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Contains hydromorphone, a Schedule II controlled opioid agonist with the highest potential for abuse and risk of respiratory depression. Alcohol, other opioids, and CNS depressants (eg, sedative-hypnotics) potentiate respiratory depressant effects, increasing the risk of respiratory depression that may result in death.
Periodically reassess after the initial dosing
Sol:Usual: 2.5-10mg q3-6h ud by clinical situation
Tab:Initial: 2-4mg q4-6hTitrate: May increase gradually if analgesia is inadequate, as tolerance develops, or if pain severity increases
Sol/Tab:Nonopioid-Tolerant: Initial: 2-4mg q4h
Taking Opioids: Base starting dose on prior opioid usageGive only 1/2 to 2/3 of the estimated dose for the 1st few doses, then increase prn according to responseChronic Pain:Administer dose around-the-clockMay give a supplemental dose of 5-15% of the total daily usage q2h prn
From Morphine Sulfate: 10mg parenteral or 40-60mg oralFrom Hydromorphone HCl: 1.3-2mg parenteral or 6.5-7.5mg oralFrom Oxymorphone HCl: 1-1.1mg parenteral or 6.6mg oralFrom Levorphanol Tartrate: 2-2.3mg parenteral or 4mg oralFrom Meperidine HCl: 75-100mg parenteral or 300-400mg oralFrom Methadone HCl: 10mg parenteral or 10-20mg oral
Renal ImpairmentModerate-Severe:Start on a lower dose and closely monitor during titrationUse oral liquid to adjust the dose
Hepatic ImpairmentModerate:Start on a lower dose and closely monitor during titrationUse oral liquid to adjust the dose
ElderlyStart at lower end of dosing range
Sol: 1mg/mL [473mL]; Tab: 2mg, 4mg, 8mg* *scored
Respiratory depression in the absence of resuscitative equipment, status asthmaticus, obstetrical analgesia.
Respiratory depression is more likely to occur in elderly, debilitated, and those suffering from conditions accompanied by hypoxia or hypercapnia; extreme caution with chronic obstructive pulmonary disease (COPD) or cor pulmonale, substantially decreased respiratory reserve, hypoxia, hypercapnia, or preexisting respiratory depression. May cause neonatal withdrawal syndrome. Respiratory depressant effects with carbon dioxide retention and secondary elevation of CSF pressure may be markedly exaggerated in the presence of head injury, other intracranial lesions, or preexisting increase in intracranial pressure (ICP). May produce effects on pupillary response and consciousness, which can obscure the clinical course and neurologic signs of further increase in ICP in patients with head injuries. May cause severe hypotension; caution with circulatory shock. Contains sodium metabisulfite; may cause allergic-type reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. Caution in elderly/debilitated and those with severe pulmonary/hepatic/renal impairment, myxedema/hypothyroidism, adrenocortical insufficiency (eg, Addison's disease), CNS depression or coma, toxic psychoses, prostatic hypertrophy, urethral stricture, gallbladder disease, acute alcoholism, delirium tremens, kyphoscoliosis, or following GI surgery; reduce initial dose. May obscure the diagnosis or clinical course in patients with acute abdominal conditions. May aggravate preexisting convulsions in patients with convulsive disorders. Mild to severe seizures and myoclonus reported in severely compromised patients administered high doses of parenteral hydromorphone. Caution with alcoholism and other drug dependencies. May impair mental/physical abilities. May produce orthostatic hypotension in ambulatory patients. May cause spasm of the sphincter of Oddi; caution in patients about to undergo biliary tract surgery. Physical dependence and tolerance may occur. Do not abruptly d/c.
Respiratory depression, apnea, lightheadedness, dizziness, sedation, N/V, sweating, flushing, dysphoria, euphoria, dry mouth, pruritus.
See Boxed Warning. Concomitant use with other CNS depressants (eg, general anesthetics, phenothiazines, tranquilizers) may produce additive depressant effects; use with caution and in reduced dosages. Do not give with alcohol. May enhance action of neuromuscular blocking agents and produce an excessive degree of respiratory depression. May cause severe hypotension with phenothiazines or general anesthetics. Mixed agonist/antagonist analgesics (pentazocine, nalbuphine, butorphanol, buprenorphine) may reduce the analgesic effect and/or may precipitate withdrawal symptoms; use with caution.
Category C, not for use in nursing.
Opioid analgesic; pure opioid agonist. Has not been established. Believed to express pharmacologic effects by combining with specific CNS opiate receptors.
Absorption: Rapid. (Tab) Bioavailability (24%); Cmax=5.5ng; Tmax=0.74 hrs; AUC=23.7ng•hr/mL. (Sol) Cmax=5.7ng; Tmax=0.73 hrs; AUC=24.6ng•hr/mL. Distribution: Plasma protein binding (8-19%); Vd=302.9L (IV bolus); crosses placenta; found in breast milk. Metabolism: Liver (extensive) via glucuronidation; hydromorphone-3-glucuronide (metabolite). Elimination: Urine; T1/2=2.6 hrs (tab), 2.8 hrs (sol).
Assess for risk factors for drug abuse or addiction, pain type/severity, prior opioid therapy, opioid tolerance, respiratory depression, COPD, cor pulmonale, decreased respiratory reserve, hypoxia, hypercapnia, asthma, renal/hepatic impairment, pregnancy/nursing status, possible drug interactions, or any other conditions where treatment is contraindicated or cautioned.
Monitor for respiratory depression, sedation, CNS depression, aggravation/induction of seizures/convulsions, increase in ICP, hypotension, tolerance, physical dependence, and other adverse reactions. Routinely monitor for signs of misuse, abuse, and addiction.
Inform that medication may cause severe adverse effects (eg, respiratory depression) if not taken ud. Instruct to report pain and adverse experiences occurring during therapy. Advise not to adjust dose or combine with alcohol or other CNS depressants without prescriber's consent. Inform that drug may impair mental/physical abilities; instruct to use caution when performing hazardous tasks (eg, operating machinery/driving). Advise to consult physician if pregnant or planning to become pregnant. Inform that drug has potential for abuse; instruct to protect it from theft and never to share with others. Advise to avoid abrupt withdrawal if taking medication for more than a few weeks and cessation of therapy is indicated. Instruct to keep drug in a secure place, and to destroy unused tabs by flushing down toilet.
25°C (77°F); excursions permitted to 15-30°C (59-86°F). Protect from light.