Hydromorphone (Dilaudid, Exalgo)

  • Brand Name : Dilaudid
  • Drug Class : Opioid Analgesics
  • Medical Author : John P. Cunha, DO, FACOEP
  • Medical Reviewer :
  • _eael_post_view_count : 9

What Is Hydromorphone Used For?

Hydromorphone is used to relieve moderate to severe pain. Hydromorphone is an opioid (narcotic) pain reliever. It acts on certain centers in the brain to give you pain relief.

Hydromorphone is available under the following different brand names: Dilaudid, Dilaudid-HP, and Exalgo.

Dosages of Hydromorphone

Adult and Pediatric Dosage Forms and Strengths

Tablet: Schedule II

  • 2mg
  • 4mg
  • 8mg

Tablet, extended-release: Schedule II (adult only)

  • 8mg
  • 12mg
  • 16mg
  • 32mg

Injection solution

  • 1mg/mL
  • 2mg/mL
  • 4mg/mL

Injection solution, preservative free: Schedule II (adult only)

10mg/mL

Oral liquid: Schedule II

5mg/5mL

Suppository: Schedule II

3mg

Prefilled syringe: Schedule II (adult only)

  • 0.2 mg/mL
  • 0.6 mg/mL

Dosage Considerations – Should be Given as Follows:

Risk of opioid addiction, abuse, and misuse, which can lead to overdose and death Assess each patient’s risk prior to prescribing and monitor all patients regularly for the development of these behaviors or conditions

Moderate-to-Severe Pain

Indicated for moderate-to-severe pain

Oral

Immediate-release: 2-4 mg every 4-6 hours as needed; a gradual increase in dose may be required Oral liquid (usual dose): 2.5-10 mg (2.5-10 mL) every 3-6 hours as needed

Subcutaneous/Intramuscular (SC/IM)

1-2 mg every 2-3 hours as needed; adjust dose according to pain and adverse effects IM dose not recommended for use as it may result in variable absorption and lag time to peak effect

Intravenous (IV)

Opioid naive: 0.2-1 mg IV every 2-3 hours as needed; may require higher doses in patients with prior opioid exposure Critically ill patients (opiate-naive patients): 0.2-0.6 mg every 1-2 hours as needed given slowly over 2-3 minutes; patients with previous opiate exposure may tolerate higher doses Continuous infusion: 0.5-3 mg/hour, titrated to response

Patient-controlled analgesia

Usual concentration, 0.2 mg/mL; demand dose, 0.1-0.2 mg; dose range is 0.05-0.4 mg Lockout interval: 5-10 minutes

Rectal

3 mg as needed every 6-8 hours

Geriatric: 2-4 mg orally every 4-6 hours as needed; a gradual increase in dose may be required

Chronic Severe Pain

Long-acting (Exalgo) is indicated for the management of pain in opioid tolerant patients severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate

Opioid tolerant patients only (extended-release:) 8-64 mg orally once/day; may administer a starting dose equivalent to patient’s total daily oral hydromorphone dose administered once daily with or without food

Should address pain relief and adverse events frequently; increase dose no more frequently than every 3-4 days; may titrate with increases of 25-50% of current daily dose; consider increasing dose if more than 2 doses of rescue medications are needed within 24 hours within 2 consecutive days

Extented-release tablets should be swallowed whole; crushing, dividing, or dissolving will release opioid content all at once and increase risk of respiratory depression and death

Converting to Exalgo

Conversion from other oral hydromorphone formulations: Start with equivalent total daily dose of immediate release formulation and administer once daily; may titrate every 3-4 days until adequate pain relief with tolerable adverse effects achieved Conversion from other opioids: Start Exalgo dose at 50% of calculated daily dose every 24 hours; titrate until adequate pain relief with tolerable adverse effects achieved Conversion from transdermal fentanyl to Exalgo: Start Exalgo 18 hours after removal of transdermal fentanyl patch at 50% of calculated total daily dose given over 24 hours; for a 25 mcg/hour fentanyl patch the equianalgesic dose is 12 mg orally every 24 hours Discontinuation of Exalgo therapy: Taper gradually by decreasing dose by 25-50% every 2-3 days to a dose of 8 mg orally every 24 hours before discontinuing

Opioid-tolerant definition

Use of higher starting doses in patients who are not opioid tolerant may cause fatal respiratory depression Patients who are opioid tolerant are those receiving, for 1 week or longer, at least 60 mg/day orally morphine, 25 mcg/hour transdermal fentanyl, 30 mg/day orally oxycodone, 8 mg/day orally hydromorphone, 25 mg/day orally oxymorphone, or an equianalgesic dose of another opioid

Limitations of use

Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with extended-release opioid formulations, reserve for patients whom alternative treatment options (e.g., non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain Not indicated for acute pain or as a as needed analgesic

Cough (Off-label)

1 mg orally every 3-4 hours as needed

Pain, Pediatric (Off-label)

Moderate-to-severe pain

Children: 0.03-0.08 mg/kg orally every 4-6 hours as needed; not to exceed 5 mg/dose  

Adolescents: 1-4 mg/dose orally every 4-6 hours as needed

Children: 0.015 mg/kg intravenously (IV) every 4-6 hours as needed

Adolescents: 1-2 mg/dose intravenously/intramuscularly/subcutaneously (IV/IM/SC) every 4-6 hours

Patient Controlled Anesthesia, Pediatric (Off-label)

Loading dose: 8 mcg/kg intravenous (IV) bolus

Demand dose (initial): 2 mcg/kg IV with a lockout time of 10 minutes

Dosing Considerations

Geriatric

Titrate dose to effect; oral and parenteral doses are not equivalent; because parenteral dose 5 times more potent than oral dose, administer one fifth of oral dose when changing to parenteral route

Oral dose: Initiate at low end of dosage range; consider lowering dose by 25-50% in patients over 70 years

Intravenous (IV): Reduce initial dose to 0.2 mg every 2-3 hours

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