Levo-Dromoran

Levo-Dromoran,

trademark for an opioid analgesic (levorphanol tartrate).

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levorphanol tartrate Warning - High-alert drug!

Levo-Dromoran

Pharmacologic class: Synthetic opioid agonist

Therapeutic class: Opioid analgesic

Controlled substance schedule II

Pregnancy risk category C

Action

Inhibits adenylate cyclase, which regulates release of pain neurotransmitters (acetylcholine, dopamine, substance P, and gamma-aminobutyric acid). Also stimulates mu and kappa opioid receptors, altering perception of and emotional response to pain.

Availability

Injection: 2 mg/ml

Tablets: 2 mg

⊘Indications and dosages

➣ Pain

Adults: 2 mg P.O. q 3 to 6 hours p.r.n., provided patient is assessed for hypoventilation and excessive sedation. Range is 8 to 16 mg over 24 hours in nontolerant patients (daily dosages above 16 mg aren't recommended). Alternatively, 2 mg subcutaneously or I.V.; may increase to 3 mg p.r.n. For cancer patients and in other situations in which long-term opioid therapy is indicated, daily dosage is approximately one-twelfth of daily oral morphine dosage; however, therapy should be individualized.

➣ Preoperative analgesia

Adults: 1 to 2 mg subcutaneously 90 minutes before surgery

Dosage adjustment

• Hepatic or renal insufficiency
• Elderly patients

Contraindications

• Hypersensitivity to drug or other opioid agonists
• Bronchial asthma
• Increased intracranial pressure
• Respiratory depression
• Acute alcoholism

Precautions

Use cautiously in:
• renal or hepatic dysfunction, chronic obstructive pulmonary disease, acute abdominal conditions, cardiovascular disease, seizure disorders, cerebral arteriosclerosis, Addison's disease, prostatic hypertrophy, toxic psychosis
• pregnant or breastfeeding patients
• children.

Administration

☞ Make sure resuscitation equipment is available before starting therapy.
• Give I.V. injection slowly, administering each 2 mg over at least 4 to 5 minutes. Monitor patient response.
• Know that I.V. route is preferred in emergencies only.
• After parenteral administration, place patient in supine position with legs elevated to minimize adverse reactions.
• Be aware that 2 mg of levorphanol tartrate is analgesically equivalent to 10 to 15 mg of morphine and 100 mg of meperidine.

Route	Onset	Peak	Duration
P.O.	10-60 min	90-120 min	4-5 hr
I.V.	Unknown	20 min	4-5 hr
I.M.	Unknown	60 min	4-5 hr
Subcut.	Unknown	60-90 min	4-5 hr

Adverse reactions

CNS: personality disorders, nervousness, insomnia, hypokinesia, dyskinesia, drowsiness, light-headedness, dizziness, depression, delusions, confusion, amnesia, sedation, euphoria, delirium, mood changes, coma, seizures

CV: palpitations, hypotension, tachycardia, bradycardia, shock, peripheral circulatory collapse, cardiac arrest

EENT: diplopia, abnormal vision

GI: nausea, vomiting, constipation, abdominal pain, dyspepsia, increased colonic motility (in patients with chronic ulcerative colitis), dry mouth

GU: dysuria, urinary retention or hesitancy, ureteral or vesicle sphincter spasms, decreased libido, oliguria

Hepatic: biliary tract spasms, hepatic failure

Respiratory: suppressed cough reflex, hyperventilation, periodic apnea

Skin: urticaria, rash, pruritus, cyanosis, facial flushing

Other: injection site pain, redness, or swelling; physical or psychological drug dependence

Interactions

Drug-drug. Alfentanil, fentanyl, sufentanil, other CNS depressants: increased CNS and respiratory depression, increased risk of hypotension

Anticholinergics: increased risk of severe constipation

Antidiarrheals (such as atropine, difenoxin, kaolin, loperamide), antihypertensives: increased risk of hypotension

Buprenorphine, naloxone, naltrexone: decreased levorphanol efficacy

Metoclopramide: antagonism of metoclopramide effects

Neuromuscular blockers: increased risk of prolonged CNS and respiratory depression

Drug-diagnostic tests. Amylase, lipase: increased levels

Drug-behaviors. Alcohol use: increased CNS depression

Patient monitoring

• Check vital signs and respiratory status, and monitor ECG carefully.
• Evaluate fluid intake and output.
• Assess neurologic status. Institute safety precautions as needed to prevent injury.
• Watch for signs and symptoms of depression.
• Monitor liver and kidney function tests.

Patient teaching

• With parenteral use, explain need for continuous vital sign and ECG monitoring.
• To minimize adverse effects, instruct patient to lie supine after parenteral administration, if possible.
☞ Instruct patient or caregiver to report adverse reactions immediately.
• Tell patient or caregiver to use safety measures as needed to prevent injury and to report significant problems.
• Instruct patient to minimize GI upset by eating small, frequent servings of food and drinking plenty of fluids.
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and behaviors mentioned above.