HYDROMORPHONE HYDROCHLORIDE tablet

United States - English - NLM (National Library of Medicine)

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Active ingredient:
HYDROMORPHONE HYDROCHLORIDE (UNII: L960UP2KRW) (HYDROMORPHONE - UNII:Q812464R06)
Available from:
Lannett Company, Inc.
INN (International Name):
HYDROMORPHONE HYDROCHLORIDE
Composition:
HYDROMORPHONE HYDROCHLORIDE 2 mg
Administration route:
ORAL
Prescription type:
PRESCRIPTION DRUG
Therapeutic indications:
Hydromorphone hydrochloride tablets are indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. Limitations of Use Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses [see Warnings and Precautions (5.2)] , reserve hydromorphone hydrochloride tablets for use in patients for whom alternative treatment options [e.g., non-opioid analgesics or opioid combination products]: - Have not been tolerated, or are not expected to be tolerated, Have not been tolerated, or are not expected to be tolerated, - Have not provided adequate analgesia, or are not expected to provide adequate analgesia Have not provided adequate analgesia, or are not expected to provide adequate analgesia Hydromorphone hydrochloride tablets are contraindicated in patients with: - Significant respiratory depression [see Warnings and Precautions (5.7)] Significant respiratory depression [see Warnings and Precautions (5.7)] -
Product summary:
Hydromorphone Hydrochloride Tablets USP, 2 mg are white, round, flat-faced beveled edge tablets debossed with “LCI” over “1353” on one side and “2” on the other side. Available in bottles of 100 (NDC 0527-1353-01). Hydromorphone Hydrochloride Tablets USP, 4 mg are white, round, flat-faced beveled edge tablets debossed with “LCI” over “1354” on one side and “4” on the other side. Available in bottles of 100 (NDC 0527-1354-01). Hydromorphone Hydrochloride Tablets USP, 8 mg are white, round, flat-faced beveled edge, scored, tablets debossed with “LCI” over “1355” on one side and plain on the other side. Available in bottles of 100 (NDC 0527-1355-01). Store at 20° to 25°C (68° to 77°F) [See USP Controlled Room Temperature]. Protect from light. Store hydromorphone hydrochloride tablets securely and dispose of properly [see Patient Counseling Information ( 17 )] .
Authorization status:
Abbreviated New Drug Application
Authorization number:
0527-1353-01, 0527-1354-01, 0527-1355-01

Lannett Company, Inc.

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Medication Guide

Hydromorphone Hydrochloride (hy-dro-MOR-fone hy-dro-KLOR-īd) Tablets, USP, CII

Hydromorphone hydrochloride tablets are:

Strong prescription pain medicines that contains an opioid (narcotic) that is used to manage pain

severe enough to require an opioid analgesic, when other pain treatments such as non-opioid pain

medicines do not treat your pain well enough or you cannot tolerate them.

Opioid pain medicines that can put you at risk for overdose and death. Even if you take your dose

correctly as prescribed you are at risk for opioid addiction, abuse, and misuse that can lead to death.

Important information about hydromorphone hydrochloride:

Get emergency help right away if you take too much hydromorphone hydrochloride tablets

(overdose).

When you first start taking hydromorphone hydrochloride tablets, when your dose is changed, or if

you take too much (overdose), serious or life-threatening breathing problems that can lead to death

may occur.

Taking hydromorphone hydrochloride tablets with other opioid medicines, benzodiazepines, alcohol,

or other central nervous system depressants (including street drugs) can cause severe drowsiness,

decreased awareness, breathing problems, coma, and death.

Never give anyone else your hydromorphone hydrochloride tablets. They could die from taking it.

Selling or giving away hydromorphone hydrochloride tablets is against the law.

Store hydromorphone hydrochloride tablets securely, out of sight and reach of children, and in a

location not accessible by others, including visitors to the home.

Do not take hydromorphone hydrochloride tablets if you have:

Severe asthma, trouble breathing, or other lung problems.

A bowel blockage or have narrowing of the stomach or intestines.

Before taking hydromorphone hydrochloride tablets, tell your healthcare provider if you have a history of:

head injury, seizures

problems urinating

liver, kidney, thyroid problems

pancreas or gallbladder problems

abuse of street or prescription drugs, alcohol addiction, or mental health problems

Tell your healthcare provider if you are:

Pregnant or planning to become pregnant. Prolonged use of hydromorphone hydrochloride tablets

during pregnancy can cause withdrawal symptoms in your newborn baby that could be life-

threatening if not recognized and treated.

Breastfeeding. Hydromorphone hydrochloride tablets pass into breast milk and may harm your baby.

Taking prescription or over-the-counter medicines, vitamins, or herbal supplements. Taking

hydromorphone hydrochloride with certain other medicines can cause serious side effects that could

lead to death.

When taking hydromorphone hydrochloride:

Do not change your dose. Take hydromorphone hydrochloride exactly as prescribed by your

healthcare provider. Use the lowest dose possible for the shortest time needed.

Do not take more than your prescribed dose. If you miss a dose, take your next dose at your usual

time.

Call your healthcare provider if the dose you are taking does not control your pain.

If you have been taking hydromorphone hydrochloride tablets, do not stop taking hydromorphone

hydrochloride tablets without talking to your healthcare provider.

Dispose of expired, unwanted, or unused hydromorphone hydrochloride tablets by promptly flushing

down the toilet, if a drug take-back option is not readily available. Visit www.fda.gov/drugdisposal

for additional information on disposal of unused medicines.

While taking hydromorphone hydrochloride DO NOT:

Drive or operate heavy machinery, until you know how hydromorphone hydrochloride tablets affect

you. Hydromorphone hydrochloride can make you sleepy, dizzy, or lightheaded.

Drink alcohol or use prescription or over-the-counter medicines that contain alcohol. Using products

containing alcohol during treatment with hydromorphone hydrochloride tablets may cause you to

overdose and die.

The possible side effects of hydromorphone hydrochloride tablets:

Constipation, nausea, sleepiness, vomiting, tiredness, headache, dizziness, abdominal pain. Call your

healthcare provider if you have any of these symptoms and they are severe.

Get emergency medical help if you have:

Trouble breathing, shortness of breath, fast heartbeat, chest pain, swelling of your face, tongue, or

throat, extreme drowsiness, light-headedness when changing positions, feeling faint, agitation, high

body temperature, trouble walking, stiff muscles, or mental changes such as confusion.

These are not all the possible side effects of hydromorphone hydrochloride tablets. Call your doctor for

medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. For more

information, go to dailymed.nlm.nih.gov

Distributed by: Lannett Company, Inc., Philadelphia, PA 19136, www.lannett.com or call 1-844-834-0530

This Medication Guide has been approved by the U.S. Food and Drug

Administration.

CIB71743D

Rev. 10/2019

Revised: 10/2019

Document Id: b9664676-8243-47c2-acc8-4fa047b0d988

34391-3

Set id: a6c981fb-28f9-4eff-962b-226736f7d0c8

Version: 12

Effective Time: 20191031

Lannett Company, Inc.

HYDROMORPHONE HYDROCHLORIDE- hydromorphone hydrochloride tablet

Lannett Company, Inc.

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HIGHLIGHTS OF PRESCRIBING INFORMATION

These highlights do not include all the information needed to use HYDROMORPHONE HYDROCHLORIDE

TABLETS safely and effectively. See full prescribing information for HYDROMORPHONE HYDROCHLORIDE

TABLETS.

HYDROMORPHONE HYDROCHLORIDE tablets, USP, for oral use, CII

Initial U.S. Approval: January 1984

WARNING: RISK OF MEDICATION ERRORS; ADDICTION, ABUSE, AND MISUSE; RISK EVALUATION

AND MITIGATION STRATEGY (REMS); LIFE-THREATENING RESPIRATORY DEPRESSION;

ACCIDENTAL INGESTION; NEONATAL OPIOID WITHDRAWAL SYNDROME; RISKS FROM

CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS

See full prescribing information for complete boxed warning.

Hydromorphone hydrochloride tablets expose users to risks of addiction, abuse, and misuse, which

can lead to overdose and death. Assess patient’s risk before prescribing and monitor regularly for

these behaviors and conditions. (5.2)

To ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and misuse, the

Food and Drug Administration (FDA) has required a Risk Evaluation and Mitigation Strategy (REMS)

for these products. (5.3)

Serious, life-threatening, or fatal respiratory depression may occur. Monitor closely, especially upon

initiation or following a dose increase. (5.4)

Accidental ingestion of hydromorphone hydrochloride tablets, especially by children, can result in a

fatal overdose of hydromorphone. (5.4)

Prolonged use of hydromorphone hydrochloride tablets during pregnancy can result in neonatal

opioid withdrawal syndrome, which may be life-threatening if not recognized and treated. If

prolonged opioid use is required in a pregnant woman, advise the patient of the risk of neonatal opioid

withdrawal syndrome and ensure that appropriate treatment will be available. (5.5)

Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants,

including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve

concomitant prescribing for use in patients for whom alternative treatment options are inadequate;

limit dosages and durations to the minimum required; and follow patients for signs and symptoms of

respiratory depression and sedation. (5.6, 7)

RECENT MAJOR CHANGES

Dosage and Administration (2.6) 10/2019

Warnings and Precautions (5.4, 5.13) 10/2019

INDICATIONS AND USAGE

Hydromorphone hydrochloride tablets contain hydromorphone, an opioid agonist, and are indicated for the management of

pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. (1)

Limitations of Use (1)

Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, reserve hydromorphone

hydrochloride tablets for use in patients for whom alternative treatment options [e.g., non-opioid analgesics or opioid

combination products]:

Have not been tolerated, or are not expected to be tolerated,

Have not provided adequate analgesia, or are not expected to provide adequate analgesia

DOSAGE AND ADMINISTRATION

Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals.

