Hydromorphone is a strong opioid analgesic, similar to morphine but more potent, used to relieve severe pain that requires an opioid and when alternatives are inadequate. It is a controlled substance: it can cause dependence, drowsiness, constipation and respiratory depression at high doses. It must be used under medical prescription and supervision.
Also known as: Dilaudid
Hydromorphone with alprazolam potentiates CNS and respiratory depression and may be fatal.
Hydromorphone is a potent opioid (mu agonist) and alprazolam a benzodiazepine: their central nervous system and respiratory centre depressant effects add up, and the risk of deep sedation, coma and death from respiratory depression is substantial — the reason for the FDA boxed warning for opioids with benzodiazepines. The combination should be avoided whenever possible; if clinically indispensable, use the lowest effective doses, limit the duration, inform the patient and family, and monitor sedation, respiratory rate and oxygen saturation, with naloxone available.
Benzodiazepine + opioid: additive CNS and respiratory depression, with risk of deep sedation, coma and death. Avoid; if unavoidable, lowest doses and close monitoring of breathing.
Additive opioid-benzodiazepine action on respiratory and CNS depression.
Respiratory rate, SpO2, sedation and pupil size.
Bradypnoea or unresponsiveness require naloxone and ventilatory support.
Avoid coadministration; if unavoidable, reduce doses and ensure supervision.
DailyMed/FDA (NIH/NLM) — approved Hydromorphone label: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4c5c1cc8-c42b-46e3-ad68-8e22f57101f2 ; approved Alprazolam label: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0cf8b567-201b-44fa-8fd3-c74023aff44f — with additional reference: Prontuário Terapêutico do INFARMED (11th ed., 2012)
Alcohol increases the CNS-depressant effects of hydromorphone.
Avoid alcohol during treatment.
EMC-UK (MHRA) — approved Palladone SR (Hydromorphone) SmPC: https://www.medicines.org.uk/emc/product/1018/smpc
Hydromorphone may cause or worsen respiratory depression.
Contraindicated in severe respiratory depression; caution in COPD, asthma and sleep apnoea.
EMC-UK (MHRA) — approved Palladone SR (Hydromorphone) SmPC: https://www.medicines.org.uk/emc/product/1018/smpc
Opioids reduce GI motility and may worsen paralytic ileus.
Contraindicated in patients with paralytic ileus or acute abdomen.
EMC-UK (MHRA) — approved Palladone SR (Hydromorphone) SmPC: https://www.medicines.org.uk/emc/product/1018/smpc
Hydromorphone crosses the placenta and may cause neonatal withdrawal with chronic use.
Not recommended unless clearly necessary; in labour may depress neonatal respiration.
Excreted into breast milk; not recommended while breastfeeding.
With chronic use, advise effective contraception.
EMC-UK (MHRA) — approved Palladone (Hydromorphone) SmPC: https://www.medicines.org.uk/emc/product/1018/smpc
Clinical and educational support tool. The information does not replace a medical prescription or the opinion of a qualified healthcare professional.
Potent mu opioid agonist (5-7x more potent than oral morphine) for severe pain requiring an opioid; oral bioavailability ~24% and short half-life; glucuronidation metabolism with renal excretion of metabolites.
Selective agonist of mu (μ) opioid receptors, activating descending pain-inhibitory pathways and inhibiting nociceptive neurotransmitter release — analgesia, sedation, euphoria and dose-dependent respiratory depression.
Rapid GI absorption with extensive first-pass metabolism: oral bioavailability ~24%; plasma peak 0.5-1 h; food lowers Cmax 25% and prolongs Tmax 0.8 h (AUC +35%); protein binding 8-19%.
Extensive hepatic glucuronidation (>95% to hydromorphone-3-glucuronide, with minor 6-hydroxy metabolites); only small amounts excreted unchanged in urine; accumulation in hepatic impairment (4x exposure in Child-Pugh B).
Terminal half-life ~2.3 h (IV); duration of effect 4-5 h; systemic clearance ~1.96 L/min; volume of distribution ~303 L; the half-life is prolonged in renal and hepatic impairment.
Medicines from the same therapeutic group (ATC classification) or the same pharmacological class.
