What are the side effects of Dilaudid (hydromorphone)?

Side Effects of Dilaudid (Hydromorphone)

Dilaudid causes common opioid side effects including constipation (which persists throughout treatment), nausea, vomiting, drowsiness, and dizziness, with most effects except constipation typically resolving within days to weeks of initiation. 1

Most Common Side Effects

Effects That Persist

• Constipation occurs universally and does not resolve with continued use - prophylactic laxatives must be prescribed routinely throughout the entire treatment period, combined with dietary modifications and adequate hydration 2, 1

Effects That Typically Resolve (Days to Weeks)

• Nausea and vomiting - occur in approximately 16% and 7% of patients respectively; if persistent beyond initial days, prescribe antiemetics after excluding other causes 1, 3
• Drowsiness and sedation - most prominent during dose titration and usually disappears within days; if persistent, evaluate for metabolic disorders or drug interactions before reducing dose 2
• Dizziness and lightheadedness - common, particularly in ambulatory patients 1

Serious Adverse Effects Requiring Immediate Attention

Respiratory Depression

• Life-threatening respiratory depression can occur, especially at treatment initiation, with dose changes, or overdose 1
• Oxygen desaturation below 95% occurred in one-third of patients receiving 2 mg IV hydromorphone in one study, with 6% experiencing oxygen saturation below 90% (lowest recorded: 82%) 3
• Risk increases dramatically when combined with benzodiazepines, alcohol, or other CNS depressants 1

Neurotoxicity (High-Dose or Renal Impairment)

• Hydromorphone metabolites may cause opioid neurotoxicity including myoclonus, hyperalgesia, and seizures - potentially more neurotoxic than morphine metabolites 2
• Monitor particularly in patients receiving high doses or those with renal impairment 2

Additional Adverse Effects by System

Cardiovascular

• Hypotension, orthostatic hypotension, syncope, flushing (from peripheral vasodilation and histamine release) 1
• Hypertension (less common) 1

Gastrointestinal

• Dry mouth, decreased appetite, biliary colic, abdominal pain 1
• Reduced GI motility with increased smooth muscle tone leading to constipation 1

Neurological

• Headache, tremor, paresthesia, nystagmus, increased intracranial pressure 1
• Confusion, hallucinations, dyskinesia, involuntary muscle contractions 1
• Miosis (pinpoint pupils) - a sign of opioid use but not necessarily overdose 2, 1

Dermatological

• Pruritus (itching), sweating, rash, urticaria 1
• Notably, hydromorphone may cause less pruritus than morphine (0% vs 6% in one comparative study) 4, 5

Genitourinary

• Urinary retention, urinary hesitation, antidiuretic effects 1

Endocrine

• Adrenal insufficiency - more common with use exceeding one month 1
• Androgen deficiency with chronic use - may manifest as low libido, erectile dysfunction, impotence, amenorrhea, or infertility 1

Psychiatric

• Euphoria, dysphoria, anxiety, depression, agitation, mood alterations, nervousness, insomnia, abnormal dreams 1

Comparative Safety Profile

Hydromorphone shows similar adverse effects to morphine and oxycodone, though diarrhea and sedation may be more common with hydromorphone 2. In direct comparison studies, hydromorphone demonstrated equivalent safety to oxycodone with similar rates of somnolence, constipation, vomiting, and nausea 6.

Critical Safety Warnings

Absolute Contraindications

• Severe asthma or respiratory problems 1
• Bowel obstruction or narrowing of stomach/intestines 1

High-Risk Situations

• Never combine with benzodiazepines - causes severe drowsiness, decreased awareness, respiratory depression, coma, and death 1
• Avoid alcohol and other CNS depressants 1
• Use extreme caution in patients with head injury, seizure history, or increased intracranial pressure 1

Special Populations

• Pregnancy: Prolonged use causes neonatal opioid withdrawal syndrome that can be life-threatening 1
• Breastfeeding: Hydromorphone passes into breast milk 1
• Renal/hepatic impairment: Requires dose reduction and cautious titration due to altered metabolism and increased risk of metabolite accumulation 2

Important Clinical Pearls

• Psychological dependence is rare in cancer patients with appropriate monitoring 2
• Physical dependence and tolerance are expected physiological responses, not addiction 2
• Respiratory depression risk is low in regularly followed patients receiving continuous therapy 2
• No contraindication exists for opioid use in asthma or respiratory failure when appropriately monitored 2
• Withdrawal symptoms occur if abruptly discontinued - never stop suddenly without medical supervision 1