Individualize dosing based on the severity of pain, patient response, prior analgesic experience, and risk factors for

addiction, abuse, and misuse. (2.1)

Usual adult starting dose for hydromorphone hydrochloride tablets is 2 mg to 4 mg, orally, every 4 to 6 hours. (2.2)

Hepatic Impairment: Initiate treatment with one-fourth to one-half the usual starting dose, depending on degree of

hepatic impairment. (2.3)

Renal Impairment: Initiate treatment with one-fourth to one-half the usual starting dose, depending on degree of renal

impairment. (2.4)

Do not abruptly discontinue hydromorphone hydrochloride tablets in a physically-dependent patient because rapid

discontinuation of opioid analgesics has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide. (2.6)

DOSAGE FORMS AND STRENGTHS

Hydromorphone hydrochloride tablets: 2 mg, 4 mg, 8 mg (3)

CONTRAINDICATIONS

Significant respiratory depression. (4)

Acute or severe bronchial asthma in an unmonitored setting or in absence of resuscitative equipment. (4)

Known or suspected gastrointestinal obstruction, including paralytic ileus. (4)

Known hypersensitivity to hydromorphone, hydromorphone salts, or sulfite-containing medications. (4)

WARNINGS AND PRECAUTIONS

Life-Threatening Respiratory Depression in Patients with Chronic Pulmonary Disease or in Elderly, Cachectic, or

Debilitated Patients: Monitor closely, particularly during initiation and titration. (5.7)

Adrenal Insufficiency: If diagnosed, treat with physiologic replacement of corticosteroids, and wean patient off of the

opioid. (5.8)

Severe Hypotension: Monitor during dosage initiation and titration. Avoid use of hydromorphone hydrochloride tablets

in patients with circulatory shock. (5.9)

Risks of Use in Patients with Increased Intracranial Pressure, Brain Tumors, Head Injury, or Impaired Consciousness:

Monitor for sedation and respiratory depression. Avoid use of hydromorphone hydrochloride tablets in patients with

impaired consciousness or coma. (5.10)

ADVERSE REACTIONS

Most common adverse reactions are lightheadedness, dizziness, sedation, nausea, vomiting, sweating, flushing, dysphoria,

euphoria, dry mouth, and pruritus. (6)

To report SUSPECTED ADVERSE REACTIONS, contact Lannett Company, Inc. at 1-844-834-0530 or FDA at 1-

800-FDA-1088 or www.fda.gov/medwatch

DRUG INTERACTIONS

Serotonergic Drugs: Concomitant use may result in serotonin syndrome. Discontinue hydromorphone hydrochloride

tablets if serotonin syndrome is suspected. (7)

Monoamine Oxidase Inhibitors (MAOIs): Can potentiate the effects of hydromorphone. Avoid concomitant use in

patients receiving MAOIs or within 14 days of stopping treatment with an MAOI. (7)

Mixed Agonist/Antagonist and Partial Agonist Opioid Analgesics: Avoid use with hydromorphone hydrochloride

because they may reduce analgesic effect of hydromorphone hydrochloride or precipitate withdrawal symptoms. (7)

USE IN SPECIFIC POPULATIONS

Pregnancy: May cause fetal harm. (8.1)

See 17 for PATIENT COUNSELING INFORMATION and Medication Guide.

Revised: 10/2019

FULL PRESCRIBING INFORMATION: CONTENTS*

RECENT MAJOR CHANGES

WARNING: RISK OF MEDICATION ERRORS; ADDICTION, ABUSE, AND MISUSE; RISK

EVALUATION AND MITIGATION STRATEGY (REMS); LIFE-THREATENING

RESPIRATORY DEPRESSION; ACCIDENTAL INGESTION; NEONATAL OPIOID

WITHDRAWAL SYNDROME; and RISKS FROM CONCOMITANT USE WITH

BENZODIAZEPINES OR OTHER CNS DEPRESSANTS

1 INDICATIONS AND USAGE

2 DOSAGE AND ADMINISTRATION

2.1 Important Dosage and Administration Instructions

2.2 Initial Dosage

2.3 Dosage Modifications in Patients with Hepatic Impairment

2.4 Dosage Modifications in Patients with Renal Impairment

2.5 Titration and Maintenance of Therapy

2.6 Safe Reduction or Discontinuation of Hydromorphone Hydrochloride Tablets

3 DOSAGE FORMS AND STRENGTHS

4 CONTRAINDICATIONS

5 WARNINGS AND PRECAUTIONS

5.1 Risk of Accidental Overdose and Death due to Medication Errors

5.2 Addiction, Abuse, and Misuse

5.3 Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS)

5.4 Life-Threatening Respiratory Depression

5.5 Neonatal Opioid Withdrawal Syndrome

5.6 Risks from Concomitant Use with Benzodiazepines or Other CNS Depressants

5.7 Life-Threatening Respiratory Depression in Patients with Chronic Pulmonary Disease or in

Elderly, Cachectic, or Debilitated Patients

5.8 Adrenal Insufficiency

5.9 Severe Hypotension

5.10 Risks of Use in Patients with Increased Intracranial Pressure, Brain Tumors, Head Injury, or

Impaired Consciousness

5.11 Risks of Use in Patients with Gastrointestinal Conditions

5.12 Increased Risk of Seizures in Patients with Seizure Disorders

5.13 Withdrawal

5.14 Risks of Driving and Operating Machinery

5.15 Sulfites

6 ADVERSE REACTIONS

6.1 Clinical Trials Experience

6.2 Postmarketing Experience

7 DRUG INTERACTIONS

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

8.2 Lactation

8.3 Females and Males of Reproductive Potential

8.4 Pediatric Use

8.5 Geriatric Use

8.6 Hepatic Impairment

8.7 Renal Impairment

9 DRUG ABUSE AND DEPENDENCE

9.1 Controlled Substance

9.2 Abuse

9.3 Dependence

10 OVERDOSAGE

11 DESCRIPTION

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

12.2 Pharmacodynamics

12.3 Pharmacokinetics

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

14 CLINICAL STUDIES

16 HOW SUPPLIED/STORAGE AND HANDLING

17 PATIENT COUNSELING INFORMATION

FULL PRESCRIBING INFORMATION

Sections or subsections omitted from the full prescribing information are not listed.

WARNING: RISK OF MEDICATION ERRORS; ADDICTION, ABUSE, AND MISUSE;

RISK EVALUATION AND MITIGATION STRATEGY (REMS); LIFE-THREATENING

RESPIRATORY DEPRESSION; ACCIDENTAL INGESTION; NEONATAL OPIOID

WITHDRAWAL SYNDROME; and RISKS FROM CONCOMITANT USE WITH

BENZODIAZEPINES OR OTHER CNS DEPRESSANTS

Addiction, Abuse, and Misuse

Hydromorphone hydrochloride tablets expose patients and other users to the risks of

opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each

patient’s risk prior to prescribing hydromorphone hydrochloride tablets, and monitor all

patients regularly for the development of these behaviors and conditions [see Warnings and

Precautions (5.2)].

Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS)

To ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and

misuse, the Food and Drug Administration (FDA) has required a REMS for these products

[see Warnings and Precautions (5.3)]. Under the requirements of the REMS, drug companies

with approved opioid analgesic products must make REMS-compliant education programs

available to healthcare providers. Healthcare providers are strongly encouraged to

complete a REMS-compliant education program,

counsel patients and/or their caregivers, with every prescription, on safe use, serious

risks, storage, and disposal of these products,

emphasize to patients and their caregivers the importance of reading the Medication

Guide every time it is provided by their pharmacist, and

consider other tools to improve patient, household, and community safety.

Life-Threatening Respiratory Depression

Serious, life-threatening, or fatal respiratory depression may occur with use of

hydromorphone hydrochloride tablets. Monitor for respiratory depression, especially

during initiation of hydromorphone hydrochloride tablets or following a dose increase [see

Warnings and Precautions (5.4)].

Accidental Ingestion

Accidental ingestion of even one dose of hydromorphone hydrochloride tablets, especially

by children, can result in a fatal overdose of hydromorphone [see Warnings and Precautions

(5.4)].

Neonatal Opioid Withdrawal Syndrome

Prolonged use of hydromorphone hydrochloride tablets during pregnancy can result in

neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and

treated, and requires management according to protocols developed by neonatology

experts. If opioid use is required for a prolonged period in a pregnant woman, advise the

patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate

treatment will be available [see Warnings and Precautions (5.5)].

Risks From Concomitant Use With Benzodiazepines Or Other CNS Depressants

Concomitant use of opioids with benzodiazepines or other central nervous system (CNS)

depressants, including alcohol, may result in profound sedation, respiratory depression,

coma, and death [see Warnings and Precautions (5.6), Drug Interactions (7)].

Reserve concomitant prescribing of hydromorphone hydrochloride tablets and

benzodiazepines or other CNS depressants for use in patients for whom alternative

treatment options are inadequate.

Limit dosages and durations to the minimum required.

Follow patients for signs and symptoms of respiratory depression and sedation.

1 INDICATIONS AND USAGE

Hydromorphone hydrochloride tablets are indicated for the management of pain severe enough to

require an opioid analgesic and for which alternative treatments are inadequate.

Limitations of Use

Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses [see

Warnings and Precautions (5.2)], reserve hydromorphone hydrochloride tablets for use in patients for

whom alternative treatment options [e.g., non-opioid analgesics or opioid combination products]:

Have not been tolerated, or are not expected to be tolerated,

Have not provided adequate analgesia, or are not expected to provide adequate analgesia

2 DOSAGE AND ADMINISTRATION

2.1 Important Dosage and Administration Instructions

Use the lowest effective dosage for the shortest duration consistent with individual patient treatment

goals [see Warnings and Precautions (5)].

Initiate the dosing regimen for each patient individually, taking into account the patient’s severity of

pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse,

and misuse [see Warnings and Precautions (5.2)].

Monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of

initiating therapy and following dosage increases with hydromorphone hydrochloride tablets and

adjust the dosage accordingly [see Warnings and Precautions (5.4)].

2.2 Initial Dosage

Initiating Treatment with Hydromorphone Hydrochloride Tablets

Initiate treatment with hydromorphone hydrochloride tablets in a dosing range of 2 mg to 4 mg, orally,

every 4 to 6 hours.

Conversion from Other Opioids to Hydromorphone Hydrochloride Tablets

There is inter-patient variability in the potency of opioid drugs and opioid formulations. Therefore, a

conservative approach is advised when determining the total daily dosage of hydromorphone

hydrochloride tablets. It is safer to underestimate a patient’s 24-hour hydromorphone hydrochloride

dosage than to overestimate the 24-hour dosage and manage an adverse reaction due to overdose.

In general, it is safest to start hydromorphone hydrochloride therapy by administering half of the usual

starting dose every 4 to 6 hours for hydromorphone hydrochloride tablets. The dose of

hydromorphone hydrochloride can be gradually adjusted until adequate pain relief and acceptable side

effects have been achieved [see Dosage and Administration (2.4)].

