Dosing & Uses
Dosage Forms & Strengths
tablet: Schedule II
- 2mg
- 4mg
- 8mg
tablet, extended-release: Schedule II
- 8mg
- 12mg
- 16mg
- 32mg
injection solution
- 1mg/mL
- 2mg/mL
- 4mg/mL
injection solution, preservative free: Schedule II
- 10mg/mL
oral liquid: Schedule II
- 5mg/5mL
suppository: Schedule II
- 3mg
Prefilled syringe: Schedule II
- 0.2 mg/mL
- 0.6 mg/mL
Moderate-to-Severe Pain
Indicated 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
- IM dose not recommended for use as it may result in variable absorption and lag time to peak effect
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
Rectal
- 3 mg PR q6-8hr
Chronic Severe Pain
Long-acting (Exalgo) is indicated for the management of pain in opioid tolerant patients severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate
Opioid tolerant patients only (extended-release:) 8-64 mg PO qDay; may administer a starting dose equivalent to patient's total daily oral hydromorphone dose administered once daily with or without food
Should address pain relief and adverse events frequently; increase dose no more frequently than q3-4days; may titrate with increases of 25-50% of current daily dose; consider increasing dose if more than 2 doses of rescue medications are needed within 24hr within 2 consecutive days
Extented-release tablets should be swallowed whole; crushing, dividing, or dissolving will release opioid content all at once and increase risk of respiratory depression and death
Converting to Exalgo
- Conversion from other oral hydromorphone formulations: Start with equivalent total daily dose of immediate release formulation and administer once daily; may titrate q3-4days until adequate pain relief with tolerable adverse effects achieved
- Conversion from other opioids: Start Exalgo dose at 50% of calculated daily dose q24hr; titrate until adequate pain relief with tolerable adverse effects achieved
- Conversion from transdermal fentanyl to Exalgo: Start Exalgo 18 hr after removal of transdermal fentanyl patch at 50% of calculated total daily dose given over 24hr; for a 25 mcg/hr fentanyl patch the equianalgesic dose is 12 mg PO q24hr
- Discontinuation of Exalgo therapy: Taper gradually by decreasing dose by 25-50% q2-3days to a dose of 8 mg PO q24hr before discontinuing
Opioid-tolerant definition
- Use of higher starting doses in patients who are not opioid tolerant may cause fatal respiratory depression
- Patients who are opioid tolerant are those receiving, for 1 week or longer, at least 60 mg/day PO morphine, 25 mcg/hr transdermal fentanyl, 30 mg/day PO oxycodone, 8 mg/day PO hydromorphone, 25 mg/day PO oxymorphone, or an equianalgesic dose of another opioid
Cough (Off-label)
1 mg PO q3-4hr PRN
Dosing Consideration
Limitations of use
- Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with extended-release opioid formulations, reserve for patients whom alternative treatment options (eg, nonopioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain
- Not indicated for acute pain or as a PRN analgesic
Access to naloxone for opioid overdose
- Assess need for naloxone upon initiating and renewing treatment
-
Consider prescribing naloxone
- Based on patient’s risk factors for overdose (eg, concomitant use of CNS depressants, a history of opioid use disorder, prior opioid overdose); presence of risk factors should not prevent proper pain management
- Household members (including children) or other close contacts at risk for accidental ingestion or overdose
-
Consult patients and caregivers on the following:
- Availability of naloxone for emergency treatment of opioid overdose
- Ways differ on how to obtain naloxone as permitted by individual state dispensing and prescribing requirements or guidelines (eg, by prescription, directly from a pharmacist, as part of a community-based program)
Dosage Forms & Strengths
tablet: Schedule II
- 2mg
- 4mg
- 8mg
oral liquid: Schedule II
- 5mg/5mL
injection solution
- 1mg/mL
- 2mg/mL
- 4mg/mL
suppository: Schedule II
- 3mg
Pain (Off-label)
Moderate-to-severe pain
Children: 0.03-0.08 mg/kg PO q4-6hr PRN; not to exceed 5 mg/dose
Adolescents: 1-4 mg/dose PO q4-6hr PRN
Children: 0.015 mg/kg IV q4-6hr PRN
Adolescents: 1-2 mg/dose IV/IM.SC q4-6hr
Patient Controlled Anesthesia (Off-label)
Loading dose: 8 mcg/kg IV bolus
Demand dose (initial): 2 mcg/kg IV with a lockout time of 10 min
Pain
Indicated for moderate-to-severe pain
2-4 mg PO q4-6hr PRN; a gradual increase in dose may be required
Dosing Considerations
Titrate dose to effect; oral and parenteral doses are not equivalent; because parenteral dose 5 times more potent than oral dose, administer one fifth of oral dose when changing to parenteral route
Oral dose: Initiate at low end of dosage range; consider lowering dose by 25-50% in patients >70 years
IV: Reduce initial dose to 0.2 mg q2-3hr
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Contraindicated (1)
- alvimopan
alvimopan, hydromorphone. receptor binding competition. Contraindicated. Alvimopan is contraindicated in opioid tolerant patients (ie, those who have taken therapeutic doses of opioids for >7 consecutive days immediately prior to taking alvimopan). Patients recently exposed to opioids are expected to be more sensitive to the effects of alvimopan and therefore may experience abdominal pain, nausea and vomiting, and diarrhea. No significant interaction is expected with concurrent use of opioid analgesics and alvimopan in patients who received opioid analgesics for 7 or fewer consecutive days prior to alvimopan.
Serious - Use Alternative (56)
- acrivastine
acrivastine and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate
- amisulpride
amisulpride and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate
- asenapine
asenapine and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate
- asenapine transdermal
asenapine transdermal and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate
- avapritinib
avapritinib and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate
- benzhydrocodone/acetaminophen
benzhydrocodone/acetaminophen, hydromorphone. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
benzhydrocodone/acetaminophen and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate - bremelanotide
bremelanotide will decrease the level or effect of hydromorphone by Other (see comment). Avoid or Use Alternate Drug. Bremelanotide may slow gastric emptying and potentially reduces the rate and extent of absorption of concomitantly administered oral medications. Avoid use when taking any oral drug that is dependent on threshold concentrations for efficacy. Interactions listed are representative examples and do not include all possible clinical examples.
- brexpiprazole
brexpiprazole and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate
- brimonidine
brimonidine and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate
- brivaracetam
brivaracetam and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate
- buprenorphine
buprenorphine, hydromorphone. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.
- buprenorphine buccal
buprenorphine buccal, hydromorphone. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.
- buprenorphine subdermal implant
buprenorphine subdermal implant and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate
- buprenorphine transdermal
buprenorphine transdermal and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate
- buprenorphine, long-acting injection
buprenorphine, long-acting injection and hydromorphone both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequate
- butorphanol
butorphanol, hydromorphone. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.
- calcium/magnesium/potassium/sodium oxybates
hydromorphone, calcium/magnesium/potassium/sodium oxybates. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- cimetidine
cimetidine increases effects of hydromorphone by decreasing metabolism. Avoid or Use Alternate Drug.
- citalopram
hydromorphone, citalopram. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
- clonidine
clonidine, hydromorphone. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration enhances CNS depressant effects.
- diazepam intranasal
diazepam intranasal, hydromorphone. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- eluxadoline
hydromorphone, eluxadoline. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Avoid coadministration with other drugs that cause constipation. Increases risk for constipation related serious adverse reactions. .
