Pharmacist consultants interested in pain management often consider hydromorphone (Dilaudid, Abbott Laboratories Inc) as an important member of the opioid family of analgesics. Hydromorphone is important because its metabolites are considered inactive, although renal failure patients may exhibit neuroexcitation possibly related to accumulated hydromorphone-3-glucuronide metabolite. Hydromorphone is not a firsttier medication, however, because of its higher cost relative to morphine. Thus, hydromorphone is reserved for those patients that do not tolerate less expensive opiates for one reason or another.
Many, if not most, patients having difficulty with morphine or other opiates appear to tolerate hydromorphone and do well with it. Therein lies its importance. Unfortunately, hydromorphone kinetics requires frequent dosing: about every 4 hours. Pain specialists working with chronic pain patients noted with interest the debut of a once-daily oral dosage form of hydromorphone, introduced as Palladone by Purdue Pharma.
Pharmacists and hospice nurses caring for patients with difficult chronic pain issues in whom methadone was inappropriate were disappointed, however, when problems with Palladone's delivery system prompted its withdrawal from the market. Concomitant ingestion of alcohol appears to defeat the extended-release pellet mechanism, allowing for the possibility of dose dumping. Since hydromorphone is very potent, this produced an unacceptable risk, resulting in its removal from the market. Purdue Pharma is investigating a means for a suitable reformulation.
In the absence of Palladone, many health care pain specialists appeared to begin considering much more aggressive and costly interventions. They tended to forget that pharmacists have offered creative ways to meet challenging medication problems for generations.
Compounding pharmacists know that the technology exists to prepare alternative dosage forms for many medications, including hydromorphone. It is very rewarding to be able to recommend a slow-release oral form of hydromorphone to a hospice interdisciplinary group meeting. A dosage regimen of twice or 3 times daily is a welcome improvement over the 6 or more times daily frequently required for hydromorphone.
Hospice professionals are often impressed when their pharmacist consultant can offer such a variety of administration options. In the case of hydromorphone, rectal suppositories, troches, nasal sprays, immediate-and slow-release oral capsules, liquids, and custom injectable forms are possible.
Pharmacists are in a unique position to provide important medication treatment options, including clinical as well as technical support for the patient. It is essential that pharmacists promote their expertise when the opportunity arises. In the unfortunate case of the missing hydromorphone once-daily dosage form, remember: HYDROMORPHONE, COMPOUND IT!
Mr. Vance is a writer with the International Journal of Pharmaceutical Compounding.
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