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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).

• 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 to 5 (eGFR less than 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.

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.

Hydromorphone is approximately 7.5 times more potent than morphine.

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• 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.

• 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.
• At high background maintenance doses of long acting hydromorphone, the burden of the number of immediate release hydromorphone capsules for the breakthrough analgesic dose should be considered.