What happened....

[GravyRPH]

...to that thread where baggy had posed a question about aminoglycosides? I can't seem to find it. Maybe we aren't allowed to discuss those topics on here?

Anyways, someone had posed another question about which pain reliever to use in pancreatitis and how meperidine was thought to have less effet on the sphincter of oddi. But I found this today on the pharmacist's letter website:

RUMOR: Meperidine is better than morphine for pancreatitis.

TRUTH:
Many clinicians were taught to use meperidine instead of morphine for pancreatitis. This recommendation still appears in some textbooks.
The thinking is that high doses of morphine can increase biliary sphincter pressure...and possibly cause bile acid build-up and pain.
But this is a medical MYTH.
Sphincter pressure is actually raised by ALL opioids...and there's no proof that increasing bile duct pressure causes pancreatic pain. You can be comfortable with morphine or hydromorphone for patients with acute pancreatitis. These last longer...and are safer than meperidine.
Meperidine has many drawbacks.
It only lasts about 3 hours...has a higher risk of dependence...and is more likely to cause seizures, tremors, and mood changes.
Meperidine also interacts with many drugs...SSRIs, dihydroergotamine, triptans, MAOIs, selegiline, isoniazid, etc.
Save meperidine for patients who can't take other opioids...or who have drug-induced rigors, post-op shivering, etc.

References:
Palacioz K. Inappropriate meperidine use. Pharmacist's Letter 2001;17:171117.

Radnay PA, Brodman E, Mankikar D, et al. The effect of equi-analgesic doses of fentanyl, morphine, meperidine and pentazocine on common bile duct pressure. Anaesthesist 1980;29:26-29.

Lee F, Cundiff D. Meperidine vs morphine in pancreatitis and cholecystitis. Arch Int Med 1998;158:2399.

Helm JF, Venu RP, Geenen JE, et al. Effects of morphine on the human sphincter of Oddi. Gut 1988;1402-7.

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[LSUMED2006]

I actually remember reading that pharmacist's letter when I was in pharmacy school (btw: pharmacist's letter is a great read). I'm not totally sure that it is safe to say that it is a "MYTH" to say that morphine is worse than meperidine as far as elevating sphincter of oddit pressure. While it certainly is true all opiates do raise SO pressure, morphine seems particularly bad (as much as 10x following 10mg sc injection). I also am not convinced that there is "NO proof" that inc bile pressure can cause pancreatic pain (I actually strongly disagree with this). Blockage of this sphincter via a gall stone causing refulx into the pancreas can cause severe pain. Am J Gastroenterol. 1991 Jul;86(7):831-4 mentions that morphine and other substances that cause contraction of this sphincter and subsequent reflux into the pancreas can contribute to a variety of pathologies. (actually a little common sense and a little knowledge of anatomy will tell you that).

Am J Gastroenterol. 2001 Apr;96(4):1266-72 states that morphine is associated with the largest elevation in SO pressure but also says there are no studies to suggest a contraindication.

Br J Surg. 1990 Sep;77(9):992-5 actually compares the effects of morphine to pethidine (demerol) and finds MS causes a much greater degree of SO pressure elevation.

If anyone didn't know, SO contractions due to narcotics can be partially reversed via atropine and almost completely via naloxone. Meperidine also causes less smooth muscle contractions overall than morphine does.

I do agree that demerol is a dirty dirty drug that should be largely replaced by sublimaze, ultiva, MS, dilaudid, and others, but there is much more evidence than you seem to acknowledge that suggests that morphine is NOT the best drug to use. It certainly is not fair to call the general rule to use dem instead of MS a "MYTH" and speak of "no proof."

 

[baggywrinkle]

Originally posted by LSUMED2006
I do agree that demerol is a dirty dirty drug that should be largely replaced by sublimaze, ultiva, MS, dilaudid, and others, but there is much more evidence than you seem to acknowledge that suggests that morphine is NOT the best drug to use. It certainly is not fair to call the general rule to use dem instead of MS a "MYTH" and speak of "no proof."

A bit of meperidine trivia for you. A British pharmacist on holiday
asked to tour our hospital pharmacy. During conversation narcotics came up and she had never heard of Demerol or meperidine. Morphine sulfate is the mainstay in GB.

I found out later that this is because meperidine was synthesized in German laboratories. Since the Brits and the Germans had their tiff back in the forties the Brits are still not inclined to use a German product if they can avoid it....

 

[badxmojo]

baggy, gravy.. your pharm knowledge seems to be far superior to most of the posters on this board.. how much expereince do you guys actually have? if you don't mind my asking.

 

[baggywrinkle]

Originally posted by badxmojo
baggy, gravy.. your pharm knowledge seems to be far superior to most of the posters on this board.. how much expereince do you guys actually have? if you don't mind my asking.

We are both practicing pharmacists.

I graduated class of '83 university of Iowa and have had a few laps around the track since then. You learn things along the way.
Some of them are actually useful. One of the best gems I ever learned was, don't let your (flight) students eat chilidogs before you take em up. Truths such as these are timeless, don't-cha-know.

 

[LSUMED2006]

Originally posted by badxmojo
baggy, gravy.. your pharm knowledge seems to be far superior to most of the posters on this board.. how much expereince do you guys actually have? if you don't mind my asking.

hey watta bout me :-( jk.

Speaking of the germans. Way back in WWII, the nazis were finding it impossible to either cultivate or aquire enough poppies/opium for MS production. So, the nazi chemists go to the lab and come up with....methadone. The original brand name of methadone is dolphine (I have read this was a nod to aldof h., but I'm not sure)

I'm pretty sure all demerol in britian is called pethidine, but I'm not 100%/

Jason

 

[GravyRPH]

Originally posted by LSUMED2006
hey watta bout me :-( jk.

Jason

You don't count because you have chosen to abandon your kirby lester and spatula for a stethoscope.
I've been practicing since just '98, but I think I've seen a lot of different things and worked for a lot of different people. I've managed to work for one of the busiest retail pharmacies in California and at several hospitals and chains to boot. Plus, I've learned how to pretend I know a lot without actually knowing much quite effectively.

 

[baggywrinkle]

Originally posted by GravyRPH
Plus, I've learned how to pretend I know a lot without actually knowing much quite effectively.

Stroking your chin and nodding sagely counts for heaps. Tough to pull off though if you still look like Doogie Houser.

My replacement on nightshift is a hoot. Brand new grad. He's good and hard working. Meticulous. My manager calls him
painfully accurate (read that slow) They've been working him at a sister store on night shift to get him ready. He's been calling me at LEAST two times a night with questions like should I call the doctor about this sub therapeutic dose of phenergan syrup for a twelve year old. I predict he gets three months into the job before the technicians revolt and threaten to change his nappies.

 

[Triangulation]

Originally posted by badxmojo
baggy, gravy.. your pharm knowledge seems to be far superior to most of the posters on this board.. how much expereince do you guys actually have? if you don't mind my asking.

Awwwww. what a nice thing to say.

just one big happy family that's never met, nor seen each other.

 

[Pilot]

I guess my knowledge base isn't mentionable either.


I still practice as a pharmacist. Worked 2 shifts just this past week (Jan 2 and 3rd). It wasn't until I got to work on the second and got the first insurance reject that I remembered that every company changes insurance plans on Jan 1. Wasn't a very pleasant day (but the money sure is nice).

 

[GravyRPH]

Baggy and I are just cooler than you.





(just kidding)

 

[baggywrinkle]

Enough sooking, back to work!