- escitalopram
hydromorphone, escitalopram. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
- fentanyl
fentanyl, hydromorphone. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration with other CNS depressants, such as skeletal muscle relaxants, may cause respiratory depression, hypotension, profound sedation, coma, and/or death. Consider dose reduction of either or both agents to avoid serious adverse effects. Monitor for hypotension, respiratory depression, and profound sedation.
- fentanyl intranasal
fentanyl intranasal, hydromorphone. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration with other CNS depressants, such as skeletal muscle relaxants, may cause respiratory depression, hypotension, profound sedation, coma, and/or death. Consider dose reduction of either or both agents to avoid serious adverse effects. Monitor for hypotension, respiratory depression, and profound sedation.
- fentanyl transdermal
fentanyl transdermal, hydromorphone. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration with other CNS depressants, such as skeletal muscle relaxants, may cause respiratory depression, hypotension, profound sedation, coma, and/or death. Consider dose reduction of either or both agents to avoid serious adverse effects. Monitor for hypotension, respiratory depression, and profound sedation.
- fentanyl transmucosal
fentanyl transmucosal, hydromorphone. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration with other CNS depressants, such as skeletal muscle relaxants, may cause respiratory depression, hypotension, profound sedation, coma, and/or death. Consider dose reduction of either or both agents to avoid serious adverse effects. Monitor for hypotension, respiratory depression, and profound sedation.
- fluoxetine
fluoxetine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.
hydromorphone, fluoxetine. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug. - fluvoxamine
fluvoxamine and hydromorphone both increase serotonin levels. Avoid or Use Alternate Drug.
- hydrocodone
hydrocodone, hydromorphone. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- isocarboxazid
isocarboxazid increases toxicity of hydromorphone by unknown mechanism. Avoid or Use Alternate Drug. Risk of hypotension, hyperpyrexia, somnolence, or death; separate by 14 d.
- linezolid
linezolid increases toxicity of hydromorphone by unknown mechanism. Avoid or Use Alternate Drug. Risk of hypotension, hyperpyrexia, somnolence, or death; separate by 14 d.
- lumefantrine
lumefantrine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.
- methylene blue
methylene blue and hydromorphone both increase serotonin levels. Avoid or Use Alternate Drug. If drug combination must be administered, monitor for evidence of serotonergic or opioid-related toxicities
- metoclopramide intranasal
hydromorphone, metoclopramide intranasal. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Avoid use of metoclopramide intranasal or interacting drug, depending on importance of drug to patient.
- nalbuphine
nalbuphine, hydromorphone. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.
- olopatadine intranasal
hydromorphone and olopatadine intranasal both increase sedation. Avoid or Use Alternate Drug. Coadministration increases risk of CNS depression, which can lead to additive impairment of psychomotor performance and cause daytime impairment.
- ozanimod
ozanimod and hydromorphone both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Avoid or Use Alternate Drug. Because the active metabolite of ozanimod inhibits MAO-B in vitro, there is a potential for serious adverse reactions, including hypertensive crisis. Therefore, coadministration of ozanimod with drugs that can increase norepinephrine or serotonin is not recommended. Monitor for hypertension with concomitant use.
- paroxetine
paroxetine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.
hydromorphone, paroxetine. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug. - pentazocine
pentazocine, hydromorphone. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.
- phenelzine
phenelzine increases toxicity of hydromorphone by unknown mechanism. Avoid or Use Alternate Drug. Risk of hypotension, hyperpyrexia, somnolence, or death; separate by 14 d.
- prasugrel
hydromorphone will decrease the level or effect of prasugrel by inhibition of GI absorption. Applies only to oral form of both agents. Avoid or Use Alternate Drug. Co-administration of opioid agonists delay and reduce absorption of prasugrel and its active metabolite presumably by slowing gastric emptying; consider the use of a parenteral anti-platelet agent in acute coronary syndrome patients requiring co-administration of opioid agonists
- procarbazine
procarbazine increases toxicity of hydromorphone by unknown mechanism. Avoid or Use Alternate Drug. MAOIs may potentiate CNS depression and hypotension. Do not use within 14 days of MAOI use. .
- quinidine
quinidine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.
- rasagiline
rasagiline increases toxicity of hydromorphone by unknown mechanism. Avoid or Use Alternate Drug. May cause additive CNS depression, drowsiness, dizziness or hypotension, so use with MAOIs should be cautious; lower initial dosages of the analgesic are recommended followed by careful titration. Avoid combination within 14 days of MAOI use.
- selegiline
selegiline increases toxicity of hydromorphone by unknown mechanism. Avoid or Use Alternate Drug. At least 14 days should elapse between the discontinuation of a MAO-inhibiting drug and the initiation of hydromorphone.
- selegiline transdermal
selegiline transdermal increases toxicity of hydromorphone by unknown mechanism. Avoid or Use Alternate Drug. Risk of hypotension, hyperpyrexia, somnolence, or death.
- selinexor
selinexor, hydromorphone. unspecified interaction mechanism. Avoid or Use Alternate Drug. Patients treated with selinexor may experience neurological toxicities. Avoid taking selinexor with other medications that may cause dizziness or confusion.
- sertraline
hydromorphone, sertraline. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
- sodium oxybate
hydromorphone, sodium oxybate. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- sufentanil SL
sufentanil SL, hydromorphone. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration may result in hypotension, profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- ticagrelor
hydromorphone will decrease the level or effect of ticagrelor by inhibition of GI absorption. Applies only to oral form of both agents. Avoid or Use Alternate Drug. Co-administration of opioid agonists delay and reduce absorption of ticagrelor and its active metabolite presumably by slowing gastric emptying; consider the use of a parenteral anti-platelet agent in acute coronary syndrome patients requiring co-administration of opioid agonists C
- tramadol
tramadol, hydromorphone. Other (see comment). Avoid or Use Alternate Drug. Comment: Tramadol may reinitiate opiate dependence in pts. previously addicted to other opiates; it may also provoke withdrawal Sx. in pts. who are currently opiate dependent.
- tranylcypromine
tranylcypromine increases toxicity of hydromorphone by unknown mechanism. Avoid or Use Alternate Drug. Risk of hypotension, hyperpyrexia, somnolence, or death; separate by 14 d.
- valerian
valerian and hydromorphone both increase sedation. Avoid or Use Alternate Drug.
- vortioxetine
hydromorphone, vortioxetine. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
Monitor Closely (210)
- albuterol
hydromorphone increases and albuterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- alfentanil
alfentanil and hydromorphone both increase sedation. Use Caution/Monitor.
- alprazolam
alprazolam and hydromorphone both increase sedation. Use Caution/Monitor.
- amiodarone
amiodarone will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- amitriptyline
hydromorphone and amitriptyline both increase sedation. Use Caution/Monitor.
- amobarbital
amobarbital and hydromorphone both increase sedation. Use Caution/Monitor.
- amoxapine
hydromorphone and amoxapine both increase sedation. Use Caution/Monitor.
- apomorphine
hydromorphone and apomorphine both increase sedation. Use Caution/Monitor.
- arformoterol
hydromorphone increases and arformoterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- aripiprazole
hydromorphone and aripiprazole both increase sedation. Use Caution/Monitor.
- armodafinil
hydromorphone increases and armodafinil decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- artemether/lumefantrine
artemether/lumefantrine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- asenapine
asenapine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- azelastine
azelastine and hydromorphone both increase sedation. Use Caution/Monitor.
- baclofen
baclofen and hydromorphone both increase sedation. Use Caution/Monitor.
- belladonna and opium
hydromorphone and belladonna and opium both increase sedation. Use Caution/Monitor.
- benperidol
hydromorphone and benperidol both increase sedation. Use Caution/Monitor.
