Signal of harm in morphine use in adults with acute pulmonary oedema: A rapid systematic review

C Hendrikse; V Ngah; I I Kallon; G Thom; T D Leong; K Cohen; M McCaul

doi:10.7196/SAMJ.2023.v113i8.348

South African Medical Journal (Aug 2023)

Signal of harm in morphine use in adults with acute pulmonary oedema: A rapid systematic review

C Hendrikse,
V Ngah,
I I Kallon,
G Thom,
T D Leong,
K Cohen,
M McCaul

Affiliations

C Hendrikse: Division of Emergency Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, South Africa; Ministerially appointed PHC/Adult Hospital Level Expert Review Committee of the National Essential Medicines List Committee, National Department of Health (2019 - 2023), Pretoria, South Africa
V Ngah: Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
I I Kallon: Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
G Thom: Ministerially appointed PHC/Adult Hospital Level Expert Review Committee of the National Essential Medicines List Committee, National Department of Health (2019 - 2023), Pretoria, South Africa; Amajuba District Clinical Specialist Team, KwaZulu-Natal Department of Health, Pretoria, South Africa
T D Leong: Secretariat to the PHC/Adult Hospital Level Expert Review Committee (2020 - 2023); Secretariat to the National Essential Medicines List Committee, National Department of Health (2021 - 2022), Durban, South Africa; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
K Cohen: Ministerially appointed PHC/Adult Hospital Level Expert Review Committee of the National Essential Medicines List Committee, National Department of Health (2019 - 2023), Pretoria, South Africa; Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
M McCaul: Ministerially appointed PHC/Adult Hospital Level Expert Review Committee of the National Essential Medicines List Committee, National Department of Health (2019 - 2023), Pretoria, South Africa; Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; South African GRADE Network, Centre for Evidence-based Health Care, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

DOI: https://doi.org/10.7196/SAMJ.2023.v113i8.348
Journal volume & issue: Vol. 112, no. 8

Abstract

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Background. Heart failure affects nearly 65 million people globally, resulting in recurrent hospital admissions and substantial healthcare expenditure. The use of morphine in the management of acute pulmonary oedema remains controversial, with conflicting guidance and significant variation in practice. Synthesised evidence is needed to inform standard treatment guidelines and clinical practice. Objective. To determine whether morphine should be used in the treatment of acute pulmonary oedema (APE) in adults. Methods. A rapid review of systematic reviews of randomised controlled trials or observational studies, and then randomised controlled trials, was conducted searching three electronic databases (PubMed, Embase, Cochrane Library) and one clinical trial registry on 12 February 2022. We used a prespecified protocol following Cochrane rapid review methods and aligned to the National Standard Treatment Guidelines and Essential Medicines List methodology. We first considered relevant high-quality systematic reviews of randomised controlled trials or observational studies, then (if required) randomised controlled trials to inform time-sensitive or urgent evidence requests, clinical practice, policy, or standard treatment guidelines. Results. We identified four systematic reviews of observational studies. The two most relevant, up-to-date, and highest-quality reviews were used to inform evidence for critical outcomes. Morphine may increase in-hospital mortality (odds ratio (OR) 1.78; 95% confidence interval (CI) 1.01 - 3.13; low certainty of evidence; six observational studies, n=151 735 participants), resulting in 15 more per 1 000 hospital deaths, ranging from 0 to 40 more hospital deaths. Morphine may result in a large increase in invasive mechanical ventilation (OR 2.72; 95% CI 1.09 - 6.80; low certainty of evidence; four observational studies, n=167 847 participants), resulting in 45 more per 1 000 ventilations, ranging from 2 more to 136 more. Adverse events and hospital length of stay were not measured across reviews or trials. Conclusion. Based on the most recent, relevant and best-available quality evidence, morphine use in adults with APE may increase in-hospital and all-cause mortality and may result in a large increase in the need for invasive mechanical ventilation compared to not using morphine. Recommending against the use of morphine in pulmonary oedema may improve patient outcomes. Disinvesting in morphine for this indication may result in cost savings, noting the possible accrued benefits of fewer patients requiring invasive ventilation and management of morphine-related side-effects.

Published in South African Medical Journal

ISSN: 0256-9574 (Print); 2078-5135 (Online)
Publisher: South African Medical Association
Country of publisher: South Africa
LCC subjects: Medicine: Medicine (General)
Website: https://samajournals.co.za/index.php/samj/index

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