hydromorphone hcl (Hydromorphone hydrochloride) tablet
hydromorphone hcl (Hydromorphone hydrochloride) solution
[Roxane Laboratories, Inc.]
Hydromorphone hydrochloride, a hydrogenated ketone of morphine, is a narcotic analgesic.
The chemical name for hydromorphone hydrochloride is Morphinan-6-one, 4,5-epoxy-3-hydroxy-17-methyl-, hydrochloride, (5α)-. The structural formula of hydromorphone hydrochloride is:
C17H19NO3· HCl M.W. 321.81
Each tablet, for oral administration, contains 8 mg of hydromorphone hydrochloride. Inactive ingredients: each tablet also contains anhydrous lactose and magnesium stearate.
Each 5 mL (1 teaspoonful), for oral administration, contains 5 mg of hydromorphone hydrochloride. The inactive ingredients are polyethylene glycol 1000, propylene glycol, methylparaben, propylparaben, saccharin sodium, sorbitol, FD & C Red #40, flavor and water.
Many of the effects described below are common to this class of mu-opioid agonist analgesics. In some instances, data may not exist to distinguish the effects of hydromorphone from those observed with other opioid analgesics. However, in the absence of data to the contrary, it is assumed that hydromorphone would possess all the actions of mu-agonist opioids.
Opioid analgesics exert their primary effects on the central nervous system and organs containing smooth muscle. The principal actions of therapeutic value are analgesia and sedation. A significant feature of the analgesia is that it can occur without loss of consciousness. Opioid analgesics also suppress the cough reflex and may cause respiratory depression, mood changes, mental clouding, euphoria, dysphoria, nausea, vomiting and electroencephalographic changes.
The precise mode of analgesic action of opioid analgesics is unknown. However, specific CNS opiate receptors have been identified. Opioids are believed to express their pharmacological effects by combining with these receptors.
Opioids depress the cough reflex by direct effect on the cough center in the medulla.
Opioids depress the respiratory reflex by a direct effect on the brain stem respiratory centers. The mechanism of respiratory depression also involves a reduction in the responsiveness of the brain stem respiratory centers to increases in carbon dioxide tension.
Opioids cause miosis. Pinpoint pupils are a common sign of opioid overdose but are not pathognomonic (e.g., pontine lesions of hemorrhagic or ischemic origin may produce similar findings) and marked mydriasis occurs with asphyxia.
Gastric, biliary and pancreatic secretions are decreased by opioids. Opioids cause a reduction in motility associated with an increase in tone in the gastric antrum and duodenum. Digestion of food in the small intestine is delayed and propulsive contractions are decreased. Propulsive peristaltic waves in the colon are decreased, and tone may be increased to the point of spasm. The end result is constipation. Opioids can cause a marked increase in biliary tract pressure as a result of spasm of the sphincter of Oddi.
Certain opioids produce peripheral vasodilation which may result in orthostatic hypotension. Release of histamine may occur with opioids and may contribute to drug-induced hypotension. Other manifestations of histamine release may include pruritus, flushing, and red eyes.
The dosage of opioid analgesics like hydromorphone should be individualized for any given patient, since adverse events can occur at doses that may not provide complete freedom from pain (see Individualization of Doses).
In a reported single-dose crossover study in 27 normal subjects the pharmacokinetics of hydromorphone hydrochloride 8 mg tablets were compared to that of 8 mL of hydromorphone hydrochloride oral solution (1 mg/mL). Plasma hydromorphone concentration was determined using a sensitive and specific assay. The pharmacokinetic parameters from this study are outlined below.
|Parameter||8 mg Tablet||8 mg Oral Solution|
|Mean & (CV)||(1 mg/mL)|
|Cmax (ng/mL)||5.5 (33%)||5.7 (31%)|
|Tmax (hr)||0.74 (34%)||0.73 (71%)|
|AUC0 –∞ (ng·hr/mL)||23.7 (28%)||24.6 (29%)|
|T 1⁄2 (hr)||2.6 (18%)||2.8 (20%)|
Dose proportionality between the 8 mg hydromorphone hydrochloride tablets and other strengths of hydromorphone hydrochloride tablets has not been established.
