Can Dilaudid (hydromorphone) be used with rasagiline?

Hydromorphone (Dilaudid) Should Not Be Used with Rasagiline Due to Risk of Serotonin Syndrome

Hydromorphone (Dilaudid) should not be used concurrently with rasagiline due to the risk of potentially life-threatening serotonin syndrome. 1

Understanding the Medications

Hydromorphone (Dilaudid)

• Hydromorphone is a potent opioid analgesic with properties similar to morphine 2
• It has a quicker onset of action compared to morphine and is available in oral tablet, liquid, suppository, and parenteral formulations 2
• Hydromorphone is recommended for acute severe pain in emergency settings at a dose of 0.015 mg/kg IV 2
• Some evidence suggests that hydromorphone metabolites may lead to opioid neurotoxicity, including myoclonus, hyperalgesia, and seizures 2

Rasagiline

• Rasagiline is a second-generation, selective, and irreversible inhibitor of monoamine oxidase type B (MAO-B) used in Parkinson's disease treatment 3, 4
• It is typically administered at 1 mg once daily as monotherapy in early Parkinson's disease or 0.5-1 mg once daily as adjunctive therapy with levodopa in advanced disease 4
• Unlike selegiline (another MAO-B inhibitor), rasagiline does not metabolize to potentially toxic amphetamine derivatives 3, 4

Drug Interaction Concerns

Risk of Serotonin Syndrome

• Combining MAO inhibitors (including selective MAO-B inhibitors like rasagiline) with opioids can precipitate serotonin syndrome 1
• Serotonin syndrome is characterized by sudden onset of altered mental status, increased neuromuscular activity, and autonomic instability 1
• There is documented evidence of serotonin syndrome occurring with combinations of rasagiline and serotonergic medications 1

Clinical Manifestations of Serotonin Syndrome

• High-grade fever, confusion, agitation, hallucination, and behavioral changes 1
• Can progress to severe complications including acute kidney injury 1
• Potentially fatal if not recognized and treated promptly 1, 5

Alternative Pain Management Options

For Patients on Rasagiline Requiring Pain Management

• Fentanyl may be considered as it has a different mechanism and is recommended over morphine for acute moderate-severe pain (weak recommendation, low quality evidence) 2
• Non-specific NSAIDs are recommended over codeine-acetaminophen combinations for mild-moderate pain (weak recommendation, moderate quality evidence) 2
• Acetaminophen at reduced doses may be appropriate, particularly in patients with compromised liver function 2

Dosing Considerations

• If opioid therapy is absolutely necessary, consultation with a neurologist and pharmacist is essential to evaluate the risk-benefit ratio
• Consider temporary discontinuation of rasagiline if strong opioid therapy is required (requires careful planning due to the irreversible nature of MAO inhibition) 4, 5

Monitoring and Precautions

If Concurrent Use Cannot Be Avoided

• Start with the lowest possible dose of the opioid 2
• Monitor closely for signs of serotonin syndrome including:
  • Mental status changes
  • Autonomic instability (hyperthermia, tachycardia)
  • Neuromuscular abnormalities (hyperreflexia, clonus)
• Have immediate access to supportive care and serotonin antagonists 1

Special Populations

• Patients with hepatic impairment require additional caution as rasagiline is extensively metabolized by the liver (primarily by CYP1A2) 4
• Elderly patients may be more susceptible to adverse effects of both medications 5

Conclusion

The combination of hydromorphone (Dilaudid) and rasagiline poses a significant risk of serotonin syndrome, a potentially life-threatening condition. Alternative pain management strategies should be employed for patients on rasagiline therapy requiring analgesia.