Dilaudid-5

Dosage Forms And Strengths

DILAUDID INJECTION: Each 1 mL colorless ampule contains 1 mg/mL, 2 mg/mL, or 4 mg/mL of hydromorphone hydrochloride in a sterile, aqueous solution.

DILAUDID-HP INJECTION (for use in opioid-tolerant patients only): Each amber ampule and amber single-dose vial contains 10 mg/mL of hydromorphone hydrochloride in a sterile, aqueous solution and is available in 1 mL or 5 mL ampules or in 50 mL single-dose vials†.

DILAUDID-HP INJECTION Sterile Lyophilized Powder: Each amber, single-dose vial† contains 250 mg of sterile, lyophilized hydromorphone hydrochloride to be reconstituted with 25 mL of Sterile Water for Injection USP to provide a solution containing 10 mg/mL.

†The Stoppers Of These Products Contain Natural Rubber Latex.

Storage And Handling

Safety And Handling Instructions

DILAUDID INJECTION and DILAUDID-HP INJECTION pose little risk of direct exposure to health care personnel and should be handled and disposed of prudently in accordance with hospital or institutional policy. When DILAUDID INJECTION or DILAUDID-HP INJECTION is no longer needed, any unused liquid should be destroyed by flushing it down the toilet.

Access to drugs with a potential for abuse such as DILAUDID INJECTION and DILAUDID-HP INJECTION presents an occupational hazard for addiction in the health care industry. Routine procedures for handling controlled substances developed to protect the public may not be adequate to protect health care workers. Implementation of more effective accounting procedures and measures to restrict access to drugs of this class (appropriate to the practice setting) may minimize the risk of self-administration by health care providers.

How Supplied

Dilaudid Injection

Dilaudid Injection (hydromorphone hydrochloride) is supplied in COLORLESS ampules. Each 1 mL of sterile, aqueous solution contains 1 mg, 2 mg, or 4 mg hydromorphone hydrochloride with 0.2% sodium citrate and 0.2% citric acid solution. Dilaudid Injection contains no added preservative and is supplied as follows:

NDC 59011-441-10: Box of ten 1 mL (1 mg/mL) ampules
NDC 59011-442-10: Box of ten 1 mL (2 mg/mL) ampules
NDC 59011-442-25: Box of twenty-five 1 mL (2 mg/mL) ampules
NDC 59011-444-10: Box of ten 1 mL (4 mg/mL) ampules

Dilaudid-HP Injection

Dilaudid-HP Injection (hydromorphone hydrochloride) is supplied in AMBER ampules, and AMBER single-dose vials. Each ampule and single-dose vial of sterile aqueous solution contains 10 mg of hydromorphone hydrochloride with 0.2% sodium citrate and 0.2% citric acid solution.

Dilaudid-HP Injection Sterile Lyophilized Powder is supplied in an AMBER single-dose vial. Each vial contains 250 mg of sterile, lyophilized hydromorphone hydrochloride.

Dilaudid-HP Injection contains no added preservative and is supplied as follows:

NDC 59011-445-01: Box of ten 1 mL (10 mg/mL) ampules
NDC 59011-445-05: Box of ten 5 mL (10 mg/mL) ampules
†NDC 59011-445-50: One 50 mL (10 mg/mL) single-dose vial with black rubber stopper and white flip-top/tear-off seal.
†NDC 59011-446-25: One 250 mg single-dose vial with black rubber stopper and black flip-top seal.

†The Stoppers for These Products Contain Natural Rubber Latex

Storage

PROTECT FROM LIGHT.

Keep covered in carton until time of use. Store at 20° to 25°C (68° to 77°F); excursions permitted to 15° to 30°C (59° to 86°F).

Healthcare professionals can telephone Purdue Pharma L.P.'s Medical Services Department (1-888-726-7535) for information on this product.

CAUTION: DEA Order Form Required.

Manufactured by Hospira, Inc., Lake Forest, IL 60045, U.S.A., For Purdue Pharma L.P. Stamford, CT 06901-3431. Revised: Oct 2011

DILAUDID INJECTION is indicated for the management of pain in patients where an opioid analgesic is appropriate.

DILAUDID-HP INJECTION is indicated for the management of moderate-to-severe pain in opioid-tolerant patients who require higher doses of opioids.

General Dosing Considerations

Take care when prescribing and administering Dilaudid and Dilaudid-HP Injection to avoid dosing errors due to confusion between the different concentrations and between mg and mL, which could result in accidental overdose and death. Take care to ensure the proper dose is communicated and dispensed. When writing prescriptions, include both the total dose in mg and the total volume of the dose.

Selection of patients and administration of Dilaudid and Dilaudid-HP injection should be governed by the same principles that apply to the use of similar opioid analgesics to treat patients with acute or chronic pain, and depends upon a comprehensive assessment of the patient. Individualize treatment in every case, using non-opioid analgesics, opioids on an as-needed basis and/or combination products, and chronic opioid therapy in a progressive plan of pain management such as outlined by the World Health Organization, the Agency for Healthcare Research and Quality, and the American Pain Society.

