Management of Patients Currently on Hydromorphone (Dilaudid)
For patients currently on hydromorphone (Dilaudid), the next step should be to evaluate their pain control, assess for side effects, and determine if dose adjustment, opioid rotation, or transition to oral therapy is appropriate based on their clinical condition and treatment goals.
Assessment and Monitoring
- Evaluate current pain control using a validated pain scale (0-10) to determine if the current regimen is effective 1
- Monitor for common opioid-related side effects including respiratory depression, sedation, constipation, nausea, and vomiting 1, 2
- Assess oxygen saturation levels, as hydromorphone can cause oxygen desaturation below 95% in approximately one-third of patients 3
- Review liver and kidney function, as dose adjustments are necessary for patients with hepatic or renal impairment 2
Dose Titration and Adjustment
- If pain is inadequately controlled, titrate the dose based on breakthrough pain requirements 4
- For IV hydromorphone infusions with breakthrough pain, consider bolus doses equal to or double the hourly infusion rate 4
- If two bolus doses are required within an hour, consider doubling the infusion rate 4
- For oral hydromorphone, adjust the dosage to obtain an appropriate balance between pain management and opioid-related adverse reactions 2
- A supplemental dose of 5-15% of the total daily usage may be administered every two hours as needed for breakthrough pain 2
Route Conversion Considerations
IV to Oral Conversion
- When converting from IV to oral hydromorphone, use a conversion ratio of 1:2.5 (1 mg IV hydromorphone = 2.5 mg oral hydromorphone) 5
- For chronic pain management, consider transitioning to oral extended-release formulations with immediate-release options for breakthrough pain 6
Opioid Rotation
- If considering rotation to another opioid, use established equianalgesic dosing guidelines 1:
- 10 mg IV morphine = 1.5 mg IV hydromorphone
- 30 mg oral oxycodone = 7.5 mg oral hydromorphone
- When converting from IV hydromorphone to oral morphine equivalent daily dose (MEDD), use a ratio of approximately 1:11.5 5
- Reduce the calculated equianalgesic dose by 25-50% when rotating to account for incomplete cross-tolerance 1
Special Population Considerations
- For patients with hepatic impairment, reduce the starting dose to 25-50% of the usual dose 2
- For patients with renal impairment, reduce the starting dose to 25-50% of the usual dose 2
- For patients with end-stage liver disease, hydromorphone may be preferred over NSAIDs, tramadol, codeine, and oxycodone 1
Monitoring and Follow-up
- Reassess pain control and side effects frequently, especially within the first 24-72 hours of therapy or following dose adjustments 2
- Monitor for signs of opioid misuse, abuse, or addiction 2
- Provide written instructions to patients regarding medication schedule, breakthrough dosing, and when to contact healthcare providers 1
- Ensure patients have access to prescribed medications, especially during transitions between care settings 1
Non-pharmacological Approaches
- Consider incorporating non-pharmacological pain management strategies as adjuncts to opioid therapy 1
- For cancer-related pain, consider radiation therapy for bone or lymph node metastasis, or interventional procedures like RFA or transarterial embolization for localized pain 1
Remember that hydromorphone is a potent opioid with a quicker onset of action compared to morphine, making it potentially superior for acute pain management, but requiring careful monitoring for side effects 1, 7.