What is the recommended dosing for Dilaudid (hydromorphone)?

Hydromorphone (Dilaudid) Dosing

For acute severe pain in the emergency department, administer hydromorphone 0.015 mg/kg IV (approximately 1-1.5 mg for average adults), which can be repeated every 15 minutes as needed for adequate pain control. 1, 2

Intravenous Dosing for Acute Pain

Initial Dosing

• Weight-based approach: 0.015 mg/kg IV provides comparable or superior analgesia to morphine 0.1 mg/kg 1, 3
• Fixed-dose approach: 0.5-1 mg IV is effective for older adults (≥65 years) and reduces oxygen desaturation risk compared to higher doses 4, 5
• Avoid 2 mg IV as initial dose: This dose causes oxygen desaturation (SO2 <95%) in approximately one-third of patients, though it provides excellent pain relief 5

Titration Protocol

• Patient-driven protocol: Administer 1 mg IV, then allow patient to request an additional 1 mg—this approach is recommended over physician-driven protocols 1, 2
• Reassess every 15 minutes after each dose to determine need for additional medication 2, 6
• For continuous infusions: If breakthrough pain occurs, give a bolus equal to or double the hourly infusion rate 2
• If two boluses required within one hour: Double the infusion rate 2

Advantages Over Morphine

• Faster onset of action reduces risk of dose stacking and subsequent respiratory depression 1
• Higher potency (5-7 times more potent than morphine) means smaller volumes and potentially better physician compliance with adequate dosing 1, 2, 7
• Lower pruritus incidence (0% vs 6% with morphine) 3
• Safer in renal impairment compared to morphine, though dose reduction still necessary 1, 6

Oral Dosing

Immediate-Release Formulations

• Opioid-naïve patients: Start with 2-4 mg PO every 4-6 hours 6
• Breakthrough pain dosing: 10-20% of total 24-hour opioid dose, available every 1-2 hours 2
• If >3-4 breakthrough doses needed daily: Increase the scheduled baseline dose 2

Conversion from IV to Oral

• No established conversion ratio between IV and oral hydromorphone exists in the provided evidence 6
• Conservative approach required: Start with lower doses and titrate carefully when switching routes 6

Conversion from Morphine

• IV morphine to IV hydromorphone: Use 5:1 ratio (10 mg IV morphine = 2 mg IV hydromorphone) 1, 2
• Reduce by 25-50% when converting to account for incomplete cross-tolerance 2

Special Populations

Hepatic Impairment

• Start with one-fourth to one-half the usual dose depending on severity of impairment 6
• Reduce dose with standard intervals rather than extending intervals 1
• Phase II metabolism: Hydromorphone undergoes glucuronidation, which may be impaired in hepatorenal syndrome 1

Renal Impairment

• Start with one-fourth to one-half the usual dose depending on degree of impairment 6
• Safer than morphine in renal failure, but active metabolites can still accumulate between dialysis treatments 1, 2
• Monitor for myoclonus with chronic use, especially with renal dysfunction 2

Elderly Patients

• Lower initial doses recommended: 0.5 mg IV with careful titration 4
• Two-step titration protocol: 0.5 mg IV initially, then 0.5 mg at 15 minutes if patient requests more medication provides 83% satisfactory analgesia with lower total opioid consumption 4

Critical Safety Considerations

Monitoring Requirements

• Respiratory depression risk highest within first 24-72 hours of initiation or after dose increases 6
• Oxygen saturation monitoring essential: Even 2 mg IV can cause desaturation in one-third of patients 5
• Assess every 15 minutes after IV administration 2, 6
• Assess every 60 minutes after oral administration 2

Constipation Prevention

• Institute stimulant or osmotic laxative in all patients receiving sustained hydromorphone unless contraindicated 2

Discontinuation

• Taper by 25-50% every 2-4 days when discontinuing in physically dependent patients to avoid withdrawal 6

Common Pitfalls to Avoid

• Do not use 2 mg IV as routine initial dose despite its efficacy—oxygen desaturation risk is too high 5
• Avoid extended-release formulations for acute pain or initial titration—immediate-release only 1
• Do not mix with agonist-antagonist opioids (e.g., nalbuphine, butorphanol) as this can precipitate withdrawal 2
• Do not dose more frequently than every 15 minutes IV or every 1-2 hours orally for breakthrough pain 2
• Avoid in end-stage liver disease per some guidelines, though dose reduction rather than complete avoidance is more commonly recommended 1