In normal human volunteers hydromorphone is metabolized primarily in the liver. It is excreted in the urine primarily as the glucuronidated conjugate, with small amounts of parent drug and minor amounts of 6-hydroxy reduction metabolites. The effects of renal disease on the clearance of hydromorphone are unknown, but caution should be taken to guard against unanticipated accumulation if renal and/or hepatic functions are seriously impaired. Hydromorphone has been shown to cross placental membranes.
Analgesic effects of single doses of hydromorphone hydrochloride oral solution administered to patients with post-surgical pain have been studied in double-blind controlled trials. In one study with 61 patients, both 5 mg and 10 mg of hydromorphone hydrochloride oral solution provided significantly more analgesia than placebo. In another trial with 80 patients, 5 mg and 10 mg of hydromorphone hydrochloride oral solution were compared to 30 mg and 60 mg of morphine sulfate oral liquid. The pain relief provided by 5 mg and 10 mg hydromorphone hydrochloride oral solution was comparable to 30 mg and 60 mg oral morphine sulfate, respectively.
Safe and effective administration of opioid analgesics to patients with acute or chronic pain depends upon a comprehensive assessment of the patient. The nature of the pain (severity, frequency, etiology, and pathophysiology) as well as the concurrent medical status of the patient will affect selection of the starting dosage.
In non opioid-tolerant patients, therapy with hydromorphone is typically initiated at an oral dose of 2 to 4 mg every four hours, but elderly patients may require lower doses (see PRECAUTIONS- Geriatric Use).
In patients receiving opioids, both the dose and duration of analgesia will vary substantially depending on the patient’s opioid tolerance. The dose should be selected and adjusted so that at least 3 to 4 hours of pain relief may be achieved. In patients taking opioid analgesics, the starting dose of hydromorphone should be based on the prior opioid usage. This should be done by converting the total daily usage of the previous opioid to an equivalent total daily dosage of oral hydromorphone using an equianalgesic table (see below). For opioids not in the table, first estimate the equivalent total daily usage of oral morphine, then use the table to find the equivalent total daily dosage of hydromorphone.
Once the total daily dosage of hydromorphone has been estimated, it should be divided into the desired number of doses. Since there is individual variation in response to different opioid drugs, only 1/2 to 2/3 of the estimated dose of hydromorphone calculated from equivalence tables should be given for the first few doses, then increased as needed according to the patient’s response.
In chronic pain, doses should be administered around-the-clock. A supplemental dose of 5 to 15% of the total daily usage may be administered every two hours on an “as-needed” basis.
Periodic reassessment after the initial dosing is always required. If pain management is not satisfactory and in the absence of significant opioid-induced adverse events, the hydromorphone dose may be increased gradually. If excessive opioid side effects are observed early in the dosing interval, the hydromorphone dose should be reduced (see CLINICAL PHARMACOLOGY, Individualization of Doses and PRECAUTIONS). If this results in breakthrough pain at the end of the dosing interval, the dosing interval may need to be shortened. Dose titration should be guided more by the need for analgesia than the absolute dose of opioid employed.
|Nonproprietary (Trade) Name||IM or SC Dose||Oral Dose|
|Morphine Sulfate||10 mg||40-60 mg|
|Hydromorphone Hydrochloride||1.3-2 mg||6.5-7.5 mg|
|Oxymorphone HCl||1-1.1 mg||6.6 mg|
|Levorphanol tartrate||2-2.3 mg||4 mg|
|Meperidine, pethidine HCl||75-100 mg||300-400 mg|
|Methadone HCl||10 mg||10-20 mg|
Hydromorphone Hydrochloride Tablets and Oral Solution are indicated for the management of pain in patients where an opioid analgesic is appropriate.
Hydromorphone Hydrochloride is contraindicated in: patients with known hypersensitivity to hydromorphone, patients with respiratory depression in the absence of resuscitative equipment, and in patients with status asthmaticus. Hydromorphone hydrochloride is also contraindicated for use in obstetrical analgesia.
Respiratory depression is the chief hazard of hydromorphone. Respiratory depression occurs most frequently in overdose situations, in the elderly, in the debilitated, and in those suffering from conditions accompanied by hypoxia of hypercapnia when even moderate therapeutic doses may dangerously decrease pulmonary ventilation.
