Literature Review of

Hydromorphone

By :
Elshurafa Mueen Zayed

DEPARTMENT OF ANESTHESIOLOGY AND REANIMATION

FACULTY OF MEDICINE UNIVERSITY OF SEBELAS MARET
Hydromorphone

Semi-synthetic opioid agonist

Commonly second line drug to morphine

Has a key role in pain management

Chemistry of Hydromorphone

Act on
Mediate pain
opioid
relieving
receptors

Receptor on
opioid
Structure Formula C17H19NO3
Solid, odorless,
crystal-like
Pharmacodynamic

Postoperative Pain Therapy

During TCI-PCA phase, two patients (5%) developed
respiratory insufficiency without somnolence with temporary
need of noninvasive ventilatory support via face mask
(Jeleazcov, 2016)
Postoperative TCI of hydromorphone followed by TCI-PCA of
hydromorphone was feasible for postoperative pain therapy
and revealed effective pain relief at rest and during
inspiration during the first 10 h after cardiac surgery with
thoracotomy (Struys et al., 2011)
Pharmacodynamic

Acute Pain Management in Trauma

there was some success of a pragmatic titration protocol
utilizing hydromorphone 1 mg followed by an additional
dose in 15 minutes if required (Chang et al., 2011)
In non elderly patients with acute pain, hydromorphone may
offer some advantage compared with morphine at similar
doses (Chang et al., 2013)
Pharmacodynamic

Hydromorphone in Management of Cancer

Pain
The equianalgesic dosage for hydromorphone and morphine
in the treatment of chronic cancer-related pain has not been
firmly settled, and nor has the dose conversion for parenteral
and oral hydromorphone.
There is good evidence to support the use of
hydromorphone as a pure opioid agonist for chronic cancer
pain (Murray, 2005)
Pharmacokinetic

Absorption via Metabolism: via

oral, parenteral, glucoronidation
or spinal in liver

Distribution: 8- Excretion: as
19% bound to hydromorphone-
plasma protein 3-glucoronide via
urine
Administration
Onset 30 mins
Oral Duration of about 4 hours
62% dose is eliminated by the liver on first pass

Via intravenous, intramuscular, subcutaneus

Parenteral Onset IV 5 mins
Max effect within 20 mins

Duration of action 7.7-19.3 hours

Spinal Epidural-parenteral equianalgesic ratio is
approximately 1:2
Daily Usage of Hydromorphone

Indication:
management of pain

Contraindication:
hypersensitive,
respiratory
depression, increased
ICP, asthma, etc.
Daily Usage of Hydromorphone
Dosage
Tablet : 2mg 4mg 8mg
Oral liquid: 5mg/5mL
tablet, extended-release: 8mg 12mg 16mg 32mg
injection solution: 1mg/mL 2mg/mL 4mg/mL 10mg/mL
suppository: 3mg
For moderate to severe pain
PO
Immediate-release: 2-4 mg q4-6hr PRN; a gradual increase in dose may be required
Oral liquid (usual dose): 2.5-10 mg (2.5-10 mL) q3-6hr PRN
SC/IM
1-2 mg q2-3hr PRN; adjust dose according to pain and adverse effects IV
Opioid naive: 0.2-1 mg IV q2-3hr PRN; may require higher doses in patients with prior opioid exposure
Critically ill patients (opiate-naive patients): 0.2-0.6 mg q1-2hr PRN given slowly over 2-3 minutes; patients with previous
opiate exposure may tolerate higher doses
Continuous infusion: 0.5-3 mg/hr, titrated to response
Patient-controlled analgesia
Usual concentration, 0.2 mg/mL; demand dose, 0.1-0.2 mg; dose range is 0.05-0.4 mg
Lockout interval: 5-10 minutes
Side Effects of Hydromorphone

Respiratory
Cardiac arrest Sedation
depression

Light
Nausea,
headedness,
vomiting
dizziness
Interactions of Hydromorphone
Hydro
morph
one
Respiratory
depression,
hypotension,
sedation
CNS
Depres
sant
Interactions of Hydromorphone
Hydro
morph
one
Hydromorphone
may reduce the
effect of
analgetics

Analge
tics
Interactions of Hydromorphone

Non
carcinogenic

No effects Non
on fertility mutagenic
References
Chang AK, Bijur PE, Campbell CM, Murphy MK, Gallagher EJ. Safety and efficacy of rapid titration using 1 mg dosesof intravenous hydromorphone in
emergency department patients with acute severe pain: the 1+1 protocol. Ann Emerg Med. 2009;54:221-225.

Chang AK, Bijur PE, Davitt M, Gallagher EJ. Randomized clinical trial comparing a patient-driven titration protocol of intravenous hydromorphone with
traditional physician-driven management of emergency department patients with acute severe pain. Ann Emerg Med. 2009;54:561-567.

Chang AK, Bijur PE, Gallagher EJ. Randomized clinical trial comparing the safety and efficacy of a hydromorphone titra- tion protocol to usual care in the
management of adult emer- gency department patients with acute severe pain. Ann Emerg Med. 2011;58:352-359.

Chang AK, Bijur PE, Napolitano A, Gallagher JE. Safety and efficacy of hydromorphone as an alternative to morphine for severe pain in older adults: a
randomized clinical trial. Acad Emerg Med. 2008;15:S56.

Halpern SH, Arellano R, Preston R, et al. Epidural morphine vs hydromorphone in post-caesarean section patients. Can J Anaesth 1996;43(6): 595598.

Jeleazcov C, Ihmsen H, Saari TI, et al. Patient-controlled Analgesia with Target-controlled Infusion of Hydromorphone in Postoperative Pain Therapy.
Anesthesiology 2016; 124:56-68)

Minto CF, Schnider TW: Contributions of PK/PD modeling to intravenous anesthesia. Clin Pharmacol Ther 2008; 84:2738

O'Neil, M.J. (ed.). The Merck Index - An Encyclopedia of Chemicals, Drugs, and Biologicals. Cambridge, UK: Royal Society of Chemistry, 2013., p. 890

Struys MM, Sahinovic M, Lichtenbelt BJ, Vereecke He, Absalom AR: optimizing intravenous drug administration by applying pharmacokinetic /
pharmacodynamic concepts. Br J Anaesth 2011; 107:3847

World Health Organization. Report on cancer pain relief and palliative care. Geneva: World Health Organization, 1990.