The nature of the pain (severity, frequency, etiology, and pathophysiology), as well as the medical status of the patient, will affect selection of the starting dosage. Opioid analgesics, including DILAUDID INJECTION and DILAUDID-HP INJECTION, have a narrow therapeutic index in certain patient populations, especially when combined with CNS depressant drugs, and should be reserved for cases where the benefits of opioid analgesia outweigh the known risks.

Individualization Of Dosing

Initiate the dosing regimen for each patient individually, taking into account the patient's prior analgesic treatment. Give attention to the following:

• the age, general condition, and medical status of the patient;
• the patient's degree of opioid tolerance;
• the daily dose, potency, and specific characteristics of the opioid the patient has been taking previously;
• concurrent medications
• the type and severity of the patient's pain
• risk factors for abuse or addiction; including whether the patient has a previous or current substance abuse problem, a family history of substance abuse, or a history of mental illness or depression;
• the balance between pain control and adverse reactions.

Periodic reassessment after the initial dosing of DILAUDID INJECTION and DILAUDID-HP INJECTION is required. If pain management is not satisfactory, and opioid-induced adverse events are tolerable, the hydromorphone dose may be increased gradually. If excessive opioid side effects are observed early in the dosing interval, reduce the hydromorphone hydrochloride dose. If this results in breakthrough pain at the end of the dosing interval, the dosing interval may need to be shortened. Dose titration should be guided more by the need for analgesia and the severity of adverse events than the absolute dose of opioid employed.

Initiation Of Therapy In Opioid-Naïve Patients

Always initiate dosing in opioid-naïve patients using Dilaudid Injection. Never administer Dilaudid-HP injection to opioid-naïve patients.

Subcutaneous or Intramuscular Administration

The usual starting dose of Dilaudid Injection is 1 mg to 2 mg every 2 to 3 hours as necessary. Depending on the clinical situation, the initial starting dose may be lowered in patients who are opioid naïve. Adjust the dose according to the severity of pain, the severity of adverse events, as well as the patient's underlying disease and age.

Intravenous Administration

The initial starting dose is 0.2 to 1 mg every 2 to 3 hours. Intravenous administration should be given slowly, over at least 2 to 3 minutes, depending on the dose. Titrate the dose to achieve acceptable analgesia and tolerable adverse events. The initial dose should be reduced in the elderly or debilitated and may be lowered to 0.2 mg.

Hepatic Impairment

Start patients with hepatic impairment on one-fourth to one-half the usual DILAUDID INJECTION starting dose depending on the extent of impairment.

Renal Impairment

Start patients with renal impairment on one-fourth to one-half the usual DILAUDID INJECTION starting dose depending on the degree of impairment.

Conversion From Prior Opioid

Use the equianalgesic dose table below (Table 1) as a guide to determine the appropriate dose of DILAUDID INJECTION. Convert the current total daily amount(s) of opioid(s) received to an equivalent total daily dose of DILAUDID

INJECTION and reduce by one-half due to the possibility of incomplete cross tolerance. Divide the new total amount by the number of doses permitted based on dosing interval (e.g., 8 doses for every-three-hour dosing). Titrate the dose according to the patient's response. For opioids not in Table 1, first estimate the daily amount of morphine that is equivalent to the current total daily amount of other opioid(s) received, then use Table 1 to find the approximate equivalent total daily dose of DILAUDID INJECTION.

Table 1: OPIOID ANALGESIC EQUIVALENTS WITH APPROXIMATELY EQUIANALGESIC POTENCY FOR CONVERSION TO DILAUDID INJECTION*

DILAUDID-HP Injection (for use in opioid-tolerant patients only)

Do not use DILAUDID-HP for patients who are not tolerant to the respiratory depressant or sedating effects of opioids. Patients considered opioid tolerant are those who are taking at least 60 mg oral morphine/day, 25 mcg transdermal fentanyl/hour, 30 mg oral oxycodone/day, 8 mg oral hydromorphone/day, 25 mg oral oxymorphone/day, or an equianalgesic dose of another opioid for one week or longer.

Use DILAUDID-HP ONLY for patients who require the higher concentration and lower total volume of DILAUDID-HP.

Because of its high concentration, the delivery of precise doses of DILAUDID-HP INJECTION may be difficult if low doses of hydromorphone are required. Therefore, use DILAUDID-HP INJECTION only if the amount of hydromorphone required can be delivered accurately with this formulation.

Base the starting dose for DILAUDID-HP INJECTION on the prior dose of DILAUDID INJECTION or on the prior dose of an alternate opioid as described above in Section 2.4 Conversion From Prior Opioid and Table 1.

Administration And Reconstitution

Inspect parenteral drug products visually for particulate matter and discoloration prior to administration, whenever solution and container permit. A slight yellowish discoloration may develop in DILAUDID INJECTION and DILAUDID-HP INJECTION ampules. No loss of potency has been demonstrated. DILAUDID INJECTION and DILAUDID-HP INJECTION are physically compatible and chemically stable for at least 24 hours at 25°C, protected from light in most common large-volume parenteral solutions.

