Hyperalgesie induziert durch ultrahohe Dosen von Morphin – eine Kasuistik

Zusammenfassung

Eine 38-jährige Patientin mit umfangreich metastasiertem Mammakarzinom fiel durch eine ausgeprägte Hyperalgesie sowie Angst und Unruhe unter ultrahohen intravenösen Morphindosen bis 56 mg/h auf. Die Hinzunahme von Esketamin als NMDA-Rezeptorantagonist bei angenommener opioidinduzierter Hyperalgesie sowie Midazolam konnte keine Verbesserung erzielen. Erst die Umstellung auf Levomethadon führte zu ausreichender Analgesie und Verbesserung der Unruhe und Angst. Unter dieser Medikation verstarb die Patientin mit ausreichender Analgesie und mit nur im finalen Stadium beeinträchtigter Kognition.

Chronische Opioideinnahme kann eine opioidinduzierte Hyperalgesie auslösen, wobei v. a. NMDA-Rezeptorantagonisten neben einem Entzug als Therapieoption empfohlen werden. Da Esketamin unzureichend wirkte, ist als möglicher Auslöser aber eher der neuroexzitatorische Morphinmetabolit Morphin-3-Glukuronid anzunehmen, der vermutlich trotz normaler Nierenfunktion diese Nebenwirkung aufgrund der extrem hohen Dosis ausgelöst hat. Bei hohen Morphindosen sollte dies als mögliche Ursache bedacht und somit ein Opioidwechsel erwogen werden.

Abstract

A 38-years old patient with breast cancer and extensive metastases showed massive hyperalgesia as well as anxiety and agitation. For pain control she received ultra-high doses of intravenous morphine (56 mg/h). Esketamine (in combination with midazolam) as NMDA-receptor antagonist for treatment of a presumed opioid-induced hyperalgesia could not improve patient’s situation. Opioid rotation to levomethadone lead to a profound improvement in analgesia and anxiety/agitation. Under this ongoing medication the patient died, with impaired cognition only in the final phase.

Chronic opioid therapy may lead to opioid induced hyperalgesia. Treatment options are mostly NMDA-receptor antagonists or a controlled withdrawal. As esketamine did not improve the hyperalgesia, the probable cause was the neuroexcitatory metabolite morphine-3-glucuronide, due to the extreme high doses of morphine, despite the normal renal function. When administering high doses of morphine, switching to a different morphine should be considered in order to avoid hyperalgesia.

Schlüsselwörter

opioidinduzierte Hyperalgesie - Morphin - Morphin-3-Glukuronid

Keywords

opioid-induced hyperalgesia - morphine - morphine-3-glucuronide

Publication History

Article published online:
06 December 2021

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