- benzphetamine
hydromorphone increases and benzphetamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- brexanolone
brexanolone, hydromorphone. Either increases toxicity of the other by sedation. Use Caution/Monitor.
- brompheniramine
brompheniramine and hydromorphone both increase sedation. Use Caution/Monitor.
- buprenorphine
buprenorphine and hydromorphone both increase sedation. Use Caution/Monitor.
- buprenorphine buccal
buprenorphine buccal and hydromorphone both increase sedation. Use Caution/Monitor.
- buprenorphine, long-acting injection
hydromorphone increases toxicity of buprenorphine, long-acting injection by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of buprenorphine and benzodiazepines or other CNS depressants increases risk of adverse reactions including overdose, respiratory depression, and death. Cessation of benzodiazepines or other CNS depressants is preferred in most cases. In some cases, monitoring at a higher level of care for tapering CNS depressants may be appropriate. In others, gradually tapering a patient off of a prescribed benzodiazepine or other CNS depressant or decreasing to the lowest effective dose may be appropriate.
- bupropion
bupropion will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- butabarbital
butabarbital and hydromorphone both increase sedation. Use Caution/Monitor.
- butalbital
butalbital and hydromorphone both increase sedation. Use Caution/Monitor.
- butorphanol
butorphanol and hydromorphone both increase sedation. Use Caution/Monitor.
- caffeine
hydromorphone increases and caffeine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- carbinoxamine
carbinoxamine and hydromorphone both increase sedation. Use Caution/Monitor.
- carisoprodol
carisoprodol and hydromorphone both increase sedation. Use Caution/Monitor.
- celecoxib
celecoxib will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- chloral hydrate
chloral hydrate and hydromorphone both increase sedation. Use Caution/Monitor.
- chlordiazepoxide
chlordiazepoxide and hydromorphone both increase sedation. Use Caution/Monitor.
- chloroquine
chloroquine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- chlorpheniramine
chlorpheniramine and hydromorphone both increase sedation. Use Caution/Monitor.
- chlorpromazine
hydromorphone and chlorpromazine both increase sedation. Use Caution/Monitor.
- chlorzoxazone
chlorzoxazone and hydromorphone both increase sedation. Use Caution/Monitor.
- cimetidine
cimetidine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- cinnarizine
cinnarizine and hydromorphone both increase sedation. Use Caution/Monitor.
- clemastine
clemastine and hydromorphone both increase sedation. Use Caution/Monitor.
- clobazam
hydromorphone, clobazam. Other (see comment). Use Caution/Monitor. Comment: Concomitant administration can increase the potential for CNS effects (e.g., increased sedation or respiratory depression).
- clomipramine
hydromorphone and clomipramine both increase sedation. Use Caution/Monitor.
- clonazepam
clonazepam and hydromorphone both increase sedation. Use Caution/Monitor.
- clorazepate
clorazepate and hydromorphone both increase sedation. Use Caution/Monitor.
- clozapine
hydromorphone and clozapine both increase sedation. Use Caution/Monitor.
- codeine
codeine and hydromorphone both increase sedation. Use Caution/Monitor.
- cyclizine
cyclizine and hydromorphone both increase sedation. Use Caution/Monitor.
- cyclobenzaprine
cyclobenzaprine and hydromorphone both increase sedation. Use Caution/Monitor.
- cyproheptadine
cyproheptadine and hydromorphone both increase sedation. Use Caution/Monitor.
- dantrolene
dantrolene and hydromorphone both increase sedation. Use Caution/Monitor.
- daridorexant
hydromorphone and daridorexant both increase sedation. Modify Therapy/Monitor Closely. Coadministration increases risk of CNS depression, which can lead to additive impairment of psychomotor performance and cause daytime impairment.
- darifenacin
darifenacin will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- desflurane
desflurane and hydromorphone both increase sedation. Use Caution/Monitor. Opioids may decrease MAC requirements, less inhalation anesthetic may be required.
- desipramine
hydromorphone and desipramine both increase sedation. Use Caution/Monitor.
- desvenlafaxine
desvenlafaxine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- deutetrabenazine
hydromorphone and deutetrabenazine both increase sedation. Use Caution/Monitor.
- dexchlorpheniramine
dexchlorpheniramine and hydromorphone both increase sedation. Use Caution/Monitor.
- dexfenfluramine
hydromorphone increases and dexfenfluramine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- dexmedetomidine
dexmedetomidine and hydromorphone both increase sedation. Use Caution/Monitor.
- dexmethylphenidate
hydromorphone increases and dexmethylphenidate decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- dextroamphetamine
hydromorphone increases and dextroamphetamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- dextromoramide
dextromoramide and hydromorphone both increase sedation. Use Caution/Monitor.
- diamorphine
diamorphine and hydromorphone both increase sedation. Use Caution/Monitor.
- diazepam
diazepam and hydromorphone both increase sedation. Use Caution/Monitor.
- dichlorphenamide
dichlorphenamide and hydromorphone both decrease serum potassium. Use Caution/Monitor.
- diethylpropion
hydromorphone increases and diethylpropion decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- difelikefalin
difelikefalin and hydromorphone both increase sedation. Use Caution/Monitor.
- difenoxin hcl
difenoxin hcl and hydromorphone both increase sedation. Use Caution/Monitor.
- dimenhydrinate
dimenhydrinate and hydromorphone both increase sedation. Use Caution/Monitor.
- diphenhydramine
diphenhydramine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
diphenhydramine and hydromorphone both increase sedation. Use Caution/Monitor. - diphenoxylate hcl
diphenoxylate hcl and hydromorphone both increase sedation. Use Caution/Monitor.
- dipipanone
dipipanone and hydromorphone both increase sedation. Use Caution/Monitor.
- dobutamine
hydromorphone increases and dobutamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- dopamine
hydromorphone increases and dopamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- dopexamine
hydromorphone increases and dopexamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- dosulepin
hydromorphone and dosulepin both increase sedation. Use Caution/Monitor.
- doxepin
hydromorphone and doxepin both increase sedation. Use Caution/Monitor.
- doxylamine
doxylamine and hydromorphone both increase sedation. Use Caution/Monitor.
- dronedarone
dronedarone will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- droperidol
hydromorphone and droperidol both increase sedation. Use Caution/Monitor.
- duloxetine
duloxetine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- eltrombopag
eltrombopag increases levels of hydromorphone by decreasing metabolism. Use Caution/Monitor. UGT inhibition; significance of interaction unclear.
- ephedrine
hydromorphone increases and ephedrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- epinephrine
hydromorphone increases and epinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- epinephrine racemic
hydromorphone increases and epinephrine racemic decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- esketamine intranasal
esketamine intranasal, hydromorphone. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.
- estazolam
estazolam and hydromorphone both increase sedation. Use Caution/Monitor.
- ethanol
hydromorphone and ethanol both increase sedation. Use Caution/Monitor.
- etomidate
etomidate and hydromorphone both increase sedation. Use Caution/Monitor.
- fenfluramine
hydromorphone increases and fenfluramine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- flibanserin
hydromorphone and flibanserin both increase sedation. Modify Therapy/Monitor Closely. Risk for sedation increased if flibanserin is coadministration with other CNS depressants.
- fluphenazine
hydromorphone and fluphenazine both increase sedation. Use Caution/Monitor.
- flurazepam
flurazepam and hydromorphone both increase sedation. Use Caution/Monitor.
- formoterol
hydromorphone increases and formoterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- gabapentin
gabapentin, hydromorphone. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of CNS depressants can result in serious, life-threatening, and fatal respiratory depression. Use lowest dose possible and monitor for respiratory depression and sedation.
