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A Myoclonic Reaction with Low-Dose Hydromorphone

at time of writing, PharmD Student, School of Pharmacy, Loma Linda University, Loma Linda, CA; now, Pharmacy Practice Resident, VA Long Beach Healthcare System, Long Beach, CA

Veda R Roshan, PharmD

at time of writing, PharmD Student, School of Pharmacy, Loma Linda University; now, Pharmacy Practice Resident, Long Beach Memorial Medical Center, Long Beach

Kelly C Lee, PharmD BCPP

Assistant Professor of Pharmacy Practice, School of Pharmacy, Loma Linda University

Rebecca J Cheung, PharmD

Assistant Professor of Pharmacy Practice, School of Pharmacy, Loma Linda University

Reprints: Dr. Cheung, School of Pharmacy, Loma Linda University, 11262 Campus St., Loma Linda, CA 92350-0001, fax 909/558-7927, rcheung{at}llu.edu

OBJECTIVE: To report a case of myoclonus associated with the use of a low dose of the opioid analgesic hydromorphone.

CASE SUMMARY: A 55-year-old white man with a history of nonobstructive hypertrophic cardiomyopathy was hospitalized for treatment of severe chest pain. On hospital day 1, intravenous hydromorphone (6 doses, total dose of 4 mg) was administered. The pain continued and, on day 2, the dose was increased, with a total of 6 mg administered on day 2. The patient developed uncontrollable jerking movements of the head, neck, arms, and legs after he received the hydromorphone. The myoclonic movements stopped within a few hours following discontinuation of hydromorphone and did not recur.

DISCUSSION: Myoclonus is a neuroexcitatory symptom that has been reported with chronic, high-dose administration of hydromorphone in patients with impaired renal function. The hydromorphone-3-glucuronide metabolite is devoid of analgesic activity and has been shown to cause neuroexcitatory effects. This patient's symptoms appeared soon after hydromorphone was initiated and resolved in a timely manner after the medication was discontinued. Based on the patient's presentation and course of therapy, it is probable, as indicated by the Naranjo probability scale, that the myoclonic symptoms were induced by hydromorphone. This case was unique, however, in that the patient received hydromorphone for only a short duration and did not have impaired renal function.

CONCLUSIONS: Neuroexcitatory effects of hydromorphone may occur at relatively low doses in patients without renal dysfunction. Early recognition and intervention are required to achieve resolution of these symptoms and prevent further sequelae to the patient.

Key Words: hydromorphone, myoclonus, toxicity

Published Online, October 17, 2006. www.theannals.com, DOI 10.1345/aph.1H243