Hydromorphone should be used with extreme caution in patients with chronic obstructive pulmonary disease or cor pulmonale, patients having a substantially decreased respiratory reserve, hypoxia, hypercapnia, or in patients with preexisting respiratory depression. In such patients even usual therapeutic doses of opioid analgesics may decrease respiratory drive while simultaneously increasing airway resistance to the point of apnea.
Hydromorphone is a Schedule II narcotic. Hydromorphone can produce drug dependence of the morphine type and therefore have the potential for being abused. Psychic dependence, physical dependence and tolerance may develop upon repeated administration of hydromorphone, which should be prescribed and administered with the degree of caution appropriate to the use of morphine. Abrupt discontinuance in the administration of hydromorphone in patients who are physically dependent on opioids is likely to result in a withdrawal syndrome (see DRUG ABUSE AND DEPENDENCE).
In general, opioids should be given with caution and the initial dose should be reduced in the elderly or debilitated and those with severe impairment of hepatic, pulmonary or renal functions; myxedema or hypothyroidism; adrenocortical insufficiency (e.g., Addison’s Disease); CNS depression or coma; toxic psychoses; prostatic hypertrophy or urethral stricture; gall bladder disease; acute alcoholism; delirium tremens; kyphoscoliosis or following gastrointestinal surgery.
The administration of opioid analgesics including hydromorphone may obscure the diagnoses or clinical course in patients with acute abdominal conditions and may aggravate preexisting convulsions in patients with convulsive disorders.
The respiratory depressant effects of hydromorphone with carbon dioxide retention and secondary elevation of cerebrospinal fluid pressure may be markedly exaggerated in the presence of head injury, other intracranial lesions, or preexisting increase in intracranial pressure. Opioid analgesics including hydromorphone may produce effects which can obscure the clinical course and neurologic signs of further increase in intracranial pressure in patients with head injuries.
Opioid analgesics, including hydromorphone, may cause severe hypotension in an individual whose ability to maintain blood pressure has already been compromised by a depleted blood volume, or a concurrent administration of drugs such as phenothiazines or general anesthetics (see also PRECAUTIONS - Drug Interactions). Therefore, hydromorphone should be administered with caution to patients in circulatory shock, since vasodilation produced by the drug may further reduce cardiac output and blood pressure.
Hydromorphone may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating machinery). Patients should be cautioned accordingly. Hydromorphone may produce orthostatic hypotension in ambulatory patients. The addition of other CNS depressants to hydromorphone therapy may produce additive depressant effects, and hydromorphone should not be taken with alcohol.
Opioid analgesics including hydromorphone should also be used with caution in patients about to undergo surgery of the biliary tract since it may cause spasm of the sphincter of Oddi.
Hydromorphone should be used with caution in patients with alcoholism and other drug dependencies due to the increased frequency of narcotic tolerance, dependence, and the risk of addiction observed in these patient populations. Abuse of hydromorphone in combination with other CNS depressant drugs can result in serious risk to the patient.
The concomitant use of other central nervous system depressants including sedatives or hypnotics, general anesthetics, phenothiazines, tranquilizers and alcohol may produce additive depressant effects. Respiratory depression, hypotension and profound sedation or coma may occur. When such combined therapy is contemplated, the dose of one or both agents should be reduced. Opioid analgesics, including hydromorphone, may enhance the action of neuromuscular blocking agents and produce an excessive degree of respiratory depression.
Studies in animals to evaluate the drug’s carcinogenic and mutagenic potential or the effects on fertility, have not been conducted.
Literature reports of hydromorphone hydrochloride administration to pregnant Syrian hamsters show that hydromorphone hydrochloride is teratogenic at a dose of 20 mg/kg which is 600 times the human dose. A maximal teratogenic effect (50% of fetuses affected) in the Syrian hamster was observed at a dose of 125 mg/kg (738 mg/m2). There are no well-controlled studies in women. Hydromorphone hydrochloride is known to cross placental membranes. Hydromorphone should be used in pregnant women only if the potential benefit justifies the potential risk to the fetus (see Labor and Delivery and DRUG ABUSE AND DEPENDENCE).
Hydromorphone is contraindicated in Labor and Delivery (see CONTRAINDICATIONS).
Low levels of opioid analgesics have been detected in human milk. As a general rule, nursing should not be undertaken while a patient is receiving hydromorphone since it, and other drugs in this class, may be excreted in the milk.
Safety and effectiveness in pediatric patients have not been established.