- gabapentin enacarbil
gabapentin enacarbil, hydromorphone. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of CNS depressants can result in serious, life-threatening, and fatal respiratory depression. Use lowest dose possible and monitor for respiratory depression and sedation.
- ganaxolone
hydromorphone and ganaxolone both increase sedation. Use Caution/Monitor.
- haloperidol
haloperidol will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
hydromorphone and haloperidol both increase sedation. Use Caution/Monitor. - hydroxyzine
hydroxyzine and hydromorphone both increase sedation. Use Caution/Monitor.
- iloperidone
hydromorphone and iloperidone both increase sedation. Use Caution/Monitor.
- imipramine
hydromorphone and imipramine both increase sedation. Use Caution/Monitor.
- isoproterenol
hydromorphone increases and isoproterenol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- ketamine
ketamine and hydromorphone both increase sedation. Use Caution/Monitor.
- ketotifen, ophthalmic
hydromorphone and ketotifen, ophthalmic both increase sedation. Use Caution/Monitor.
- lasmiditan
lasmiditan, hydromorphone. Either increases effects of the other by sedation. Use Caution/Monitor. Coadministration of lasmiditan and other CNS depressant drugs, including alcohol have not been evaluated in clinical studies. Lasmiditan may cause sedation, as well as other cognitive and/or neuropsychiatric adverse reactions.
- lemborexant
lemborexant, hydromorphone. Either increases effects of the other by sedation. Modify Therapy/Monitor Closely. Dosage adjustment may be necessary if lemborexant is coadministered with other CNS depressants because of potentially additive effects.
- levalbuterol
hydromorphone increases and levalbuterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- levorphanol
hydromorphone and levorphanol both increase sedation. Use Caution/Monitor.
- lisdexamfetamine
hydromorphone increases and lisdexamfetamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- lofepramine
hydromorphone and lofepramine both increase sedation. Use Caution/Monitor.
- lofexidine
hydromorphone and lofexidine both increase sedation. Use Caution/Monitor.
- loprazolam
loprazolam and hydromorphone both increase sedation. Use Caution/Monitor.
- lorazepam
lorazepam and hydromorphone both increase sedation. Use Caution/Monitor.
- lormetazepam
lormetazepam and hydromorphone both increase sedation. Use Caution/Monitor.
- loxapine
hydromorphone and loxapine both increase sedation. Use Caution/Monitor.
- loxapine inhaled
hydromorphone and loxapine inhaled both increase sedation. Use Caution/Monitor.
- lurasidone
lurasidone, hydromorphone. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: Potential for increased CNS depressant effects when used concurrently; monitor for increased adverse effects and toxicity.
- maprotiline
hydromorphone and maprotiline both increase sedation. Use Caution/Monitor.
- maraviroc
maraviroc will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- marijuana
marijuana will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
hydromorphone and marijuana both increase sedation. Use Caution/Monitor. - melatonin
hydromorphone and melatonin both increase sedation. Use Caution/Monitor.
- meperidine
hydromorphone and meperidine both increase sedation. Use Caution/Monitor.
- meprobamate
hydromorphone and meprobamate both increase sedation. Use Caution/Monitor.
- metaproterenol
hydromorphone increases and metaproterenol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- metaxalone
metaxalone and hydromorphone both increase sedation. Use Caution/Monitor.
- methadone
hydromorphone and methadone both increase sedation. Use Caution/Monitor.
- methamphetamine
hydromorphone increases and methamphetamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- methocarbamol
methocarbamol and hydromorphone both increase sedation. Use Caution/Monitor.
- methylenedioxymethamphetamine
hydromorphone increases and methylenedioxymethamphetamine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- midazolam
midazolam and hydromorphone both increase sedation. Use Caution/Monitor.
- midazolam intranasal
midazolam intranasal, hydromorphone. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Concomitant use of barbiturates, alcohol, or other CNS depressants may increase the risk of hypoventilation, airway obstruction, desaturation, or apnea and may contribute to profound and/or prolonged drug effect.
- midodrine
hydromorphone increases and midodrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- mirtazapine
hydromorphone and mirtazapine both increase sedation. Use Caution/Monitor.
- modafinil
hydromorphone increases and modafinil decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- morphine
hydromorphone and morphine both increase sedation. Use Caution/Monitor.
- motherwort
hydromorphone and motherwort both increase sedation. Use Caution/Monitor.
- moxonidine
hydromorphone and moxonidine both increase sedation. Use Caution/Monitor.
- nabilone
hydromorphone and nabilone both increase sedation. Use Caution/Monitor.
- nalbuphine
hydromorphone and nalbuphine both increase sedation. Use Caution/Monitor.
- norepinephrine
hydromorphone increases and norepinephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- nortriptyline
hydromorphone and nortriptyline both increase sedation. Use Caution/Monitor.
- olanzapine
hydromorphone and olanzapine both increase sedation. Use Caution/Monitor.
- oliceridine
oliceridine, hydromorphone. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.
- opium tincture
hydromorphone and opium tincture both increase sedation. Use Caution/Monitor.
- orphenadrine
orphenadrine and hydromorphone both increase sedation. Use Caution/Monitor.
- oxazepam
oxazepam and hydromorphone both increase sedation. Use Caution/Monitor.
- oxycodone
hydromorphone and oxycodone both increase sedation. Use Caution/Monitor.
- oxymorphone
hydromorphone and oxymorphone both increase sedation. Use Caution/Monitor.
- paliperidone
hydromorphone and paliperidone both increase sedation. Use Caution/Monitor.
- papaveretum
hydromorphone and papaveretum both increase sedation. Use Caution/Monitor.
- papaverine
hydromorphone and papaverine both increase sedation. Use Caution/Monitor.
- parecoxib
parecoxib will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- pegvisomant
hydromorphone decreases effects of pegvisomant by unknown mechanism. Use Caution/Monitor.
- pentazocine
hydromorphone and pentazocine both increase sedation. Use Caution/Monitor.
- pentobarbital
pentobarbital and hydromorphone both increase sedation. Use Caution/Monitor.
- perampanel
perampanel and hydromorphone both increase sedation. Use Caution/Monitor.
- perphenazine
perphenazine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
hydromorphone and perphenazine both increase sedation. Use Caution/Monitor. - phendimetrazine
hydromorphone increases and phendimetrazine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- phenobarbital
phenobarbital and hydromorphone both increase sedation. Use Caution/Monitor.
- phentermine
hydromorphone increases and phentermine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- phenylephrine
hydromorphone increases and phenylephrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- phenylephrine PO
hydromorphone increases and phenylephrine PO decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor. .
- pholcodine
hydromorphone and pholcodine both increase sedation. Use Caution/Monitor.
- pimozide
hydromorphone and pimozide both increase sedation. Use Caution/Monitor.
- pirbuterol
hydromorphone increases and pirbuterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- pregabalin
pregabalin, hydromorphone. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of CNS depressants can result in serious, life-threatening, and fatal respiratory depression. Use lowest dose possible and monitor for respiratory depression and sedation.
- primidone
primidone and hydromorphone both increase sedation. Use Caution/Monitor.
- prochlorperazine
hydromorphone and prochlorperazine both increase sedation. Use Caution/Monitor.
- promethazine
promethazine and hydromorphone both increase sedation. Use Caution/Monitor.
- propafenone
propafenone will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- propofol
propofol and hydromorphone both increase sedation. Use Caution/Monitor.
- propylhexedrine
hydromorphone increases and propylhexedrine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- protriptyline
hydromorphone and protriptyline both increase sedation. Use Caution/Monitor.