Conversion from Hydromorphone Hydrochloride Tablets to Extended-Release Hydromorphone

Hydrochloride

The relative bioavailability of hydromorphone hydrochloride tablets compared to extended-release

hydromorphone hydrochloride is unknown, so conversion to extended-release tablets must be

accompanied by close observation for signs of excessive sedation and respiratory depression.

2.3 Dosage Modifications in Patients with Hepatic Impairment

Initiate treatment with one-fourth to one-half the usual hydromorphone hydrochloride starting dose

depending on the degree of impairment [see Use in Specific Populations (8.6), and Clinical Pharmacology

(12.3)].

2.4 Dosage Modifications in Patients with Renal Impairment

Initiate treatment with one-fourth to one-half the usual hydromorphone hydrochloride starting dose

depending on the degree of impairment [see Use in Specific Populations (8.7), and Clinical Pharmacology

(12.3)].

2.5 Titration and Maintenance of Therapy

Individually titrate hydromorphone hydrochloride tablets to a dose that provides adequate analgesia and

minimizes adverse reactions. Continually reevaluate patients receiving hydromorphone hydrochloride

tablets to assess the maintenance of pain control and the relative incidence of adverse reactions, as well

as monitoring for the development of addiction, abuse, or misuse [see Warnings and Precautions (5.2)].

Frequent communication is important among the prescriber, other members of the healthcare team, the

patient, and the caregiver/family during periods of changing analgesic requirements, including initial

titration.

If the level of pain increases after dosage stabilization, attempt to identify the source of increased pain

before increasing the hydromorphone hydrochloride tablets dosage. If unacceptable opioid-related

adverse reactions are observed, consider reducing the dosage. Adjust the dosage to obtain an

appropriate balance between management of pain and opioid-related adverse reactions.

For chronic pain, doses should be administered around-the-clock. A supplemental dose of 5 to 15% of

the total daily usage may be administered every two hours on an as-needed basis.

2.6 Safe Reduction or Discontinuation of Hydromorphone Hydrochloride Tablets

Do not abruptly discontinue hydromorphone hydrochloride tablets in patients who may be physically

dependent on opioids. Rapid discontinuation of opioid analgesics in patients who are physically

dependent on opioids has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide.

Rapid discontinuation has also been associated with attempts to find other sources of opioid analgesics,

which may be confused with drug-seeking for abuse. Patients may also attempt to treat their pain or

withdrawal symptoms with illicit opioids, such as heroin, and other substances.

When a decision has been made to decrease the dose or discontinue therapy in an opioid dependent

patient taking hydromorphone hydrochloride tablets, there are a variety of factors that should be

considered, including the dose of hydromorphone hydrochloride tablets the patient has been taking, the

duration of treatment, the type of pain being treated, and the physical and psychological attributes of the

patient. It is important to ensure ongoing care of the patient and to agree on an appropriate tapering

schedule and follow-up plan so that patient and provider goals and expectations are clear and realistic.

When opioid analgesics are being discontinued due to a suspected substance use disorder, evaluate and

treat the patient, or refer for evaluation and treatment of the substance use disorder. Treatment should

include evidence-based approaches, such as medication assisted treatment of opioid use disorder.

Complex patients with co-morbid pain and substance use disorders may benefit from referral to a

specialist.

There are no standard opioid tapering schedules that are suitable for all patients. Good clinical practice

dictates a patient-specific plan to taper the dose of the opioid gradually. For patients on hydromorphone

hydrochloride tablets who are physically opioid-dependent, initiate the taper by a small enough

increment (e.g., no greater than 10% to 25% of the total daily dose) to avoid withdrawal symptoms, and

proceed with dose-lowering at an interval of every 2 to 4 weeks. Patients who have been taking opioids

for briefer periods of time may tolerate a more rapid taper.

It may be necessary to provide the patient with lower dosage strengths to accomplish a successful taper.

Reassess the patient frequently to manage pain and withdrawal symptoms, should they emerge. Common

withdrawal symptoms include 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. If withdrawal symptoms arise, it may be

necessary to pause the taper for a period of time or raise the dose of the opioid analgesic to the

previous dose, and then proceed with a slower taper. In addition, monitor patients for any changes in

mood, emergence of suicidal thoughts, or use of other substances.

When managing patients taking opioid analgesics, particularly those who have been treated for a long

duration and/or with high doses for chronic pain, ensure that a multimodal approach to pain management,

including mental health support (if needed), is in place prior to initiating an opioid analgesic taper. A

multimodal approach to pain management may optimize the treatment of chronic pain, as well as assist

with the successful tapering of the opioid analgesic [see Warnings and Precautions (5.13), Drug Abuse

and Dependence (9.3)].

3 DOSAGE FORMS AND STRENGTHS

2 mg tablets (white, round, flat-faced beveled edge tablets debossed with “LCI” over “1353” on one

side and “2” on the other side)

4 mg tablets (white, round, flat-faced beveled edge tablets debossed with “LCI” over “1354” on one

side and “4” on the other side)

8 mg tablets (white, round, flat-faced beveled edge, scored, tablets debossed with “LCI” over

“1355” on one side and plain on the other side)

4 CONTRAINDICATIONS

Hydromorphone hydrochloride tablets are contraindicated in patients with:

Significant respiratory depression [see Warnings and Precautions (5.7)]

Acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative

equipment [see Warnings and Precautions (5.7)]

Known or suspected gastrointestinal obstruction, including paralytic ileus [see Warnings and

Precautions (5.11)]

Hypersensitivity to hydromorphone, hydromorphone salts, any other components of the product, or

sulfite-containing medications (e.g., anaphylaxis) [see Warnings and Precautions (5.15), Adverse

Reactions (6.1)]

5 WARNINGS AND PRECAUTIONS

5.1 Risk of Accidental Overdose and Death due to Medication Errors

Dosing errors can result in accidental overdose and death. Ensure that the dose is communicated clearly

and dispensed accurately.

5.2 Addiction, Abuse, and Misuse

Hydromorphone hydrochloride tablets, USP contain hydromorphone, a Schedule II controlled

substance. As an opioid, hydromorphone hydrochloride exposes users to the risks of addiction, abuse,

and misuse [see Drug Abuse and Dependence (9)].

Although the risk of addiction in any individual is unknown, it can occur in patients appropriately

prescribed hydromorphone hydrochloride tablets. Addiction can occur at recommended dosages and if

the drug is misused or abused.

Assess each patient’s risk for opioid addiction, abuse, or misuse prior to prescribing hydromorphone

hydrochloride tablets, and monitor all patients receiving hydromorphone hydrochloride tablets for the

development of these behaviors and conditions. Risks are increased in patients with a personal or family

history of substance abuse (including drug or alcohol abuse or addiction) or mental illness (e.g., major

depression). The potential for these risks should not, however, prevent the proper management of pain

in any given patient. Patients at increased risk may be prescribed opioids such as hydromorphone

hydrochloride tablets, but use in such patients necessitates intensive counseling about the risks and

proper use of hydromorphone hydrochloride tablets along with intensive monitoring for signs of

addiction, abuse, and misuse.

Opioids are sought by drug abusers and people with addiction disorders and are subject to criminal

diversion. Consider these risks when prescribing or dispensing hydromorphone hydrochloride tablets.

Strategies to reduce these risks include prescribing the drug in the smallest appropriate quantity and

advising the patient on the proper disposal of unused drug [see Patient Counseling Information (17)].

Contact local state professional licensing board or state controlled substances authority for information

on how to prevent and detect abuse or diversion of this product.

5.3 Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS)

To ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and misuse, the

Food and Drug Administration (FDA) has required a Risk Evaluation and Mitigation Strategy (REMS)

for these products. Under the requirements of the REMS, drug companies with approved opioid

analgesic products must make REMS-compliant education programs available to healthcare providers.

Healthcare providers are strongly encouraged to do all of the following:

Complete a REMS-compliant education program offered by an accredited provider of continuing

education (CE) or another education program that includes all the elements of the FDA Education

Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain.

Discuss the safe use, serious risks, and proper storage and disposal of opioid analgesics with

patients and/or their caregivers every time these medicines are prescribed. The Patient Counseling

Guide (PCG) can be obtained at this link: www.fda.gov/OpioidAnalgesicREMSPCG.

Emphasize to patients and their caregivers the importance of reading the Medication Guide that they

will receive from their pharmacist every time an opioid analgesic is dispensed to them.

Consider using other tools to improve patient, household, and community safety, such as patient-

prescriber agreements that reinforce patient-prescriber responsibilities.

To obtain further information on the opioid analgesic REMS and for a list of accredited REMS

CME/CE, call 1-800-503-0784, or log on to www.opioidanalgesicrems.com. The FDA Blueprint can

be found at www.fda.gov/OpioidAnalgesicREMSBlueprint.

5.4 Life-Threatening Respiratory Depression

Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids,

even when used as recommended. Respiratory depression, if not immediately recognized and treated,

may lead to respiratory arrest and death. Management of respiratory depression may include close

observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical

status [see Overdosage (10)]. Carbon dioxide (CO ) retention from opioid-induced respiratory

depression can exacerbate the sedating effects of opioids.

While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of

hydromorphone hydrochloride tablets, the risk is greatest during the initiation of therapy or following a

dosage increase. Monitor patients closely for respiratory depression, especially within the first 24 to

72 hours of initiating therapy with and following dosage increases of hydromorphone hydrochloride

tablets.

To reduce the risk of respiratory depression, proper dosing and titration of hydromorphone

hydrochloride tablets are essential [see Dosage and Administration (2)]. Overestimating the

hydromorphone hydrochloride tablets dosage when converting patients from another opioid product can

result in a fatal overdose with the first dose.

Accidental ingestion of even one dose of hydromorphone hydrochloride tablets, especially by children,

can result in respiratory depression and death due to an overdose of hydromorphone.

Opioids can cause sleep-related breathing disorders including central sleep apnea (CSA) and sleep-

related hypoxemia. Opioid use increases the risk of CSA in a dose-dependent fashion. In patients who

present with CSA, consider decreasing the opioid dosage using best practices for opioid taper [see

Dosage and Administration (2.6)].

5.5 Neonatal Opioid Withdrawal Syndrome

Prolonged use of hydromorphone hydrochloride tablets during pregnancy can result in withdrawal in

the neonate. Neonatal opioid withdrawal syndrome, unlike opioid withdrawal syndrome in adults, may be

life-threatening if not recognized and treated, and requires management according to protocols

developed by neonatology experts. Observe newborns for signs of neonatal opioid withdrawal

syndrome and manage accordingly. Advise pregnant women using opioids for a prolonged period of the

risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available [see

Use in Specific Populations (8.1), Patient Counseling Information (17)].

