From the Guidelines
Dilaudid (hydromorphone) can cause life-threatening bradycardia, particularly in vulnerable patients or at higher doses, due to its opioid-mediated effects on the cardiovascular system. This medication activates mu-opioid receptors, leading to increased parasympathetic tone and decreased sympathetic activity, which can slow the heart rate [ 1 ]. Patients at highest risk include those with pre-existing cardiac conditions, elderly individuals, and those taking other medications that slow heart rate, such as beta-blockers or calcium channel blockers [ 1 ].
Key Considerations
- Signs of dangerous bradycardia include heart rates below 50 beats per minute, lightheadedness, confusion, weakness, or syncope.
- Treatment for life-threatening bradycardia typically involves stopping the Dilaudid and administering naloxone to reverse opioid effects, providing supplemental oxygen, and potentially using atropine for severe bradycardia, as outlined in guidelines for managing bradycardia [ 1 ].
- Healthcare providers should start with lower Dilaudid doses in at-risk patients, monitor vital signs closely, and have naloxone readily available [ 1 ].
Management Strategies
- Alternative pain management strategies may be necessary for patients who develop significant bradycardia with Dilaudid.
- According to the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay, atropine can be used at a dose of 0.5–1 mg IV (may be repeated every 3–5 min to a maximum dose of 3 mg) for symptomatic sinus bradycardia or atrioventricular block [ 1 ].
- The guideline also suggests the use of dopamine, isoproterenol, and epinephrine in specific scenarios of bradycardia management, highlighting the importance of tailored treatment approaches [ 1 ].
From the FDA Drug Label
Acute overdose with hydromorphone hydrochloride tablets can be manifested by ... bradycardia, hypotension, partial or complete airway obstruction, atypical snoring, and death
- Bradycardia is listed as a potential manifestation of acute overdose with hydromorphone hydrochloride tablets.
- The presence of bradycardia in the context of an overdose suggests that it can be a life-threatening condition.
- Therefore, yes, Dilaudid (hydromorphone) can cause life-threatening bradycardia, particularly in the setting of an overdose 2.
From the Research
Opioid-Induced Bradycardia
- Opioids can lead to bradycardia and vasodilation, and as a result can rarely lead to edema, hypotension, orthostatic hypotension, and syncope when used at analgesic doses 3.
- There are limited data to suggest that chronic opioid administration may be associated with an increased risk for cardiac-related adverse effects, including bradycardia 3.
Mechanism of Bradycardia
- The activation sequence of high and low right atrial electrograms revealed that a pacemaker shift was responsible for the nonvagally mediated bradycardia observed with acute cardiac tamponade and severe hemorrhage, suggesting that ischemia of the sinoatrial node was the apparent cause of the pacemaker shift and resultant bradycardia 4.
- Oxycodone, an opioid, exerts its effects by binding to Mu opioid receptors located in the central nervous system, resulting in the opening of potassium (k+) channels and the closing of calcium channels, decreasing synaptic transmission, which can lead to bradycardia 5.
Clinical Evidence
- A case report described a 62-year-old male who developed persistent bradycardia following treatment with phenytoin and oxycodone for seizure disorder and pain, respectively, suggesting that combination of these medications can induce bradycardia 5.
- However, there is no direct evidence in the provided studies that specifically links Dilaudid (hydromorphone) to life-threatening bradycardia.
Risk Factors
- Patients with renal insufficiency, patients with clinical sinus node dysfunction, and patients who had developed bradycardia while taking other sympatholytic agents or who were currently receiving another sympatholytic drug are at risk for severe bradycardia during oral clonidine therapy, which may be relevant to opioid-induced bradycardia 6.