Problems associated with meperidine use have resulted in inadequate pain control and adverse effects for many patients through the years. First‑line opioids such as morphine, hydromorphone or oxycodone should be used in preference to meperidine, which should be utilized only as outlined below. Meperidine, in spite of its Food and Drug Administration-labeled indication, is not suitable for chronic pain.  To promote safe medication usage and optimal pain management, the Pharmacy and Therapeutics Committee has established the following guidelines for use of meperidine. 

Appropriate Indications for Use 

 Management of acute episodes of moderate to severe pain if the patient has a history of one or more of the following problems: 

• Unmanageable adverse reactions to other first-line opioids. 
• Treatment failure to other first-line opioids given in adequate doses. 
•  Prevention or treatment of drug-induced or blood product-induced rigors (e.g., amphotericin B, muromonab, platelets), and treatment of post-anesthesia shivering. 
•  Management of pain during medical procedures. 
•  Research protocols specifying the use of meperidine. 
•  Neuraxial analgesia for acute pain management, administered by the anesthesiology service. 
•  Dose, Route and Duration of Therapy 

Meperidine should not be used for longer than 48 hours or at doses greater than 600 mg/24 hours in patients with normal renal function. 

Adult parenteral doses may range from 25 to 100 mg intravenously or subcutaneously every 3 hours as needed.  The slow intravenous (IV) push route may be used, at a starting dose of 25 mg, increasing in 25 mg increments to a maximum of 100 mg, every 2 to 3 hours as needed, within the limitations noted in point 1.0 above. Intramuscular (IM) absorption is erratic and IM injections are painful; therefore, they are to be used only in emergent situations where another route is not immediately available. 

For the prevention of rigors, 12.5 to 50 mg should be administered via slow IV push. For treatment of rigors or post-anesthesia shivering, 12.5 to 50 mg should be given by slow IV push every 15 to 20 minutes until symptoms are controlled. 

Meperidine is seldom indicated for analgesia in children. The analgesic dose is 0.75 to 1.0 mg/kg SC or slow IV push every 3 hours as needed. For the prevention or treatment of rigors, a single dose of 0.5 mg/kg may be administered via slow IV push. 

For pre-procedural sedation, single doses of 25 to 100 mg IV 30 minutes prior to procedures may be given.   

The oral dosage form is non-formulary and is, therefore, not available. In addition, this dosage form SHOULD NOT BE USED due to high first pass metabolism and increased concentration of normeperidine. 

Meperidine is inappropriate therapy for migraine headache, although it is very commonly used. Meperidine is not recommended for this use because of its very short duration, its toxic metabolite, and because it is painful to inject. While IM meperidine has a slightly faster onset than morphine, its disadvantages outweigh this very small advantage. 

 Contraindications    Hypersensitivity to meperidine. 

• Patients who are receiving MAO inhibitors or those who have received MAO inhibitors in the past 14 days.  Concurrent use of meperidine and MAO inhibitors may result in hypertensive crisis, hyperpyrexia and cardiovascular system collapse, and may be fatal. 
•  Patients with renal insufficiency (creatinine clearance less than 50 ml/min). 
•  Patients with untreated hypothyroidism, Addison's disease, benign prostatic hypertrophy, or urethral stricture. 

Inappropriate Indications 

Meperidine has not been shown to have any specific benefit compared to other narcotic analgesics in patients with biliary colic.  (See Chalverus, CA. J Pharm Care in Pain & Symptom Control 2001; 9(3):37-55 for a review). 

Meperidine has not been shown to have any unique benefit compared to other narcotic analgesics in the treatment of pain due to acute pancreatitis. 

Routine use of meperidine prior to the first dose of amphotericin is inappropriate. If a patient does develop rigors, prophylactic use prior to subsequent doses is warranted. 

 Precautions 

Meperidine should be discontinued when the following central nervous system effects occur: 

•·          Anxiety 

•·          Fluctuations in awareness levels 

•·           Hallucinations 

•·          Agitation 

•·          Illusions 

•·          Disorientation 

•·          Restlessness 

•·          Bizarre feelings (feeling frightened) 

•·          Seizures 

•·          Diaphoresis 

•·          Shakiness 

•·          Myoclonic jerks 

•·          Nervousness 

•·          Tremors 

•·          Confusion 

In cases of normeperidine neurotoxicity, naloxone should not be used.  Naloxone does not reverse the effects of normeperidine, and may actually precipitate seizure activity as the sedative effects of meperidine are reversed allowing the full effect of normeperidine to act on the central nervous system. Naloxone is effective in reversing episodes of apnea induced by meperidine. 

The following management guidelines have been recommended: 

• Discontinue meperidine completely 
• Add an alternative opioid agonist (morphine or hydromorphone). 
• Use diazepam, phenytoin or other anticonvulsants for seizure control (Kaiko RF, et al. Ann Neurol 1983;13:180-5.). 
• In all cases, meperidine should be given with caution. The initial dose should be reduced in all patients with decreased renal or hepatic function, and in the elderly. 
• Meperidine should be used with extreme caution in patients with pre-existing convulsive disorders, and in patients receiving drugs that are known to predispose patients to seizures (e.g., imipenem).