5.6 Risks from Concomitant Use with Benzodiazepines or Other CNS Depressants

Profound sedation, respiratory depression, coma, and death may result from the concomitant use of

hydromorphone hydrochloride tablets with benzodiazepines or other CNS depressants (e.g., non-

benzodiazepine sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics,

antipsychotics, other opioids, alcohol). Because of these risks, reserve concomitant prescribing of

these drugs for use in patients for whom alternative treatment options are inadequate.

Observational studies have demonstrated that concomitant use of opioid analgesics and benzodiazepines

increases the risk of drug-related mortality compared to use of opioid analgesics alone. Because of

similar pharmacological properties, it is reasonable to expect similar risk with the concomitant use of

other CNS depressant drugs with opioid analgesics [see Drug Interactions (7)].

If the decision is made to prescribe a benzodiazepine or other CNS depressant concomitantly with an

opioid analgesic, prescribe the lowest effective dosages and minimum durations of concomitant use. In

patients already receiving an opioid analgesic, prescribe a lower initial dose of the benzodiazepine or

other CNS depressant than indicated in the absence of an opioid, and titrate based on clinical response.

If an opioid analgesic is initiated in a patient already taking a benzodiazepine or other CNS depressant,

prescribe a lower initial dose of the opioid analgesic, and titrate based on clinical response. Follow

patients closely for signs and symptoms of respiratory depression and sedation.

Advise both patients and caregivers about the risks of respiratory depression and sedation when

hydromorphone hydrochloride tablets are used with benzodiazepines or other CNS depressants

(including alcohol and illicit drugs). Advise patients not to drive or operate heavy machinery until the

effects of concomitant use of the benzodiazepine or other CNS depressant have been determined.

Screen patients for risk of substance use disorders, including opioid abuse and misuse, and warn them

of the risk for overdose and death associated with the use of additional CNS depressants including

alcohol and illicit drugs [see Drug Interactions (7), Patient Counseling Information (17)].

5.7 Life-Threatening Respiratory Depression in Patients with Chronic Pulmonary Disease or in

Elderly, Cachectic, or Debilitated Patients

The use of hydromorphone hydrochloride tablets in patients with acute or severe bronchial asthma in an

unmonitored setting or in the absence of resuscitative equipment is contraindicated.

Patients with Chronic Pulmonary Disease: Hydromorphone hydrochloride tablet-treated patients with

significant chronic obstructive pulmonary disease or cor pulmonale, and those with a substantially

decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression are at

increased risk of decreased respiratory drive including apnea, even at recommended dosages of

hydromorphone hydrochloride tablets [see Warnings and Precautions (5.4)].

Elderly, Cachectic, or Debilitated Patients: Life-threatening respiratory depression is more likely to

occur in elderly, cachectic, or debilitated patients because they may have altered pharmacokinetics or

altered clearance compared to younger, healthier patients [see Warnings and Precautions (5.4)].

Monitor such patients closely, particularly when initiating and titrating hydromorphone hydrochloride

tablets and when hydromorphone hydrochloride is given concomitantly with other drugs that depress

respiration [see Warnings and Precautions (5.4)]. Alternatively, consider the use of non-opioid

analgesics in these patients.

5.8 Adrenal Insufficiency

Cases of adrenal insufficiency have been reported with opioid use, more often following greater than

one month of use. Presentation of adrenal insufficiency may include non-specific symptoms and signs

including nausea, vomiting, anorexia, fatigue, weakness, dizziness, and low blood pressure. If adrenal

insufficiency is suspected, confirm the diagnosis with diagnostic testing as soon as possible. If adrenal

insufficiency is diagnosed, treat with physiologic replacement doses of corticosteroids. Wean the

patient off of the opioid to allow adrenal function to recover and continue corticosteroid treatment until

adrenal function recovers. Other opioids may be tried as some cases reported use of a different opioid

without recurrence of adrenal insufficiency. The information available does not identify any particular

opioids as being more likely to be associated with adrenal insufficiency.

5.9 Severe Hypotension

Hydromorphone hydrochloride tablets may cause severe hypotension including orthostatic hypotension

and syncope in ambulatory patients. There is increased risk in patients whose ability to maintain blood

pressure has already been compromised by a reduced blood volume or concurrent administration of

certain CNS depressant drugs (e.g., phenothiazines or general anesthetics) [see Drug Interactions (7)].

Monitor these patients for signs of hypotension after initiating or titrating the dosage of hydromorphone

hydrochloride tablets. In patients with circulatory shock, hydromorphone hydrochloride may cause

vasodilation that can further reduce cardiac output and blood pressure. Avoid the use of

hydromorphone hydrochloride tablets in patients with circulatory shock.

5.10 Risks of Use in Patients with Increased Intracranial Pressure, Brain Tumors, Head Injury,

or Impaired Consciousness

In patients who may be susceptible to the intracranial effects of CO retention (e.g., those with evidence

of increased intracranial pressure or brain tumors), hydromorphone hydrochloride tablets may reduce

respiratory drive, and the resultant CO retention can further increase intracranial pressure. Monitor

such patients for signs of sedation and respiratory depression, particularly when initiating therapy with

hydromorphone hydrochloride tablets.

Opioids may also obscure the clinical course in a patient with a head injury. Avoid the use of

hydromorphone hydrochloride in patients with impaired consciousness or coma.

5.11 Risks of Use in Patients with Gastrointestinal Conditions

Hydromorphone hydrochloride tablets are contraindicated in patients with known or suspected

gastrointestinal obstruction, including paralytic ileus.

The hydromorphone in hydromorphone hydrochloride tablets may cause spasm of the sphincter of

Oddi. Opioids may cause increases in serum amylase. Monitor patients with biliary tract disease,

including acute pancreatitis, for worsening symptoms.

5.12 Increased Risk of Seizures in Patients with Seizure Disorders

The hydromorphone in hydromorphone hydrochloride tablets may increase the frequency of seizures in

patients with seizure disorders, and may increase the risk of seizures occurring in other clinical settings

associated with seizures. Monitor patients with a history of seizure disorders for worsened seizure

control during hydromorphone hydrochloride tablets therapy.

5.13 Withdrawal

Do not abruptly discontinue hydromorphone hydrochloride tablets in a patient physically dependent on

opioids. When discontinuing hydromorphone hydrochloride tablets in a physically dependent patient,

gradually taper the dosage. Rapid tapering of hydromorphone in a patient physically dependent on

opioids may lead to a withdrawal syndrome and return of pain [see Dosage and Administration (2.6), Drug

Abuse and Dependence (9.3)].

Additionally, avoid the use of mixed agonist/antagonist (e.g., pentazocine, nalbuphine, and butorphanol)

or partial agonist (e.g., buprenorphine) analgesics in patients who are receiving a full opioid agonist

analgesic, including hydromorphone hydrochloride tablets. In these patients, mixed agonist/antagonist

and partial agonist analgesics may reduce the analgesic effect and/or precipitate withdrawal symptoms

[see Drug Interactions (7)].

5.14 Risks of Driving and Operating Machinery

Hydromorphone hydrochloride tablets may impair the mental or physical abilities needed to perform

potentially hazardous activities such as driving a car or operating machinery. Warn patients not to drive

or operate dangerous machinery unless they are tolerant to the effects of hydromorphone hydrochloride

tablets and know how they will react to the medication.

5.15 Sulfites

Hydromorphone hydrochloride tablets 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 of hydromorphone hydrochloride tablets is contraindicated in patients with hypersensitivity

to sulfite-containing medications.

6 ADVERSE REACTIONS

The following serious adverse reactions are described, or described in greater detail, in other

sections:

Addiction, Abuse, and Misuse [see Warnings and Precautions (5.2)]

Life-Threatening Respiratory Depression [see Warnings and Precautions (5.4)]

Neonatal Opioid Withdrawal Syndrome [see Warnings and Precautions (5.5)]

Interactions with Benzodiazepines or Other CNS Depressants [see Warnings and Precautions (5.6)]

Adrenal Insufficiency [see Warnings and Precautions (5.8)]

Severe Hypotension [see Warnings and Precautions (5.9)]

Gastrointestinal Adverse Reactions [see Warnings and Precautions (5.11)]

Seizures [see Warnings and Precautions (5.12)]

Withdrawal [see Warnings and Precautions (5.13)]

6.1 Clinical Trials Experience

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 hydromorphone hydrochloride include respiratory

depression and apnea and, to a lesser degree, circulatory depression, respiratory arrest, shock, and

cardiac arrest.

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

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: urticaria, rash, hyperhidrosis

Vascular disorders: flushing, hypotension, hypertension

6.2 Postmarketing Experience

The following adverse reactions have been identified during post approval use of hydromorphone.

Because these reactions 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.

Confusional state, convulsions, drowsiness, dyskinesia, dyspnea, erectile dysfunction, fatigue, hepatic

enzymes increased, hyperalgesia, hypersensitivity reaction, lethargy, myoclonus, oropharyngeal

swelling, peripheral edema, and somnolence.

Serotonin syndrome: Cases of serotonin syndrome, a potentially life-threatening condition, have been

reported during concomitant use of opioids with serotonergic drugs.

Adrenal insufficiency: Cases of adrenal insufficiency have been reported with opioid use, more often

following greater than one month of use.

Anaphylaxis: Anaphylaxis has been reported with ingredients contained in hydromorphone

hydrochloride tablets.

Androgen deficiency: Cases of androgen deficiency have occurred with chronic use of opioids [see

Clinical Pharmacology (12.2)].

7 DRUG INTERACTIONS

Table 1 includes clinically significant drug interactions with hydromorphone hydrochloride.

Table 1: Clinically Significant Drug Interactions with Hydromorphone Hydrochloride

Benzodiazepines and other Central Nervous System (CNS) Depressants

Clinical Impact:

Due to additive pharmacologic effect, the concomitant use of benzodiazepines or

other CNS depressants, including alcohol, can increase the risk of hypotension,

respiratory depression, profound sedation, coma, and death.

Intervention:

Reserve concomitant prescribing of these drugs for use in patients for whom

alternative treatment options are inadequate. Limit dosages and durations to the

minimum required. Follow patients closely for signs of respiratory depression and

sedation [see Warnings and Precautions (5.6)].

