From the Guidelines
Patients with an allergy to morphine and codeine can safely take Dilaudid (hydromorphone) as it causes little or no histamine release, making it a suitable option for those with a type 2 allergy to morphine. When considering the use of Dilaudid in patients with morphine and codeine allergies, it's essential to understand the differences in chemical structure and potential for cross-reactivity. According to a study published in Critical Care in 2013 1, hydromorphone may be safely administered to patients who report a type 2 allergy to morphine, characterized by symptoms such as urticaria, pruritis, and facial flushing. This is because hydromorphone causes minimal histamine release, reducing the risk of an allergic reaction.
Key considerations for the use of Dilaudid in these patients include:
- The potency of hydromorphone, which is higher than morphine, allowing for effective pain management at smaller doses
- The potential benefits of using hydromorphone over standard morphine and fentanyl dosing, including fewer repeat orders and more effective pain treatment
- The importance of individualizing treatment decisions based on the patient's specific allergy symptoms, severity, and history, as well as their pain management needs and the availability of alternative treatments.
It's crucial to note that while hydromorphone may be a safer option for patients with morphine and codeine allergies, close medical supervision is still necessary to monitor for any potential adverse reactions. As stated in the study 1, oral NSAIDs, oxycodone, and hydromorphone are generally superior to codeine-acetaminophen combinations, although the quality of evidence is very low due to bias, indirectness, and imprecision. Ultimately, the decision to use Dilaudid in patients with morphine and codeine allergies should be made on a case-by-case basis, taking into account the patient's unique needs and medical history.
From the FDA Drug Label
Anaphylaxis: Anaphylaxis has been reported with ingredients contained in hydromorphone hydrochloride tablets.
Allergy to Morphine and Codeine:
- The patient has an allergy to morphine and codeine, which are opioids.
- Hydromorphone is also an opioid, and anaphylaxis has been reported with ingredients contained in hydromorphone hydrochloride tablets.
- Given the patient's allergy to other opioids, it is likely that they may also be allergic to hydromorphone.
- Therefore, it is not recommended for a patient with an allergy to morphine and codeine to take Dilaudid (hydromorphone) due to the risk of anaphylaxis 2.
From the Research
Opioid Allergy and Cross-Reactivity
- Opioid allergies are often reported, but true allergies are rare, and most reactions can be attributed to side effects or pseudo-allergies 3.
- Studies have shown that cross-reactivity among opioid classes is low, with one study finding no cross-reactivity among natural, semisynthetic, and synthetic opioids 4.
- Another study found that patients with historical opioid allergies were able to tolerate subsequent opioid exposure, with cross-reactivity rates ranging from 0% to 6.7% 5.
Hydromorphone and Opioid Allergy
- Hydromorphone is a semisynthetic opioid, and its use in patients with opioid allergies has not been extensively studied.
- However, given the low cross-reactivity among opioid classes, it is possible that a patient with an allergy to morphine and codeine may be able to tolerate hydromorphone 4, 5.
- One study suggests that hydromorphone is an acceptable alternative to morphine for patients with significant adverse effects from morphine or severe renal dysfunction, but it does not specifically address opioid allergy 6.
Clinical Implications
- The low likelihood of true opioid allergy and cross-reactivity suggests that opioid allergy labels may be overly cautious, and patients may be able to tolerate opioids despite a reported allergy 3, 5.
- Clinicians should carefully evaluate patients with reported opioid allergies and consider the use of alternative opioids, such as hydromorphone, on a case-by-case basis 4, 5.