500 mg/50 mL Vial

To use this single dose presentation, do not penetrate the stopper with a syringe. Instead, remove both the aluminum flipseal and rubber stopper in a suitable work area such as under a laminar flow hood (or equivalent clean air compounding area). The contents may then be withdrawn for preparation of a single, large-volume parenteral solution. Discard any unused portion in an appropriate manner.

Reconstitution of Sterile Lyophilized DILAUDID-HP INJECTION 250 mg

Reconstitute immediately prior to use with 25 mL of Sterile Water for Injection USP to provide a sterile solution containing 10 mg/mL of hydromorphone hydrochloride.

Both DILAUDID INJECTION and DILAUDID-HP INJECTION are contraindicated:

• In patients with known hypersensitivity to hydromorphone, hydromorphone salts, any other components of the product, or sulfite-containing medications.
• In any situation where opioids are contraindicated, e.g., in patients with respiratory depression in the absence of resuscitative equipment or in unmonitored settings; or patients with acute or severe bronchial asthma.
• In patients with, or at risk of developing, gastrointestinal obstruction, especially paralytic ileus because hydromorphone diminishes the propulsive peristaltic wave in the gastrointestinal tract and may prolong the obstruction.

DILAUDID-HP INJECTION is contraindicated in patients who are not opioid tolerant.

WARNINGS

Included as part of the PRECAUTIONS section.

PRECAUTIONS

Risk Of Medication Errors

DILAUDID-HP INJECTION is a 10 mg/mL concentrated solution of hydromorphone, and is intended for use in opioid-tolerant patients only. Patients considered opioid tolerant are those who are taking at least 60 mg oral morphine/day, 25 mcg transdermal fentanyl/hour, 30 mg oral oxycodone/day, 8 mg oral hydromorphone/day, 25 mg oral oxymorphone/day, or an equianalgesic dose of another opioid for one week or longer.

Do not confuse DILAUDID-HP INJECTION with standard parenteral formulations of DILAUDID INJECTION (1 mg/mL, 2 mg/mL, 4 mg/mL) or other opioids, as overdose and death could result.

Morphine does not convert to hydromorphone on a mg per mg basis. Use Table 1 when converting a patient from morphine to hydromorphone to avoid errors that can lead to overdose or death.

Respiratory Depression

Respiratory depression is the chief hazard of DILAUDID INJECTION and DILAUDID-HP INJECTION. Respiratory depression occurs most frequently in the elderly, in the debilitated, and in those suffering from conditions accompanied by hypoxia or hypercapnia, or upper airway obstruction, in whom even moderate therapeutic doses may dangerously decrease pulmonary ventilation. Respiratory depression is also a particular problem following large initial doses in non opioid-tolerant patients or when opioids are given in conjunction with other agents that depress respiration.

Use DILAUDID INJECTION and DILAUDID-HP INJECTION with extreme caution in patients with chronic obstructive pulmonary disease or cor pulmonale, patients having a substantially decreased respiratory reserve, hypoxia, hypercapnia, or preexisting respiratory depression. In such patients, even usual therapeutic doses of opioid analgesics may decrease respiratory drive while simultaneously increasing airway resistance to the point of apnea. Consider using non-opioid analgesics, and administer DILAUDID only under careful medical supervision at the lowest effective dose in such patients.

Misuse, Abuse And Diversion Of Opioids

DILAUDID INJECTION and DILAUDID-HP INJECTION contain hydromorphone, an opioid agonist with an abuse liability similar to morphine, and a Schedule II, controlled substance. Hydromorphone has the potential for being abused, is sought by drug abusers and people with addiction disorders, and is subject to criminal diversion. Diversion of Schedule II products is an act subject to criminal penalty.

Abuse of DILAUDID INJECTION and DILAUDID-HP INJECTION, poses a hazard of overdose and death. This risk is increased with concurrent abuse of alcohol or other substances. Schedule II opioid agonists have the highest potential for abuse and risk of fatal respiratory depression.

DILAUDID INJECTION and DILAUDID-HP INJECTION can be abused in a manner similar to other opioid agonists, legal or illicit. This should be considered when prescribing or dispensing DILAUDID INJECTION and DILAUDID-HP INJECTION in situations where the physician or pharmacist is concerned about an increased risk of misuse, abuse or diversion.

Concerns about abuse, addiction, and diversion should not prevent the proper management of pain. Healthcare professionals should contact their State Professional Licensing Board or State Controlled Substances Authority for information on how to prevent and detect abuse or diversion of this product.

Interactions With Alcohol And Other CNS Depressants

The concurrent use of DILAUDID INJECTION or DILAUDID-HP INJECTION with other central nervous system (CNS) depressants, including, but not limited to, other opioids, illicit drugs, sedatives, hypnotics, general anesthetics, phenothiazines, muscle relaxants, other tranquilizers, and alcohol, increases the risk of respiratory depression, hypotension, and profound sedation, potentially resulting in coma or death. Use with caution and in reduced dosages in patients taking CNS depressants.

