Resolution of Intrathecal Hydromorphone or Morphine-induced Peripheral Edema by Opioid Rotation to Fentanyl: A Case Series

IntroductionIntrathecal therapy [IT] has become an important modality for treatment of intractable cancer and noncancer pain although adverse events limit its effectiveness. ObjectiveThe purpose of this case series was to report and discuss the lower limb edema from IT hydromorphone and morphine therapy and its resolution or nonrecurrence upon rotating the IT solution to fentanyl. MethodsCase series. ResultsFive patients, 4 women and 1 man, 55 to 67 years old implanted with IT delivery device systems [IDDS] were treated with continuous infusion of hydromorphone [4 subjects] at 95 40 mcg/24 hours and morphine [1 subject] at 0.67 mg/24 hours. They developed peripheral edema of the lower extremities at an average of 4.2 months [mean, range 1 to 8 months] after implant. In 4 subjects, peripheral edema resolved by changing the IT agent to fentanyl. The mean time for complete resolution of edema was 50 +/- 20 days while patients were treated with continuous infusion of fentanyl. It should be noted that all patients were receiving bupivacaine in addition to the IT opioid. In one subject, infusion of IT saline resulted in faster resolution of peripheral edema. ConclusionPeripheral lower extremity edema may occur in patients treated with IT infusion of hydromorphone or morphine, even at low doses. This report presents, to the best of our knowledge, the first case series describing the benefit of IT opioid rotation to fentanyl in alleviating challenging lower extremity edema from IT hydromorphone and morphine.