Hydromorphone (Dilaudid)
Pharmacologic classification: opioid Therapeutic classification: analgesic, antitussive Pregnancy risk category C Controlled substance schedule II
Available forms Available by prescription only Injection: 1 mg/ml, 2 mg/ml, 3 mg/ml, 4 mg/ml, 10 mg/ml Oral liquid: 5 mg/5 ml Suppository: 3 mg Tablets: 1 mg, 2 mg, 3 mg, 4 mg, 8 mg
Indications and dosages
Moderate to severe pain. Adults: 2 to 10 mg P.O. q 3 to 6 hours, p.r.n., or around-the-clock. Or, 2 to 4 mg I.M., S.C., or I.V. q 4 to 6 hours, p.r.n., or around-the-clock (give I.V. dose over 3 to 5 minutes). Or, 3 mg rectal suppository q 6 to 8 hours, p.r.n., or around-the-clock. (Give 1 to 14 mg Dilaudid-HP S.C. or I.M. q 4 to 6 hours.)
Note: Give hydromorphone hydrochloride in the smallest effective dose to minimize the development of tolerance and physical dependence. Dose must be individually adjusted based on patient’s severity of pain, age, and size.
Cough. Adults: 1 mg P.O. q 3 to 4 hours, p.r.n. Children ages 6 to 12: 0.5 mg P.O. q 3 to 4 hours, p.r.n.
Pharmacodynamics
Antitussive action: Hydromorphone acts directly on the cough center in the medulla, producing an antitussive effect. Analgesic action: Hydromorphone has analgesic properties related to opiate receptor affinity and is recommended for moderate to severe pain. Unlike other opioids, there’s no intrinsic limit to the analgesic effect of hydromorphone.
Pharmacokinetics Absorption: Well absorbed after oral, rectal, or parenteral administration. Distribution: Unknown. Metabolism: Metabolized primarily in the liver, where it undergoes conjugation with glucuronic acid. Excretion: Excreted primarily in urine as the glucuronide conjugate. Duration of action is 4 to 5 hours.
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Contraindications and precautions Contraindicated in patients hypersensitive to drug; in those with intracranial lesions caused by increased intracranial pressure; and whenever ventilator function is depressed, such as in status asthmaticus, COPD, cor pulmonale, emphysema, and kyphoscoliosis.
Use cautiously in elderly or debilitated patients and in those with hepatic or renal disease, Addison’s disease, hypothyroidism, prostatic hyperplasia, or urethral strictures.
Interactions Drug-drug. Anticholinergics: Increases risk of paralytic ileus. Avoid use together. Cimetidine: Increases respiratory and CNS depression, causing confusion, disorientation, apnea, or seizures. Reduced dosage of hydromorphone is usually needed.
CNS depressants (antihistamines, barbiturates, benzodiazepines, general anesthetics, muscle relaxants, narcotic analgesics, phenothiazines, sedative-hypnotics, tricyclic antidepressants): Increases respiratory and CNS depression, sedation, and hypotensive effects of drug. Use together with extreme caution. General anesthetics: May cause severe CV depression. Avoid use together. Narcotic antagonist: Patients who become physically dependent on drug may experience acute withdrawal syndrome. Avoid use together. Drug-lifestyle. Alcohol use: Increases CNS effects of drug. Discourage alcohol use.
Adverse reactions
CNS: sedation, somnolence, clouded sensorium, dizziness, euphoria. CV: hypotension, bradycardia. EENT: blurred vision, diplopia, nystagmus. GI: nausea, vomiting, constipation, ileus. GU: urine retention. Respiratory: respiratory depression, bronchospasm. Other: induration (with repeated S.C. injections), physical dependence.
Effects on lab test results • May increase amylase and lipase levels.
Overdose and treatment
-The most common signs and symptoms of hydromorphone overdose are CNS depression, respiratory depression, and miosis. Other effects include hypotension, bradycardia, hypothermia, shock, apnea, cardiopulmonary arrest, circulatory collapse, pulmonary edema, and seizures. -To treat an acute overdose, first establish adequate respiratory exchange via a patent airway and ventilation as needed; administer a narcotic antagonist (naloxone) to reverse respiratory depression. (Because the duration of action of hydromorphone is longer than that of naloxone, repeated dosing is needed.) Naloxone shouldn’t be given unless patient has clinically significant respiratory or CV depression. Monitor vital signs closely. -If patient is seen within 2 hours of ingestion of an oral overdose, empty the stomach immediately by inducing emesis with ipecac syrup or using gastric lavage. Use caution to avoid aspiration. Give activated charcoal via nasogastric tube for further removal of an oral overdose. Provide symptomatic and supportive treatment (continued respiratory support, correction of fluid or electrolyte imbalance). Monitor laboratory values, vital signs, and neurologic status closely. -Contact the local or regional poison control center for further information.
Special considerations • For a better analgesic effect, give drug before patient has intense pain. • Dilaudid-HP, a highly concentrated form (10 mg/ml), may be administered in smaller volumes to prevent the discomfort of large-volume I.M. or S.C. injections. • Rotate injection sites to avoid induration with S.C. injection. • Keep narcotic antagonist (naloxone) available. ALERT Don’t confuse hydromorphone with morphine. • For infusion, drug may be mixed in D5W, normal saline solution, D5W in normal saline solution, D5W in half-normal saline solution, or Ringer’s or lactated Ringer’s solutions. • Respiratory depression and hypotension can occur with I.V. administration. Give by direct injection over no less than 2 minutes and monitor patient constantly. Keep resuscitation equipment available. • Drug may worsen or mask gallbladder pain. • Increased biliary tract pressure resulting from contraction of the sphincter of Oddi may interfere with hepatobiliary imaging studies. • Prevent constipation with the use of stool softeners or senna preparations at the start of therapy. Breast-feeding patients • It isn’t known whether drug appears in breast milk. Use cautiously in breast-feeding women. Geriatric patients • Lower doses are usually indicated for elderly patients because they may be more sensitive to therapeutic and adverse effects of drug.
Patient education • Instruct patient to take or ask for drug before pain becomes intense. • Warn patient to avoid hazardous activities that require mental alertness. • Advise patient to avoid alcohol.
Reference:
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