Neonatal Withdrawal Syndrome

Infants born to mothers physically dependent on DILAUDID INJECTION or DILAUDID-HP INJECTION will also be physically dependent and may exhibit signs of withdrawal. The withdrawal signs include irritability and excessive crying, tremors, hyperactive reflexes, increased respiratory rate, increased stools, sneezing, yawning, vomiting, and fever. The intensity of the syndrome does not always correlate with the duration of maternal opioid use or dose. Neonatal opioid withdrawal syndrome may be life-threatening and should be treated according to protocols developed by neonatology experts.

Use In Increased Intracranial Pressure Or Head Injury

The respiratory depressant effects of DILAUDID INJECTION and DILAUDID-HP INJECTION promote carbon dioxide retention which results in elevation of cerebrospinal fluid pressure. This increase in intracranial pressure may be markedly exaggerated in the presence of head injury, intracranial lesions, or other conditions that predispose patients to increased intracranial pressure.

DILAUDID INJECTION and DILAUDID-HP INJECTION may produce effects on pupillary response and consciousness which can obscure the clinical course and neurologic signs of further increase in pressure in patients with head injuries.

Hypotensive Effect

DILAUDID INJECTION and DILAUDID-HP INJECTION may cause severe hypotension in patients whose ability to maintain blood pressure is compromised by a depleted blood volume, or a concurrent administration of drugs such as phenothiazines, general anesthetics, or other agents which compromise vasomotor tone.

DILAUDID INJECTION and DILAUDID-HP INJECTION may produce orthostatic hypotension in ambulatory patients.

Administer DILAUDID INJECTION and DILAUDID-HP INJECTION with caution to patients in circulatory shock, since vasodilation produced by the drug may further reduce cardiac output and blood pressure.

Sulfites

DILAUDID INJECTION and DILAUDID-HP INJECTION contain sodium metabisulfite, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people.

Use In Pancreatic/Biliary Tract Disease And Other Gastrointestinal Conditions

The administration of DILAUDID INJECTION or DILAUDID-HP INJECTION may obscure the diagnosis or clinical course in patients with acute abdominal conditions.

Use DILAUDID INJECTION and DILAUDID-HP with caution in patients who are at risk of developing ileus.

Use DILAUDID INJECTION and DILAUDID-HP INJECTION with caution in patients with biliary tract disease, including acute pancreatitis, as hydromorphone may cause spasm of the sphincter of Oddi and diminish biliary and pancreatic secretions.

Special Risk Patients

Give DILAUDID INJECTION and DILAUDID-HP INJECTION with caution and the initial dose should be reduced in the elderly or debilitated and those with severe impairment of hepatic, pulmonary, or renal function; myxedema or hypothyroidism; adrenocortical insufficiency (e.g., Addison's Disease); CNS depression or coma; toxic psychoses; prostatic hypertrophy or urethral stricture; acute alcoholism; delirium tremens; or kyphoscoliosis associated with respiratory depression.

The administration of opioid analgesics including DILAUDID INJECTION and DILAUDID-HP INJECTION may aggravate preexisting convulsions in patients with convulsive disorders.

DILAUDID INJECTION and DILAUDID-HP INJECTION, as with other opioids, may aggravate convulsions in patients with convulsive disorders, and may induce or aggravate seizures in some clinical settings.

Reports of mild to severe seizures and myoclonus have been reported in severely compromised patients administered high doses of parenteral hydromorphone.

Use In Drug And Alcohol Dependent Patients

Use DILAUDID INJECTION and DILAUDID-HP INJECTION with caution in patients with alcoholism and other drug dependencies due to the increased frequency of opioid tolerance, dependence, and the risk of addiction observed in these patient populations. Abuse of DILAUDID INJECTION or DILAUDID-HP INJECTION in combination with other CNS depressant drugs can result in serious risk to the patient.

DILAUDID INJECTION and DILAUDID-HP INJECTION contain hydromorphone, an opioid with no approved use in the management of addiction disorders. Its proper usage in individuals with drug or alcohol dependence, either active or in remission, is for the management of pain requiring opioid analgesia.

Use In Ambulatory Patients

DILAUDID INJECTION and DILAUDID-HP INJECTION may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating machinery). Patients should be cautioned accordingly. DILAUDID INJECTION and DILAUDID-HP INJECTION may produce orthostatic hypotension in ambulatory patients.

Parenteral Administration

DILAUDID INJECTION may be given intravenously, but the injection should be given very slowly. Rapid intravenous injection of opioid analgesics increases the possibility of side effects such as hypotension and respiratory depression.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

Carcinogenesis

Long term studies in animals to evaluate the carcinogenic potential of hydromorphone have not been conducted.

Mutagenesis

Hydromorphone was not mutagenic in the in vitro bacterial reverse mutation assay (Ames assay). Hydromorphone was not clastogenic in either the in vitro human lymphocyte chromosome aberration assay or the in vivo mouse micronucleus assay.

Impairment of Fertility

No effects on fertility, reproductive performance, or reproductive organ morphology were observed in male or female rats given oral doses up to 7 mg/kg/day which is 3-fold higher than the human dose of 24 mg DILAUDID INJECTION (4 mg every 4 hours), on a body surface area basis.

