Is adding hydromorphone (Dilaudid) 0.5mg-1mg PO (by mouth) q4-6hr (every 4-6 hours) an appropriate breakthrough dose for a patient already taking hydrocodone (HM) 0.5mg PO QID (four times a day)?

Hydromorphone Breakthrough Dosing for a Patient on Hydrocodone

Yes, hydromorphone 0.5mg-1mg PO q4-6hr is an appropriate breakthrough dose for a patient taking hydrocodone 0.5mg PO QID. 1

Rationale for Breakthrough Dosing

• The National Comprehensive Cancer Network recommends breakthrough doses should be approximately 10-20% of the total 24-hour opioid dose 2
• For a patient taking hydrocodone 0.5mg QID (total daily dose of 2mg), a breakthrough dose of hydromorphone 0.5-1mg is appropriate based on equianalgesic conversion 1
• When converting between opioids, it's important to account for relative potency differences and incomplete cross-tolerance 2

Equianalgesic Considerations

• Hydromorphone is approximately 5-7 times more potent than morphine, while hydrocodone is less potent than morphine 1
• When converting between different opioids, calculate the equianalgesic dose based on the current regimen 2
• For opioid-tolerant patients, the rescue dose should typically be 10-20% of the 24-hour total opioid requirement 2

Dosing Schedule

• Breakthrough medication should be available every 4-6 hours as needed 3
• The FDA label for hydromorphone indicates that a supplemental dose of 5-15% of the total daily usage may be administered every two hours on an as-needed basis 3
• For patients receiving regular oral opioids, breakthrough pain may be managed with doses varying from 30-100% of the 4-hourly dose 2

Clinical Considerations

• Hydromorphone has a quicker onset of action compared to morphine, making it potentially beneficial for breakthrough pain management 1
• Pain relief with hydrocodone may be due primarily to its active metabolite hydromorphone, suggesting pharmacological compatibility when using hydromorphone for breakthrough dosing 4
• Norhydrocodone, another metabolite of hydrocodone, also has analgesic properties but is significantly less potent than hydromorphone 5

Monitoring and Titration

• Assess efficacy and side effects 60 minutes after administering breakthrough doses of oral hydromorphone 1
• If pain control remains inadequate after 2-3 cycles of breakthrough dosing, consider increasing the regular dose of the around-the-clock medication 2
• Monitor patients closely for respiratory depression, especially within the first 24-72 hours of initiating therapy 3

Cautions

• Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals 3
• Be aware that some patients may metabolize hydrocodone to hydromorphone differently based on CYP2D6 genetic variations, potentially affecting response to both medications 4
• If the patient requires frequent breakthrough doses, this indicates the need to increase the regular scheduled dose 2