Winter 2014 – Morphine-induced Myoclonus in a Patient with End-stage Renal Disease

Morphine-Induced Myoclonus in a Patient with End-Stage Renal Disease.
Victoria L. Stahl1*, Hassan I. Ahmad2, and James E. Novak3
Author Affiliations:
1School of Medicine, Wayne State University, Detroit, MI, USA.
2Department of Medicine, Henry Ford Hospital, Detroit, MI, USA.
3Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA.


[button link=”” type=”icon” icon=”download” color=green] Full Text Article PDF [/button]
*Corresponding author: Victoria Stahl, BS; vstahl[at]

Key Words: End-Stage Renal Disease; Dialysis; Myoclonus; Morphine; Opioid Rotation.
Introduction and Patient Profile: Pain is a common complaint, and pain control is frequently challenging. End-stage renal disease (ESRD) patients constitute a special population in whom commonly-prescribed medications, including pain medications, must be adjusted or discontinued for safety. We describe a patient with ESRD in whom myoclonus developed after he received 60 days of morphine. Interventions and Outcomes: Morphine was discontinued, and symptoms resolved. Discussion: Morphine is hepatically metabolized to morphine-3-glucuronide (M3G), which is renally cleared. In patients with ESRD, M3G and other metabolites are neither renally cleared nor easily removed by dialysis, increasing the risk of neuroexcitatory symptoms such as myoclonus. The use and dosing of renally-cleared medications in ESRD patients should be carefully reviewed by prescribers and pharmacists.

Published: January 1, 2014
Senior Editor: Jack Mettler
Junior Editor: Margaret Chi
DOI: Pending
Stahl VL, Ahmad HI, Novak JE. Morphine-Induced Myoclonus in a Patient with End-Stage Renal Disease. Medical Student Research Journal. 2014;3(Winter):023-5.
1. Munar M, Singh H. Drug Dosing Adjustments in Patients with Chronic Kidney Disease. American Family Physician. May 2007;75(10):1487-1496.
2. Pauli-Magnus C, Hofmann U, Mikus G, Kuhlmann U, Mettang T. Pharmocokinetics of Morphine and its Glucuronides Following Intravenous Administration of Morphine in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis. Nephrology Dialysis Transplantation. April 1999;14(4):903-909.
3. Dean M. Opioids in Renal Failure and Dialysis Patients. Journal of Pain and Symptom Management. November 2004;28(5):497-504.
4. Andersen G, Christrup L, Sjøgren P. Relationships Among Morphine Metabolism, Pain and Side Effects During Long-Term Treatment: An Update. Journal of Pain and Symptom Management. January 2003;25(1):74-91.
5. Hemstapat K, Monteith G, Smith D, Smith MT. Morphine-3-Glucuronide’s Neuro-Excitatory Effects Are Mediated via Indirect Activation of N-Methyl-D-Aspartic Acid Receptors: Mechanistic Studies in Embryonic Cultured Hippocampal Neurones. Anesthesia and Analgesia. August 2003;97(2):494-505.
6. Indelicato RA, Portenoy RK. Opioid Rotation in the Management of Refractory Cancer Pain. Journal of Clinical Oncology. January 2002;20(1):348-352.
7. Narabayashi M, Saijo Y, Takenoshita S, Chida M, Shimoyama N, Miura T, Tani K, Nishimura K, Onozawa Y, Hosokawa T, Kamoto T, Tsushima T. Opioid Rotation from Oral Morphine to Oral Oxycodone in Cancer Patients with Intolerable Adverse Effects: An Open-Label Trial. Japanese Journal of Clinical Oncology. April 2008;38(4):296-304.
8. Gagnon DJ, Jwo K. Tremors and Agitation Following Low-Dose Intravenous Hydromorphone Administration in a Patient with Kidney Dysfunction. Annals of Pharmacotherapy. July/August 2013;47(7-8);e34.
9. Paramanandam G, Prommer E, Schwenke DC. Adverse Effects in Hospice Patients with Chronic Kidney Disease Receiving Hydromorphone. Journal of Palliative Medicine. September 2011;14(9):1029-1033.
10. King S, Forbes K, Hanks GW, Ferro CJ, Chambers EJ. A Systemic Review of the Use of Opioid Medication for Those with Moderate to Severe Cancer Pain and Renal Impairment: A European Palliative Care Research Collaborative Opioid Guidelines Project. Palliative Medicine. July 2011;25(5):525-552.