- quazepam
quazepam and hydromorphone both increase sedation. Use Caution/Monitor.
- quetiapine
hydromorphone and quetiapine both increase sedation. Use Caution/Monitor.
- quinacrine
quinacrine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- ramelteon
hydromorphone and ramelteon both increase sedation. Use Caution/Monitor.
- ranolazine
ranolazine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- remimazolam
remimazolam, hydromorphone. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely. Coadministration may result in profound sedation, respiratory depression, coma, and/or death. Continuously monitor vital signs during sedation and recovery period if coadministered. Carefully titrate remimazolam dose if administered with opioid analgesics and/or sedative/hypnotics.
- risperidone
hydromorphone and risperidone both increase sedation. Use Caution/Monitor.
- ritonavir
ritonavir will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- salmeterol
hydromorphone increases and salmeterol decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- scullcap
hydromorphone and scullcap both increase sedation. Use Caution/Monitor.
- secobarbital
secobarbital and hydromorphone both increase sedation. Use Caution/Monitor.
- sertraline
sertraline will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- sevoflurane
sevoflurane and hydromorphone both increase sedation. Use Caution/Monitor.
- shepherd's purse
hydromorphone and shepherd's purse both increase sedation. Use Caution/Monitor.
- stiripentol
stiripentol, hydromorphone. Either increases effects of the other by sedation. Use Caution/Monitor. Concomitant use stiripentol with other CNS depressants, including alcohol, may increase the risk of sedation and somnolence.
- sufentanil
hydromorphone and sufentanil both increase sedation. Use Caution/Monitor.
- suvorexant
suvorexant and hydromorphone both increase sedation. Modify Therapy/Monitor Closely. Dosage adjustments of suvorexant and concomitant CNS depressants may be necessary
- tapentadol
hydromorphone and tapentadol both increase sedation. Use Caution/Monitor.
- temazepam
temazepam and hydromorphone both increase sedation. Use Caution/Monitor.
- terbutaline
hydromorphone increases and terbutaline decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- thioridazine
thioridazine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
hydromorphone and thioridazine both increase sedation. Use Caution/Monitor. - thiothixene
hydromorphone and thiothixene both increase sedation. Use Caution/Monitor.
- tipranavir
tipranavir will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- topiramate
hydromorphone and topiramate both increase sedation. Modify Therapy/Monitor Closely.
- tramadol
hydromorphone and tramadol both increase sedation. Use Caution/Monitor.
- trazodone
hydromorphone and trazodone both increase sedation. Use Caution/Monitor.
- triazolam
triazolam and hydromorphone both increase sedation. Use Caution/Monitor.
- triclofos
triclofos and hydromorphone both increase sedation. Use Caution/Monitor.
- trifluoperazine
hydromorphone and trifluoperazine both increase sedation. Use Caution/Monitor.
- trimipramine
hydromorphone and trimipramine both increase sedation. Use Caution/Monitor.
- triprolidine
triprolidine and hydromorphone both increase sedation. Use Caution/Monitor.
- venlafaxine
venlafaxine will increase the level or effect of hydromorphone by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.
- xylometazoline
hydromorphone increases and xylometazoline decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- yohimbine
hydromorphone increases and yohimbine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
- ziconotide
hydromorphone and ziconotide both increase sedation. Use Caution/Monitor.
- ziprasidone
hydromorphone and ziprasidone both increase sedation. Use Caution/Monitor.
- zotepine
hydromorphone and zotepine both increase sedation. Use Caution/Monitor.
Minor (6)
- brimonidine
brimonidine increases effects of hydromorphone by pharmacodynamic synergism. Minor/Significance Unknown. Increased CNS depression.
- dextroamphetamine
dextroamphetamine increases effects of hydromorphone by unspecified interaction mechanism. Minor/Significance Unknown.
- eucalyptus
hydromorphone and eucalyptus both increase sedation. Minor/Significance Unknown.
- lidocaine
lidocaine increases toxicity of hydromorphone by pharmacodynamic synergism. Minor/Significance Unknown. Risk of increased CNS depression.
- sage
hydromorphone and sage both increase sedation. Minor/Significance Unknown.
- ziconotide
ziconotide, hydromorphone. Mechanism: unspecified interaction mechanism. Minor/Significance Unknown. Additive decreased GI motility. Additive analgesia. Ziconotide does NOT potentiate opioid induced respiratory depression.
Adverse Effects
Frequency Not Defined
Anticholinergic: Dry mouth, palpitation, tachycardia, urinary retention
Cardiovascular: Angina pectoris, bradycardia, cardiac arrest, circulatory depression, myocardial infarction, QT-interval prolongation, severe cardiac arrhythmias, shock, ST-segment elevation, syncope, ventricular tachycardia
Central nervous system (CNS): Agitation, coma, dizziness, dysphoria, mental clouding or depression, euphoria, faintness, nervousness, restlessness, sedation, seizures, visual disturbances, weakness
Gastrointestinal (GI): Constipation, nausea, vomiting, anorexia, abdominal distention, bilieary tract spasm, decreased appetite, decreased intestinal motility, gastroesophageal reflux disease, paralytic ileus,
Respiratory: Respiratory depression, respiratory arrest, hypoxia, bronchospasm, dyspnea, rhinorrhea, flu-like symptoms (Exalgo)
Other: Flushing, pruritus, sweating, urticaria, skin rash, hyperhidrosis, warmness of face/neck/upper thorax
Postmarketing Reports
Confusional state, convulsions, drowsiness, dyskinesia, erectile dysfunction, fatigue, hepatic enzymes increased, hyperalgesia, hypersensitivity reaction, lethargy, myoclonus, oropharyngeal swelling, peripheral edema, and somnolence, serotonin syndrome, adrenal insufficiency, anaphylaxis, androgen deficiency
Warnings
Black Box Warnings
Opioid analgesic risk evaluation and mitigation strategy (REMS)
- To ensure that benefits of opioid analgesics outweigh risks of addiction, abuse, and misuse, the Food and Drug Administration (FDA) has required a REMS for these products; under requirements of the REMS, drug companies with approved opioid analgesic products must make REMS-compliant education programs available to healthcare providers
Healthcare providers are strongly encouraged to:
- Complete a REMS-compliant education program
- Counsel patients and/or their caregivers, with every prescription, on safe use, serious risks, storage, and disposal of these products
- Emphasize to patients and their caregivers the importance of reading the Medication Guide every time it is provided by their pharmacist
- Consider other tools to improve patient, household, and community safety
Hydromorphone high-potency formulation
- Hydromorphone high-potency injection is highly concentrated solution of hydromorphone, a potent Schedule II controlled opioid agonist intended for use in opioid-tolerant patients; it is not to be confused with standard parenteral formulations of hydromorphone or other opioids; overdose and death could result
- Use caution to avoid confusing the highly concentrated (Dilaudid-HP) injection with the less concentrated (Dilaudid) injectable product
- Schedule II opioid agonists (eg, morphine, oxymorphone, oxycodone, fentanyl, methadone) have highest potential for abuse and risk of producing respiratory depression
- Alcohol, other opioids, and CNS depressants (eg, sedative-hypnotics) potentiate respiratory depressant effects of hydromorphone, increasing risk of respiratory depression that might result in death
- Accidental intake may lead to fatal overdose, especially in children High potential for abuse
Risk of medication errors
- Ensure accuracy when prescribing, dispensing, and administering oral Solution; dosing errors due to confusion between mg and mL can result in accidental overdose and death
Addiction, abuse, and misuse
- Risk of opioid addiction, abuse, and misuse, which can lead to overdose and death
- Assess each patient’s risk prior to prescribing and monitor all patients regularly for the development of these behaviors or conditions
Life-threatening respiratory depression
- Serious, life-threatening, or fatal respiratory depression may occur
- Monitor for respiratory depression, especially during initiation or following a dose increase
- Instruct patients to swallow tablet/capsule whole; crushing, chewing, or dissolving can cause rapid release and absorption of a potentially fatal dose
Accidental exposure
- Accidental of even 1 dose, especially by children, can result in a fatal overdose
Neonatal opioid withdrawal syndrome
- Prolonged use during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts
- Syndrome presents as irritability, hyperactivity and abnormal sleep pattern, high pitched cry, tremor, vomiting, diarrhea and failure to gain weight
- Onset, duration, and severity of neonatal opioid withdrawal syndrome vary based on the specific opioid used, duration of use, timing and amount of last maternal use, and rate of elimination of the drug by the newborn
- If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available
Risks from concomitant use with benzodiazepines or other CNS depressants
- Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death.
