What is the recommended rate of dose increase for Hydromorph Contin (hydromorphone) in an inpatient?

Hydromorphone Dose Titration in Inpatients

For inpatients on continuous hydromorphone infusions, double the infusion rate if the patient requires two bolus doses within one hour; for scheduled dosing, increase the regular dose by 25-50% every 24 hours if pain control remains inadequate. 1

Continuous Infusion Titration

Rapid Titration Protocol

• Administer bolus doses equal to or double the hourly infusion rate when breakthrough pain occurs 1
• If two bolus doses are needed within one hour, double the entire infusion rate immediately 1
• Order IV hydromorphone bolus doses every 15 minutes as needed for adequate pain control, not every hour 1
• This aggressive approach is supported for inpatient settings where close monitoring is available 1

Pharmacologic Rationale

• Hydromorphone has a quicker onset of action compared to morphine, making frequent smaller dosing particularly effective for acute severe pain 1
• The elimination half-life is 2-4 hours, with steady state reached within 24 hours after dose adjustment 1
• Weight-based dosing of 0.015 mg/kg IV provides faster onset and reduces risk of dose stacking 1

Scheduled Dosing Titration

Standard Dose Escalation

• When pain returns before the next scheduled dose, increase the dose by 25-50% rather than shortening the dosing interval 1, 2
• Maintain 4-hourly intervals for immediate-release formulations—there is no advantage to more frequent dosing and considerable disadvantage in terms of medication errors and compliance 1
• For controlled-release formulations, maintain 12-hourly dosing and increase the individual dose 3

Breakthrough Dosing Strategy

• Breakthrough doses should equal 10-20% of the total 24-hour opioid dose 1
• If the patient requires more than 3 breakthrough doses per day, increase the regular scheduled dose 1
• The breakthrough dose should always equal the regular 4-hourly dose for immediate-release formulations—there is no logic to using a smaller rescue dose 1

Special Population Considerations

Renal Impairment

• Start with one-fourth to one-half the usual dose in patients with renal dysfunction 1
• Hydromorphone is safer than morphine in renal failure, but active metabolites (hydromorphone-3-glucuronide) can accumulate and cause neurotoxicity even with low doses over short periods 1, 4
• Monitor closely for tremors, myoclonus, and agitation, which may paradoxically worsen with dose increases 1, 4

Hepatic Impairment

• Reduce the calculated dose by one-fourth to one-half, as exposure increases 4-fold in moderate hepatic impairment 1
• Reduce the dose with standard intervals rather than extending intervals 1

Opioid Conversion Context

• When converting from other opioids, reduce the calculated hydromorphone dose by 25-50% to account for incomplete cross-tolerance 1, 2
• The conversion ratio from IV morphine to IV hydromorphone is approximately 5:1 (10 mg IV morphine = 2 mg IV hydromorphone) 1, 2

Critical Safety Monitoring

Respiratory Monitoring

• While 2 mg IV hydromorphone provides efficacious pain relief, oxygen desaturation below 95% occurred in approximately one-third of patients in one study, though no clinical signs of hypoxemia were noted 5
• This suggests caution with initial bolus dosing, particularly in opioid-naïve patients 5

Neurotoxicity Surveillance

• Monitor for myoclonus, especially with chronic use, renal failure, electrolyte disturbances, or dehydration 1
• If myoclonus occurs, decrease the dose or rotate to a different opioid structure at a lower equianalgesic dose 1
• Neurotoxicity can manifest as tremors and agitation that paradoxically worsen with dose escalation—this requires dose reduction or opioid rotation, not further increases 4

Common Pitfalls to Avoid

• Do not increase dosing frequency to every 3 hours—this creates non-standard schedules that increase medication errors without pharmacologic advantage 1
• Do not use mixed agonist-antagonist opioids in combination with hydromorphone, as this could precipitate withdrawal in opioid-dependent patients 1
• Do not assume that agitation or tremors always indicate inadequate pain control—these may represent opioid neurotoxicity requiring dose reduction, not escalation 4
• Institute prophylactic bowel regimen with stimulant laxatives in all patients, as constipation is universal with opioid therapy 1