Use In Specific Populations

Pregnancy

Teratogenic Effects

Pregnancy Category C: There are no adequate and well-controlled studies in pregnant women. Hydromorphone crosses the placenta. DILAUDID INJECTION or DILAUDID-HP INJECTION should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

No effects on teratogenicity or embryotoxicity were observed in pregnant rats given oral doses up to 7 mg/kg/day which is 3-fold higher than the human dose of 24 mg DILAUDID INJECTION (4 mg every 4 hours), on a body surface area basis. Hydromorphone administration to pregnant Syrian hamsters and CF-1 mice during major organ development revealed teratogenic effects likely the result of maternal toxicity associated with sedation and hypoxia. In Syrian hamsters given single subcutaneous doses from 14 to 258 mg/kg during organogenesis (gestation days 8-10), doses ≥ 19 mg/kg of hydromorphone produced skull malformations (exencephaly and cranioschisis). In CF-1 mice, continuous infusion of hydromorphone ( ≥ 15 mg/kg over 24 hours) via implanted osmotic pumps during organogenesis (gestation days 7-10) produced soft tissue malformations (cryptorchidism, cleft palate, malformed ventricles and retina), and skeletal variations (split supraoccipital, checkerboard and split sternebrae, delayed ossification of the paws and ectopic ossification sites). The malformations and variations observed in the hamsters and mice were observed at doses approximately 6-fold and 3-fold higher, respectively, than the human dose of 24 mg DILAUDID INJECTION (4 mg every 4 hours) on a body surface area basis.

Labor And Delivery

DILAUDID should be used with caution during labor. Opioids cross the placenta and may produce respiratory depression and physiologic effects in neonates. Sinusoidal fetal heart rate patterns may occur with the use of opioid analgesics.

Occasionally, opioid analgesics, including DILAUDID INJECTION and DILAUDID-HP INJECTION, may prolong labor through actions which temporarily reduce the strength, duration, and frequency of uterine contractions. However, this effect is not consistent and may be offset by an increased rate of cervical dilatation, which tends to shorten labor.

Opioid analgesics, including DILAUDID INJECTION and DILAUDID-HP INJECTION, may cause respiratory depression in the newborn. Closely observe neonates whose mothers received opioid analgesics during labor for signs of respiratory depression. Have a specific opioid antagonist, such as naloxone or nalmefene, available for reversal of opioid-induced respiratory depression in the neonate.

Neonates whose mothers have been taking opioids chronically may also exhibit withdrawal signs, either at birth or in the nursery, because they have developed physical dependence. This is not, however, synonymous with addiction. Neonatal opioid withdrawal syndrome, unlike opioid withdrawal syndrome in adults, may be life-threatening and should be treated according to protocols developed by neonatology experts. The effect of DILAUDID, if any, on the later growth, development, and functional maturation of the child is unknown.

Nursing Mothers

Low levels of opioid analgesics have been detected in human milk. As a general rule, nursing should not be undertaken while a patient is receiving DILAUDID INJECTION or DILAUDID-HP INJECTION since it, and other drugs in this class, may be excreted in the milk.

Pediatric Use

The safety and effectiveness of DILAUDID INJECTION and DILAUDID-HP INJECTION in pediatric patients has not been established.

Geriatric Use

Clinical studies of DILAUDID INJECTION and DILAUDID-HP INJECTION did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Respiratory depression is the chief risk in elderly or debilitated patients, usually the result of large initial doses in non opioid-tolerant patients. Titration in these patients should proceed cautiously.

Renal Impairment

The pharmacokinetics of hydromorphone following an oral administration of hydromorphone at a single 4 mg dose (2 mg hydromorphone immediate-release tablets) are affected by renal impairment. Mean exposure to hydromorphone (Cmax and AUC0-∞) is increased by 2-fold in patients with moderate (CLcr = 40 - 60 mL/min) renal impairment and increased by 4-fold in patients with severe (CLcr < 30 mL/min) renal impairment compared with normal subjects (CLcr > 80 mL/min). In addition, in patients with severe renal impairment, hydromorphone appeared to be more slowly eliminated with a longer terminal elimination half-life (40 hr) compared to patients with normal renal function (15 hr). Start patients with renal impairment on one-fourth to one-half the usual starting dose depending on the degree of impairment. Patients with renal impairment should be closely monitored during dose titration.

Hepatic Impairment

The pharmacokinetics of hydromorphone following an oral administration of hydromorphone at a single 4 mg dose (2 mg hydromorphone immediate-release tablets) are affected by hepatic impairment. Mean exposure to hydromorphone (Cmax and AUC∞) is increased 4-fold in patients with moderate (Child-Pugh Group B) hepatic impairment compared with subjects with normal hepatic function. Due to increased exposure of hydromorphone, patients with moderate hepatic impairment should be started at one-fourth to one-half the recommended starting dose depending on the degree of hepatic dysfunction and closely monitored during dose titration. The pharmacokinetics of hydromorphone in patients with severe hepatic impairment has not been studied. A further increase in Cmax and AUC of hydromorphone in this group is expected and should be taken into consideration when selecting a starting dose.

