Hydromorphone

DILAUDID

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Pronunciation: hye-droe-MOR-foen

Hydromorphone ballicule: receptor binding, kinetics and half-life diagram — Mechanism of action: Hydromorphone ballicule

Hydromorphone DILAUDID mascot mnemonic cartoon — Visual mnemonic: Hydromorphone mascot
**“Dial, you did (to say) Hi (on) more phones”**
pinpoint pupils → opioid
Several opioids are metabolized to hydromorphone, “All lines lead to hydro–”more phones”

What it isPotent full mu-opioid agonist; severe pain.

Why this oneIt has no analgesically active metabolite and releases less histamine than morphine, useful when morphine is poorly tolerated.

What limits itConversion errors can be fatal because of its potency; its glucuronide still accumulates in renal failure and can cause myoclonus.

Hydromorphone molecular structure (skeletal formula) — Molecular structure: Hydromorphone

FDA-approved for

pain (~1984)

FDA label

Read the full label on DailyMed ↗

BOXED WARNING Addiction/abuse/misuse; life-threatening respiratory depression; accidental ingestion can be fatal; neonatal opioid withdrawal; profound sedation/death with benzodiazepines or CNS depressants; REMS

FDA dosing	Population	Start	Target	Max
Pain (severe, requiring opioid)	opioid-naive adult	2-4 mg PO q4-6h PRN

Renal Start at 1/4 to 1/2 usual starting dose per degree of impairment

Hepatic Start at 1/4 to 1/2 usual starting dose per degree of impairment; severe impairment not studied

When converting from another opioid, start at ~half the usual dose

Instructions

Use lowest effective dose for shortest duration
Supplemental dose 5-15% of total daily dose q2h PRN
Do not stop abruptly in physically dependent patients; taper ~10-25% every 2-4 weeks
Ensure access to an opioid overdose reversal agent (naloxone/nalmefene)

Available strengths

tab 2, 4, 8 mg
ER tab 8, 12, 16, 24, 32 mg
sol 40 mg/20 mL
sol 5 mg/5 mL
supp 3 mg
inj 0.2, 1, 2, 4, 10 mg/mL

Contraindications

Significant respiratory depression
Acute or severe bronchial asthma (unmonitored / no resuscitative equipment)
Known or suspected GI obstruction, including paralytic ileus
Known sulfite hypersensitivity

Cautions

Opioid-induced hyperalgesia/allodynia
Respiratory depression in COPD, elderly, cachectic, or debilitated patients
Adrenal insufficiency
Severe hypotension; avoid in circulatory shock
Avoid with increased ICP, brain tumor, head injury, or impaired consciousness
Serotonin syndrome with serotonergic drugs
Seizures

Adverse reactions

Lightheadedness, dizziness, sedation
Nausea, vomiting
Sweating, flushing
Dysphoria/euphoria, dry mouth
Pruritus
Constipation

Pregnancy No human data; prolonged use may cause neonatal opioid withdrawal syndrome; not recommended during labor

Lactation Low levels in human milk; monitor infant for sedation and respiratory depression

Cost

Hydromorphone (DILAUDID)

What pharmacies pay · NADAC 9/30/26

Strength		#/mo	generic $/unit	CostPlus
2 mg	tab	per unit	$0.17/ea	not offered
4 mg	tab	per unit	$0.22/ea	not offered
8 mg	tab	per unit	$0.56/ea	not offered

Other forms: Hydromorphone ER (EXALGO)

Generic entry1995

⚠ BOXED WARNINGS

Addiction, abuse and misuse
Life-threatening respiratory depression
Risk from concomitant use with benzodiazepines

Classes and tags

Clinical profile

Therapeutic safety burden3 / 4

Overdose danger4 / 4

Weight-gain liability0 / 4

Sedation liability2 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk2 / 4

Legacy pregnancy categoryC

Defining liabilityRespiratory depression, dependence and overdose; risk rises sharply with sedatives or impaired clearance.

Serotonicity

This drug is routinely called serotonergic. By Gillman’s human-effect criteria it does not raise serotonin in the synapse.

Opioid effects and respiratory/CNS-depressant interactions remain important, but this drug is not a clinically significant SRI by the Gillman framework.

Gillman’s four human testsA measurable SERT affinity that fails all four is not clinical serotonicity.