From the Guidelines
A patient with a codeine allergy can typically receive Dilaudid (hydromorphone) safely, as it belongs to a different chemical subclass of opioids and does not share the same metabolic pathways that often trigger allergic reactions. According to the most recent and highest quality study available 1, codeine is a prodrug that requires conversion to morphine by the liver enzyme CYP2D6, whereas hydromorphone is a semi-synthetic opioid with a different molecular structure.
Some key points to consider:
- True allergic reactions to opioids are relatively rare, and when they do occur, they're usually specific to one chemical subclass rather than representing cross-reactivity across all opioids 1.
- Hydromorphone has properties similar to morphine and is available in various formulations, including oral, parenteral, and rectal delivery 1.
- The patient should be monitored for any adverse reactions when first receiving Dilaudid, especially if they have a history of multiple drug allergies or severe allergic reactions.
- If the patient has experienced only side effects from codeine (like nausea or constipation) rather than a true allergic reaction, the risk of problems with Dilaudid is even lower.
It's essential to note that caution is still warranted, and the prescribing physician should be informed about the codeine allergy. Additionally, the patient's medical history and current condition should be taken into account when making a decision about administering Dilaudid. As stated in the study 1, opioids with no active metabolites are preferred for patients with renal insufficiency or ESRD, and hydromorphone should be used with caution and adjusted dosage in these cases.
From the Research
Opioid Allergy and Cross-Reactivity
- The risk of cross-reactivity between different opioid classes is low, with rates ranging from 0% to 6.7% 2
- A study found that 92.5% of patients with historical opioid allergies tolerated readministration of opioids despite a chart-documented allergy 2
- Opioid allergy labels are often unsubstantiated in clinical practice, and the removal of erroneous labels is important for pain management 3
Codeine Allergy and Alternatives
- Codeine is a prodrug that owes its analgesic effect to its metabolite morphine, and genetic polymorphisms can contribute to unpredictable pharmacokinetics 4, 5
- Due to the risks associated with codeine, particularly in pediatric patients, regulatory bodies have issued warnings and restrictions on its use 4, 5
- Alternative pain control drugs and strategies are available and can be used to ensure adequate pain control in patients with codeine allergies or intolerances 4, 5
Hydromorphone (Dilaudid) and Codeine Allergy
- There is no direct evidence to suggest that a patient with a codeine allergy cannot receive hydromorphone (Dilaudid) 3, 2
- However, it is essential to consider the individual patient's medical history, allergy profile, and potential cross-reactivity between opioids when making prescribing decisions 3, 2