Can a patient who had an adverse reaction to Dilaudid (hydromorphone) be given oxycodone?

Opioid Selection After Adverse Reaction to Hydromorphone

Yes, oxycodone can be safely given to a patient who had an adverse reaction to Dilaudid (hydromorphone), as these medications have different chemical structures and metabolic pathways. 1

Understanding Opioid Cross-Reactivity

Hydromorphone (Dilaudid) and oxycodone are different opioid analgesics with distinct chemical structures:

• Hydromorphone is a semi-synthetic opioid derived from morphine
• Oxycodone is a semi-synthetic opioid derived from thebaine
• True allergic reactions to opioids are rare; most "adverse reactions" are side effects related to histamine release or other pharmacological properties 2, 1

Decision Algorithm for Opioid Selection After Adverse Reaction

1. Determine the nature of the previous adverse reaction:

   • If the reaction was a true allergic reaction (urticaria, angioedema, anaphylaxis): Consider non-opioid analgesics or consult allergy specialist
   • If the reaction was intolerable side effects (nausea, vomiting, excessive sedation): Try alternative opioid class

2. Select appropriate alternative opioid:

   • Oxycodone is an effective alternative to hydromorphone with a different chemical structure 2
   • Start with low dose: 5-15 mg PO every 4-6 hours PRN for opioid-naïve patients 2

3. Monitor for effectiveness and adverse effects:

   • Assess pain relief within 30-60 minutes of administration
   • Watch for common opioid side effects (nausea, constipation, sedation)

Evidence Supporting Opioid Rotation

The European Association for Palliative Care recommends that when patients develop intolerable adverse effects with one opioid, switching to an alternative opioid agonist may allow titration to adequate analgesia without the same disabling effects 2. This practice is sometimes called "opioid rotation."

Studies comparing hydromorphone and oxycodone have shown:

• Similar analgesic efficacy at equianalgesic doses 3
• Different metabolic pathways: hydromorphone undergoes glucuronidation while oxycodone is primarily metabolized through CYP3A4 and CYP2D6 4
• Distinct side effect profiles in some patients, allowing for successful rotation when one causes adverse effects 2

Important Considerations and Precautions

• Start with lower doses: Begin with 5-15 mg of oral oxycodone every 4-6 hours PRN 2
• Avoid concurrent use: Never administer hydromorphone and oxycodone simultaneously, as this combination has been associated with increased risk of respiratory depression 5
• Monitor for cross-sensitivity: While uncommon, some patients may experience similar adverse effects with different opioids
• Consider patient-specific factors: Renal function, hepatic function, and drug interactions may influence opioid selection 2

Special Populations

• Patients with renal impairment: Both hydromorphone and oxycodone should be used with caution in patients with renal dysfunction 2
• Patients with hepatic impairment: Oxycodone dosing should be initiated at lower doses in patients with hepatic dysfunction 2
• Breastfeeding women: Oxycodone should be used with caution as it may pose a greater risk of causing infant sedation than other opioids 2

By understanding the differences between hydromorphone and oxycodone, clinicians can safely prescribe oxycodone for patients who have experienced adverse reactions to hydromorphone, while monitoring for effectiveness and tolerability.