Hydromorphone

Indications

  • Moderate-to-severe pain
  • Acute or chronic pain

Dosage - opioid-naïve adult

Oral

  • Immediate release product: start with 2 mg every 4-6 hours. Older patients may require lower doses.
  • Controlled release product (Jurnista®): total daily dose as determined from total daily dose of immediate release product given once every 24 hours. Do not use controlled release product for initial stabilisation. Titrate dose depending on response.

SC

  • initially 0.5-1 mg every 2 hours as required

IV

  • Start with 0.1–0.4 mg. Titrate dose according to response, sedation score and respiratory rate. Use the lower dose in older patients.

Opioid-tolerant adult

  • Starting dose is based on prior opioid dose (see conversion table).

Dose equivalence

  • For equianalgesic doses, morphine 10 mg IM/SC is equivalent to hydromorphone 1.5 to 2 mg SC; morphine 30 mg oral is equivalent to hydromorphone 6 to 7.5 mg oral. When changing drugs, start lower than the suggested dose and titrate according to response.

Breakthrough pain

  • Use an immediate release product in a dose equivalent to one-tenth to one-sixth the usual total daily dose.

Patient advice

  • Controlled release product (Jurnista©): swallow whole; do not crush, chew or break.

Precautions

Renal

  • Reduce dose in renal impairment and monitor for adverse effects. Accumulation of 3‑glucuronide metabolite also occurs in renal impairment and may cause psychotic symptoms.

Hepatic

  • Reduce dose in moderate hepatic impairment.

Practice considerations

  • For acute pain, use immediate release product in patients intolerant of morphine or oxycodone; however, evidence is lacking for its use as an alternative opioid in cases of true morphine allergy.
  • Do not use controlled release product for acute pain management as slow onset and offset make rapid, safe titration impossible.
  • For chronic cancer and non-cancer pain, use hydromorphone if intolerant of morphine or if a smaller volume is required for SC use.

Available brands

  • Hydromorphone hydrochloride 2 mg/mL, 10 mg/mL, 50 mg/mL injection

  • Hydromorphone hydrochloride – modified release tablet

    Jurnista® 4, 8, 16, 32, 64 mg tablets

    Hydromorphone hydrochloride - immediate release tablets

    • Dilaudid® 2, 4, 8 mg