hydromorphone hydrochloride: clinical use

Prescribing considerations

• Confirm the indication and agree treatment goals, review arrangements and a discontinuation plan.
• Assess previous opioid exposure when selecting a formulation or changing opioids; conversions require clinical assessment and retitration.
• Evaluate risks of respiratory depression, sleep apnoea, constipation, misuse, dependence and concurrent CNS depressants.
• Use particular caution in frail older people and renal or hepatic impairment.
• The concentrated injection is not intended as initial opioid therapy.

Contraindications and cautions

• Hypersensitivity to hydromorphone or formulation excipients.
• Severe respiratory depression, severe obstructive pulmonary disease or severe bronchial asthma.
• Coma, acute abdomen or paralytic ileus.
• Concurrent MAOI treatment or recent discontinuation.
• Cor pulmonale is contraindicated for the selected injection.
• Hepatic impairment is contraindicated for the selected prolonged-release capsule; the injection instead requires caution in severe hepatic impairment.

Monitoring

• Pain response, function and continuing clinical need.
• Respiratory rate, sedation, oxygenation and symptoms of sleep-related breathing disorders.
• Bowel function, nausea, urinary retention and blood pressure.
• Renal and hepatic status where relevant.
• Tolerance, withdrawal, opioid-induced hyperalgesia, misuse and opioid use disorder.
• Possible endocrine effects during prolonged treatment.

Clinical pharmacology

Hydromorphone is a full, mu-selective opioid agonist. It acts mainly in the central nervous system and bowel, is principally metabolised by hepatic conjugation and is not expected to have clinically important CYP-mediated metabolic inhibition.

Formulation and product differences

• Prolonged-release capsules contain pellets that must remain intact; capsules may be opened only for sprinkling onto cold soft food.
• The selected injection is a clear solution for intravenous or subcutaneous injection or infusion and is normally administered by healthcare professionals.
• The oral product lists hepatic impairment as a contraindication, whereas the injection requires careful individual assessment in hepatic impairment.
• Injection-site reactions can occur with parenteral administration.

Capsule

Route: Oral

Strengths: 1.3 mg, 2 mg, 4 mg, 8 mg, 16 mg, 24 mg