This information is intended for use by health professionals

1. Name of the medicinal product

Morphine Sulfate 1 mg per ml solution for injection

2. Qualitative and quantitative composition

Each 10 ml ampoule contains 10 mg morphine sulfate pentahydrate

Excipient with known effect:

This medicinal product contains 35 mg sodium per each 10 ml ampoule, equivalent to 2% of the WHO recommended maximum daily intake of 2 g sodium for an adult.

For the full list of excipients, see section 6.1.

3. Pharmaceutical form

Solution for injection

4. Clinical particulars
4.1 Therapeutic indications

Morphine sulfate injection is indicated for the relief of moderate to severe pain. Morphine sulfate injection is used especially in pain associated with cancer, myocardial infarction and surgery. Morphine also helps to relieve the anxiety and insomnia which may be associated with severe pain.

4.2 Posology and method of administration

Posology

Adults and children over 12 years:

Morphine sulfate injection is formulated for use by the intravenous route in Patient Controlled Analgesia (PCA) systems. PCA, which permits adjustment of dosage according to the patient's individual needs, must only be carried out in departments and by staff who are trained and have experience of the system. Patient selection for the use of PCA must ensure that the patient is capable of understanding and following the instructions of the medical/nursing staff. The specific department or unit protocols must be covered to ensure aseptic transfer of the contents of the vial to the PCA system.

There is a considerable variation in analgesic requirements among patients and therefore individualised treatment strategies are required. Dosage should be based on the severity of the pain and the response and opiate tolerance of the patient.

Loading dose

Loading doses of typically between 1 mg and 10 mg (maximum 15 mg) of morphine sulfate may be given by intravenous infusion over four or five minutes. The loading dose used will depend upon the patient's diagnosis and condition.

PCA demand dose

An initial demand dose of 1 mg Morphine sulfate injection with a lockout period of 5 to 10 minutes is recommended. Dosages may vary depending on the loading dose, the tolerance and condition of the patient, and whether a background infusion of morphine is being given.

The patient should be specifically monitored for pain, sedation and respiratory rate during the first few hours of treatment to ensure that the dosage regimen is suitable.

The duration of treatment should be kept to a minimum, although dependence and tolerance are not generally a problem when morphine is used legitimately in patients with opioid-sensitive pain.

Discontinuation of therapy:

An abstinence syndrome may be precipitated if opioid administration is suddenly discontinued. Therefore the dose should be gradually reduced prior to discontinuation.

Use in children:

Not recommended for children under 12 years.

Use in the elderly:

Morphine doses need to be reduced in elderly patients.

Method of administration

For intravenous injection.

The product should not be diluted before use.

The medicinal product is to be visually inspected prior to use. Only clear solutions practically free from particles should be used.

4.3 Contraindications

Morphine sulfate injection is contraindicated in

- hypersensitivity to the active substance, to other opioid preparations or to any of the excipients listed in section 6.1

- respiratory depression; obstructive airways disease; excessive bronchial secretions; during a bronchial asthma attack or in heart failure secondary to chronic lung disease

- head injury; raised intra-cranial pressure

- coma

- convulsion disorders

- ulcerative colitis

- presence of a risk of paralytic ileus

- biliary and renal tract spasm

- acute alcoholism

- phaeochromocytoma

- moderate to severe renal impairment (glomerular filtration rate <20ml/min)

- severe or acute liver failure

- patients receiving monoamine oxidase inhibitors or within two weeks of discontinuing such treatment

Use of Morphine sulfate injection during pregnancy or lactation is not recommended.

4.4 Special warnings and precautions for use

As with other narcotics, a dose reduction may be appropriate in elderly patients, in patients with hypothyroidism, renal and chronic hepatic disease.

Morphine sulfate injection should be used with caution in debilitated patients and those with adrenocortical insufficiency (see below); hypopituitarism; prostatic hypertrophy; shock; diabetes mellitus; diseases of the biliary tract; myasthenia gravis; cardiac arrhythmias; excessive obesity; hypotension and severe cardiac failure. It should also be used with caution post-operatively following total joint arthroplasty (colonic pseudo-obstruction).

Concomitant use of other opioid analgesics such as codeine, administered orally or by some other route of administration, increases the CNS depressant effect of morphine (see Section 4.5 – Interaction with other medicinal products and other forms of interaction).

