New Delhi, India
  1. Correspondence to Dr Rakesh Garg, drrgarg{at}


Oral morphine remains the drug of choice for the management of severe pain due to cancer as per WHO ladder of analgesia. Providing adequate pain relief in palliative care settings for pain due to cancer is challenging. Options become limited in cases of associated systemic comorbidities such as renal dysfunction, hypoproteinaemia, anaemia. Patients with renal dysfunction and other comorbidities may develop drug overdose due to abnormal pharmacokinetics. Renal dysfunction affects the pharmacokinetics of morphine by altering its absorption, metabolism and clearance. Plasma albumin also influences drug availability, its plasma distribution and thus available free morphine for its clinical effect. Morphine should be used cautiously for the treatment of pain in patients with renal failure, hypoproteinaemia, hyperbilirubinaemia and anaemia. In such patients, alternate opiates like fentanyl, hydromorphone, or oxycodone may be used as these drugs are not significantly excreted by the kidneys.

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  • Contributors VK involved in the conduct and follow-up of the care. VK and RG planned the study, collected case-related data, involved in literature search and wrote the manuscript. RG, NG, SJB were involved in conduct and follow-up of care. All approved the final manuscript.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.