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Introduction
The Palladone® range comprises Palladone® and Palladone® SR capsules.
Both products contain hydromorphone hydrochloride, a strong opioid analgesic indicated for the relief of severe cancer pain. Palladone® SR capsules are a prolonged release formulation designed to be taken 12-hourly; they are available in 2 mg, 4 mg, 8 mg, 16 mg and 24 mg strengths. Palladone® capsules are an immediate release formulation designed to be taken 4-hourly; they are available in 1.3 mg and 2.6 mg strengths, and can be used to treat breakthrough and incident pain in patients receiving Palladone® SR capsules.
For patients who have difficulty swallowing, Palladone® SR capsules can be opened and their contents sprinkled onto soft, cold food. However, the capsule contents should not be chewed or crushed as this will disrupt the prolonged release mechanism and could lead to overdose.
Although morphine is seen as the gold standard and first-line choice for treating cancer pain, it is widely accepted that some patients do not respond well to morphine and that others find the side effects intolerable. It is therefore desirable to have an alternative opioid analgesic for these patients. This resource contains 14 case studies of patients in whom Palladone® SR and/or Palladone® capsules have been used effectively for opioid switching.
In contrast to morphine, the metabolites of hydromorphone are not thought to have any analgesic activity. This could confer an advantage in patients in whom metabolite accumulation could be a problem, e.g. cancer patients with renal failure. Six of the case studies are of patients with renal failure in whom Palladone® SR and/or Palladone® capsules have been effective. However, it should be noted that, as with morphine-3-glucuronide, accumulation of hydromorphone-3-glucuronide may be associated with neuroexcitation.1 In addition, patients with renal impairment may need a lower dose to achieve adequate analgesia.
Opioid switching
Case 1
A 79-year-old man with spinal cord compression caused by a tumour, was becoming depressed because of his severe pain and his family were distressed. He was initially treated with 30 mg prolonged release morphine 12-hourly, but he became delusional, sedated and confused. Decreasing his dose of morphine to 10 mg 12-hourly did not improve the side effects, so he was switched to Palladone® SR capsules 2 mg 12-hourly with 2.6 mg Palladone® capsules for breakthrough pain. He was released from hospital with his pain under control and no intolerable side effects.
Case 2
A 43-year-old woman with mediastinal thyoma and metastatic spread to the cervical vertebrae, was suffering severe neuropathic pain down her right arm. She had been treated with fentanyl patches, but increasing her dose to 100 μg/h had led to respiratory collapse and emergency admission to hospital on two occasions. She was started on prolonged release morphine and her dose was titrated up to 380 mg 12-hourly. At this dose, she was pain-free, but extremely confused and unable to carry out normal daily activities. Alongside her morphine, she was also receiving gabapentin and dexamethasone. She was admitted to the hospice and switched from morphine to Palladone® SR capsules. She became pain-free when her dose was titrated up to 32 mg 12-hourly with 10.4 mg Palladone® capsules for breakthrough pain. She was discharged from the hospice, and was able to drive and be involved with her family, giving her a reasonable quality of life.
Case 3
A 56-year-old man with renal carcinoma, and lung and bone metastases, was referred to a hospice with a long history of severe and incapacitating pain in his right hip. Radiotherapy, pamidronate and local steroid injections had failed to relieve the pain, which seemed to be bony in origin, but also had a neuropathic component. The pain was disturbing his sleep and preventing him from working. His was taking tramadol 100 mg four times daily and diclofenac 50 mg three times daily. He was experiencing indigestion, so the hospice withdrew the diclofenac, and started gabapentin and oral steroids. The steroids relieved the pain, but rapidly led to weight gain and oedema. His asked to discontinue the steroids because of toxicity. The hospice withdrew the tramadol and started treatment with methadone, but at doses above 15 mg/day, H became drowsy and hallucinated. He was switched to Palladone® SR capsules and, at a dose of 8 mg 12-hourly with 2.6 mg Palladone® capsules at night, his pain was stable with minimal side effects.
Case 4
A 73-year-old man with pancreatic cancer and liver metastases, had severe abdominal pain following surgery for his pancreatic cancer. Analgesics from Step 2 of the World Health Organization analgesic ladder were not adequate, so he was prescribed fentanyl patches. A 25 μg/h patch alleviated the pain slightly, but he experienced considerable side effects, including nausea, dizziness and constipation. He was switched to Palladone® SR capsules 4 mg 12-hourly, which provided complete pain relief with no side effects. He did not need any analgesia for breakthrough pain and, having previously been unable to walk 300 m to the supermarket, he was now able to take a holiday with his family.
To view case studies 5 to 8, please click here
To view case studies relating to renal failure and opioid switching, please click here
Reference:
1. Smith MT. Neuroexcitatory effects of morphine and hydromorphone: evidence implicating the 3-glucuronide metabolites. Clin Exp Pharmacol Physiol 2000; 27:524-8.