Converting from Immediate-Release to Extended-Release Hydromorphone
When switching a patient from immediate-release (IR) hydromorphone to extended-release (ER) hydromorphone, use the same total daily dose for the ER formulation, administered once daily, with close monitoring for signs of excessive sedation and respiratory depression. 1
Conversion Process
- Calculate the total daily dose of immediate-release hydromorphone the patient is currently taking 1
- Convert to the same total daily dose of extended-release hydromorphone, administered once daily 2
- No dose reduction is typically needed when converting between IR and ER formulations of the same medication, as studies have shown comparable effects at the same total daily dose 2
- Close observation is required during conversion due to unknown relative bioavailability between formulations 1
Special Patient Populations
- For patients with hepatic impairment, reduce the starting dose to one-fourth to one-half of the usual dose depending on the degree of impairment 1
- For patients with renal impairment, reduce the starting dose to one-fourth to one-half of the usual dose depending on the degree of impairment 1
- For elderly patients or those with other risk factors for opioid-related adverse effects, consider starting at a lower dose and titrating more cautiously 1
Titration and Breakthrough Pain Management
- After conversion, continually reevaluate patients to assess pain control and adverse reactions 1
- For breakthrough pain during the transition period, provide immediate-release hydromorphone as rescue medication 1
- A supplemental dose of 5-15% of the total daily usage may be administered every two hours as needed 1
- If the patient requires more than 3 rescue doses per day, consider increasing the extended-release dose 3
Monitoring and Follow-up
- Monitor closely for signs of excessive sedation and respiratory depression, especially during the first 24-48 hours after conversion 1
- Assess pain control using validated pain scales; dose stabilization is typically defined as a 3-day period with unchanged ER dose and ≤3 rescue doses per day 3
- In clinical studies, approximately 70% of patients achieved dose stabilization within 12 days (range 3-33 days) 3
- About 43% of patients remain at their initial conversion dose, 54% require dose increases, and 3% need dose decreases 4
Potential Pitfalls and Cautions
- The FDA label specifically warns that the relative bioavailability between IR and ER hydromorphone is unknown, necessitating close observation during conversion 1
- Extended-release formulations should never be crushed, chewed, or dissolved as this can lead to rapid release and absorption of a potentially fatal dose 5
- If pain increases after dosage stabilization, identify the source of increased pain before increasing the hydromorphone dosage 1
- If unacceptable opioid-related adverse reactions occur, consider reducing the dosage rather than discontinuing therapy 1