Acute opioid withdrawal following administration of oral oxycodone–naloxone due to portosystemic shunts

Abstract

Background: The management of pain in patients with advanced liver disease is a clinical challenge. Initial pharmacokinetic safety data advised against the use of oxycodone–naloxone in this population, but in clinical practice it is commonly used. Our case aims to illustrate a potential mechanism by which administration of oxycodone–naloxone can cause systemic opioid antagonism and harm to patients. Clinical details: A 45-year-old man received two separate doses of oxycodone–naloxone in the immediate postoperative setting, resulting in symptoms and signs consistent with acute opioid withdrawal. A review of his imaging revealed significant portosystemic shunts. Outcomes: Portosystemic shunts in patients with advanced liver disease may lead to a decrease in the Phase II hepatic metabolism of naloxone and increased systemic levels. In the case of someone with pre-existing opioid dependence, this may precipitate acute opioid withdrawal. Conclusion: The use of oxycodone–naloxone preparations should be avoided in patients with liver disease and portosystemic shunts.