- Reserve concomitant prescribing of oral solution or tablets and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate
- Limit dosages and durations to the minimum required
- Follow patients for signs and symptoms of respiratory depression and sedation
Contraindications
Hypersensitivity
Dilaudid Liquid and Tablets
- Obstetrical analgesia
- Acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment
- Known or suspected gastrointestinal obstruction, including paralytic ileus
- Hypersensitivity to hydromorphone, hydromorphone salts, any other components of the product, or sulfite-containing medications (e.g., anaphylaxis)
Suppository
- Increased intracranial pressure resulting from intracranial lesion; conditions resulting in depressed ventilatory function including COPD, emphysema, status asthmaticus, kyphoscoliosis, cor pulmonale
Dilaudid injection
- Dilaudid HP: Paralytic ileus, opioid nontolerant patients, known ro suspected pre-existing GI surgery or diseases resulting in narrowing of GI tract loops in the GI tract or GI obstruction
- Dilaudid HP is contraindicated in non-opioid tolerant patients
Extended-release (Exalgo)
- Opioid nontolerant patients
- Paralytic ileus, opioid nontolerant patients, known ro suspected pre-existing GI surgery or diseases resulting in narrowing of GI tract loops in the GI tract or GI obstruction
- Significant respiratory depression
- Acute or severe bronchial asthma
Cautions
Dosing errors can result in accidental overdose and death; ensure dose is communicated clearly and dispensed accurately; a household teaspoon or tablespoon is not an adequate measuring device; given inexactitude of household spoon measure and possibility of using a tablespoon instead of a teaspoon, which could lead to overdosage, the enclosed measuring device should be used or a calibrated measuring device obtained from the pharmacist; health care providers should recommend a calibrated device that can measure and deliver the prescribed dose accurately, and instruct caregivers to use extreme caution in measuring the dosage
Opioids can cause sleep-related breathing disorders including central sleep apnea (CSA) and sleep-related hypoxemia; opioid use increases risk of CSA in a dose-dependent fashion; in patients who present with CSA, consider decreasing opioid dosage using best practices for opioid taper
The oral solution or tablets are contraindicated in patients with known or suspected gastrointestinal obstruction, including paralytic ileus; may cause spasm of sphincter of Oddi; opioids may cause increases in serum amylase; monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms
Avoid use of mixed agonist/antagonist (e.g., pentazocine, nalbuphine, and butorphanol) or partial agonist (e.g., buprenorphine) analgesics in patients who are receiving a full opioid agonist analgesic; mixed agonist/antagonist and partial agonist analgesics may reduce analgesic effect and/or precipitate withdrawal symptoms
Patients with significant chronic obstructive pulmonary disease or cor pulmonale, and those with a substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression are at increased risk of decreased respiratory drive including apnea, even at recommended dosages; monitor such patients closely, particularly when initiating and titrating dosages
Do not abruptly discontinue buprenorphine in a patient physically dependent on opioids; when discontinuing therapy, in a physically dependent patient, gradually taper the dosage; rapid tapering in a patient physically dependent on opioids may lead to a withdrawal syndrome and return of pain
May impair physical or mental abilities; use caution when performing work that require mental alertness such as operating machinery or driving
Myoclonus and seizures reported with high doses; use caution in patients with history of seizure disorders
Use with caution in patients with hypersensitivity reactions to other phenanthrene derivative opioid agonists, including codeine, hydrocodone, levorphanol, oxycodone, oxymorphone
May cause hyptension especially in patients with cardiovascular disease or hypovolemia; may cause severe hypertension, including orthostatic hypotension and syncope; use caution in patients taking drugs that may exagerate hypotensive effects, including phenothiazines or general anesthetics; avoid use in patients with circultory shock; may reduce cardiac output and blood pressure
May prevent diagnosis of patients with acute abdominal conditions
Use caution in patients with biliary tract dysfunction
Use caution in patients with inflammatory or obstructive bowel disorder, acute pancreatitis secondary to biliary tract disease, and patients undergoing biliary surgery
Cases of adrenal insufficiency have been reported with opioid use, more often following greater than one month of use; if adrenal insufficiency suspected, confirm diagnosis with diagnostic testing as soon as possible; if diagnosed, treat with physiologic replacement doses of corticosteroids; wean patient off of opioid to allow adrenal function to recover and continue corticosteroid treatment until adrenal function recovers; other opioids may be tried as some cases reported use of different opioid without recurrence of adrenal insufficiency
In patients who may be susceptible to intracranial effects of CO2 retention (eg, those with evidence of increased intracranial pressure or brain tumors), therapy may reduce respiratory drive, and resultant CO2 retention can further increase intracranial pressure; monitor such patients for signs of sedation and respiratory depression, particularly when initiating therapy
Use cuation in delirium tremens
Long-term opioid use may cause secondary hypogonadism, which may lead to sexual dysfunction, infertility, mood disorders, and osteoporosis
Use caution in renal/hepatic impairment, obesity, prostatic hyperplasia/urinary stricture, psychoses, respiratory disease or thyroid dysfunction
Use within 14 days of MAO intake not recommended
Controlled-release formulation should only be used when continuous analgesia is required over an extended period of time; not for use PRN
IM formulation may result in variable absorption and a lag time to peak effect
Tailor opioid-containing analgesic regimen to each patient's needs
May cause constipation; consider preventive measures to reduce potential of constipation; use with caution in patients with chronic constipation
Use caution in patients who are morbidly obese
Some formulations may contain lactose; consider lactose content prior to initiating therapy in patients with hereditary disease of galatose intolerance
Vial stoppers of single-dose injectable vials may contain latex
Some dosage forms may contain trace amounts of sodium metabisulfite, which may cause allergic reactions
Opioid analgesic risk evaluation and mitigation strategy (REMS)
- To ensure that benefits of opioid analgesics outweigh risks of addiction, abuse, and misuse, the Food and Drug Administration (FDA) has required a Risk Evaluation and Mitigation Strategy (REMS) for these products
- Discuss the safe use, serious risks, and proper storage and disposal of opioid analgesics with patients and/or their caregivers every time these medicines are prescribed; use the following link to obtain the Patient Counseling Guide (PCG): www.fda.gov/OpioidAnalgesicREMSPCG