SIDE EFFECTS

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

Serious adverse reactions associated with DILAUDID INJECTION and DILAUDID-HP INJECTION include respiratory depression and apnea and, to a lesser degree, circulatory depression, respiratory arrest, shock, and cardiac arrest.

The following serious adverse reactions described elsewhere in the labeling include:

• Respiratory depression and secondary effects on intracranial pressure
• Hypotension
• Gastrointestinal effects and effects in sphincter of Oddi
• Drug abuse, addiction, and dependence
• Effects on the ability to drive and operate machinery

The most common adverse effects are lightheadedness, dizziness, sedation, nausea, vomiting, sweating, flushing, dysphoria, euphoria, dry mouth, and pruritus. These effects seem to be more prominent in ambulatory patients and in those not experiencing severe pain.

Less Frequently Observed Adverse Reactions

Cardiac disorders: tachycardia, bradycardia, palpitations

Eye disorders: vision blurred, diplopia, miosis, visual impairment

Gastrointestinal disorders: constipation, ileus, diarrhea, abdominal pain

General disorders and administration site conditions: weakness, feeling abnormal, chills, injection site urticaria

Hepatobiliary disorders: biliary colic

Metabolism and nutrition disorders: decreased appetite

Musculoskeletal and connective tissue disorders: muscle rigidity

Nervous system disorders: headache, tremor, paraesthesia, nystagmus, increased intracranial pressure, syncope, taste alteration, involuntary muscle contractions, presyncope

Psychiatric disorders: agitation, mood altered, nervousness, anxiety, depression, hallucination, disorientation, insomnia, abnormal dreams

Renal and urinary disorders: urinary retention, urinary hesitation, antidiuretic effects

Respiratory, thoracic, and mediastinal disorders: bronchospasm, laryngospasm

Skin and subcutaneous tissue disorders: injection site pain, urticaria, rash, hyperhidrosis

Vascular disorders: flushing, hypotension, hypertension

Postmarketing Experience

The following adverse reactions have been identified during post-approval use of hydromorphone. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure: anaphylactic reactions, confusional state, convulsions, drowsiness, dyskinesia, dyspnea, erectile dysfunction, fatigue, hepatic enzymes increased, hyperalgesia, hypersensitivity reaction, injection site reactions, lethargy, myoclonus, oropharyngeal swelling, peripheral edema, and somnolence.

DRUG INTERACTIONS

Drug Interactions With Other CNS Depressants

DILAUDID INJECTION and DILAUDID-HP INJECTION should be used with caution and in reduced dosages when administered to patients concurrently receiving other central nervous system depressants including sedatives or hypnotics, general anesthetics, phenothiazines, centrally acting anti-emetics, tranquilizers, and alcohol because respiratory depression, hypotension, and profound sedation or coma may result.

When such combined therapy is contemplated, the dose of one or both agents should be reduced. Opioid analgesics, including DILAUDID INJECTION and DILAUDID-HP INJECTION, may enhance the action of neuromuscular blocking agents and produce an increased degree of respiratory depression.

Interactions With Mixed Agonist/Antagonist Opioid Analgesics

Agonist/antagonist analgesics (e.g., pentazocine, nalbuphine, and butorphanol) and partial agonist analgesics (buprenorphine) should be administered with caution to a patient who has received or is receiving a course of therapy with a pure opioid agonist analgesic such as DILAUDID INJECTION and DILAUDID-HP INJECTION. In this situation, mixed agonist/antagonist analgesics may reduce the analgesic effect of DILAUDID INJECTION and DILAUDID-HP INJECTION and/or may precipitate withdrawal symptoms in these patients.

Monoamine Oxidase Inhibitors (MAOIs)

MAOIs may potentiate the action of DILAUDID INJECTION and DILAUDID-HP INJECTION. Allow at least 14 days after stopping treatment with MAOIs before initiating treatment with DILAUDID INJECTION and DILAUDID-HP INJECTION.

Anticholinergics

Anticholinergics or other medications with anticholinergic activity when used concurrently with DILAUDID INJECTION and DILAUDID-HP INJECTION may result in increased risk of urinary retention and severe constipation, which may lead to paralytic ileus.

Drug Abuse And Dependence

Controlled Substance

DILAUDID INJECTION and DILAUDID-HP INJECTION contain hydromorphone, which is a Schedule II controlled substance with an abuse liability similar to morphine. DILAUDID can be abused and is subject to criminal diversion.

Abuse

DILAUDID INJECTION and DILAUDID-HP INJECTION are intended for parenteral use only under the direct supervision of an appropriately licensed health care professional.

Abuse of DILAUDID INJECTION and DILAUDID-HP INJECTION poses a hazard of overdose and death. This risk is increased with concurrent abuse of alcohol or other substances. Parenteral drug abuse is commonly associated with transmission of infectious diseases, such as hepatitis and HIV.