Examples:

Benzodiazepines and other sedatives/hypnotics, anxiolytics, tranquilizers, muscle

relaxants, general anesthetics, antipsychotics, other opioids, alcohol.

Serotonergic Drugs

Clinical Impact:

The concomitant use of opioids with other drugs that affect the serotonergic

neurotransmitter system has resulted in serotonin syndrome.

Intervention:

If concomitant use is warranted, carefully observe the patient, particularly during

treatment initiation and dose adjustment. Discontinue hydromorphone hydrochloride

tablets if serotonin syndrome is suspected.

Examples:

Selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake

inhibitors (SNRIs), tricyclic antidepressants (TCAs), triptans, 5-HT3 receptor

antagonists, drugs that affect the serotonin neurotransmitter system (e.g., mirtazapine,

trazodone, tramadol), certain muscle relaxants (i.e., cyclobenzaprine, metaxalone),

monoamine oxidase (MAO) inhibitors (those intended to treat psychiatric disorders

and also others, such as linezolid and intravenous methylene blue).

Monoamine Oxidase Inhibitors (MAOIs)

Clinical Impact:

MAOI interactions with opioids may manifest as serotonin syndrome or opioid

toxicity (e.g., respiratory depression, coma) [see Warnings and Precautions (5.4)].

If urgent use of an opioid is necessary, use test doses and frequent titration of small

doses to treat pain while closely monitoring blood pressure and signs and symptoms

of CNS and respiratory depression.

Intervention:

The use of hydromorphone hydrochloride tablets is not recommended for patients

taking MAOIs or within 14 days of stopping such treatment.

Examples:Phenelzine, tranylcypromine, and linezolid.

Mixed Agonist/Antagonist and Partial Agonist Opioid Analgesics

Clinical Impact:

May reduce the analgesic effect of hydromorphone hydrochloride tablets and/or

precipitate withdrawal symptoms.

Intervention:Avoid concomitant use.

Examples:Butorphanol, nalbuphine, pentazocine, and buprenorphine.

Muscle Relaxants

Clinical Impact:

Hydromorphone may enhance the neuromuscular blocking action of skeletal muscle

relaxants and produce an increased degree of respiratory depression.

Intervention:

Monitor patients for signs of respiratory depression that may be greater than

otherwise expected and decrease the dosage of hydromorphone hydrochloride tablets

and/or the muscle relaxant as necessary.

Diuretics

Clinical Impact:

Opioids can reduce the efficacy of diuretics by inducing the release of antidiuretic

hormone.

Intervention:

Monitor patients for signs of diminished diuresis and/or effects on blood pressure and

increase the dosage of the diuretic as needed.

Anticholinergic Drugs

Clinical Impact:

The concomitant use of anticholinergic drugs may increase risk of urinary retention

and/or severe constipation, which may lead to paralytic ileus.

Intervention:

Monitor patients for signs of urinary retention or reduced gastric motility when

hydromorphone hydrochloride tablets are used concomitantly with anticholinergic

drugs.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Risk Summary

Prolonged use of opioid analgesics during pregnancy may cause neonatal opioid withdrawal syndrome

[see Warnings and Precautions (5.5)]. There are no available data with hydromorphone hydrochloride in

pregnant women to inform a drug-associated risk for major birth defects and miscarriage.

In animal reproduction studies, reduced postnatal survival of pups, and decreased were noted following

oral treatment of pregnant rats with hydromorphone during gestation and through lactation at doses 0.8

times the human daily dose of 24 mg/day (HDD), respectively. In published studies, neural tube defects

were noted following subcutaneous injection of hydromorphone to pregnant hamsters at doses 6.4 times

the HDD and soft tissue and skeletal abnormalities were noted following subcutaneous continuous

infusion of 3 times the HDD to pregnant mice. No malformations were noted at 4 or 40.5 times the HDD

in pregnant rats or rabbits, respectively [see Data]. Based on animal data, advise pregnant women of the

potential risk to a fetus.

The estimated background risk of major birth defects and miscarriage for the indicated population is

unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In

the U.S. general population, the estimated background risk of major birth defects and miscarriage in

clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.

Clinical Considerations

Fetal/Neonatal Adverse Reactions

Prolonged use of opioid analgesics during pregnancy for medical or nonmedical purposes can result in

physical dependence in the neonate and neonatal opioid withdrawal syndrome shortly after birth.

Neonatal opioid withdrawal syndrome presents as irritability, hyperactivity and abnormal sleep pattern,

high pitched cry, tremor, vomiting, diarrhea and failure to gain weight. The onset, duration, and severity

of neonatal opioid withdrawal syndrome vary based on the specific opioid used, duration of use, timing

and amount of last maternal use, and rate of elimination of the drug by the newborn. Observe newborns

for symptoms of neonatal opioid withdrawal syndrome and manage accordingly [see Warnings and

Precautions (5.5)].

Labor or Delivery

Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in

neonates. An opioid antagonist, such as naloxone, must be available for reversal of opioid-induced

respiratory depression in the neonate. Hydromorphone hydrochloride tablets are not recommended for

use in pregnant women during or immediately prior to labor, when other analgesic techniques are more

appropriate. Opioid analgesics, including hydromorphone hydrochloride tablets, can 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 dilation, which

tends to shorten labor. Monitor neonates exposed to opioid analgesics during labor for signs of excess

sedation and respiratory depression.

Data

Animal Data

Pregnant rats were treated with hydromorphone hydrochloride from Gestation Day 6 to 17 via oral

gavage doses of 1, 5, or 10 mg/kg/day (0.4, 2, or 4 times the HDD of 24 mg based on body surface

area, respectively). Maternal toxicity was noted in all treatment groups (reduced food consumption and

body weights in the two highest dose groups). There was no evidence of malformations or

embryotoxicity reported.

Pregnant rabbits were treated with hydromorphone hydrochloride from Gestation Day 7 to 19 via oral

gavage doses of 10, 25, or 50 mg/kg/day (8.1, 20.3, or 40.5 times the HDD of 24 mg based on body

surface area, respectively). Maternal toxicity was noted in the two highest dose groups (reduced food

consumption and body weights). There was no evidence of malformations or embryotoxicity reported.

In a published study, neural tube defects (exencephaly and cranioschisis) were noted following

subcutaneous administration of hydromorphone hydrochloride (19 to 258 mg/kg) on Gestation Day 8 to

pregnant hamsters (6.4 to 87.2 times the HDD of 24 mg/day based on body surface area). The findings

cannot be clearly attributed to maternal toxicity. No neural tube defects were noted at 14 mg/kg (4.7

times the human daily dose of 24 mg/day).

In a published study, CF-1 mice were treated subcutaneously with continuous infusion of 7.5, 15, or 30

mg/kg/day hydromorphone hydrochloride (1.5, 3, or 6.1 times the human daily dose of 24 mg based on

body surface area) via implanted osmotic pumps during organogenesis (Gestation Days 7 to 10). 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) were observed at doses 3 times the human dose of 24 mg/day based on body

surface area. The findings cannot be clearly attributed to maternal toxicity.

Increased pup mortality and decreased pup body weights were noted at 0.8 and 2 times the human daily

dose of 24 mg in a study in which pregnant rats were treated with hydromorphone hydrochloride from

Gestation Day 7 to Lactation Day 20 via oral gavage doses of 0, 0.5, 2, or 5 mg/kg/day (0.2, 0.8, or 2

times the HDD of 24 mg based on body surface area, respectively). Maternal toxicity (decreased food

consumption and body weight gain) was also noted at the two highest doses tested.

8.2 Lactation

Risk Summary

Low levels of opioid analgesics have been detected in human milk. The developmental and health

benefits of breastfeeding should be considered along with the mother’s clinical need for

hydromorphone hydrochloride tablets and any potential adverse effects on the breastfed infant from

hydromorphone hydrochloride tablets or from the underlying maternal condition.

Clinical Considerations

Monitor infants exposed to hydromorphone hydrochloride through breast milk for excess sedation and

respiratory depression. Withdrawal symptoms can occur in breastfed infants when maternal

administration of hydromorphone is stopped, or when breast-feeding is stopped.

8.3 Females and Males of Reproductive Potential

Infertility

Chronic use of opioids may cause reduced fertility in females and males of reproductive potential. It is

not known whether these effects on fertility are reversible [see Adverse Reactions (6.2), Clinical

Pharmacology (12.2), Nonclinical Toxicology (13.1)].

8.4 Pediatric Use

The safety and effectiveness of hydromorphone hydrochloride in pediatric patients have not been

established.

8.5 Geriatric Use

Elderly patients (aged 65 years or older) may have increased sensitivity to hydromorphone. In general,

use caution when selecting a dosage for an elderly patient, 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 for elderly patients treated with opioids, and has occurred after

large initial doses were administered to patients who were not opioid-tolerant or when opioids were

co-administered with other agents that depress respiration. Titrate the dosage of hydromorphone

hydrochloride slowly in geriatric patients and monitor closely for signs of central nervous system and

respiratory depression [see Warnings and Precautions (5.7)].

Hydromorphone is known to be substantially excreted by the kidney, and the risk of adverse reactions to

this drug may be greater in patients with impaired renal function. Because elderly patients are more

likely to have decreased renal function, care should be taken in dose selection, and it may be useful to

monitor renal function.

8.6 Hepatic Impairment

The pharmacokinetics of hydromorphone is affected by hepatic impairment. Due to increased exposure

of hydromorphone, patients with 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 C

and AUC of hydromorphone in this group is

expected and should be taken into consideration when selecting a starting dose [see Clinical

Pharmacology (12.3)].

8.7 Renal Impairment

The pharmacokinetics of hydromorphone is affected by renal impairment. In addition, in patients with

severe renal impairment, hydromorphone appeared to be more slowly eliminated with a longer terminal

elimination half-life. 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 [see Clinical Pharmacology (12.3)].

9 DRUG ABUSE AND DEPENDENCE

9.1 Controlled Substance

Hydromorphone hydrochloride tablets contain hydromorphone, a Schedule II controlled substance.

9.2 Abuse

Hydromorphone hydrochloride tablets contain hydromorphone, a substance with a high potential for

abuse similar to other opioids including fentanyl, hydrocodone, oxycodone, methadone, morphine,

abuse similar to other opioids including fentanyl, hydrocodone, oxycodone, methadone, morphine,

oxymorphone and tapentadol. Hydromorphone hydrochloride tablets can be abused and is subject to

misuse, addiction, and criminal diversion [see Warnings and Precautions (5.2)].

