Adult Dosing
Moderate to severe pain
IR Form
- TABS: Start 2-4 mg PO q3-4 hrs; then individualize on the basis of baseline clinical status and pain severity
- SUSP: 2.5-10 mg PO q3-6 hrs
- Notes:
- Individualize dosage since adverse reactions may occur at any dosage; use lower starting dose in geriatric patients and non-opioid-tolerant patients
- Adjust dosage so that at least 3-4 hrs of pain relief is achieved
- In patients taking opioid analgesics, the starting dose should be based on prior opioid usage [Refer Table below]. Once the total daily dosage has been estimated, it should be divided into the desired number of doses. Only 1/2-2/3 of the estimated dose calculated from equivalence tables should be given for the first few doses, then titrated as needed
Opioid analgesic equivalents with approximately equianalgesic potency
| Nonproprietary (Trade) name | IM/SC dose | Oral dose |
|---|
| Morphine sulphate | 10 mg | 40-60 mg |
| Hydromorphone HCL (Dilaudid) | 1.3-2 mg | 6.5-7.5 mg |
| Oxymorphone HCL (Numorphan) | 1-1.1 mg | 6.6 mg |
| Levorphanol tartarate (Levo-Dromoran) | 2-2.3 mg | 4 mg |
| Meperidine, pethidine HCL (Demerol) | 75-100 mg | 300-400 mg |
| Methadone HCL (Dolophine) | 10 mg | 10-20 mg |
ER form
- 8-64 mg PO q24 hrs
- Notes:
- Individualize dosage on the basis of opioid intake [See table below]; use lower starting dose in geriatric patients
- May increase dose q3-4 days; increase 25%-50%; taper dose 25-50% q2-3 days to 8 mg/day while discontinuing
- Titrate dose upwards if more than two doses of rescue medication are needed within a 24 hour period for two consecutive days. Administer q24 hrs
- Select opioid from the table given, sum the total daily dose, and then multiply the dose by the conversion ratio to calculate the approximate oral hydromorphone equivalent
- Monitor carefully while converting; these conversions are only to be used for the conversion from current opioid therapy to extended release hydromorphone
| Table 2 |
|---|
| Previous opioid | Approximate equivalent oral dose | Oral conversion ratio |
|---|
| Hydromorphone | 12 mg | 1 |
| Codeine | 200 mg | 0.06 |
| Hydrocodone | 30 mg | 0.4 |
| Methadone | 20 mg | 0.6 |
| Morphine | 60 mg | 0.2 |
| Oxycodone | 30 mg | 0.4 |
| Oxymorphone | 20 mg | 0.6 |
Maintenance therapy (ER form)
- Monitor for signs of abuse, misuse, and addiction
- Assess patients for their clinical risks for opioid abuse, addiction, or diversion particularly with high-dose formulations
- Titrate dose while on maintenance therapy re-establish pain control
Conversion from transdermal fentanyl to extended release hydromorphone
- Extended release hydromorphone can be initiated after eighteen hours of removal of transdermal fentanyl patch. For each 25 mcg/hr fentanyl transdermal dose the equianalgesic dose of extended release hydromorphone is 12 mg PO q12 hrs. An appropriate starting dose of extended release hydromorphone is 50% of the calculated total daily dose every 24 hours
Pediatric Dosing
- Safety and effectiveness in pediatric patients
17 yrs of age have not been established
Moderate to severe pain [Not FDA approved]
- IR Tabs: 12 yrs; 0.03-0.08 mg/kg PO q4-6 hrs PRN
- IR Tabs: >12 yrs; Use adult dose
[Outline]
See Supplemental Patient Information
- Schedule II controlled substance with high potential for abuse/drug dependence and risk of severe respiratory depression [US Black Box Warning]
- In patients with decreased respiratory reserve, consider alternative non-opioid analgesics, or use ER formulation only under careful medical supervision at the lowest effective dose
- Respiratory depression with decrease in pulmonary ventilation may occur even with moderate therapeutic doses in the elderly, debilitated and in those suffering from conditions accompanied by hypoxia of hypercapnia
- Respiratory depressant effects are markedly exaggerated in the presence of head injury, intracranial lesions or a preexisting increase in intracranial pressure
- Hydromorphone may cause severe hypotension; patients with depleted blood volume, or those receiving concurrent phenothiazines, general anesthetics, or other agents that compromise vasomotor tone, are at an increased risk
- There have been reports of obstructive symptoms in patients with known strictures or at risk of strictures (previous GI surgery) with ER formulations
- Concurrent use of ER formulation with other central nervous system (CNS) depressants, (opioids, illicit drugs, sedatives, hypnotics, general anesthetics, phenothiazines, muscle relaxants, other tranquilizers, and alcohol) increases the risk of respiratory depression, hypotension, and profound sedation, potentially resulting in coma or death
- Hydromorphone is a schedule II narcotic, may produce drug dependence of the morphine type and therefore has the potential for being abused. Repeated administration may cause psychic dependence, physical dependence and tolerance
- Slowly taper to discontinue if at risk for physical dependence. Abrupt cessation can cause a withdrawl syndrome or precipitate seizures
- May impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating machinery)
- Monitor for signs of abuse, misuse, and addiction
- May aggrevate pre-existing convulsions in patients with convulsive disorders
Cautions: Use cautiously in
- Medications with anticholinergic activity (increase risk of urinary retention and severe constipation)
- Renal impairment
- Hepatic impairment
- Pre-existing respiratory depression
- Asthma
- COPD
- Cor pulmonale
- Hypoxia
- Hypercapnia
- Severe obesity
- Sleep apnea
- Adreno-cortical insufficiency
- Head trauma
- Thyroid disorder
- CNS depression
- Increased intracranial pressure
- Alcohol/drug abuse
- Coma
- Toxic psychoses
- Concurrent MAO inhibitors
- Delirium tremens
- Undiagnosed abdominal pain
- Prostatic hypertrophy
- Acute pancreatitis
- Myxedema
- Hypothyroidism
- Gallbladder disease
- Kyphoscoliosis
- Gastrointestinal surgery
- Geriatric population
- Note: For information on prevention, detect abuse or diversion of this product healthcare professionals should contact their State Professional Licensing Board or State Controlled Substances Authority
Supplemental Patient Information
- Patients receiving hydromorphone or their caregivers should be given information on its effect, adverse effects, alcohol and other medication precautions, pregnancy implications, potential for abuse, taper of dosing and secure storage of the medication.
Pregnancy Category:C
Breastfeeding: Minimally excreted in breastmilk; newborn infants may be particularly sensitive to the effects of even small dosages, especially in the first week of life. Alternative non-narcotic analgesics may be preferred. This information is based upon LactMed database (available at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT last accessed 12 October 2010). Manufacturer recommends discontinuation of nursing.
Pricing data from www.DrugStore.com in U.S.A.
- Dilaudid 8 MG TABS [Bottle] (PURDUE PHARMA L.P.)
20 mg = $57.77
30 mg = $86.66 - Dilaudid-5 1 MG/ML LIQD [Bottle] (PURDUE PHARMA L.P.)
473 ml = $192.6
1419 ml = $577.81 - Dilaudid 4 MG TABS [Bottle] (PURDUE PHARMA L.P.)
20 mg = $36.99
30 mg = $49.97
Warning: This pricing information is subject to change at the sole discretion of DS Pharmacy. For the most current and up-to-date pricing information, please visit drugstore.com.
