Drug information of propoxyphene
Dextropropoxyphene is an analgesic in the opioid category, patented (1955) and manufactured by Eli Lilly and Company. It is intended to treat mild pain and also has antitussive and local anaesthetic effects. The drug has been taken off the market in Europe and the US due to concerns of fatal overdoses and heart arrhythmias. An estimated 10 million patients have used these products.
The drug is often referred to as the general form, "propoxyphene", however only the dextro-isomer (dextropropoxyphene) has any analgesic effect. The levo-isomer appears to exhibit a very limited antitussive effect.
Mechanism of effect
Propoxyphene acts as a weak agonist at OP1, OP2, and OP3 opiate receptors within the central nervous system (CNS). Propoxyphene primarily affects OP3 receptors, which are coupled with G-protein receptors and function as modulators, both positive and negative, of synaptic transmission via G-proteins that activate effector proteins. Binding of the opiate stimulates the exchange of GTP for GDP on the G-protein complex.
As the effector system is adenylate cyclase and cAMP located at the inner surface of the plasma membrane, opioids decrease intracellular cAMP by inhibiting adenylate cyclase. Subsequently, the release of nociceptive neurotransmitters such as substance P, GABA, dopamine, acetylcholine, and noradrenaline is inhibited. Opioids such as propoxyphene also inhibit the release of vasopressin, somatostatin, insulin, and glucagon.
Opioids close N-type voltage-operated calcium channels (OP2-receptor agonist) and open calcium-dependent inwardly rectifying potassium channels (OP3 and OP1 receptor agonist). This results in hyperpolarization and reduced neuronal excitability.
Absorption: Not Available
Volume of distribution: 16 L/kg
Protein binding: Not Available
Route of elimination
The major route of metabolism is cytochrome CYP3A4 mediated N-demethylation to norpropoxyphene, which is excreted by the kidneys. In 48 hours, approximately 20% to 25% of the administered dose of propoxyphene is excreted via the urine, most of which is free or conjugated norpropoxyphene.
Half life: 6-12 hours
Clearance: 2.6 L/min
Darvon (propoxyphene) is intended for the management of mild to moderate pain. The dose should be individually adjusted according to severity of pain, patient response and patient size.
Darvon is given orally. The usual dosage is one 65 mg propoxyphene hydrochloride capsule every 4 hours as needed for pain. The maximum dose of Darvon (propoxyphene) is 6 tablets per day. Do not exceed the maximum daily dose.
Patients receiving propoxyphene and any CYP3A4 inhibitor should be carefully monitored for an extended period of time and dosage adjustments should be made if warranted.Consideration should be given to a reduced total daily dosage in elderly patients and in patients with hepatic or renal impairment
Drug contraindicationshypersensitivity to this drug
Side effectsHeadache , nausea , constipation , Tachycardia , dizziness , vomiting , Blurred vision , Bradycardia , asthenia , confusion , itching , GI bleeding , hallucinations , cardiac failure , metabolic acidosis , difficulty urinating , skin rush , shortness of breath , Abdominal pain , Rash , Syncope , tachycardia
InteractionsOxecarbazepin , Promethazine , Ropinirole , Sibutramine , Metoclopramide , Midazolam , Tapentadol , Amiodarone , Aprepitant , Erythromycin , Itraconazole , Diltiazem , Rifampin , nalbuphine , Nefazodone , ritonavir , nelfinavir , Amprenavir , Fosamprenavir , Butorphanol , Fluconazole , Verapamil , Ketoconazole , Clarithromycin , Buprenorphine , Grapefruit , codeine , Pergolide , Phenindione , Dolasetron , vandetanib , Cyclizine , Dofetilide , Promazine , Chloral hydrate , Meclizine , Trimethobenzamide , Azatadine , Carbinoxamine , Halofantrine , Grepafloxacin , Flavoxate , Doxylamine , Dexchlorpheniramine , chlorcyclizine + pseudoephedrine , chlorcyclizine + phenylephrine , Phenindamine , Molindone , Triprolidine , Tripelennamine , Trimeprazine , Asenapine , Alvimopan , Paraldehyde , Brompheniramine , Oxymorphone , Levomilnacipran , Eliglustat , entacapone , Bepridil , bedaquiline , Nabilone , Rufinamide , chlorcyclizine
There have been numerous cases of accidental and intentional overdose with propoxyphene products either alone or in combination with other CNS depressants, including alcohol.
Fatalities within the first hour of overdosage are not uncommon. Many of the propoxyphene-related deaths have occurred in patients with previous histories of emotional disturbances or suicidal ideation/attempts and/or concomitant administration of sedatives, tranquilizers, muscle relaxants, antidepressants, or other CNS-depressant drugs. Do not prescribe propoxyphene for patients who are suicidal or have a history of suicidal ideation.
Points of recommendation
- Patients should be advised to report pain and adverse experiences occurring during therapy. Individualization of dosage is essential to make optimal use of this medication.
- Patients should be advised not to adjust the dose of propoxyphene without consulting the prescribing professional.
- Patients should be advised that propoxyphene may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery).
- Patients should not combine propoxyphene with central nervous system depressants (e.g., sleep aids, tranquilizers) except by the orders of the prescribing physician, because additive effects may occur.
- Patients should be instructed not to consume alcoholic beverages, including prescription and over-the-counter medications that contain alcohol, while using propoxyphene because of risk of serious adverse events including death.
- Women of childbearing potential who become, or are planning to become, pregnant should be advised to consult their physician regarding the effects of analgesics and other drug use during pregnancy on themselves and their unborn child.
- Patients should be advised that propoxyphene is a potential drug of abuse. They should protect it from theft, and it should never be given to anyone other than the individual for whom it was prescribed.
- Patients should be advised that if they have been receiving treatment with propoxyphene for more than a few weeks and cessation of therapy is indicated, it may be appropriate to taper the propoxyphene dose, rather than abruptly discontinue it, due to the risk of precipitating withdrawal symptoms. Their physician can provide a dose schedule to accomplish a gradual discontinuation of the medication.