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Oral modified release morphine for breathlessness in chronic heart failure: a randomised placebo-controlled trial

Johnson, Miriam; Cockayne, Sarah; Currow, David; Bell, Kerry; Hicks, Kate; Fairhurst, Caroline; Gabe, Rhian; Torgerson, David; Jefferson, Laura; Oxberry, Stephen; Ghosh, Justin; Hogg, Karen; Murphy, Jeremy; Allgar, Victoria; Cleland, John; Clark, Andrew

Authors

Sarah Cockayne

David Currow

Kerry Bell

Kate Hicks

Caroline Fairhurst

Rhian Gabe

David Torgerson

Laura Jefferson

Stephen Oxberry

Justin Ghosh

Karen Hogg

Jeremy Murphy

Victoria Allgar

John Cleland

Andrew Clark



Abstract

ABSTRACT
Aims: Morphine is shown to relieve chronic breathless in chronic obstructive pulmonary disease. There are no definitive data in people with heart failure. We aimed to determine the effectiveness and cost-effectiveness of 12 weeks’ morphine therapy for the relief of chronic breathlessness in people with chronic heart failure compared with placebo.

Methods: Parallel-group, double-blind, randomised, placebo-controlled, phase III trial of 20mg daily oral modified-release morphine conducted in 13 sites in England and Scotland; hospital/community cardiology or palliative care out-patients. The primary analysis compared between-group numerical rating scale average breathlessness at week 4 using a covariance pattern linear mixed model. Secondary outcomes included treatment-emergent harms (worse, or new).

Results: The trial closed early, randomising 45 participants (average age 72 [range 39 to 89] years; 84% men; 98% New York Heart Association class III). For the primary analysis, the adjusted mean difference was 0.26 (95% CI -0.86 to 1.37) in favour of placebo. All other breathlessness measures improved in both groups (week 4 change-from-baseline), but by more in those assigned to morphine. Neither group was excessively drowsy at baseline or week 4. There were no between-group differences in quality of life (Kansas) or cognition (Montreal) at any time point. There was no exercise-related desaturation and no change between baseline and week 4 in either group. There was no change in vital signs at week 4. The natriuretic peptide measures fell in both groups, but by more in the morphine group (morphine 2169 [1092, 3851] pg/mL vs placebo 2851 [1694, 5437]) pg/mL. There was no excess serious adverse events in the morphine group. Treatment-emergent harms during the first week were more common in the morphine group; all apart from one were ≤ grade 2.

Conclusions: We could not answer our primary objectives due to inadequate power. However, we provide novel placebo-controlled medium-term benefit and safety data useful for clinical practice and future trial design. Morphine should only be prescribed in this population when other measures are unhelpful, and with early management of side-effects.

Journal Article Type Article
Electronic ISSN 2055-5822
Publisher Wiley Open Access
Peer Reviewed Peer Reviewed
APA6 Citation Johnson, M., Cockayne, S., Currow, D., Bell, K., Hicks, K., Fairhurst, C., …Clark, A. (in press). Oral modified release morphine for breathlessness in chronic heart failure: a randomised placebo-controlled trial. ESC Heart Failure, https://doi.org/10.1002/ehf2.12498
DOI https://doi.org/10.1002/ehf2.12498
Keywords Heart failure; Randomized controlled trial; Morphine; Breathlessness; Dyspnea
Publisher URL https://onlinelibrary.wiley.com/doi/full/10.1002/ehf2.12498
Related Public URLs http://eprints.whiterose.ac.uk/147608/

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Copyright Statement
©2019 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology. ESC HEART FAILURE ESC Heart Failure(2019)Published online in Wiley Online Library (wileyonlinelibrary.com) DOI:10.1002/ehf2.12498 This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.





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