Risk from concomitant use of sedative medicines such as benzodiazepines or related drugs

Concomitant use of morphine and sedative medicines such as benzodiazepines or related drugs may result in sedation, respiratory depression, coma and death. Because of these risks, concomitant prescribing with these sedative medicines should be reserved for patients for whom alternative treatment options are not possible. If a decision is made to prescribe morphine concomitantly with sedative medicines, the lowest effective dose should be used, and the duration of treatment should be as short as possible.

The patients should be followed closely for signs and symptoms of respiratory depression and sedation. In this respect, it is strongly recommended to inform patients and their caregivers to be aware of these symptoms (see section 4.5).

Abuse potential

Morphine has an abuse potential similar to other strong agonist opioids, and should be used with particular caution in patients with a history of alcohol or drug abuse.

Dependence and withdrawal (abstinence) syndrome

Use of opioid analgesics may be associated with the development of physical and/or psychological dependence or tolerance. The risk increases with the time the drug is used, and with higher doses. Symptoms can be minimised with adjustments of dose or dosage form, and gradual withdrawal of morphine. For individual symptoms, see section 4.8. However, when doses of morphine are carefully titrated against pain, clinically significant respiratory depression, dependence, rapid tolerance and euphoria rarely develop. If patients no longer require morphine for relief of pain, doses should be gradually reduced in order to prevent withdrawal symptoms. Clinically significant tolerance to morphine is unusual in cancer patients with severe pain.

Acute chest syndrome (ACS) in patients with sickle cell disease (SCD)

Due to possible association between ACS and morphine use in SCD patients treated with morphine during a vaso-occlusive crisis, close monitoring for ACS is warranted.

Adrenal insufficiency

Opioid analgesics may cause reversible adrenal insufficiency requiring monitoring and glucocorticoid replacement therapy. Symptoms of adrenal insufficiency may include e.g. nausea, vomiting, loss of appetite, fatigue, weakness, dizziness, or low blood pressure.

Decreased Sex Hormones and increased prolactin

Long-term use of opioid analgesics may be associated with decreased sex hormone levels and increased prolactin. Symptoms include decreased libido, impotence or amenorrhea.

Hyperalgesia

Hyperalgesia that does not respond to a further dose increase of morphine may occur in particular in high doses. A morphine dose reduction or change in opioid may be required.

Rifampicin

Plasma concentrations of morphine may be reduced by rifampicin. The analgesic effect of morphine should be monitored and doses of morphine adjusted during and after treatment with rifampicin (see section 4.5).

Sodium content

This medicinal product contains 35 mg sodium per each 10 ml ampoule, equivalent to 2% of the WHO recommended maximum daily intake of 2 g sodium for an adult.

4.5 Interaction with other medicinal products and other forms of interaction

Monoamine oxidase inhibitors (MAOIs):

Concomitant or recent use of monoamine oxidase inhibitors with morphine is contraindicated since interactions have been reported, resulting in CNS excitation or depression with hyper- or hypotensive crises (see section 4.3).

Hyperpyrexia and CNS toxicity may result from an opiate selegiline combination. Such combinations should, therefore, be used with extreme caution.

Sedative medicines such as benzodiazepines or related drugs

The concomitant use of opioids with sedative medicines such as benzodiazepines or related drugs increases the risk of sedation, respiratory depression, coma and death because of additive CNS depressant effect. The dose and duration of concomitant use should be limited (see section 4.4).

Other CNS depressants

The CNS depressant effects of morphine are increased by the co-administration of CNS depressants including alcohol, anaesthetics, muscle relaxants, hypnotics, sedatives, tricyclics, neuroleptics and phenothiazines as well as other opioid analgesics.

The analgesic effects of opioids tend to be enhanced by the concomitant administration of dexamphetamine, hydroxyzine and some phenothiazines (although the latter may also cause respiratory depression).

Diuretics:

Morphine may reduce the efficacy of diuretics by inducing the release of the antidiuretic hormone.

Anticholinergics:

The combination of morphine with anticholinergics may enhance the constipatory effect and urinary retention.

Antihistamines:

Cimetidine and ranitidine appear to interfere with the metabolism of morphine.

Disulfiram:

The metabolism and excretion of morphine may be inhibited by disulfiram.

Prokinetics:

Increased morphine levels may result from the co-administration of cisapride.

Metoclopramide and domperidone may antagonise morphine's gastrointestinal effects and metoclopramide enhances it sedative effect.

