Known brand names include Dilaudid.
A strong opioid pain reliever given by injection or by mouth for pain severe enough that other treatments are not enough. Doses are much smaller than morphine doses, and mix-ups between the two have caused deadly overdoses. Like all opioids, it can slow or stop breathing and cause addiction.
A common choice for severe acute pain in the hospital, especially by IV or patient-controlled analgesia, and often preferred over morphine in renal impairment because it has fewer active metabolites that accumulate. It is roughly five to seven times as potent as morphine per mg, so doses are much smaller; use non-opioid options first and the lowest dose for the shortest time.
A full opioid agonist, relatively selective for mu receptors, with no ceiling for analgesia; dosing is limited by respiratory and CNS depression. It depresses brainstem respiratory centers, causes miosis, slows GI motility, and causes vasodilation from histamine release. It is extensively glucuronidated in the liver to hydromorphone-3-glucuronide; the IV half-life is about 2.3 hours. Moderate hepatic impairment raises exposure about 4-fold.
The labels do not describe a narrow therapeutic index or direct dosing by measured blood levels of the drug.
Doses come from the FDA label. Study tool, not for clinical decisions.
Begin with 25% to 50% of the normal starting dose, scaled to how impaired the kidneys are, and monitor closely during titration.
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Serious and life-threatening risks: addiction, abuse, and misuse that can lead to overdose and death; life-threatening respiratory depression, highest at the start and after dose increases; profound sedation, respiratory depression, coma, and death with benzodiazepines, alcohol, or other CNS depressants; neonatal opioid withdrawal syndrome after prolonged use in pregnancy; fatal overdose from accidental ingestion, especially by children; and oral solution dosing errors from mg and mL confusion.
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Naloxone (or nalmefene) for clinically significant respiratory or circulatory depression, after securing the airway and ventilation. Reversal wears off before hydromorphone does, so keep monitoring until spontaneous breathing is reliable and redose as needed. In opioid-dependent patients, the usual dose can precipitate acute withdrawal.
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Prolonged use in pregnancy can cause neonatal opioid withdrawal syndrome, which can be life-threatening; plan for neonatal care at delivery. No human data on birth defects or miscarriage.
Low levels of opioids pass into milk. Monitor breastfed infants for excess sleepiness and slowed breathing, and for withdrawal when the drug or breastfeeding stops.
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Patients 65 and older may be more sensitive, and respiratory depression is the main risk. Start low, titrate slowly, and consider renal function, since it is largely excreted by the kidneys.
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