What is the equivalent dose of intravenous (IV) hydromorphone for a patient taking 10mg of oral oxycodone?

Opioid Conversion: Oral Oxycodone to IV Hydromorphone

10 mg oral oxycodone is equivalent to approximately 0.5 mg IV hydromorphone.

Conversion Algorithm

Using the National Comprehensive Cancer Network equianalgesic conversion table, follow this stepwise approach 1:

Step 1: Convert Oral Oxycodone to Oral Morphine Equivalent

• 10 mg oral oxycodone = 15 mg oral morphine 1
• From the NCCN table: 30 mg/day oral oxycodone equals 60 mg/day oral morphine, establishing a 1:2 ratio 1

Step 2: Convert Oral Morphine to IV Morphine

• 15 mg oral morphine = 5 mg IV morphine 1
• The oral-to-IV morphine ratio is approximately 3:1 due to first-pass metabolism 1

Step 3: Convert IV Morphine to IV Hydromorphone

• 5 mg IV morphine = 1 mg IV hydromorphone 1, 2
• The NCCN guideline establishes a 5:1 conversion ratio (IV morphine to IV hydromorphone) 2

Step 4: Apply Safety Reduction for Incomplete Cross-Tolerance

• Reduce the calculated dose by 25-50% when converting between opioids 2
• Final dose: 0.5-0.75 mg IV hydromorphone
• Start with 0.5 mg IV hydromorphone to minimize risk of oversedation 2

Critical Safety Considerations

Dosing Frequency and Breakthrough Pain

• Administer IV hydromorphone bolus doses every 15 minutes as needed for adequate pain control 3
• Provide breakthrough doses of 10-20% of the total 24-hour opioid dose for transient pain exacerbations 3
• If two bolus doses are required within one hour, consider doubling any continuous infusion rate 3

Special Population Adjustments

• Renal impairment: Start with one-fourth to one-half the calculated dose, as hydromorphone exposure increases 2-fold in moderate and 3-fold in severe renal impairment 2
• Hepatic impairment: Start with one-fourth to one-half the calculated dose, as exposure increases 4-fold in moderate hepatic impairment 2

Monitoring Requirements

• Assess efficacy and side effects every 60 minutes after administration 3
• Institute prophylactic bowel regimen with stimulant laxatives, as constipation is universal with opioid therapy 2
• Monitor for myoclonus, especially with chronic use, renal failure, or dehydration 3

Common Pitfalls to Avoid

• Do not use a 1:1 conversion ratio between different opioids without accounting for incomplete cross-tolerance 2
• Avoid mixed agonist-antagonist opioids in combination with hydromorphone, as this could precipitate withdrawal 2
• Do not simply calculate equianalgesic doses without the 25-50% reduction—this frequently leads to oversedation 2
• Hydromorphone is 5-7 times more potent than morphine, requiring careful dose calculation to avoid errors 3, 2

Nuances in the Evidence

The NCCN guideline table provides the most authoritative conversion ratios for clinical practice 1. Research data supports these conversions, with one study finding the IV-to-oral hydromorphone ratio to be 2.5:1 4, which aligns with the guideline recommendations when accounting for the morphine intermediate conversion. The guideline emphasizes that clinical judgment must be used to titrate to the desired response due to patient variability 1, but the starting point of 0.5 mg IV hydromorphone for 10 mg oral oxycodone represents the safest initial approach.