Antibiotics:

Ciprofloxacin concentration may be reduced.

Anti-arrhythmics:

Mexiletine absorption may be delayed by co-administered opiate. Co-administration of morphine with esmolol results in a slight increase in the esmolol levels, but the clinical implications of this increase are not considered very significant.

Enzyme modulating agents:

Animal data suggest that propranolol may increase the toxicity of opioids. Ritonavir can induce the formation of metabolising enzymes made in the liver and can cause increased metabolism of morphine which can reduce the clinical efficacy of the analgesic.

Rifampicin

Plasma concentrations of morphine may be reduced by rifampicin. The analgesic effect of morphine should be monitored and doses of morphine adjusted during and after treatment with rifampicin (see section 4.4).

4.6 Fertility, pregnancy and lactation

Pregnancy

There are no adequate data from the use of morphine in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). Morphine sulfate injection is not, therefore, recommended for use in pregnancy.

Newborns whose mothers received opioid analgesics during pregnancy should be monitored for signs of neonatal withdrawal (abstinence) syndrome. Treatment may include an opioid and supportive care.

Breast-feeding

Morphine has been shown to suppress lactation, although morphine is secreted in breast milk and may cause respiratory depression in the infant. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from morphine therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman.

Fertility

Non-clinical data based on conventional studies reveal no special hazard additional to the known safety profile of morphine in humans (see Section 5.3 – Preclinical safety data). Animal studies have shown that morphine may reduce fertility (see section 5.3 – Preclinical safety data).

4.7 Effects on ability to drive and use machines

Morphine has major influence on the ability to drive and use machines. It may modify the patient's reactions to a varying extent depending on the dosage and individual susceptibility. Ambulatory patients should be warned not to use machines.

This medicine can impair cognitive function and can affect a patient's ability to drive safely. This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988. When prescribing this medicine, patients should be told:

The medicine is likely to affect your ability to drive

Do not drive until you know how the medicine affects you

It is an offence to drive while under the influence of this medicine

However, you would not be committing an offence (called 'statutory defence') if:

o The medicine has been prescribed to treat a medical or dental problem and

o You have taken it according to the instructions given by the prescriber and in the information provided with the medicine and

o It was not affecting your ability to drive safely

4.8 Undesirable effects

The side-effects most commonly seen with morphine and other opioids are respiratory depression, nausea, vomiting, constipation, drowsiness and confusion. With long term use these symptoms generally lessen, although constipation frequently persists.

The following adverse events are from published literature and frequencies are not known.

Immune system disorders

Anaphylactic reactions and anaphylactoid reactions to morphine have been reported rarely.

Endocrine disorders

Long term use of opioid analgesics can cause adrenal insufficiency. Exacerbation of pancreatitis.

Psychiatric disorders

Dependence, restlessness, mood changes, hallucinations, delirium, disorientation, excitation, agitation, sleep disturbance.

Nervous system disorders

Headache, vertigo, euphoria, dysphoria, dizziness, taste disturbances, seizures, paraesthesia, raised intracranial pressure, hyperhidrosis. Allodynia and hyperalgesia have been reported (see section 4.4)..

Eye disorders

Visual disturbances, nystagmus, miosis.

Ear and labyrinth disorders

Vertigo.

Cardiac disorders

Bradycardia, tachycardia, palpitations, syncope.

Vascular disorders

Orthostatic hypotension, hypotension, hypertension, facial flushing, oedema.

Respiratory, thoracic and mediastinal disorders

Bronchospasm (in association with anaphylaxis), inhibition of cough reflex.

Gastrointestinal disorders

Dyspepsia, paralytic ileus, abdominal pain, anorexia, dry mouth.

Hepatobiliary disorders

Biliary spasm.

Skin and subcutaneous tissue disorders

Rashes, urticaria, pruritus.

Musculoskeletal and connective tissue disorders

Muscle fasciculation, myoclonus, rhabdomyolysis, muscle rigidity.

Renal and urinary disorders

Difficult micturition, ureteric spasm, urinary retention.

Reproductive system and breast disorders

Long term use of opioid analgesics can cause hypogonadism in both men and women.

This can lead to amenorrhoea, reduced libido, infertility, depression and erectile dysfunction.

General disorders and administration site conditions

Hypothermia, malaise, asthenia, pain and irritation at the injection site. Drug withdrawal (abstinence) syndrome (see below).

