What is the equivalent dose of Dilaudid (hydromorphone) for a patient on oral morphine 30 mg/day and transdermal Fentanyl (fentanyl) 25 mcg/hr (micrograms per hour) every 72 hours?

From the Guidelines

For a patient transitioning from oral morphine 30 mg per day and transdermal fentanyl 25 mcg/hr every 72 hours, an equivalent dose of hydromorphone (Dilaudid) would be approximately 8-12 mg per day, divided into 4-6 doses (2-3 mg every 4-6 hours). To calculate this, we first need to determine the total daily morphine equivalent dose (MED) by converting both the morphine and fentanyl components. The 30 mg oral morphine equals 30 MED directly, as the conversion factor for morphine is 1.0 1. The fentanyl patch 25 mcg/hr is equivalent to approximately 60 MED per day, as the conversion factor for fentanyl transdermal is 2.4 1. Combined, this gives a total daily MED of 90.

Given that hydromorphone has a conversion factor of 5.0 1, we divide the total MED by 5 to find the equivalent hydromorphone dose, which is approximately 18 mg per day. However, considering the potency and individual variability, it's prudent to start at a lower dose and titrate as needed.

Key considerations in this conversion include:

• Starting at the lower end of the dosing range and titrating as needed for pain control
• Monitoring for side effects like respiratory depression, sedation, and constipation
• Initiating a bowel regimen concurrently
• Gradually converting with overlapping coverage during transition to prevent withdrawal or inadequate pain control

It's crucial to note that equianalgesic dose conversions are estimates and cannot account for individual variability in genetics and pharmacokinetics 1. Therefore, caution and close monitoring are essential when converting opioids.

From the FDA Drug Label

TABLE D Name Equianalgesic Dose (mg) IM‡,§ PO Morphine 10 60 (30)¶ Hydromorphone (Dilaudid®) 1.5 7.5

TABLE E Oral 24-hour Morphine (mg/day) Fentanyl Transdermal System Dose (mcg/hr) 60-134 25

To calculate the equivalent dose of Dilaudid (hydromorphone) for a patient on oral morphine 30 mg/day and transdermal Fentanyl (fentanyl) 25 mcg/hr, we need to follow these steps:

• First, we need to calculate the total oral morphine equivalent dose. The patient is already taking oral morphine 30 mg/day.
• According to Table E, a transdermal Fentanyl dose of 25 mcg/hr corresponds to an oral morphine dose of 60-134 mg/day.
• Since the patient is taking oral morphine 30 mg/day in addition to transdermal Fentanyl, we need to add this to the equivalent oral morphine dose of the transdermal Fentanyl. However, we cannot directly add it to the range, so we will consider the lower end of the range (60 mg/day) as the equivalent dose for 25 mcg/hr of transdermal Fentanyl for this calculation.
• The total oral morphine equivalent dose is 60 mg/day (from transdermal Fentanyl) + 30 mg/day (oral morphine) = 90 mg/day.
• According to Table D, 60 mg of oral morphine is equivalent to 7.5 mg of oral hydromorphone.
• To find the equivalent dose of hydromorphone for 90 mg of oral morphine, we can set up a proportion:
  • 60 mg oral morphine / 7.5 mg oral hydromorphone = 90 mg oral morphine / x mg oral hydromorphone
  • Solving for x, we get x = (90 mg oral morphine * 7.5 mg oral hydromorphone) / 60 mg oral morphine
  • x = 11.25 mg oral hydromorphone Therefore, the equivalent dose of Dilaudid (hydromorphone) for a patient on oral morphine 30 mg/day and transdermal Fentanyl (fentanyl) 25 mcg/hr is 11.25 mg/day 2.

From the Research

Equivalent Dose Calculation

To calculate the equivalent dose of Dilaudid (hydromorphone) for a patient on oral morphine 30 mg/day and transdermal Fentanyl (fentanyl) 25 mcg/hr, we need to consider the conversion ratios between these opioids.

• The conversion ratio between oral morphine and oral hydromorphone is approximately 5:1, as reported in several studies 3, 4.
• The conversion ratio between transdermal fentanyl and oral morphine is approximately 100:1, as reported in several studies 5, 4.

Calculation Steps

1. Convert transdermal fentanyl to oral morphine equivalent:

   • Transdermal fentanyl dose: 25 mcg/hr
   • Conversion ratio: 100:1 (transdermal fentanyl to oral morphine)
   • Oral morphine equivalent: 25 mcg/hr x (1 hr / 1 hr) x (1 mg / 100 mcg) x (100:1) = 0.25 mg/hr x 24 hr = 6 mg/day (approximately)

2. Add oral morphine and oral morphine equivalent from transdermal fentanyl:

   • Total oral morphine equivalent: 30 mg/day (oral morphine) + 6 mg/day (from transdermal fentanyl) = 36 mg/day

3. Convert total oral morphine equivalent to oral hydromorphone:

   • Conversion ratio: 5:1 (oral morphine to oral hydromorphone)
   • Oral hydromorphone equivalent: 36 mg/day / 5 = 7.2 mg/day

Result

The equivalent dose of Dilaudid (hydromorphone) for a patient on oral morphine 30 mg/day and transdermal Fentanyl (fentanyl) 25 mcg/hr is approximately 7.2 mg/day, based on the conversion ratios provided in the studies 3, 5, 4.