Thank you for your recent inquiry.
I am not sure that I have a satisfactory answer for you. Morphine and codeine probably produce flushing and urticaria (and in some instances, anaphylaxis) via a direct interaction between these drugs and an opiate receptor on mast cells. Thus, it is very likely that readministration of either one of these two drugs would cause an urticarial reaction. Meperidine, tramadol, and fentanyl do not directly trigger mast cell degranulation and therefore a patient with morphine or codeine allergy can usually take these without difficulty.
Clearly, Dilaudid can cause urticaria and anaphylaxis. This is listed as one of its potential side effects. However, the "good news" is that hydromorphone, in some systems, does not appear to produce histamine release. In an in vivo model in dogs, administration of hydromorphone did not produce histamine release (2).
In one study using human skin mast cells, an analog of hydromorphone (oxymorphone) failed to release histamine (3). Another encouraging investigation was conducted by M. Ennis, et al. In this study, several opiate analgesics were tested in a rat peritoneal mast cell and human skin mast cell model. In this study, hydromorphone did not produce a large amount of histamine release (4).
From the above studies, it is clear that not all opiates release histamine. However, there was no definitive data that I could find which would allow you to precisely predict whether Dilaudid would cause histamine release in your patient, in spite of the fact that morphine has done so.
As far as pretreatment is concerned, there is very little information in the literature that I could find as to whether or not pretreatment would ameliorate or prevent the symptoms due to histamine release from opiates. There is at least one case report where an antihistamine did not control the symptoms produced by morphine injection.
Based on an overall evaluation of the above articles, it cannot be determined precisely whether or not your patient will react to Dilaudid infusion. Also, it cannot be determined precisely whether or not pretreatment, and treatment during the infusion, will alter any potential event. However, if this drug is necessary, I would suggest giving it in a graded dosage fashion if possible, starting with perhaps 1/100th of the desirable final dose and increasing the dose gradually, if possible, by doubling the dose perhaps every 10 minutes. This would allow you to detect side effects early before larger doses might produce a greater problem.
Certainly you could accompany this type of graded administration with pretreatment as well. You would simply have to speculate on the dose and the drug administered, but diphenhydramine IM given perhaps one hour prior to the treatment, as is done with radiocontrast, would be a reasonable choice. If one used steroids, you could either treat with a simultaneous infusion of methylprednisolone, for example, and/or pretreat with oral prednisone in a dose of 50 mg given several hours before the procedure.
In addition, I would also add an H2 antagonist based upon studies of the effect of morphine on blood pressure. In patients who experience transient hypotension after morphine, the combination of an H1 and an H2 antagonist was superior to an H1 antagonist alone (5).
Thank you again for your inquiry and we hope this response is helpful to you.
References:
Patterson's Allergic Disease 7th edition page 297
Smith L, et al. Journal of the American Veterinary Association 2001; 218(7):1101-1105.
Hermens JM, et al Anesthesiology 1985; 62(2):124-129.
Ennis M, et al. Inflammation Research 1991; 33(1-2):20-22.
Moss J, et al. Anesthesiology 1983; 59:331-339.
Sincerely,
Phil Lieberman, M.D.