- Emphasize to patients and their caregivers the importance of reading the Medication Guide that they will receive from their pharmacist every time an opioid analgesic is dispensed to them
- Consider using other tools to improve patient, household, and community safety, such as patient-prescriber agreements that reinforce patient-prescriber responsibilities
- To obtain further information on opioid analgesic REMS and for a list of accredited REMS CME/CE, call 1-800-503-0784, or log on to www.opioidanalgesicrems.com; the FDA Blueprint can be found at www.fda.gov/OpioidAnalgesicREMSBlueprint
Long-acting opioids
- Schedule II opioid analgesics expose users to the risks of addiction, abuse, and misuse; there is a greater risk for overdose and death with extended-release opioids due to the larger amount of active opioid present (see Black Box Warnings)
- Although risk of addiction in any individual is unknown, it can occur in patients appropriately prescribed opiates; addiction can occur at recommended dosages; assess each patient’s risk for opioid addiction, abuse, or misuse prior to prescribing; monitor all patients receiving therapy for the development of these behaviors and conditions; potential for these risks should not prevent proper management of pain in any given patient; intensive monitoring is necessary
- Serious, life-threatening, or fatal respiratory depression reported with use of opioids, even when used as recommended; management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on patient’s clinical status
- Risk of respiratory depression is greatest during initiation of therapy or following a dosage increase; monitor patients closely for respiratory depression, especially within first 24-72 hr of initiating therapy and following dosage increases
- Accidental exposure reported, including fatalities (see Black Box Warnings)
- Neonatal opioid withdrawal syndrome, unlike opioid withdrawal syndrome in adults, may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts; advise pregnant women using opioids for a prolonged period of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available (see Black Box Warnings)
- Profound sedation, respiratory depression, coma, and death may result from concomitant use with benzodiazepines or other CNS depressants; because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate; if decision is made to prescribe a benzodiazepine or other CNS depressant concomitantly with an opioid analgesic, prescribe lowest effective dosages and minimum durations of concomitant use; if concomitant use is warranted, consider prescribing naloxone for emergency treatment of opioid overdose
- Life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients as they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients
- Due to risk of respiratory depression with concomitant use of skeletal muscle relaxants and opioids, consider prescribing naloxone for emergency treatment of opioid overdose
Patient access to naloxone for emergency treatment of opioid overdose
- Assess potential need for naloxone; consider prescribing for emergency treatment of opioid overdose
- Consult on availability and ways to obtain naloxone as permitted by individual state naloxone dispensing and prescribing requirements or guidelines
- Educate patients regarding the signs and symptoms of respiratory depression and to call 911 or seek immediate emergency medical help in the event of a known or suspected overdose
Pregnancy & Lactation
Pregnancy category: C
Lactation: Drug excreted in breast milk; use not recommended
Pregnancy Categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available.Pharmacology
Mechanism of Action
Mu-opioid receptor agonist; inhibits ascending pain pathways, thus altering response to pain; main therapeutic action is analgesia
Other pharmacologic effects include respiratory depression and sedation; suppresses cough by acting centrally in medulla
Absorption
Bioavailability: 62%
Onset: 15-30 min (PO); 15 min (SC); 15 min (IM); 5 min (IV); 15-30 min (PR); 6 hr (ER)
Duration: 3-4 hr (PO/IV); extended-release (13 hr)
Peak plasma time: 30-60 min (PO); SC, 30-90 min; IM, 30-60 min; IV, 15-30 min; PR, 30-90 min
Distribution
Protein bound: 8-19%
Vd: 4 L/kg
Metabolism
Metabolized in liver to CYP2D6 via conjugation with glucuronic acid to active metabolite only
Elimination
Half-life: 2-3 hr (immediate-release); 11 hr (extended-release)
Excretion: Urine (primarily)
Administration
IV Incompatibilities
Additive: Sodium bicarbonate, thiopental
Syringe: Ampicillin, diazepam, hyaluronidase, phenobarbital, phenytoin
Y-site: Amphotericin B cholesteryl sulfate complex, diazepam, minocycline, phenobarbital, phenytoin, sargramostim, tetracycline, thiopental
IV/IM Administration
May be given IV, SC, or IM
Direct injection: Dilute to 4-5 mL with NS or SWI, and administer over at least 2-3 minutes or give 2 mg over 3-5 minutes
Intermittent administration: Dilute in 50-100 mL D5W or NS, and infuse over 15-30 minutes
IV administration (eg, rapid IV push) has been associated with increased systemic effects, especially respiratory depression and hypotension
Monitor patient constantly; keep resuscitation equipment and narcotic antagonist (eg, naloxone) readily available
IV Preparation
Direct injection: Dilute to 4-5 mL with NS or SWI
Continuous infusion: Dilute in 100-1000 mL of D5W, NS, D5/NS, D5½NS, Ringer solution, or LR
Solution may appear slightly yellow; this does not alter potency
Vial stopper contains latex
Storage
Store at 25°C (77°F)
Images
| BRAND | FORM. | UNIT PRICE | PILL IMAGE |
|---|---|---|---|
| hydromorphone rectal - | 3 mg suppos |  | |
| Dilaudid oral - | 4 mg tablet |  | |
| Dilaudid oral - | 8 mg tablet |  | |
| Dilaudid oral - | 2 mg tablet |  | |
| hydromorphone oral - | 2 mg tablet | | |
| hydromorphone oral - | 4 mg tablet | | |
| hydromorphone oral - | 2 mg tablet |  | |
| hydromorphone oral - | 4 mg tablet |  | |
| hydromorphone oral - | 32 mg tablet |  | |
| hydromorphone oral - | 16 mg tablet |  | |
| hydromorphone oral - | 12 mg tablet |  | |
| hydromorphone oral - | 2 mg tablet |  | |
| hydromorphone oral - | 4 mg tablet |  | |
| hydromorphone oral - | 2 mg tablet |  | |
| hydromorphone oral - | 8 mg tablet |  | |
| hydromorphone oral - | 4 mg tablet |  | |
| hydromorphone oral - | 8 mg tablet |  | |
| hydromorphone oral - | 8 mg tablet |  | |
| hydromorphone oral - | 8 mg tablet |  | |
| hydromorphone oral - | 1 mg/mL liquid |  | |
| hydromorphone oral - | 8 mg tablet |  | |
| hydromorphone oral - | 4 mg tablet |  | |
| hydromorphone oral - | 8 mg tablet |  | |
| hydromorphone injection - | 2 mg/mL vial |  | |
| hydromorphone injection - | 2 mg/mL vial |  | |
| hydromorphone injection - | 2 mg/mL vial |  | |
| hydromorphone injection - | 2 mg/mL vial |  | |
| hydromorphone injection - | 2 mg/mL vial |  | |
| hydromorphone injection - | 2 mg/mL vial |  | |
| hydromorphone injection - | 2 mg/mL vial |  | |
| hydromorphone injection - | 2 mg/mL solution |  | |
| hydromorphone injection - | 4 mg/mL solution |  | |
| hydromorphone injection - | 1 mg/mL solution |  |
Copyright © 2010 First DataBank, Inc.