DILAUDID INJECTION and DILAUDID-HP INJECTION can be abused in a manner similar to other opioid agonists, legal or illicit. This should be considered when prescribing, dispensing, ordering, or administering DILAUDID INJECTION or DILAUDID-HP INJECTION in situations where the physician or pharmacist is concerned about an increased risk of misuse, abuse, or diversion. Prescribers should monitor all patients receiving opioids for signs of abuse, misuse, and addiction. Furthermore, patients should be assessed for their potential for opioid abuse prior to being prescribed opioid therapy. Persons at increased risk for opioid abuse include those with a personal or family history of substance abuse (including drug or alcohol abuse) or mental illness (e.g., depression). Opioids may still be appropriate for use in these patients, however, they will require intensive monitoring for indications of abuse.

Opioid drugs are sought by people with substance use disorders (abuse or addiction, the latter of which is also called “substance dependence”) and criminals who supply them by diverting medicines out of legitimate distribution channels. DILAUDID INJECTION and DILAUDID-HP INJECTION are targets for diversion.

“Drug-seeking” behavior is very common in persons with substance use disorders. Drug-seeking tactics include, but are not limited to, emergency calls or visits near the end of office hours, refusal to undergo appropriate examination, testing or referral, repeated “loss” of prescriptions, altering or forging of prescriptions and reluctance to provide prior medical records or contact information for other treating physician(s). “Doctor shopping” to obtain additional prescriptions is common among people with untreated substance use disorders and criminals who divert controlled substances.

The risks of misuse and abuse should be considered when prescribing or dispensing DILAUDID INJECTION or DILAUDID-HP INJECTION. Concerns about abuse and addiction, should not prevent the proper management of pain, however. Treatment of pain should be individualized, balancing the potential benefits and risks for each patient.

Addiction is defined as a chronic, neurobiological disorder with genetic, psychosocial, and environmental aspects, characterized by one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Drug addiction is a treatable disease, utilizing a multidisciplinary approach, but relapse is common.

Abuse and addiction are separate and distinct from physical dependence and tolerance. Physicians should be aware that addiction may not be accompanied by concurrent tolerance and symptoms of physical dependence in all addicts. In addition, abuse of opioids can occur in the absence of addiction and is characterized by misuse for non-medical purposes, often in combination with other psychoactive substances. Careful record keeping of prescribing information, including quantity, frequency, and renewal requests is strongly advised.

Proper assessment of the patient, proper prescribing practices, periodic re-evaluation of therapy, proper dispensing and correct storage and handling are appropriate measures that help to limit misuse and abuse of opioid drugs. Careful record-keeping of prescribing information, including quantity, frequency, and renewal requests is strongly advised.

Healthcare professionals should contact their State Professional Licensing Board or State Controlled Substances Authority for information on how to prevent and detect abuse or diversion of this product.

Dependence

Tolerance to opioids is demonstrated by the need for increasing doses to maintain a defined effect such as analgesia (in the absence of disease progression or other external factors). Tolerance to different effects of opioids may develop to varying degrees and at varying rates in a given individual. There is also inter-patient variability in the rate and extent of tolerance that develops to various opioid effects, whether the effect is desirable (e.g., analgesia) or undesirable (e.g., nausea). In general, patients taking opioid analgesics that are appropriately titrated for pain control develop tolerance to the respiratory depressant effects fairly reliably. Conversely, tolerance to the constipating effects of opioids rarely develops, even when they are administered over long periods of time.

Physical dependence is manifested by withdrawal symptoms after abrupt discontinuation of a drug or upon administration of an antagonist. Physical dependence and tolerance are not unusual during chronic opioid therapy.

The opioid abstinence or withdrawal syndrome is characterized by some or all of the following: restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis. Other signs and symptoms also may develop, including: irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate.

In general, opioids used regularly should not be abruptly discontinued.

Teratogenic Effects

Pregnancy Category C: There are no adequate and well-controlled studies in pregnant women. Hydromorphone crosses the placenta. DILAUDID INJECTION or DILAUDID-HP INJECTION should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

No effects on teratogenicity or embryotoxicity were observed in pregnant rats given oral doses up to 7 mg/kg/day which is 3-fold higher than the human dose of 24 mg DILAUDID INJECTION (4 mg every 4 hours), on a body surface area basis. Hydromorphone administration to pregnant Syrian hamsters and CF-1 mice during major organ development revealed teratogenic effects likely the result of maternal toxicity associated with sedation and hypoxia. In Syrian hamsters given single subcutaneous doses from 14 to 258 mg/kg during organogenesis (gestation days 8-10), doses ≥ 19 mg/kg of hydromorphone produced skull malformations (exencephaly and cranioschisis). In CF-1 mice, continuous infusion of hydromorphone ( ≥ 15 mg/kg over 24 hours) via implanted osmotic pumps during organogenesis (gestation days 7-10) produced soft tissue malformations (cryptorchidism, cleft palate, malformed ventricles and retina), and skeletal variations (split supraoccipital, checkerboard and split sternebrae, delayed ossification of the paws and ectopic ossification sites). The malformations and variations observed in the hamsters and mice were observed at doses approximately 6-fold and 3-fold higher, respectively, than the human dose of 24 mg DILAUDID INJECTION (4 mg every 4 hours) on a body surface area basis.

