Names and pronunciation
rems (hye-droe-mor′fone) Dilaudid, Hydromorph Contin, Jurnista
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Drug reference
rems (hye-droe-mor′fone) Dilaudid, Hydromorph Contin, Jurnista
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Func. class.: Opiate analgesic
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Chem. class.: Semisynthetic phen- anthrene Controlled Substance Schedule II
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Do not confuse: HYDROmorphone/meperidine/morphine Dilaudid/Demerol
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ACTION: Inhibits ascending pain pathways in CNS, increases pain thresh- old, alters pain perception
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USES: Moderate to severe pain
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CONTRAINDICATIONS: Hyper- sensitivity to this product/sulfite, COPD, cor pulmonale, emphysema, GI obstruc- tion, ileus, increased intracranial pressure, obstetric delivery, status asthmaticus
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Black Box Warning: Respiratory depres- sion, opioid-naive patients Precautions: Pregnancy, breastfeeding, children <18 yr, addictive personality, renal/hepatic disease, abrupt discontinua- tion, adrenal insufficiency, angina, asthma, biliary tract disease, bladder obstruction, hypothyroidism, hypovolemia, hypoxemia, IBD, IV use, lactase/paraben deficiency, labor, latex hypersensitivity, myxedema, seizure disorders, sleep apnea Black Box Warning: Substance abuse, accidental exposure, potential for over- dose/poisoning, neonatal opioid with- drawal syndrome Black Box Warning: Do not use ext rel prod- ucts in opioid-naive patients or with other ext rel opioids; do not use with other ext rel hy- dromorphone products; may be fatal Extended release • Converting from oral opioids: initiate ext rel tabs at 50% of total daily equiva- lent dose of ext rel, give q24hr; max in- crease q3-4days, titrate increases of 25%-50% with each step • Converting from transdermal patch (fentaNYL): initiate ext rel tabs 18 hr after removal of patch; for each 25 mcg/hr dose of transdermal fentaNYL dose is 12 mg q24hr, start dose at 50% of HYDRO- morphone ext rel dose q24hr; titrate no more often than q3-4days, may increase dose of 25%-50% with each step; if more than 2 rescue doses are required in 24 hr, consider titration SUBCUT route • Use short 30-G needle; make sure not to inject ID • Rotate inj sites IM route • Rotate sites IV route • Direct, diluted with 5 mL sterile wa- ter or NS; give through Y-connector or 3-way stopcock; give ≤2 mg over 3-5 min, very slowly • IV INFUSION: Dilute each 0.1-1 mg/mL NS (0.1-1 mg/mL), deliver by opioid sy- ringe infuser; may be diluted in D5W, D5/ NaCl, 0.45% NaCl, NS for larger amounts, delivery through infusion pump Y-site compatibilities: Acyclovir, allopuri- nol, amifostine, amikacin, amsacrine, aztreonam, cefamandole, cefepime, cefo- perazone, cefotaxime, cefOXitin, cefTAZi- dime, ceftizoxime, cefuroxime, chloram- phenicol, cisatracurium, CISplatin, cladribine, clindamycin, cyclophospha- mide, cytarabine, diltiazem, DOBUTamine, DOPamine, DOXOrubicin, DOXOrubicin liposome, doxycycline, EPINEPHrine, eryth- romycin lactobionate, famotidine, fentaNYL, filgrastim, fludarabine, foscarnet, furose- mide, gentamicin, granisetron, heparin, kanamycin, labetalol, LORazepam, magne- sium sulfate, melphalan, methotrexate, metroNIDAZOLE, midazolam, milrinone, morphine, nafcillin, niCARdipine, nitroglyc- erin, norepinephrine, ondansetron, oxacillin, PACLitaxel, penicillin G potas- sium, piperacillin, piperacillin/tazobactam, propofol, ranitidine, remifentanil, tenipo- side, thiotepa, ticarcillin, tobramycin, trimethoprim-sulfamethoxazole, vancomy- cin, vecuronium, vinorelbine Black Box Warning: Respiratory dys- function: respiratory depression, char- acter, rate, rhythm; notify prescriber if respirations <10/min Black Box Warning: Substance abuse/ opioid addiction: assess for previous or current substance abuse; risk for abuse will be increased in these patients; as- sess for misuse of medication • I&O ratio; check for decreasing out- put; may indicate urinary retention • CNS changes: dizziness, drowsiness, hal- lucinations, euphoria, LOC, pupil reaction • Bowel function, constipation • Allergic reactions: rash, urticaria • Need for pain medication, physical dependence • Assistance with ambulation • Safety measures: side rails, night-light, call bell within easy reach • Beers: avoid in older adults unless safer alternative is unavailable; may cause ataxia, impaired psychomotor function • Pregnancy/breastfeeding: use only if benefits outweigh fetal risk; neonatal withdrawal syndrome may occur if used in pregnancy for prolonged periods; do not breastfeed Black Box Warning: Substance abuse: that physical dependency may result when used for extended periods; that withdrawal symptoms—nausea, vomit- ing, cramps, fever, faintness, anorexia— may occur • To avoid driving, other hazardous ac- tivities because drowsiness occurs; to take with food if nausea occurs Black Box Warning: That extended- release products must be taken whole; not to use with alcohol, medications with alcohol content • To notify provider if pain is not con- trolled adequately • To use sugarless gum, frequent sips of water for dry mouth, use good oral hygiene
