From the FDA Drug Label
Elderly patients (aged 65 years or older) may have increased sensitivity to hydromorphone. In general, use caution when selecting a dosage for an elderly patient, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function and of concomitant disease or other drug therapy Respiratory depression is the chief risk for elderly patients treated with opioids, and has occurred after large initial doses were administered to patients who were not opioid-tolerant or when opioids were co-administered with other agents that depress respiration Titrate the dosage of hydromorphone hydrochloride slowly in geriatric patients and monitor closely for signs of central nervous system and respiratory depression
The best dose adjustment for an elderly patient taking HM contin 6mg qAM and 9mg QHS with 6mg of PRNs on average during the day is to titrate the dosage slowly and monitor closely for signs of central nervous system and respiratory depression.
- Start at the low end of the dosing range
- Monitor renal function as hydromorphone is substantially excreted by the kidney
- Adjust the dosage to obtain an appropriate balance between management of pain and opioid-related adverse reactions 1
From the Research
For an elderly patient in palliative care currently taking hydromorphone (HM Contin) 6mg in the morning and 9mg at bedtime, with an average of 6mg in PRN doses during the day, I recommend consolidating the regimen to a total daily dose of 21mg divided into 10mg in the morning and 11mg at bedtime. This adjustment maintains the same total daily dose (21mg) while simplifying the regimen and potentially improving pain control throughout the day. The morning dose increase should help reduce the need for PRN doses during daytime hours. For elderly patients, it's essential to monitor for side effects such as sedation, confusion, constipation, and respiratory depression after any dose adjustment, as noted in studies such as 2. Start this new regimen and reassess after 48-72 hours. If breakthrough pain persists, maintain PRN doses at approximately 10-15% of the total daily dose (2-3mg). Elderly patients often have altered pharmacokinetics due to decreased renal function, reduced hepatic metabolism, and changes in body composition, which can lead to increased sensitivity to opioids, so close monitoring is essential during any dose adjustment, as discussed in 3 and 2. Key considerations in managing pain in elderly patients include:
- Simplifying the medication regimen to improve adherence and reduce the risk of adverse effects
- Monitoring for signs of opioid toxicity, such as sedation and respiratory depression
- Adjusting doses based on individual patient response and tolerance
- Considering the use of adjuvant therapies, such as gabapentin or pregabalin, to enhance pain control, as discussed in 4 and 5. However, the most recent and highest quality study 5 does not directly address dose adjustment for hydromorphone in elderly patients, but it provides insight into the mechanisms of action of gabapentin and pregabalin, which may be useful in managing neuropathic pain in this population. Overall, the goal of pain management in elderly patients is to achieve adequate pain control while minimizing adverse effects and improving quality of life, as emphasized in 3 and 6.