All patients treated with opioids require careful monitoring for signs of abuse and addiction, because

use of opioid analgesic products carries the risk of addiction even under appropriate medical use.

Prescription drug abuse is the intentional non-therapeutic use of a prescription drug, even once, for its

rewarding psychological or physiological effects.

Drug addiction is a cluster of behavioral, cognitive, and physiological phenomena that develop after

repeated substance use and includes: a strong desire to take the drug, difficulties in controlling its use,

persisting in its use despite harmful consequences, a higher priority given to drug use than to other

activities and obligations, increased tolerance, and sometimes a physical withdrawal.

“Drug-seeking” behavior is very common in persons with substance use disorders. Drug-seeking

tactics include emergency calls or visits near the end of office hours, refusal to undergo appropriate

examination, testing, or referral, repeated “loss” of prescriptions, tampering with prescriptions, and

reluctance to provide prior medical records or contact information for other treating healthcare

provider(s). “Doctor shopping” (visiting multiple prescribers to obtain additional prescriptions) is

common among drug abusers and people suffering from untreated addiction. Preoccupation with

achieving adequate pain relief can be appropriate behavior in a patient with poor pain control.

Abuse and addiction are separate and distinct from physical dependence and tolerance. Healthcare

providers 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 true

addiction.

Hydromorphone hydrochloride, like other opioids, can be diverted for nonmedical use into illicit

channels of distribution. Careful recordkeeping of prescribing information, including quantity,

frequency, and renewal requests, as required by state and federal law, is strongly advised.

Proper assessment of the patient, proper prescribing practices, periodic reevaluation of therapy, and

proper dispensing and storage are appropriate measures that help to limit abuse of opioid drugs.

Risks Specific to Abuse of Hydromorphone Hydrochloride

Hydromorphone hydrochloride tablets are for oral use only. Abuse of hydromorphone hydrochloride

tablets poses a risk of overdose and death. The risk is increased with concurrent abuse of

hydromorphone hydrochloride tablets with alcohol and other central nervous system depressants.

Parenteral drug abuse is commonly associated with transmission of infectious diseases such as hepatitis

and HIV.

9.3 Dependence

Both tolerance and physical dependence can develop during chronic opioid therapy. Tolerance is the

need for increasing doses of opioids to maintain a defined effect such as analgesia (in the absence of

disease progression or other external factors). Tolerance may occur to both the desired and undesired

effects of drugs, and may develop at different rates for different effects.

Physical dependence is a physiological state in which the body adapts to the drug after a period of

regular exposure, resulting in withdrawal symptoms after abrupt discontinuation or a significant dosage

reduction of a drug. Withdrawal also may be precipitated through the administration of drugs with

opioid antagonist activity (e.g., naloxone, nalmefene), mixed agonist/antagonist analgesics (e.g.,

pentazocine, butorphanol, nalbuphine), or partial agonists (e.g., buprenorphine). Physical dependence

may not occur to a clinically significant degree until after several days to weeks of continued opioid

usage.

Do not abruptly discontinue hydromorphone hydrochloride tablets in a patient physically dependent on

opioids. Rapid tapering of hydromorphone hydrochloride tablets in a patient physically dependent on

opioids may lead to serious withdrawal symptoms, uncontrolled pain, and suicide. Rapid discontinuation

has also been associated with attempts to find other sources of opioid analgesics, which may be

confused with drug-seeking for abuse.

When discontinuing hydromorphone hydrochloride tablets, gradually taper the dosage using a patient-

specific plan that considers the following: the dose of hydromorphone hydrochloride tablets the patient

has been taking, the duration of treatment, and the physical and psychological attributes of the patient. To

improve the likelihood of a successful taper and minimize withdrawal symptoms, it is important that the

opioid tapering schedule is agreed upon by the patient. In patients taking opioids for a long duration at

high doses, ensure that a multimodal approach to pain management, including mental health support (if

needed), is in place prior to initiating an opioid analgesic taper [see Dosage and Administration (2.6),

Warnings and Precautions (5.13)].

Infants born to mothers physically dependent on opioids will also be physically dependent and may

exhibit respiratory difficulties and withdrawal signs [see Use in Specific Populations (8.1)].

10 OVERDOSAGE

Clinical Presentation

Acute overdose with hydromorphone hydrochloride tablets can be manifested by respiratory

depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy

skin, constricted pupils, and, in some cases, pulmonary edema, bradycardia, hypotension, partial or

complete airway obstruction, atypical snoring, and death. Marked mydriasis rather than miosis may be

seen with hypoxia in overdose situations [see Clinical Pharmacology (12.2)].

Treatment of Overdose

In case of overdose, priorities are the reestablishment of a patent and protected airway and institution of

assisted or controlled ventilation, if needed. Employ other supportive measures (including oxygen and

vasopressors) in the management of circulatory shock and pulmonary edema as indicated. Cardiac arrest

or arrhythmias will require advanced life-support techniques.

The opioid antagonists, naloxone or nalmefene, are specific antidotes to respiratory depression

resulting from opioid overdose. For clinically significant respiratory or circulatory depression

secondary to hydromorphone overdose, administer an opioid antagonist. Opioid antagonists should not

be administered in the absence of clinically significant respiratory or circulatory depression secondary

to hydromorphone overdose.

Because the duration of opioid reversal is expected to be less than the duration of action of

hydromorphone in hydromorphone hydrochloride tablets, carefully monitor the patient until spontaneous

respiration is reliably reestablished. If the response to an opioid antagonist is suboptimal or only brief

in nature, administer additional antagonist as directed by the product’s prescribing information.

In an individual physically dependent on opioids, administration of the recommended usual dosage of the

antagonist will precipitate an acute withdrawal syndrome. The severity of the withdrawal symptoms

experienced will depend on the degree of physical dependence and the dose of the antagonist

administered. If a decision is made to treat serious respiratory depression in the physically dependent

patient, administration of the antagonist should be initiated with care and by titration with smaller than

usual doses of the antagonist.

11 DESCRIPTION

Hydromorphone hydrochloride, a hydrogenated ketone of morphine, is an opioid agonist.

Hydromorphone hydrochloride tablets, USP are supplied in 2 mg, 4 mg, and 8 mg tablets for oral

administration. The tablet strengths describe the amount of hydromorphone hydrochloride in each tablet.

The chemical name is 4,5α-epoxy-3-hydroxy-17-methylmorphinan-6-one hydrochloride. The molecular

weight is 321.80. Its molecular formula is C

H NO ·HCl, and it has the following chemical

structure:

Hydromorphone hydrochloride is a white or almost white crystalline powder that is freely soluble in

water, very slightly soluble in ethanol (96%), and practically insoluble in methylene chloride.

The 2 mg, 4 mg, and 8 mg tablets contain the following inactive ingredients: anhydrous lactose, lactose

monohydrate and magnesium stearate.

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

Hydromorphone is a full opioid agonist and is relatively selective for the mu-opioid receptor, although

it can bind to other opioid receptors at higher doses. The principal therapeutic action of

hydromorphone is analgesia. Like all full opioid agonists, there is no ceiling effect for analgesia with

morphine. Clinically, dosage is titrated to provide adequate analgesia and may be limited by adverse

reactions, including respiratory and CNS depression.

The precise mechanism of the analgesic action is unknown. However, specific CNS opioid receptors

for endogenous compounds with opioid-like activity have been identified throughout the brain and

spinal cord and are thought to play a role in the analgesic effects of this drug.

12.2 Pharmacodynamics

Effects on the Central Nervous System

Hydromorphone produces respiratory depression by direct action on brain stem respiratory centers.

The respiratory depression involves a reduction in the responsiveness of the brain stem respiratory

centers to both increases in carbon dioxide tension and to electrical stimulation.

Hydromorphone causes miosis, even in total darkness. Pinpoint pupils are a sign of opioid overdose but

are not pathognomonic (e.g., pontine lesions of hemorrhagic or ischemic origins may produce similar

findings). Marked mydriasis rather than miosis may be seen due to hypoxia in overdose situations.

Effects on the Gastrointestinal Tract and Other Smooth Muscle

Hydromorphone causes a reduction in motility associated with an increase in smooth muscle tone in the

antrum of the stomach and duodenum. Digestion of food in the small intestine is delayed and propulsive

contractions are decreased. Propulsive peristaltic waves in the colon are decreased, while tone may be

increased to the point of spasm, resulting in constipation. Other opioid-induced effects may include a

reduction in biliary and pancreatic secretions, spasm of sphincter of Oddi, and transient elevations in

serum amylase.

Effects on the Cardiovascular System

Hydromorphone produces peripheral vasodilation which may result in orthostatic hypotension or

syncope. Manifestations of histamine release and/or peripheral vasodilation may include pruritus,

flushing, red eyes and sweating and/or orthostatic hypotension.

Effects on the Endocrine System

Opioids inhibit the secretion of adrenocorticotropic hormone (ACTH), cortisol, and luteinizing

hormone (LH) in humans [see Adverse Reactions (6.2)]. They also stimulate prolactin, growth hormone

(GH) secretion, and pancreatic secretion of insulin and glucagon.

Chronic use of opioids may influence the hypothalamic-pituitary-gonadal axis, leading to androgen

deficiency that may manifest as low libido, impotence, erectile dysfunction, amenorrhea, or infertility.

The causal role of opioids in the clinical syndrome of hypogonadism is unknown because the various

medical, physical, lifestyle, and psychological stressors that may influence gonadal hormone levels

have not been adequately controlled for in studies conducted to date [see Adverse Reactions (6.2)].

Effects on the Immune System

Opioids have been shown to have a variety of effects on components of the immune system in

in vitro and animal models. The clinical significance of these findings is unknown. Overall, the effects

of opioids appear to be modestly immunosuppressive.

Concentration–Efficacy Relationships

The minimum effective analgesic concentration will vary widely among patients, especially among

patients who have been previously treated with potent agonist opioids. The minimum effective analgesic

concentration of hydromorphone for any individual patient may increase over time due to an increase in

pain, the development of a new pain syndrome, and/or the development of analgesic tolerance [see

Dosage and Administration (2.1, 2.5)].

Concentration–Adverse Reaction Relationships

There is a relationship between increasing hydromorphone plasma concentration and increasing

frequency of dose-related opioid adverse reactions such as nausea, vomiting, CNS effects, and

respiratory depression. In opioid-tolerant patients, the situation may be altered by the development of

tolerance to opioid-related adverse reactions [see Dosage and Administration (2.2, 2.3, 2.5)].