Hydromorphone has not been studied in geriatric patients. Elderly subjects have been shown to have at least twice the sensitivity (as measured by EEG changes) of young adults to some opioids. When administering hydromorphone to the elderly, the initial dose should be reduced (see Individualization of Doses and PRECAUTIONS).
The adverse effects of hydromorphone hydrochloride are similar to those of other agonist opioid analgesics, and represent established pharmacological effects of the drug class. The major hazards include respiratory depression and apnea. To a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest have occurred.
The most frequently observed adverse effects are light-headedness, dizziness, sedation, nausea, vomiting, sweating, flushing, dysphoria, euphoria, dry mouth, and pruritus. These effects seem to be more prominent in ambulatory patients and in those not experiencing severe pain. Syncopal reactions and related symptoms in ambulatory patients may be alleviated if the patient lies down.
General and CNS: Weakness, headache, agitation, tremor, uncoordinated muscle movements, alterations of mood (nervousness, apprehension, depression, floating feelings, dreams), muscle rigidity, paresthesia, muscle tremor, blurred vision, nystagmus, diplopia and miosis, transient hallucinations and disorientation, visual disturbances, insomnia and increased intracranial pressure may occur.
Chills, tachycardia, bradycardia, palpitation, faintness, syncope, hypotension and hypertension have been reported.
Bronchospasm and laryngospasm have been known to occur.
Constipation, biliary tract spasm, ileus, anorexia, diarrhea, cramps and taste alteration have been reported.
Urinary retention or hesitancy, and antidiuretic effects have been reported.
Urticaria, other skin rashes, and diaphoresis.
Hydromorphone hydrochloride is a Schedule II narcotic similar to morphine. Opioid analgesics may cause psychological and physical dependence (see WARNINGS). Physical dependence results in withdrawal symptoms in patients who abruptly discontinue the drug. Withdrawal symptoms also may be precipitated in the patient with physical dependence by the administration of a drug with opioid antagonist activity, e.g., naloxone (see also OVERDOSAGE).
Physical dependence usually does not occur to a clinically significant degree until after several weeks of continued opioid usage, but it may become clinically detectable after as little as a week. Tolerance, in which increasingly large doses are required in order to produce the same degree of analgesia, is initially manifested by a shortened duration of analgesic effect, and subsequently, by decreases in the intensity of analgesia. In chronic pain patients, and in opioid- tolerant cancer patients. the dose of hydromorphone should be guided by the degree of tolerance manifested.
In chronic pain patients in whom opioid analgesics including hydromorphone are abruptly discontinued, a severe abstinence syndrome should be anticipated. This may be similar to the abstinence syndrome noted in patients who withdraw from heroin. Because of excessive loss of fluids through sweating, or vomiting and diarrhea, patients experiencing the syndrome usually exhibit marked weight loss, dehydration, ketosis, and disturbances in acid-base balance. Cardiovascular collapse can occur. Without treatment most observable symptoms disappear in 5 to 14 days; however, there appears to be a phase of secondary or chronic abstinence which may last for 2 to 6 months characterized by insomnia, irritability, muscular aches, and autonomic instability.
In the treatment of physical dependence on hydromorphone, the patient may be detoxified by gradual reduction of the dosage, although this is unlikely to be necessary in the terminal cancer patient. If abstinence symptoms become severe, the patient may be detoxified with methadone. Temporary administration of tranquilizers and sedatives may aid in reducing patient anxiety. Gastrointestinal disturbances or dehydration should be treated accordingly.
Serious overdosage with hydromorphone hydrochloride is characterized by respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, constricted pupils, and sometimes bradycardia and hypotension. In serious overdosage, particularly following intravenous injection, apnea, circulatory collapse, cardiac arrest and death may occur.
In the treatment of overdosage, primary attention should be given to the reestablishment of adequate respiratory exchange through provision of a patent airway and institution of assisted or controlled ventilation. A potentially serious oral ingestion, if recent, should be managed with gut decontamination. In unconscious patients with a secure airway, instill activated charcoal (30 to 100 g in adults, 1 to 2 g/kg in infants) via a nasogastric tube. A saline cathartic or sorbitol may be added to the first dose of activated charcoal.