Patient Handout
hydromorphone rectal
HYDROMORPHONE SUPPOSITORY - RECTAL
(hye-droe-MOR-fone)
COMMON BRAND NAME(S): Dilaudid
WARNING: Hydromorphone has a risk for abuse and addiction, which can lead to overdose and death. Hydromorphone may also cause severe, possibly fatal, breathing problems. To lower your risk, your doctor should have you use the smallest dose of hydromorphone that works, and use it for the shortest possible time. See also How to Use section for more information about addiction.Ask your doctor or pharmacist if you should have naloxone available to treat opioid overdose. Teach your family or household members about the signs of an opioid overdose and how to treat it.The risk for severe breathing problems is higher when you start this medication and after a dose increase, or if you use the wrong dose/strength. Using this medication with alcohol or other drugs that can cause drowsiness or breathing problems may cause very serious side effects, including death. Be sure you know how to use hydromorphone and what other drugs you should avoid using with it. See also Drug Interactions section. Get medical help right away if any of these very serious side effects occur: slow/shallow breathing, unusual lightheadedness, severe drowsiness/dizziness, difficulty waking up.Keep this medicine in a safe place to prevent theft, misuse, or abuse. If someone accidentally swallows this drug, get medical help right away.Before using this medication, women of childbearing age should talk with their doctor(s) about the risks and benefits. Tell your doctor if you are pregnant or if you plan to become pregnant. During pregnancy, this medication should be used only when clearly needed. It may slightly increase the risk of birth defects if used during the first two months of pregnancy. Also, using it for a long time or in high doses near the expected delivery date may harm the unborn baby. To lessen the risk, use the smallest effective dose for the shortest possible time. Babies born to mothers who use this drug for a long time may develop severe (possibly fatal) withdrawal symptoms. Tell the doctor right away if you notice any symptoms in your newborn baby such as crying that doesn't stop, slow/shallow breathing, irritability, shaking, vomiting, diarrhea, poor feeding, or difficulty gaining weight.
USES: Hydromorphone is used to treat moderate to severe pain. It acts on certain centers in the brain to give you pain relief. This medication is an opioid pain reliever.
HOW TO USE: Wash your hands before and after using the suppository. Unwrap and insert one suppository into the rectum as directed by your doctor. Lie down on your left side with right knee bent. Gently push the suppository into the rectum with your finger. Remain lying down for a few minutes, and avoid having a bowel movement for an hour or longer so the drug will be absorbed. The suppository is for use in the rectum only.If you have nausea, ask your doctor or pharmacist about ways to decrease nausea (such as lying down for 1 to 2 hours with as little head movement as possible).The dosage is based on your medical condition and response to treatment. Do not increase your dose, use the medication more often, or use it for a longer time than prescribed. Properly stop the medication when so directed.Pain medications work best if they are used when the first signs of pain occur. If you wait until the pain has worsened, the medication may not work as well.Suddenly stopping this medication may cause withdrawal, especially if you have used it for a long time or in high doses. To prevent withdrawal, your doctor may lower your dose slowly. Tell your doctor or pharmacist right away if you have any withdrawal symptoms such as restlessness, mental/mood changes (including anxiety, trouble sleeping, thoughts of suicide), watering eyes, runny nose, nausea, diarrhea, sweating, muscle aches, or sudden changes in behavior.When this medication is used for a long time, it may not work as well. Talk with your doctor if this medication stops working well.Though it helps many people, this medication may sometimes cause addiction. This risk may be higher if you have a substance use disorder (such as overuse of or addiction to drugs/alcohol). Use this medication exactly as prescribed to lower the risk of addiction. Ask your doctor or pharmacist for more details.Tell your doctor if your pain does not get better or if it gets worse.
SIDE EFFECTS: See also Warning section.Nausea, vomiting, constipation, lightheadedness, dizziness, drowsiness, increased sweating, or dry mouth may occur. If any of these effects last or get worse, tell your doctor or pharmacist promptly.To prevent constipation, eat dietary fiber, drink enough water, and exercise. You may also need to take a laxative. Ask your pharmacist which type of laxative is right for you.To reduce the risk of dizziness and lightheadedness, get up slowly when rising from a sitting or lying position.Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Tell your doctor right away if you have any serious side effects, including: interrupted breathing during sleep (sleep apnea), mental/mood changes (such as agitation, hallucinations, confusion), difficulty urinating, vision changes, slow/fast heartbeat, severe stomach/abdominal pain, signs of your adrenal glands not working well (such as loss of appetite, unusual tiredness, weight loss).Get medical help right away if you have any very serious side effects, including: slow/shallow breathing, fainting, seizures, severe drowsiness/difficulty waking up.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
PRECAUTIONS: Before using hydromorphone, tell your doctor or pharmacist if you are allergic to it; or to other opioid pain medications (such as hydrocodone, morphine); or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: kidney disease, liver disease, lung disease (such as asthma, chronic obstructive pulmonary disease-COPD), a certain spinal problem (kyphoscoliosis), breathing problems (such as slow/shallow breathing, sleep apnea), certain heart problems (irregular heartbeat), personal or family history of a substance use disorder (such as overuse of or addiction to drugs/alcohol), brain disorders (such as seizures, head injury, tumor, increased intracranial pressure), underactive thyroid (hypothyroidism), difficulty urinating (for example, due to enlarged prostate or narrowed urethra), disease of the pancreas (such as pancreatitis), mental/mood disorders (such as toxic psychosis), gallbladder disease, adrenal gland problem (such as Addison's disease), intestinal disorders (such as colitis, blockage, paralytic ileus, infectious diarrhea).This drug may make you dizzy or drowsy. Alcohol or marijuana (cannabis) can make you more dizzy or drowsy. Do not drive, use machinery, or do anything that needs alertness until you can do it safely. Avoid alcoholic beverages. Talk to your doctor if you are using marijuana (cannabis).Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).Older adults may be more sensitive to the side effects of this drug, especially confusion, dizziness, drowsiness, and slow/shallow breathing.During pregnancy, this medication should be used only when clearly needed. It may harm an unborn baby. Discuss the risks and benefits with your doctor. (See also Warning section.)This drug passes into breast milk and the effect on a nursing infant is not known. Discuss the risks and benefits with your doctor before breast-feeding.
DRUG INTERACTIONS: See also Warning section.Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.Some products that may interact with this drug include: certain pain medications (mixed opioid agonist-antagonists such as butorphanol, nalbuphine, pentazocine), naltrexone, samidorphan.The risk of serious side effects (such as slow/shallow breathing, severe drowsiness/dizziness) may be increased if this medication is used with other products that may also cause drowsiness or breathing problems. Tell your doctor or pharmacist if you are using other products such as other opioid pain or cough relievers (such as codeine, hydrocodone), alcohol, marijuana (cannabis), drugs for sleep or anxiety (such as alprazolam, lorazepam, zolpidem), muscle relaxants (such as carisoprodol, cyclobenzaprine), or antihistamines (such as cetirizine, diphenhydramine).Check the labels on all your medicines (such as allergy or cough-and-cold products) because they may contain ingredients that cause drowsiness. Ask your pharmacist about using those products safely.This medication may interfere with certain lab tests (such as amylase and lipase levels), possibly causing false test results. Make sure lab personnel and all your doctors know you use this drug.
OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, give them naloxone if available, then call 911. If the person is awake and has no symptoms, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: slow/shallow breathing, severe drowsiness, slow heartbeat, severe dizziness, pinpoint pupils, coma.
NOTES: Do not share this medication with others. Sharing it is against the law.This medication has been prescribed for your current condition only. Do not use it later for another condition unless told to do so by your doctor. A different medication may be necessary in that case.
MISSED DOSE: If you use this medication regularly and miss a dose, use it as soon as you remember. If it is near the time of the next dose, skip the missed dose. Use your next dose at the regular time. Do not double the dose to catch up.
STORAGE: Store in the refrigerator away from light. Do not store in the bathroom. Keep all medications away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.
Information last revised June 2023. Copyright(c) 2023 First Databank, Inc.
IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.
Formulary
Adding plans allows you to compare formulary status to other drugs in the same class.
To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.
Adding plans allows you to:
- View the formulary and any restrictions for each plan.
- Manage and view all your plans together – even plans in different states.
- Compare formulary status to other drugs in the same class.
- Access your plan list on any device – mobile or desktop.