12.3 Pharmacokinetics

Absorption

The analgesic activity of hydromorphone hydrochloride is due to the parent drug, hydromorphone.

Hydromorphone is rapidly absorbed from the gastrointestinal tract after oral administration and

undergoes extensive first-pass metabolism. Exposure of hydromorphone (C

and AUC

) is dose-

proportional at a dose range of 2 and 8 mg. In vivo bioavailability following single-dose administration

of the 8 mg tablet is approximately 24% (coefficient of variation 21%).

After oral administration of hydromorphone hydrochloride, peak plasma hydromorphone concentrations

are generally attained within ½ to 1 hour.

Mean (%cv)

Dosage Form C

T

AUC T

(ng) (hrs) (ng*hr/mL) (hrs)

8 mg Tablet 5.5 (33%) 0.74 (34%) 23.7 (28%) 2.6 (18%)

Food Effects

In a study conducted with a single 8 mg dose of hydromorphone (2 mg hydromorphone immediate-

release tablets), food lowered C

by 25%, prolonged T

by 0.8 hour, and increased AUC by 35%.

The effects may not be clinically relevant.

Distribution

At therapeutic plasma levels, hydromorphone is approximately 8 to 19% bound to plasma proteins.

After an intravenous bolus dose, the steady state of volume distribution [mean (% cv)] is 302.9 (32%)

liters.

Elimination

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.

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.

Excretion

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.

Specific Populations

Hepatic Impairment

After oral administration of a single 4 mg dose (2 mg hydromorphone immediate-release tablets), mean

exposure to hydromorphone (C

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 a

lower dose and closely monitored during dose titration. Pharmacokinetics of hydromorphone in severe

hepatic impairment patients has not been studied. Further increase in C

and AUC of hydromorphone

in this group is expected. As such, starting dose should be even more conservative [see Use in Specific

Populations (8.6)].

Renal Impairment

After oral administration of a single 4 mg dose (2 mg hydromorphone immediate-release tablets),

exposure to hydromorphone (C

and AUC

) is increased in patients with impaired renal function by

2-fold in moderate (CLcr = 40 to 60 mL/min) and 3-fold in 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 longer terminal elimination half-life (40 hr)

compared to patients with normal renal function (15 hr). Patients with moderate renal impairment should

be started on a lower dose. Starting doses for patients with severe renal impairment should be even

lower. Patients with renal impairment should be closely monitored during dose titration [see Use in

Specific Populations (8.7)].

Age: Geriatric Population

In the geriatric population, age has no effect on the pharmacokinetics of hydromorphone.

Sex

Sex has little effect on the pharmacokinetics of hydromorphone. Females appear to have higher C

0-24

max

max

½

0-48

(25%) than males with comparable AUC

values. The difference observed in C

may not be

clinically relevant.

13 NONCLINICAL TOXICOLOGY

13.1 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 positive in the mouse lymphoma assay in the presence of metabolic activation, but

was negative in the mouse lymphoma assay in the absence of metabolic activation. 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

Reduced implantation sites and viable fetuses were noted at 2.1 times the human daily dose of 32 mg/day

in a study in which female rats were treated orally with 1.75, 3.5, or 7 mg/kg/day hydromorphone

hydrochloride (0.5, 1.1, or 2.1 times a human daily dose of 24 mg/day (HDD) based on body surface

area) beginning 14 days prior to mating through Gestation Day 7 and male rats were treated with the

same hydromorphone hydrochloride doses beginning 28 days prior to and throughout mating.

14 CLINICAL STUDIES

Analgesic effects of single doses of hydromorphone hydrochloride oral solution administered to

patients with post-surgical pain have been studied in double-blind controlled trials. In one study, both 5

mg and 10 mg of hydromorphone hydrochloride oral solution provided significantly more analgesia

than placebo. In another trial, 5 mg and 10 mg of hydromorphone hydrochloride oral solution were

compared to 30 mg and 60 mg of morphine sulfate oral liquid. The pain relief provided by 5 mg and 10

mg hydromorphone hydrochloride oral solution was comparable to 30 mg and 60 mg oral morphine

sulfate, respectively.

16 HOW SUPPLIED/STORAGE AND HANDLING

Hydromorphone Hydrochloride Tablets USP, 2 mg are white, round, flat-faced beveled edge tablets

debossed with “LCI” over “1353” on one side and “2” on the other side. Available in bottles of 100

(NDC 0527-1353-01).

Hydromorphone Hydrochloride Tablets USP, 4 mg are white, round, flat-faced beveled edge tablets

debossed with “LCI” over “1354” on one side and “4” on the other side. Available in bottles of 100

(NDC 0527-1354-01).

Hydromorphone Hydrochloride Tablets USP, 8 mg are white, round, flat-faced beveled edge, scored,

tablets debossed with “LCI” over “1355” on one side and plain on the other side. Available in bottles of

100 (NDC 0527-1355-01).

Store at 20° to 25°C (68° to 77°F) [See USP Controlled Room Temperature].

Protect from light.

Store hydromorphone hydrochloride tablets securely and dispose of properly [see Patient Counseling

Information (17)].

17 PATIENT COUNSELING INFORMATION

Advise the patient to read the FDA-approved patient labeling (Medication Guide).

Storage and Disposal

Because of the risks associated with accidental ingestion, misuse, and abuse, advise patients to store

hydromorphone hydrochloride tablets securely, out of sight and reach of children, and in a location not

accessible by others, including visitors to the home [see Warnings and Precautions (5.2, 5.4), Drug

Abuse and Dependence (9.2)]. Inform patients that leaving hydromorphone hydrochloride tablets

unsecured can pose a deadly risk to others in the home.

Advise patients and caregivers that when medicines are no longer needed, they should be disposed of

promptly. Expired, unwanted, or unused hydromorphone hydrochloride tablets should be disposed of by

flushing the unused medication down the toilet if a drug take-back option is not readily available. Inform

0-24

patients that they can visit www.fda.gov/drugdisposal for a complete list of medicines recommended for

disposal by flushing, as well as additional information on disposal of unused medicines.

Addiction, Abuse, and Misuse

Inform patients that the use of hydromorphone hydrochloride tablets, even when taken as recommended,

can result in addiction, abuse, and misuse, which can lead to overdose and death [see Warnings and

Precautions (5.2)]. Instruct patients not to share hydromorphone hydrochloride tablets with others and to

take steps to protect hydromorphone hydrochloride tablets from theft or misuse.

Life-Threatening Respiratory Depression

Inform patients of the risk of life-threatening respiratory depression, including information that the risk

is greatest when starting hydromorphone hydrochloride tablets or when the dosage is increased, and

that it can occur even at recommended dosages [see Warnings and Precautions (5.4)]. Advise patients

how to recognize respiratory depression and to seek medical attention if breathing difficulties develop.

Accidental Ingestion

Inform patients that accidental ingestion, especially by children, may result in respiratory depression or

death [see Warnings and Precautions (5.4)].

Interactions with Benzodiazepines and Other CNS Depressants

Inform patients and caregivers that potentially fatal additive effects may occur if hydromorphone

hydrochloride tablets are used with benzodiazepines or other CNS depressants, including alcohol, and

not to use these concomitantly unless supervised by a health care provider [see Warnings and

Precautions (5.5), Drug Interactions (7)].

Serotonin Syndrome

Inform patients that hydromorphone hydrochloride could cause a rare but potentially life-threatening

condition resulting from concomitant administration of serotonergic drugs. Warn patients of the

symptoms of serotonin syndrome and to seek medical attention right away if symptoms develop. Instruct

patients to inform their healthcare providers if they are taking, or plan to take serotonergic medications

[see Drug Interactions (7)].

MAOI Interaction

Inform patients to avoid taking hydromorphone hydrochloride tablets while using any drugs that inhibit

monoamine oxidase. Patients should not start MAOIs while taking hydromorphone hydrochloride tablets

[see Drug Interactions (7)].

Adrenal Insufficiency

Inform patients that opioids could cause adrenal insufficiency, a potentially life-threatening condition.

Adrenal insufficiency may present with non-specific symptoms and signs such as nausea, vomiting,

anorexia, fatigue, weakness, dizziness, and low blood pressure. Advise patients to seek medical

attention if they experience a constellation of these symptoms [see Warnings and Precautions (5.8)].

Important Administration Instructions

Instruct patients how to properly take hydromorphone hydrochloride.

Advise patients not to adjust the dose of hydromorphone hydrochloride tablets without consulting

with a physician or other healthcare professional.

Important Discontinuation Instructions

In order to avoid developing withdrawal symptoms, instruct patients not to discontinue hydromorphone

hydrochloride tablets without first discussing a tapering plan with the prescriber [see Dosage and

Administration (2.6)].

Hypotension

Inform patients that hydromorphone hydrochloride tablets may cause orthostatic hypotension and

syncope. Instruct patients how to recognize symptoms of low blood pressure and how to reduce the risk

of serious consequences should hypotension occur (e.g., sit or lie down, carefully rise from a sitting or

lying position) [see Warnings and Precautions (5.9)].

Anaphylaxis

Inform patients that anaphylaxis has been reported with ingredients contained in hydromorphone

hydrochloride tablets. Advise patients how to recognize such a reaction and when to seek medical

attention [see Contraindications (4), Adverse Reactions (6)].

Pregnancy

Neonatal Opioid Withdrawal Syndrome

Inform female patients of reproductive potential that prolonged use of hydromorphone hydrochloride

tablets during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-

threatening if not recognized and treated [see Warnings and Precautions (5.5), Use in Specific Populations

(8.1)].

Embryo-Fetal Toxicity

Inform female patients of reproductive potential that hydromorphone hydrochloride tablets can cause

fetal harm and to inform their healthcare provider of a known or suspected pregnancy [see Use in

Specific Populations (8.1), Warnings and Precautions (5.5)].

Lactation

Advise nursing mothers to monitor infants for increased sleepiness (more than usual), breathing

difficulties, or limpness. Instruct nursing mothers to seek immediate medical care if they notice these

signs [see Use in Specific Populations (8.2)].

Infertility

Inform patients that chronic use of opioids may cause reduced fertility. It is not known whether these

effects on fertility are reversible [see Use in Specific Populations (8.3)].

Driving or Operating Heavy Machinery

Inform patients that hydromorphone hydrochloride tablets may impair the ability to perform potentially

hazardous activities such as driving a car or operating heavy machinery. Advise patients not to perform

such tasks until they know how they will react to the medication [see Warnings and Precautions (5.14)].

