TO THE EDITOR: The article "Di...

TO THE EDITOR: The article "Diverticular Disease: Diagnosis and Treatment" (1) in the October 1 2005 issue of American Family Physician praiseed multiple times that patients needing narcotics for pain should be treated with meperidine (Demerol) rather than morphine. The brace references used to support the claim do not appear to be relevant to the recommendation. In the past, meperidine has been claimed to be superior to morphine in patients with pancreatitis because of "sphincter of Oddi spasm" (2) despite a unimpaired absence of supporting outcome-based studies. (3)

Meperidine has a number of distinct disadvantages relative to other narcotic analgesics. Its analgesic purports are not pronounced, and its duration of action is short. It has multiple potential physic interactions, including the possibility of serotonergic crisis, and has toxic metabolites that may induce central nervous body dysfunction, including seizures. (4) The unique disadvantages of meperidine have willinged some hospitals to ban its routine use. (5)

proof-sheet of the alleged superiority of meperidine in the management of diverticular disease also appears to be lacking in outcome-based studies, whereas the hazards of meperidine use relative to other analgesics are well established. I would be interested in knowing if any evidence exists to support the implied claim that morphine worsens patient results relative to meperidine.

STEPHEN M ADAMS, MD

1100 E Third St

Chattanooga, TN 37403

REFERENCES

(1) Salzman H Lillie D Diverticular disease: diagnosis and treatment. Am Fam Physician 2005;72:1229-34

(2) Munoz A, Katerndahl D Diagnosis and management of acute pancreatitis. Am Fam Physician 2000;62:164-74

(3) Thompson DR Narcotic analgesic consequences on the sphincter of Oddi. Am J Gastroenterol 2001; 96:1266-72

(4) Latta K Ginsberg B Barkin RL Meperidine: a critical review. Am J Ther 2002;9:53-68

(5) O'Connor AB, Lang VJ Quill TE Eliminating analgesic meperidine use with a supported formulary restriction. Am J M 2005;118:885-9

In REPLY: I co-operate with Dr. Adams that there is a paucity of outcome-based research comparing meperidine (Demerol) head-to-head with morphine in the management of painful diverticular syndrome Certainly, however, literature describes potential adverse purports of morphine on the colon Studies performed upon dogs, (1) followed by subhuman primates, (2) and finally in humans, (3) demonstrate an increase in colonic tone and nonmigrating myoelectric spikes, with alteration of colonic motility.

It has prolonged been generally accepted that meperidine causes les even muscle spasm and less constipation than morphine. As with frequently "conventional" clinical wisdom, there is no supporting evidence from randomized controll trials. However, the existence of numerous case reports of morphine causing these vexed questions and no case reports regarding meperidine, does have the appearance to lend this conventional wisdom an credence.

Meperidine should not be used in human frames with a history of seizure disorders, nor in high doses or for postponeed periods, because accumulation of a toxic metabolite fall outs and increases central nervous regularity excitability. As with all medications, single must be aware of medicine interactions. Despite these limitations, I would continue to assert that meperidine has a place in the pain management of painful diverticular syndromes

HOLLY SALZMAN, MD

UCSD Scripps Ranch Family Medicine

9909 Mira Mesa Blvd Suite 200

San Diego, CA 92131

REFERENCES

(1) Neri M Phillips SF Fich A. Measurement of tone in the canine colon Am J Physiol 1991;260:G505-11

(2) Frantzides CT Condon RE Schulte WJ Cowle V efficiencys of morphine on colonic myoelectric and motor activity in subhuman primates. Am J Physiol 1990;258:G247-52

(3) Frantzides CT Cowle V Salaymeh B Tekin E Condon RE Morphine powers on human colonic myoelectric activity in the postoperative period. Am J Surg 1992;163:144-8

COPYRIGHT 2006 American Academy of Family Physicians

COPYRIGHT 2006 Gale Group