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SIDE EFFECTS CNS: Drowsiness, dizziness, confu- sion, headache, sedation, euphoria, mood changes, seizures CV: Palpitations, bradycardia, change in B/P, hypotension, tachycardia, peripheral vasodilation EENT: Tinnitus, blurred vision, miosis, diplopia GI: Nausea, vomiting, anorexia, con- stipation, cramps, dry mouth, paralytic ileus GU: Increased urinary output, dysuria, urinary retention INTEG: Rash, urticaria, bruising, flush- ing, diaphoresis, pruritus RESP: Respiratory depression, dyspnea MISC: Physical/psychologic depen- dence
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INTERACTIONS Increase: effects—other CNS depressants (alcohol, opiates, sedative/hypnotics, antipsychotics, skeletal muscle relaxants) Increase: CNS, respiratory depression— MAOIs, separate by ≥14 days Decrease: HYDROmorphone effects— opiate antagonists Drug/Herb Increase: action—chamomile, hops, kava, lavender, St. John’s wort, valerian Drug/Lab Test Increase: amylase
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TREATMENT OF OVERDOSE: Naloxone (Narcan) 0.2-0.8 mg IV (nontol- erant patients), O2, IV fluids, vasopressors
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DOSAGE AND ROUTES Analgesic • Adult: PO (oral solution) 2.5-10 mg q3-6hr or (tabs) 2-4 mg q4-6hr; EXT REL: convert to EXT REL by giving total daily dose of immediate release/day, in 1 daily dose, if needed titrate EXT REL q3- 4days until adequate pain relief; use 25%-50% increase for each titration step, if more than 2 doses of rescue medication needed in 24 hr consider ti- tration; IV 0.2-1 mg q2-3hr given over 2-3 min; IM/SUBCUT 1-2 mg q4-6hr prn, may be increased (opioid-naive pa- tients may require lower dose); RECT 3 mg q6-8hr prn • Geriatric: PO 1-2 mg q4-6hr • Child >50 kg (unlabeled): PO 2-4 mg q3-4hr in opioid-naive patients, titrate; IV 0.2-1 mg q2-4hr or 0.3 mg/kg infu- H sion (opioid-naive will require lower dose) • Infant >6 mo/child <50 kg (unla- beled): PO 0.04-0.08 mg/kg q3-4hr in opioid-naive patients, titrate; IV 0.015- 0.02 mg/kg q2-4hr or 0.006 mg/kg/hr infusion (opioid-naive) Renal dose • Adult: PO (moderate impairment) ext rel decrease dose by 50%, severe impairment decrease dose by 75% Hepatic disease • Adult: Child-Pugh B, or C (oral liquid, immediate rel tab, supp) give reduced dose based on response, impairment (parenteral), give 25%-50% of dose (moderate impairment)
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Available forms: Powder for inj 250 mg; inj 1, 2, 4, 10 mg/mL; tabs 2, 4, 8 mg; supp 3 mg; oral sol 5 mg/5 mL; ext rel tab 8, 12, 16, 32 mg
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Administer: PO route • Give with food or milk for GI irritation • Ext rel (Exalgo): discontinue all other ext rel opioids, give q24hr; do not crush, break, chew • When pain is beginning to return; de- termine interval by response • Store in light-resistant area at room temperature
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Assess: • Pain: control, sedation by scoring on 0-10 scale, around-the-clock dosing is best for pain control
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Evaluate: • Therapeutic response: decrease in pain
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CLINICAL CONSIDERATIONS
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Patient and caregiver information: • To report any symptoms of CNS changes, allergic reactions • That product is contained in a hard tablet shell that may be seen in a bowel movement, which is normal • Not to stop taking the product without discussing with provider
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PHARMACOKINETICS IM: Onset 15-30 min, peak ½-1 hr, dura- tion 4-5 hr, metabolized by liver, excreted by kidneys, crosses placenta, excreted in breast milk, half-life 2-3 hr
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• Adult: PO (oral solution) 2.5-10 mg q3-6hr or (tabs) 2-4 mg q4-6hr; EXT REL: convert to EXT REL by giving total daily dose of immediate release/day, in 1 daily dose, if needed titrate EXT REL q3- 4days until adequate pain relief; use 25%-50% increase for each titration step, if more than 2 doses of rescue medication needed in 24 hr consider ti- tration; IV 0.2-1 mg q2-3hr given over 2-3 min; IM/SUBCUT 1-2 mg q4-6hr prn, may be increased (opioid-naive pa- tients may require lower dose); RECT 3 mg q6-8hr prn
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• Geriatric: PO 1-2 mg q4-6hr
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• Child >50 kg (unlabeled): PO 2-4 mg q3-4hr in opioid-naive patients, titrate; IV 0.2-1 mg q2-4hr or 0.3 mg/kg infu- H sion (opioid-naive will require lower dose)
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• Infant >6 mo/child <50 kg (unla- beled): PO 0.04-0.08 mg/kg q3-4hr in opioid-naive patients, titrate; IV 0.015- 0.02 mg/kg q2-4hr or 0.006 mg/kg/hr infusion (opioid-naive) Renal dose
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• Adult: PO (moderate impairment) ext rel decrease dose by 50%, severe impairment decrease dose by 75% Hepatic disease
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• Adult: Child-Pugh B, or C (oral liquid, immediate rel tab, supp) give reduced dose based on response, impairment (parenteral), give 25%-50% of dose (moderate impairment)
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