Long Term Use

Long term use of opioid analgesics has been associated with a state of abnormal pain sensitivity (hyperalgesia).

Tolerance and psychological and physical dependence may occur (see below). Decreased potency may be experienced.

High doses may produce respiratory depression and hypotension, with deepening coma. Convulsions may occur particularly in infants.

Drug dependence and withdrawal (abstinence) syndrome

Use of opioid analgesics may be associated with the development of physical and/or psychological dependence or tolerance. An abstinence syndrome may be precipitated when opioid administration is suddenly discontinued or opioid antagonists administered, or can sometimes be experienced between doses. For management, see 4.4.

Physiological withdrawal symptoms include: Body aches, tremors, restless legs syndrome, diarrhoea, abdominal colic, nausea, flu-like symptoms, tachycardia and mydriasis. Psychological symptoms include dysphoric mood, anxiety and irritability. In drug dependence, “drug craving” is often involved.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9 Overdose

Signs:

The signs of morphine overdosage consist of pin-point pupils, respiratory depression (potentially leading to fatal respiratory failure), pneumonia aspiration, and hypotension. Circulatory failure and deepening coma may develop in severe cases and death may ensue. Less severe cases may be manifest by nausea, vomiting, tremor, dysphoria, hypothermia, hypotension, confusion and sedation. Rhabdomyolysis progressing to renal failure can also be a consequence of overdosage.

Treatment:

It is vital to maintain and support respiration and circulation. The specific opioid antagonist naloxone should be employed for the reversal of coma and restoration of spontaneous respiration. 400 micrograms of naloxone should be administered intravenously, repeated at 2-3 minute intervals as necessary up to a maximum dose of 10 mg.

5. Pharmacological properties
5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Opioids, natural opium alkaloids, ATC code: N02AA01

Morphine acts as a competitive agonist at opiate receptors in the CNS, particularly mu and to a lesser extent kappa receptors. Activity at the mu-1 subtype receptor is thought to mediate analgesia, euphoria and dependence whilst activity at the mu-2 receptor is thought to be responsible for respiratory depression and inhibition of gut motility. Action at the kappa receptor may mediate spinal analgesia. The analgesic action of morphine is effective at several spinal and supraspinal sites.

5.2 Pharmacokinetic properties

Absorption

Onset of action is rapid following parenteral administration of morphine with peak analgesic effect occurring within 20 minutes via the intravenous route.

Distribution

Morphine is widely distributed in the body, with an apparent volume of distribution of 2-3 lkg-1. Due to its relatively hydrophilic nature, morphine does not readily cross the blood-brain barrier although it is detectable in the cerebrospinal fluid.

Biotransformation

Morphine is extensively metabolised by the liver. Renal glucuronidation also takes place. The major metabolite, quantitatively, is morphine-3-glucuronide although morphine-6-glucuronide is significant in terms of potency. The metabolites are excreted mainly via the renal route.

5.3 Preclinical safety data

Non-clinical data based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, toxicity to reproduction and development reveal no special hazard additional to the known safety profile of morphine in humans.

In male rats, reduced fertility and chromosomal damage in gametes have been reported.

6. Pharmaceutical particulars
6.1 List of excipients

Sodium chloride

Hydrochloric acid

Water for injections

6.2 Incompatibilities

Morphine sulfate injection is physically incompatible with aciclovir sodium, aminophylline, amobarbital sodium, cefepime hydrochloride, chlorothiazide sodium, floxacillin sodium, furosemide, gallium nitrate, heparin sodium, meperidine hydrochloride, meperidine sodium, methicillin sodium, minocycline hydrochloride, pentobarbital sodium, phenobarbital sodium, phenytoin sodium, sargramostim, sodium bicarbonate, thiopental sodium.

Physicochemical incompatibility (formation of precipitates) has been demonstrated between solutions of morphine sulphate and 5- fluorouracil.

6.3 Shelf life

36 months

6.4 Special precautions for storage

Do not store above 25°C. Keep the ampoules in the outer carton in order to protect from light.

6.5 Nature and contents of container

10 ml colourless glass ampoules (type I) in packs of 10 ampoules.

6.6 Special precautions for disposal and other handling

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

7. Marketing authorisation holder

hameln pharmaceuticals ltd

Gloucester

UK

8. Marketing authorisation number(s)

PL 01502/0098

9. Date of first authorisation/renewal of the authorisation

28/10/2015

10. Date of revision of the text

21/11/2018