Constipation

Advise patients of the potential for severe constipation, including management instructions and when to

seek medical attention [see Adverse Reactions (6), Clinical Pharmacology (12.2)].

Healthcare professionals can telephone Lannett Company, Inc. (1-844-834-0530) for information on this

product.

Distributed by:

Lannett Company, Inc.

Philadelphia, PA 19136

CIB70325F

Rev. 10/2019

Medication Guide

Hydromorphone Hydrochloride (hy-dro-MOR-fone hy-dro-KLOR-īd) Tablets, USP, CII

Hydromorphone hydrochloride tablets are:

Strong prescription pain medicines that contains an opioid (narcotic) that is used to manage pain

severe enough to require an opioid analgesic, when other pain treatments such as non-opioid pain

medicines do not treat your pain well enough or you cannot tolerate them.

Opioid pain medicines that can put you at risk for overdose and death. Even if you take your dose

correctly as prescribed you are at risk for opioid addiction, abuse, and misuse that can lead to death.

Important information about hydromorphone hydrochloride:

Get emergency help right away if you take too much hydromorphone hydrochloride tablets

(overdose).

When you first start taking hydromorphone hydrochloride tablets, when your dose is changed, or if

you take too much (overdose), serious or life-threatening breathing problems that can lead to death

may occur.

Taking hydromorphone hydrochloride tablets with other opioid medicines, benzodiazepines,

alcohol, or other central nervous system depressants (including street drugs) can cause severe

drowsiness, decreased awareness, breathing problems, coma, and death.

Never give anyone else your hydromorphone hydrochloride tablets. They could die from taking it.

Selling or giving away hydromorphone hydrochloride tablets is against the law.

Store hydromorphone hydrochloride tablets securely, out of sight and reach of children, and in a

location not accessible by others, including visitors to the home.

Do not take hydromorphone hydrochloride tablets if you have:

Severe asthma, trouble breathing, or other lung problems.

A bowel blockage or have narrowing of the stomach or intestines.

Before taking hydromorphone hydrochloride tablets, tell your healthcare provider if you have a

history of:

head injury, seizures

problems urinating

liver, kidney, thyroid problems

pancreas or gallbladder problems

abuse of street or prescription drugs, alcohol addiction, or mental health problems

Tell your healthcare provider if you are:

Pregnant or planning to become pregnant. Prolonged use of hydromorphone hydrochloride

tablets during pregnancy can cause withdrawal symptoms in your newborn baby that could be life-

threatening if not recognized and treated.

Breastfeeding. Hydromorphone hydrochloride tablets pass into breast milk and may harm your

baby.

Taking prescription or over-the-counter medicines, vitamins, or herbal supplements. Taking

hydromorphone hydrochloride with certain other medicines can cause serious side effects that

could lead to death.

When taking hydromorphone hydrochloride:

Do not change your dose. Take hydromorphone hydrochloride exactly as prescribed by your

healthcare provider. Use the lowest dose possible for the shortest time needed.

Do not take more than your prescribed dose. If you miss a dose, take your next dose at your usual

time.

Call your healthcare provider if the dose you are taking does not control your pain.

If you have been taking hydromorphone hydrochloride tablets, do not stop taking hydromorphone

hydrochloride tablets without talking to your healthcare provider.

Dispose of expired, unwanted, or unused hydromorphone hydrochloride tablets by promptly

flushing down the toilet, if a drug take-back option is not readily available. Visit

www.fda.gov/drugdisposal for additional information on disposal of unused medicines.

While taking hydromorphone hydrochloride DO NOT:

Drive or operate heavy machinery, until you know how hydromorphone hydrochloride tablets affect

you. Hydromorphone hydrochloride can make you sleepy, dizzy, or lightheaded.

Drink alcohol or use prescription or over-the-counter medicines that contain alcohol. Using

products containing alcohol during treatment with hydromorphone hydrochloride tablets may cause

you to overdose and die.

The possible side effects of hydromorphone hydrochloride tablets:

Constipation, nausea, sleepiness, vomiting, tiredness, headache, dizziness, abdominal pain. Call your

healthcare provider if you have any of these symptoms and they are severe.

Get emergency medical help if you have:

Trouble breathing, shortness of breath, fast heartbeat, chest pain, swelling of your face, tongue, or

throat, extreme drowsiness, light-headedness when changing positions, feeling faint, agitation, high

body temperature, trouble walking, stiff muscles, or mental changes such as confusion.

These are not all the possible side effects of hydromorphone hydrochloride tablets. Call your doctor

for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. For

more information, go to dailymed.nlm.nih.gov

Distributed by: Lannett Company, Inc., Philadelphia, PA 19136, www.lannett.com or call 1-844-834-

0530

This Medication Guide has been approved by the U.S. Food and Drug

Administration.

CIB71743D

Rev. 10/2019

PRINCIPAL DISPLAY PANEL - 2 mg Tablet Bottle Label

NDC 0527-1353-01

Hydromorphone

Hydrochloride

Tablets, USP

2 mg

Rx Only

100 TABLETS

Lannett

PRINCIPAL DISPLAY PANEL - 4 mg Tablet Bottle Label

NDC 0527-1354-01

Hydromorphone

Hydrochloride

Tablets, USP

4 mg

Rx Only

100 TABLETS

Lannett

PRINCIPAL DISPLAY PANEL - 8 mg Tablet Bottle Label

NDC 0527-1355-01

Hydromorphone

Hydrochloride

Tablets, USP

8 mg

Rx Only

100 TABLETS

Lannett

HYDROMORPHONE HYDROCHLORIDE

hydromorphone hydrochloride tablet

Product Information

Product T ype

HUMAN PRESCRIPTION DRUG

Ite m Code (Source )

NDC:0 527-1353

Route of Administration

ORAL

DEA Sche dule

Active Ingredient/Active Moiety

Ingredient Name

Basis of Strength

Stre ng th

HYDRO MO RPHO NE HYDRO CHLO RIDE (UNII: L9 6 0 UP2KRW) (HYDROMORPHONE -

UNII:Q 8 1246 4R0 6 )

HYDROMORPHONE

HYDROCHLORIDE

2 mg

Inactive Ingredients

Ingredient Name

Stre ng th

ANHYDRO US LACTO SE (UNII: 3SY5LH9 PMK)

LACTO SE MO NO HYDRATE (UNII: EWQ57Q8 I5X)

MAGNESIUM STEARATE (UNII: 70 0 9 7M6 I30 )

Product Characteristics

Color

WHITE

S core

no sco re

S hap e

ROUND

S iz e

6 mm

Flavor

Imprint Code

LCI;1353;2

Contains

Packag ing

#

Item Code

Package Description

Marketing Start

Date

Marketing End

Date

1

NDC:0 527-1353-

10 0 in 1 BOTTLE, PLASTIC; Type 0 : No t a Co mbinatio n

Pro duc t

12/0 9 /20 0 9

Marketing Information

Marke ting Cate gory

Application Numbe r or Monograph Citation

Marke ting Start Date

Marke ting End Date

ANDA

ANDA0 77471

12/0 9 /20 0 9

HYDROMORPHONE HYDROCHLORIDE

hydromorphone hydrochloride tablet

Product Information

Product T ype

HUMAN PRESCRIPTION DRUG

Ite m Code (Source )

NDC:0 527-1354

Route of Administration

ORAL

DEA Sche dule

Active Ingredient/Active Moiety

Ingredient Name

Basis of Strength

Stre ng th

HYDRO MO RPHO NE HYDRO CHLO RIDE (UNII: L9 6 0 UP2KRW) (HYDROMORPHONE -

UNII:Q 8 1246 4R0 6 )

HYDROMORPHONE

HYDROCHLORIDE

4 mg

Inactive Ingredients

Ingredient Name

Stre ng th

ANHYDRO US LACTO SE (UNII: 3SY5LH9 PMK)

LACTO SE MO NO HYDRATE (UNII: EWQ57Q8 I5X)

MAGNESIUM STEARATE (UNII: 70 0 9 7M6 I30 )

Product Characteristics

Color

WHITE

S core

no sco re

S hap e

ROUND

S iz e

6 mm

Flavor

Imprint Code

LCI;1354;4

Contains

Packag ing

#

Item Code

Package Description

Marketing Start

Date

Marketing End

Date

1

NDC:0 527-1354-

10 0 in 1 BOTTLE, PLASTIC; Type 0 : No t a Co mbinatio n

Pro duc t

12/0 9 /20 0 9

Marketing Information

Marke ting Cate gory

Application Numbe r or Monograph Citation

Marke ting Start Date

Marke ting End Date

ANDA

ANDA0 77471

12/0 9 /20 0 9

HYDROMORPHONE HYDROCHLORIDE

hydromorphone hydrochloride tablet

Product Information

Product T ype

HUMAN PRESCRIPTION DRUG

Ite m Code (Source )

NDC:0 527-1355

Route of Administration

ORAL

DEA Sche dule

Active Ingredient/Active Moiety

Ingredient Name

Basis of Strength

Stre ng th

HYDRO MO RPHO NE HYDRO CHLO RIDE (UNII: L9 6 0 UP2KRW) (HYDROMORPHONE -

UNII:Q 8 1246 4R0 6 )

HYDROMORPHONE

HYDROCHLORIDE

8 mg

Inactive Ingredients

Ingredient Name

Stre ng th

ANHYDRO US LACTO SE (UNII: 3SY5LH9 PMK)

LACTO SE MO NO HYDRATE (UNII: EWQ57Q8 I5X)

MAGNESIUM STEARATE (UNII: 70 0 9 7M6 I30 )

Product Characteristics

Color

WHITE

S core

2 pieces

S hap e

ROUND

S iz e

8 mm

Flavor

Imprint Code

LCI;1355

Lannett Company, Inc.

Contains

Packag ing

#

Item Code

Package Description

Marketing Start

Date

Marketing End

Date

1

NDC:0 527-1355-

10 0 in 1 BOTTLE, PLASTIC; Type 0 : No t a Co mbinatio n

Pro duc t

12/0 9 /20 0 9

Marketing Information

Marke ting Cate gory

Application Numbe r or Monograph Citation

Marke ting Start Date

Marke ting End Date

ANDA

ANDA0 77471

12/0 9 /20 0 9

Labeler -

Lannett Company, Inc. (002277481)

Revised: 10/2019

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