Nalbuphine


Article Author:
Devin Larsen


Article Editor:
Christopher Maani


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Grant Goold
Kyle Cohen


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Tehmina Warsi


Updated:
1/9/2019 12:48:56 PM

Indications

Nalbuphine is FDA indicated for moderate to severe pain in which an opioid agent is required when other alternative treatments have been insufficient.  Non-FDA approved uses of nalbuphine do exist such as treatment of labor pain, opioid-induced urinary retention, opioid-induced respiratory depression, and pruritus associated with neuraxial opioid use.

Pruritus is usually secondary to opioid activation of the mu-opioid receptor. Because nalbuphine is an antagonist at the mu-opioid receptor, it is used as a treatment for opioid-induced pruritus.  In fact, nalbuphine was found to be superior in treating opioid-induced pruritus when compared with placebo, control, diphenhydramine, naloxone, or propofol in patients receiving neuraxial opioids for acute pain related to surgery or childbirth1.[1]

Although nalbuphine can result in respiratory depression, due to its antagonism of the mu-opioid receptor, it antagonizes the respiratory depressant effects of other opioid medications while concomitantly adding to the analgesic activities of these drugs.[2] When used acutely in the perioperative period, nalbuphine is useful for providing analgesic benefits with less respiratory depression than morphine. In one study, intravenous nalbuphine has been utilized to reduce opioid-induced respiratory suppression following intrathecal morphine administration in post-thoracotomy patients.[3] 

Mechanism of Action

Nalbuphine is a kappa-opioid receptor agonist and a partial mu-opioid receptor antagonist. Analgesic properties are mediated through agonist activity at the kappa-opioid receptor. Because of this unique mixed agonist-antagonist opioid receptor activity of nalbuphine, it provides analgesia with less nausea, pruritus, and respiratory depression when compared to morphine.[4]

Pharmacology:

  • Absorption: The onset of action of nalbuphine after intravenous injection is 2 to 3 minutes. With subcutaneous or intramuscular administration onset of action is within 15 minutes. The duration of action of nalbuphine ranges from 3 to 6 hours. 
  • Distribution: Protein binding not significant.
  • Metabolism: Nalbuphine is hepatically metabolized.
  • Elimination: Elimination half-life of about 5 hours. Excreted in urine and feces.

Administration

Nalbuphine is available in 10 mg/ml and 20 mg/ml injectable solutions. Nalbuphine is not available in oral form secondary to poor oral bioavailability.

Adult Dosing:

A typical recommended dose is 10 mg for a 70 kg individual. Administration is subcutaneous, intramuscular, or intravenous; this dose may be repeated every 3 to 6 hours as necessary. The recommended single maximum dose is 20mg in an opioid nontolerant individual with a total maximum daily dose is 160mg. In opioid-dependent patients the dose should be reduced by ¼ and the patient should be observed for signs of opioid withdrawal. In patients who are not opioid tolerant, withdrawal symptoms have not been seen from other opioid medications that have been given in the same acute setting as nalbuphine. The potency of nalbuphine is comparable to morphine on a mg-to-mg basis.[5]

Pediatric Dosing:

Less than one year: safety and efficacy not established.

Greater than one year: 0.1-0.2 mg/kg intravenously, intramuscularly or subcutaneously every 3-4 hours as needed. The maximum single dose is 20 mg. Maximum daily dose 160 mg.

Renal impairment: use caution, may require a reduced dose.

Hepatic impairment: use caution, may require a reduced dose.

Adverse Effects

The most common adverse effects following nalbuphine administration are sedation, sweating, nausea, vomiting, dizziness, vertigo, dry mouth, or a headache.

The following are less common adverse effects have been reported at an incidence of less than 1%:

  • Central nervous system: Nervousness, depression, restlessness, crying, euphoria, floating, hostility, unusual dreams, confusion, faintness, hallucinations, dysphoria, a feeling of heaviness, numbness, tingling, or unreality.
  • Cardiovascular: hypertension, hypotension, bradycardia, or tachycardia.
  • Gastrointestinal: cramps, dyspepsia, or bitter taste.
  • Respiratory: depression, dyspnea, or asthma.
  • Dermatologic: itching, burning, or urticaria.
  • Allergic Reactions: anaphylactic, anaphylactoid, or severe hypersensitivity reactions have been reported with nalbuphine use, and care should be given providing immediate supportive medical treatment should they occur.

Black Box Warning

Concomitant use of nalbuphine with benzodiazepines or other CNS depressants, including alcohol, may result in critical sedation, respiratory depression, coma, and death.

Concomitant prescribing should only be used in patients for whom alternative treatment options have proved inadequate; dose and duration should be limited to the minimum required, and follow patients for signs and symptoms of respiratory depression and sedation.

Cautions

Because of altered pharmacokinetics and clearance in elderly, debilitated, or cachectic patients, caution should be used when administering nalbuphine to these patient populations because life-threatening respiratory depression can result. The respiratory depressant effects of nalbuphine can result in carbon dioxide retention which can further increase intracranial pressure in patients with baseline elevated intracranial pressure, head injury, or intracranial lesions as well as possibly confound the ability to obtain and follow an accurate neurological examination due to sedative properties. Therefore, nalbuphine should be used with extreme in these clinical scenarios.

