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Morphine or hydromorphone: which should be preferred? A systematic review
  1. Sarah Spénard1,2,
  2. Charles Gélinas3,
  3. Evelyne D. Trottier4,
  4. Fannie Tremblay-Racine5,6,
  5. Niina Kleiber7,8,9
  1. 1Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
  2. 2Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
  3. 3Department of Anesthesia, McGill University, Montreal, Quebec, Canada
  4. 4Department of Pediatrics, Division of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
  5. 5Library, CHU Sainte-Justine, Montreal, Quebec, Canada
  6. 6Institut Universitaire de Réadaptation en Déficience Physique de Montréal (IURDPM), CIUSSS Centre-Sud-de-l'Ile-de-Montreal, Montreal, Quebec, Canada
  7. 7Department of Pediatrics, Division of General Pediatrics And Clinical Pharmacology Unit, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
  8. 8Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
  9. 9Department of Pharmacology and Physiology, Université de Montréal, Montréal, Quebec, Canada
  1. Correspondence to Dr Niina Kleiber, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada; niina.kleiber{at}


Objective To systematically review available paediatric literature on comparisons between morphine (Mo) and hydromorphone (Hm), to guide clinicians to rationally use these medications.

Design Systematic review within four databases for all studies published from 1963 to July 2019.

Setting All paediatric settings.

Eligibility All studies comparing Mo to Hm in individuals younger than 21 years.

Main outcome measures The primary outcome was to compare clinical efficacy and side effects of Mo and Hm. The secondary outcomes were the comparison of pharmacokinetic profiles and the description of predefined Mo to Hm conversion ratios used across the paediatric literature.

Results Among 754 abstracts reviewed, 59 full-text articles met inclusion criteria and 24 studies were included in the analysis: 4 studies compared pharmacodynamics of Mo and Hm and 20 studies reported the use of a predefined Mo to Hm conversion ratio. Most studies had a poor methodological quality. Available evidence suggests that, when given intravenously, the equianalgesic ratio of Mo to Hm is 5:1. Intravenous administration with this ratio results in a similar rate of adverse effects, including pruritus and nausea. The epidural administration with a ratio of 10:1 results in more pruritus and urinary retention with Mo than Hm. Pharmacokinetic data were reported in only one study. A wide range of pre-established ratios for different routes of administration were reported, but few were based on evidence.

Conclusion Current literature does not permit a rational choice between Mo and Hm. A ratio of 5:1 seems adequate for intravenous administration and leads to a similar rate of adverse effects.

  • general paediatrics
  • pharmacology

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Correction notice This article has been corrected since it first published. The provenance and peer review statement has been included.

  • Contributors FT-R completed the systematic literature search and reviewed the final manuscript. SS and CG collected and analysed data and drafted and reviewed the manuscript. ED-T reviewed the final manuscript. NK and SS designed the methods of the study. NK contributed to data collection when there was disagreement between SS and CG and also completed data analysis and quality assessment of included studies. NK also participated in the redaction of the manuscript and reviewed its final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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