Example Change From 90 Mg Q12 Ms Contin to Iv Hydromorphone as a Continuous Infusion
Hydromorphone
Introduction
Description: Potent opioid.
Fourth-line opioid: only for use with specialist advice.
Preparations
| Route | Preparation | Available strengths | |
| Oral | Immediate release hydromorphone Palladone® capsules | 1.3mg, 2.6mg | |
| Modified release (long acting) hydromorphone Palladone SR® capsules | 2mg, 4mg, 8mg, 16mg, 24mg | ||
| | 10mg/ml (other strengths can be made on request) Unlicensed preparation but can be made to order (contact local non-sterile pharmacy production unit via specialist pharmacist) | ||
| Injection | Palladone® injection Used as a subcutaneous infusion or as a subcutaneous bolus injection. | 2mg/ml 10 mg/ml 20 mg/ml 50 mg/ml Licensed preparation available via wholesalers (made by NAPP Pharmaceuticals) Non formulary in some NHS boards | |
Indications
- Must have specialist input. Fourth-line oral and injectable analgesic for moderate to severe opioid responsive pain in patients unable to tolerate oral morphine/oxycodone, subcutaneous diamorphine/morphine or oxycodone due to persistent side effects (for example sedation, confusion, hallucinations, itch).
Cautions
- Immediate release and modified release capsules have similar names. Some NHS boards recommend prescribing by brand name to avoid confusion.
- Frail or elderly patients need smaller doses less frequently and slower titration.
- Liver impairment:
- Reduced clearance (may need reduced dosing frequency). Note that the summaries of product characteristics (SPC) list hepatic impairment as a contra-indication, but this would not preclude its use in palliative care. Patients with moderate hepatic impairment should be started at a lower dose and closely monitored during dose titration.
- Renal impairment:
- Reduced excretion (may need reduced dosing frequency). Titrate slowly and monitor carefully in mild to moderate renal impairment. Avoid in chronic kidney disease stages 4-5 (eGFR <30ml/min). Check renal handbook.
- Drug interactions:
- Similar to other strong opioids such as morphine/oxycodone. Hydromorphone may be expected to have additive effects when used in conjunction with alcohol, other opioids, or drugs that cause central nervous system (CNS) depression (for example sedatives, hypnotics, general anaesthetics, phenothiazines, tranquilisers). Respiratory depression, hypotension and profound sedation or coma may occur.
- Side effects:
- Opioid side effects similar to morphine/oxycodone - monitor for opioid toxicity.
- Constipation: prescribe a laxative to be taken regularly and anti-emetic as needed (for example metoclopramide).
- Drowsiness: hydromorphone may cause drowsiness, impairing mental and/or physical ability. If affected do not drive or operate machinery. Avoid alcohol.
Dose and Administration
| Route | Dosage |
| Immediate release oral hydromorphone | Prescribe 4 hourly regularly and use the same dose as required for breakthrough pain. The capsules can be opened and the contents sprinkled on cold, soft food. |
| Modified release (long acting) oral hydromorphone (Palladone SR) | Prescribe 12 hourly, with a 1/6th to 1/10th of the 24-hour dose as immediate release oral hydromorphone for breakthrough pain. Palladone SR capsules can be opened (if difficulty when swallowing the SR capsules) and the contents sprinkled on cold, soft food, but the granules should NOT be broken, chewed, dissolved or crushed as this could lead to a rapid release of the drug and a potential overdose. Seek pharmacy advice if the patient has a feeding tube. |
| Hydromorphone injection | Continuous subcutaneous infusion in a syringe pump over 24 hours. In addition, prescribe 1/6th to 1/10th of the 24-hour infusion dose subcutaneously, 1 to 2 hourly as required for breakthrough pain (max 6 doses in 24 hours). Diluent: water for injection. Refer to stability and compatibility tables in Syringe Pump guideline. Sodium chloride 0.9% can also be used as a diluent. Seek specialist palliative care/pharmacy advice. |
Dose Conversions
Hydromorphone is approximately 7.5 times more potent than morphine.
| Morphine dosage | Hydromorphone dosage |
| Oral morphine 10mg | ≈oral hydromorphone 1.3mg |
| Oral hydromorphone 10mg | ≈subcutaneous hydromorphone 5mg |
| Subcutaneous morphine 30mg | ≈subcutaneous hydromorphone 4mg |
| Subcutaneous diamorphine 20mg | ≈subcutaneous hydromorphone 4mg |
- As with all opioid conversions, these are approximate (≈) doses.
- Dose conversions should be conservative and doses rounded down.
- Monitor the patient carefully so that the dose can be adjusted if necessary.
- If the patient has opioid toxicity, reduce the dose by 1/3rd when changing opioid.
Practice Points
- The GP, community pharmacist, district nurse and unscheduled care service should be informed that the patient is receiving this fourth-line opioid, for example via eKIS.
- Hydromorphone can be prescribed by the patient's GP for the indications/uses listed in liaison with local palliative care specialists.
- Patients should receive an initial supply on discharge to allow adequate time for the community pharmacist to order the preparation(s) required.
References
- References
Source: https://www.palliativecareguidelines.scot.nhs.uk/guidelines/medicine-information-sheets/hydromorphone.aspx
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