Since tolerance to the respiratory and CNS depressant effects of opioids develops concomitantly with tolerance to their analgesic effects, serious respiratory depression due to an acute overdose is unlikely to be seen in opioid-tolerant patients receiving the usual therapeutic dosage of hydromorphone for chronic pain.
Note: In an individual who is physically dependent on opioids, administration of the usual dose of an opioid antagonist will precipitate an acute withdrawal syndrome. The severity will depend on the degree of physical dependence and the dose of the antagonist administered. If necessary to treat serious respiratory depression in the physically-dependent patient, opioid antagonist should be administered with care and by titration, using fractional (one fifth to one tenth) doses of the antagonist.
The opioid antagonist, naloxone, is a specific antidote against respiratory depression which may result from overdosage, or unusual sensitivity to hydromorphone. A dose of naloxone hydrochloride (usually given as a test dose of 0.4 mg, followed by up to 2 mg if needed) should be administered intravenously, if possible, simultaneously with respiratory resuscitation. The dose can be repeated in 3 minutes. Naloxone should not be administered in the absence of clinically significant respiratory or circulatory depression. Naloxone should be administered cautiously to persons who are known, or suspected to be physically dependent on hydromorphone (see Opioid-tolerant Patient, above).
Since the duration of action of hydromorphone may exceed that of the antagonist, the patient should be kept under continued surveillance; repeated doses of the antagonist may be required to maintain adequate respiration. Apply other supportive measures when indicated.
Supportive measures (including oxygen, vasopressors) should be employed in the management of circulatory shock and pulmonary edema accompanying overdose as indicated. Cardiac arrest or arrhythmias may require cardiac massage or defibrillation.
The usual adult oral dosage of hydromorphone hydrochloride oral solution is one-half (2.5 mL) to two teaspoonfuls (10 mL) (2.5 mg - 10 mg) every 3 to 6 hours as directed by the clinical situation. Oral dosages higher than the usual dosages may be required in some patients.
The usual starting dose for hydromorphone hydrochloride tablets is 2 mg to 4 mg, orally, every 4 to 6 hours. Appropriate use of the 8 mg tablet must be decided by careful evaluation of each clinical situation.
A gradual increase in dose may be required if analgesia is inadequate, as tolerance develops, or if pain severity increases. The first sign of tolerance is usually a reduced duration of effect.
Hydromorphone Hydrochloride Tablets and Oral Solution pose little risk of direct exposure to health care personnel and should be handled and disposed of prudently in accordance with hospital or institutional policy. Significant absorption from dermal exposure is unlikely; accidental dermal exposure to hydromorphone hydrochloride oral solution should be treated by removal of any contaminated clothing and rinsing the affected area with cool water. Patients and their families should be instructed to flush any Hydromorphone Hydrochloride Oral Solution that is no longer needed.
Access to abusable drugs such as Hydromorphone Hydrochloride Tablets and Oral Solution presents an occupational hazard for addiction in the health care industry. Routine procedures for handing controlled substances developed to protect the public may not be adequate to protect health care workers. Implementation of more effective accounting procedures and measures to restrict access to drugs of this class (appropriate to the practice setting) may minimize the risk of self-administration by health care providers.
Hydromorphone Hydrochloride Tablets USP
8 mg off-white-colored, round, scored tablets
(Tablets Identified 54 403)
NDC 0054-4370-25: Bottles of 100 tablets.
Hydromorphone Hydrochloride Oral Solution
5 mg per 5 mL, red-colored,
NDC 0054-8349-16: Unit Dose Patient CupsTM filled to deliver 4 mL (4 mg hydromorphone hydrochloride), ten 4 mL Patient CupsTM per shelf pack, four shelf packs per shipper.
NDC 0054-8350-16: Unit Dose Patient CupsTM filled to deliver 8 mL (8 mg hydromorphone hydrochloride), ten 8 mL Patient CupsTM per shelf pack, four shelf packs per shipper.
NDC 0054-3387-58: Bottles of 250 mL.
Hydromorphone Hydrochloride Tablets and Oral Solution should be stored between 59°-77°F (15°-25°C). Protect from light.
A schedule II Narcotic DEA Order Form is required.
© RLI, 2002
|Hydromorphone HCl (Hydromorphone hydrochloride)|
|Hydromorphone HCl (Hydromorphone hydrochloride)|
Data are from FDA and U.S. National Library of Medicine.