DOSAGE AND ADMINISTRATION
Hydromorphone hydrochloride tablets (2 mg, 4 mg, 8 mg): The usual starting dose for hydromorphone hydrochloride tablets is 2 mg to 4 mg, orally, every 4 to 6 hours. Appropriate use of the hydromorphone hydrochloride tablets 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.
Patients with hepatic and renal impairment should be started on lower starting dose (See CLINICAL PHARMACOLOGY: Pharmacokinetics and Metabolism).
INDIVIDUALIZATION OF DOSAGE
The dosage of opioid analgesics like hydromorphone hydrochloride should be individualized for any given patient, since adverse events can occur at doses that may not provide complete freedom from pain.
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 2-4 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 3-4 hours of pain relief may be achieved. In patients taking opioid analgesics, the starting dose of hydromorphone hydrochloride should be based on 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 hydrochloride using an equianalgesic table (see below). For opioids not in the table, first estimate the equivalent total daily usage of oral usage of oral morphine, then use the table to find the equivalent total daily dosage of hydromorphone hydrochloride.
Once the total daily dosage of hydromorphone hydrochloride 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 ½ to ⅔ of the estimated dose of hydromorphone hydrochloride calculated from equivalence tables should be given for the first few doses, then increased as needed according to the patient’s response.
Since the pharmacokinetics of hydromorphone are affected in hepatic and renal impairment with a consequent increase in exposure, Patients with hepatic and renal impairment should be started on a lower starting dose (see CLINCIAL PHARMCOLOGY: Pharmacokinetics and Metabolism).
In chronic pain, doses should be administered around-the-clock. A supplemental dose of 5-15% 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. 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.
| OPIOID ANALGESIC EQUIVALENTS WITH |
APPROXIMATELY EQUIANALGESIC POTENCY*
|*Dosages, and ranges of dosages represented, are a compilation of estimated equipotent dosages from published references comparing opioid analgesics in cancer and severe pain.|
| Nonproprietary |
| IM or SC |
| ORAL |
|Morphine sulfate||10 mg||40-60 mg|
|Hydromorphone HCl||1.3-2 mg||6.5-7.5 mg|
|1-1.1 mg||6.6 mg|
|2-2.3 mg||4 mg|
|Meperidine, pethidine HCl|
|75-100 mg||300-400 mg|
|10 mg||10-20 mg|