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

Serious adverse reactions associated with DILAUDID INJECTION and DILAUDID-HP INJECTION include respiratory depression and apnea and, to a lesser degree, circulatory depression, respiratory arrest, shock, and cardiac arrest.

The following serious adverse reactions described elsewhere in the labeling include:

• Respiratory depression and secondary effects on intracranial pressure
• Hypotension
• Gastrointestinal effects and effects in sphincter of Oddi
• Drug abuse, addiction, and dependence
• Effects on the ability to drive and operate machinery

The most common adverse effects are lightheadedness, dizziness, sedation, nausea, vomiting, sweating, flushing, dysphoria, euphoria, dry mouth, and pruritus. These effects seem to be more prominent in ambulatory patients and in those not experiencing severe pain.

Less Frequently Observed Adverse Reactions

Cardiac disorders: tachycardia, bradycardia, palpitations

Eye disorders: vision blurred, diplopia, miosis, visual impairment

Gastrointestinal disorders: constipation, ileus, diarrhea, abdominal pain

General disorders and administration site conditions: weakness, feeling abnormal, chills, injection site urticaria

Hepatobiliary disorders: biliary colic

Metabolism and nutrition disorders: decreased appetite

Musculoskeletal and connective tissue disorders: muscle rigidity

Nervous system disorders: headache, tremor, paraesthesia, nystagmus, increased intracranial pressure, syncope, taste alteration, involuntary muscle contractions, presyncope

Psychiatric disorders: agitation, mood altered, nervousness, anxiety, depression, hallucination, disorientation, insomnia, abnormal dreams

Renal and urinary disorders: urinary retention, urinary hesitation, antidiuretic effects

Respiratory, thoracic, and mediastinal disorders: bronchospasm, laryngospasm

Skin and subcutaneous tissue disorders: injection site pain, urticaria, rash, hyperhidrosis

Vascular disorders: flushing, hypotension, hypertension

Postmarketing Experience

The following adverse reactions have been identified during post-approval use of hydromorphone. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure: anaphylactic reactions, confusional state, convulsions, drowsiness, dyskinesia, dyspnea, erectile dysfunction, fatigue, hepatic enzymes increased, hyperalgesia, hypersensitivity reaction, injection site reactions, lethargy, myoclonus, oropharyngeal swelling, peripheral edema, and somnolence.

Signs And Symptoms

Signs and symptoms of acute overdosage with DILAUDID INJECTION or DILAUDID-HP INJECTION include: respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, constricted pupils, bradycardia, hypotension, partial or complete airway obstruction, atypical snoring, apnea, circulatory collapse, cardiac arrest, and death.

Hydromorphone may cause miosis, even in total darkness. Pinpoint pupils are a sign of opioid overdose but are not pathognomonic (pontine lesions of hemorrhagic or ischemic origin may produce similar findings). Marked mydriasis, rather than miosis, may be seen with hypoxia in overdose situations.

Treatment

In the treatment of overdosage, primary attention should be given to the reestablishment of a patent airway and institution of assisted or controlled ventilation. Supportive measures (including oxygen, vasopressors) should be employed in the management of circulatory shock and pulmonary edema accompanying overdose as indicated. Cardiac arrest or arrhythmias may require cardiac massage or defibrillation.

The opioid antagonist, naloxone, is a specific antidote against respiratory depression which may result from overdosage, or unusual sensitivity to DILAUDID INJECTION or DILAUDID-HP INJECTION. Therefore, an appropriate dose of this antagonist should be administered, preferably by the intravenous route, simultaneously with efforts at respiratory resuscitation. Naloxone should not be administered in the absence of clinically significant respiratory or circulatory depression. Naloxone should be administered cautiously to persons who are known, or suspected, to be physically dependent on DILAUDID INJECTION or DILAUDID-HP INJECTION. In such cases, an abrupt or complete reversal of opioid effects may precipitate an acute withdrawal syndrome.

Since the duration of action of DILAUDID INJECTION and DILAUDID-HP INJECTION may exceed that of the antagonist, the patient should be kept under continued surveillance; repeated doses of the antagonist may be required to maintain adequate respiration. Apply other supportive measures when indicated.

Distribution

At therapeutic plasma levels, hydromorphone is approximately 8-19% bound to plasma proteins. After an intravenous bolus dose, the steady state of volume of distribution [mean (%CV)] is 302.9 (32%) liters.

Metabolism

Hydromorphone is extensively metabolized via glucuronidation in the liver, with greater than 95% of the dose metabolized to hydromorphone-3-glucuronide along with minor amounts of 6-hydroxy reduction metabolites.

Elimination

Only a small amount of the hydromorphone dose is excreted unchanged in the urine. Most of the dose is excreted as hydromorphone-3-glucuronide along with minor amounts of 6-hydroxy reduction metabolites. The systemic clearance is approximately 1.96 (20%) liters/minute. The terminal elimination half-life of hydromorphone after an intravenous dose is about 2.3 hours.