Section 19 · Monograph
Hydromorphone
Reviewed Nov 2026FDA label
DilaudidOpioid agonist (CII)
- Forms
- Tab: 2, 4, 8mg | Soln: 1mg/mL | Inj: 1, 2, 4mg/mL
- Dose
- Opioid-naive: 1-2mg PO every 4-6h as needed; IV 0.2-1mg every 2-3h; preferred over morphine in renal impairment
- MOA
- μ-opioid receptor agonism
Black Box Warning
- Addiction, abuse and misuse; life-threatening respiratory depression; accidental ingestion; neonatal opioid withdrawal syndrome; risks from concomitant use with benzodiazepines or other CNS depressants; opioid analgesic REMS
Indications
- Management of pain severe enough to require an opioid analgesicFDA-labeled
Mechanism of Action
- Semisynthetic full mu-opioid agonist; metabolite H3G can accumulate in renal failure and cause neuroexcitation
Full Dosing
Adult / usual
- Opioid-naive: 1-2mg PO every 4-6 hours as needed (label 2-4mg); IV 0.2-1mg every 2-3 hours as needed
- Approximate potency: 1.5mg IV or 7.5mg PO hydromorphone is roughly equivalent to 10mg IV or 30mg PO morphine — use a conversion table with dose reduction for incomplete cross-tolerance
Renal
- Often preferred over morphine in renal impairment
Contraindications
- Significant respiratory depression
- Acute or severe bronchial asthma in an unmonitored setting
- Known or suspected gastrointestinal obstruction
- Hypersensitivity to hydromorphone
Drug Interactions
- Benzodiazepines, gabapentinoids, alcohol and other CNS depressants
- Serotonergic drugs and MAO inhibitors
Adverse Effects
- Constipation, nausea, sedation
- Respiratory depression
- Myoclonus and neuroexcitation at high doses in renal failure
- Pruritus, urinary retention
Monitoring Parameters
- Sedation, respiratory rate and pain control
- Bowel function
- Renal function
Pregnancy & Lactation
- Neonatal opioid withdrawal syndrome with prolonged use
- Present in milk; monitor infants