What is the next best dose adjustment for a patient's hydromorphone (Dilaudid) Contin, currently taking 4.5 mg every morning and 9 mg at bedtime, with three daily as-needed (PRN) doses of 1 mg hydromorphone immediate release?

From the Guidelines

I recommend increasing the hydromorphone Contin to 6 mg in the morning and maintaining the 9 mg at bedtime. This adjustment accounts for the patient's current total daily opioid use, which includes 13.5 mg of hydromorphone Contin (4.5 mg morning + 9 mg bedtime) plus approximately 3 mg from the PRN immediate-release doses. The 1.5 mg increase to the morning dose incorporates part of the regularly used PRN medication into the long-acting formulation, which should provide more consistent pain control throughout the day. This approach is preferable to increasing the bedtime dose since the patient appears to need more coverage during daytime hours as evidenced by the PRN use.

The patient should continue to have access to the immediate-release hydromorphone for breakthrough pain, but may require fewer doses after this adjustment. This change should be monitored closely for efficacy and side effects, with particular attention to respiratory status, sedation level, and pain control. If the patient continues to require multiple PRN doses daily after this adjustment, further increases to the long-acting formulation may be warranted, as suggested by the European Association for Palliative Care 1.

It is also important to note that the goal is to keep the drug regimen as simple as possible, and increasing the dose is generally preferred over increasing the frequency of administration, as it allows for a more consistent regimen without producing troublesome adverse effects associated with peak blood concentrations 1. The patient's response to this adjustment should be closely monitored, and further adjustments made as needed to ensure optimal pain control and minimize side effects.

From the FDA Drug Label

Individually titrate hydromorphone hydrochloride tablets to a dose that provides adequate analgesia and minimizes adverse reactions Continually reevaluate patients receiving hydromorphone hydrochloride tablets to assess the maintenance of pain control and the relative incidence of adverse reactions, If the level of pain increases after dosage stabilization, attempt to identify the source of increased pain before increasing the hydromorphone hydrochloride tablets dosage If unacceptable opioid-related adverse reactions are observed, consider reducing the dosage. Adjust the dosage to obtain an appropriate balance between management of pain and opioid-related adverse reactions.

The patient is currently taking 4.5 mg of Hydromorphone Contin in the morning and 9 mg at bedtime, with 3 daily PRN of 1 mg hydromorphone immediate release. To determine the next best dose adjustment, it is essential to reevaluate the patient's pain control and adverse reactions. Since the FDA label does not provide a direct conversion for the patient's current dosage, a conservative approach is advised. Consider increasing or decreasing the dose by small increments, monitoring the patient's response, and adjusting as needed to achieve an optimal balance between pain management and adverse reactions 2. However, without more information about the patient's current condition, it is impossible to provide a specific dose adjustment.

From the Research

Dose Adjustment for Hydromorphone Contin

To determine the next best dose adjustment for the patient's hydromorphone Contin, we need to consider the current dosage and the patient's response to the medication. The patient is currently taking 4.5 mg of Hydromorphone Contin in the morning and 9 mg at bedtime, with three daily PRN (as needed) doses of 1 mg hydromorphone immediate release.

Current Dosage and Equianalgesic Ratios

• The patient's total daily dose of hydromorphone Contin is 13.5 mg (4.5 mg + 9 mg).
• The patient is also taking 3 mg of hydromorphone immediate release per day (3 x 1 mg PRN doses).
• According to the study 3, the dose equivalence of immediate-release hydromorphone and once-daily osmotic-controlled extended-release hydromorphone suggests that the same total daily dose of both formulations can provide equivalent analgesia.

Considerations for Dose Adjustment

• The study 4 notes that hydromorphone is metabolized to analgesically inactive metabolites, which can be associated with neuroexcitatory states and other toxicity.
• The study 5 found that hydromorphone-induced tolerance is correlated with analgesic efficacy and treatment protocol, suggesting that continuous infusion treatments may induce more tolerance compared to intermittent treatments.
• The study 6 confirmed the non-inferiority of hydromorphone versus oxycodone in cancer patients, with similar efficacy and safety profiles.

Potential Dose Adjustment Options

• Based on the study 3, the patient's current dose of hydromorphone Contin could be adjusted to a single daily dose of 16.5 mg (13.5 mg + 3 mg), taking into account the equivalent analgesic effect of the immediate-release and extended-release formulations.
• Alternatively, the patient's dose could be adjusted to account for potential tolerance and toxicity, as suggested by the studies 4 and 5.
• However, without further information on the patient's response to the current dosage and any potential side effects, it is difficult to determine the most appropriate dose adjustment.