Like other commonly used opioid medications, nalbuphine can alter normal mental or physical abilities required to perform potentially dangerous tasks, including driving or operating heavy machinery. Patients counseling regarding these risks prior to the administration of this medication is indicated.

Nalbuphine has been used for obstetrical analgesia, and there are reports of severe fetal bradycardia in laboring women. In one study, fetal heart rate flattening occurred in 53% of the cases.[6] The benefits of analgesia versus risks to the fetus should be weighed in this clinical situation. If nalbuphine is administered to the laboring woman, fetal heart rate monitoring should be utilized and appropriate procedures in place to manage any adverse effects to the fetus. Naloxone may reverse these effects.

Due to antagonist action at the µ-opioid receptor, caution should be used in nalbuphine administration to patients on sustained release opioids because withdrawal symptoms are possible.[4] When using nalbuphine in these patients, reduced dosing is advised, and the patient should be observed for signs of withdrawal.

Even though nalbuphine is an antagonist at the µ-opioid receptor, it still provides drug liking properties and has abuse potential.[4]  Of note, naloxone was initially classified as a scheduled II controlled substance, however through subsequent petitioning to the FDA by its manufacturer, it was removed from all schedules and is no longer a controlled substance in the U.S.

Contraindications

Nalbuphine is contraindicated in patients with:

  • Significant respiratory depression
  • Severe or active bronchial asthma
  • Known or suspected gastrointestinal obstruction including ileus
  • Hypersensitivity to nalbuphine or any other ingredients in the injection

Monitoring

Significant respiratory depression can occur at any time with nalbuphine, use although it is most common after initiation of the medication or increase in dosage. Patients should undergo close monitoring for the first 24-72 hours after initiating therapy or increasing dosage.

Toxicity

In cases of overdose or adverse reactions, intravenous naloxone administration is the antidote.[2]

Enhancing Healthcare Team Outcomes

Use of nalbuphine along with other potent opioid medications requires a multidisciplinary approach to patient management involving physicians, nurses, and pharmacists to ensure patient safety beginning from medication ordering, preparation, administration, and to patient monitoring following administration of the drug. Although nalbuphine is not classified as a controlled substance under the controlled substances act, it is still a prescription medication and caution should be undertaken with its use. The responsibility falls on all healthcare professionals on the healthcare team to inform patients of possible increased risk associated with opioid medications in an effort to protect patients from the dangerous adverse effects of this class of medications.


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Nalbuphine - Questions

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A 59-year-old female presents for a lumbar laminectomy. She has been using opioids for her back pain for many years. It would be best to avoid which of the following analgesic medications in this patient?



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Which of the following is a mixed opioid agonist-antagonist?



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A 16-year-old female with a history of severe asthma was given nalbuphine in the emergency department for severe knee pain after playing soccer. A nursing student mistakenly administers four times the dose that was intended. The patient subsequently develops respiratory distress with altered mental status. Her oxygen saturation begins to fall on SpO2 monitoring. Which of the following medications would be indicated in this situation?



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A 58-year-old male who has been taking chronic opioid medications for many years for chronic back pain presents to the postanesthesia care unit following laparoscopic appendectomy. He is complaining of pain which is 10/10. He was given fentanyl and hydromorphone intraoperatively, but his pain remains unbearable. Which of the following drugs would be most inappropriate to administer to this patient?



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What is the risk of taking both nalbuphine and codeine?



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A medical student is asked on rounds what the mechanism of action for nalbuphine is. He remembered it was an opioid analgesic but could not recall which receptors it effects. Which of the following is true regarding the mechanism of action of nalbuphine?



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A 23-year-old female underwent a scheduled cesarian section for a full-term intrauterine pregnancy 12 hours ago. She received a single injection, subarachnoid block which contained fentanyl, morphine, and bupivacaine. She now is complaining of severe itching while on the mother-baby unit. Which of the following medications would be most beneficial to decrease her pruritus?



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Nalbuphine - References

References

Does nalbuphine have a niche in managing pain?, Davis MP,Fernandez C,Regel S,McPherson ML,, Journal of opioid management, 2018 Mar/Apr     [PubMed]
Nalbuphine for Treatment of Opioid-induced Pruritus: A Systematic Review of Literature., Jannuzzi RG,, The Clinical journal of pain, 2016 Jan     [PubMed]
Schmidt WK,Tam SW,Shotzberger GS,Smith DH Jr,Clark R,Vernier VG, Nalbuphine. Drug and alcohol dependence. 1985 Feb     [PubMed]
Baxter AD,Samson B,Penning J,Doran R,Dube LM, Prevention of epidural morphine-induced respiratory depression with intravenous nalbuphine infusion in post-thoracotomy patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie. 1989 Sep     [PubMed]
Errick JK,Heel RC, Nalbuphine. A preliminary review of its pharmacological properties and therapeutic efficacy. Drugs. 1983 Sep     [PubMed]
Nicolle E,Devillier P,Delanoy B,Durand C,Bessard G, Therapeutic monitoring of nalbuphine: transplacental transfer and estimated pharmacokinetics in the neonate. European journal of clinical pharmacology. 1996     [PubMed]

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