Dosage Forms & Strengths
tablet: Schedule II
2mg
4mg
8mg
tablet, extended-release: Schedule II
8mg
12mg
16mg
32mg
injection solution
1mg/mL
2mg/mL
4mg/mL
injection solution, preservative free: Schedule II
10mg/mL
oral liquid: Schedule II
5mg/5mL
suppository: Schedule II
3mg
Prefilled syringe: Schedule II
0.2 mg/mL
0.6 mg/mL
 
Moderate-to-Severe Pain
Indicated for moderate-to-severe pain
PO
Immediate-release: 2-4 mg q4-6hr PRN; a gradual increase in dose may be required
Oral liquid (usual dose): 2.5-10 mg (2.5-10 mL) q3-6hr PRN
SC/IM
1-2 mg q2-3hr PRN; adjust dose according to pain and adverse effects
IM dose not recommended for use as it may result in variable absorption and lag time to peak effect
IV
Opioid naive: 0.2-1 mg IV q2-3hr PRN; may require higher doses in patients with prior opioid exposure
Critically ill patients (opiate-naive patients): 0.2-0.6 mg q1-2hr PRN given slowly over 2-3 minutes; patients with previous opiate exposure may tolerate higher doses
Continuous infusion: 0.5-3 mg/hr, titrated to response
Patient-controlled analgesia
Usual concentration, 0.2 mg/mL; demand dose, 0.1-0.2 mg; dose range is 0.05-0.4 mg
Lockout interval: 5-10 minutes
Rectal
3 mg PR q6-8hr
Chronic Severe Pain
Long-acting (Exalgo) is indicated for the management of pain in opioid tolerant patients severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate
Opioid tolerant patients only (extended-release:) 8-64 mg PO qDay; may administer a starting dose equivalent to patient's total daily oral hydromorphone dose administered once daily with or without food
Should address pain relief and adverse events frequently; increase dose no more frequently than q3-4days; may titrate with increases of 25-50% of current daily dose; consider increasing dose if more than 2 doses of rescue medications are needed within 24hr within 2 consecutive days
Extented-release tablets should be swallowed whole; crushing, dividing, or dissolving will release opioid content all at once and increase risk of respiratory depression and death
Converting to Exalgo
Conversion from other oral hydromorphone formulations: Start with equivalent total daily dose of  immediate release formulation and administer once daily; may titrate q3-4days until adequate pain relief with tolerable adverse effects achieved
Conversion from other opioids: Start Exalgo dose at 50% of calculated daily dose q24hr; titrate until adequate pain relief with tolerable adverse effects achieved
Conversion from transdermal fentanyl to Exalgo: Start Exalgo 18 hr after removal of transdermal fentanyl patch at 50% of calculated total daily dose given over 24hr; for a 25 mcg/hr fentanyl patch the equianalgesic dose is 12 mg PO q24hr
Discontinuation of Exalgo therapy: Taper gradually by decreasing dose by 25-50% q2-3days to a dose of 8 mg PO q24hr before discontinuing
Opioid-tolerant definition
Use of higher starting doses in patients who are not opioid tolerant may cause fatal respiratory depression
Patients who are opioid tolerant are those receiving, for 1 week or longer, at least 60 mg/day PO morphine, 25 mcg/hr transdermal fentanyl, 30 mg/day PO oxycodone, 8 mg/day PO hydromorphone, 25 mg/day PO oxymorphone, or an equianalgesic dose of another opioid
Limitations of use
Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with extended-release opioid formulations, reserve for patients whom alternative treatment options (eg, nonopioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain
Not indicated for acute pain or as a PRN analgesic