ND Clinical Board Review: Hydrocodone and Acetaminophen

Today's med: Hydrocodone and Acetaminophen

(brand names: hycet, Lorcet, Lortab, Margesic H, Maxidone, Norco, Stagesic, Vicoden,(and Vicodin ES or HP), Xodol (10/300,5/300 or 7.5/300), Zamicet, Zolvit, Zydone)

Similar: Hydrocodone and Ibuprofen (brand names: Ibudone, Repraxain, Vicoprofin)

Drug Class: Analgesic [Combination (Opioid)]

Other Drugs in this class: Oxycodone,Acetaminophen, Tramadol, Codeine,Ibuprofen,

Hydrocodone/ibuprofen,Morphine, Hydromorphone, Buprenorphine,Gabapentin, Methadone, Aspirin,

Hydroxyzine, Meperidine, Fentanyl,Ketoprofen, Phenazopyridine, Menthol,Butorphanol, Sufentanil, Magnesium salicylate, Ziconotide, Alfentanil, Gabapentin enacarbil

Indications: Relief of moderate-to-severe pain

Contraindications: Hypersensitivity to hydrocodone, acetaminophen, or any component of the formulation; CNS depression; severe respiratory depression

Adverse Effects: Cardiovascular: Bradycardia, cardiac arrest, circulatory collapse, coma, hypotension

Central nervous system: Anxiety, dizziness, drowsiness, dysphoria, euphoria, fear, lethargy, lightheadedness, malaise, mental clouding, mental impairment, mood changes, physiological dependence, sedation, somnolence, stupor

Dermatologic: Pruritus, rash

Endocrine & metabolic: Hypoglycemic coma

Gastrointestinal: Abdominal pain, constipation, gastric distress, heartburn, nausea, peptic ulcer, vomiting, xerostomia

Genitourinary: Ureteral spasm, urinary retention, vesical sphincter spasm

Hematologic: Agranulocytosis, bleeding time prolonged, hemolytic anemia, iron deficiency anemia, occult blood loss, thrombocytopenia

Hepatic: Hepatic necrosis, hepatitis

Neuromuscular & skeletal: Skeletal muscle rigidity

Otic: Hearing impairment or loss (chronic overdose)

Renal: Renal toxicity, renal tubular necrosis

Respiratory: Acute airway obstruction, apnea, dyspnea, respiratory depression (dose related)

Miscellaneous: Allergic reactions, clamminess, diaphoresis

Lab Test Interference: Acetaminophen may cause false-positive urinary 5-hydroxyindoleacetic acid.

Concerns related to adverse effects:

• CNS depression: May cause CNS depression, which may impair physical or mental abilities; patients must be cautioned about performing tasks which require mental alertness (eg, operating machinery or driving).

• Hepatotoxicity: [U.S. Boxed Warning]: Acetaminophen may cause severe hepatotoxicity, potentially requiring liver transplant or resulting in death; hepatotoxicity is usually associated with excessive acetaminophen intake (>4 g/day). Risk is increased with alcohol use, pre-existing liver disease, and intake of more than one source of acetaminophen-containing medications. Chronic daily dosing in adults has also resulted in liver damage in some patients.

• Hypersensitivity/anaphylactic reactions: Hypersensitivity and anaphylactic reactions have been reported with acetaminophen use; discontinue immediately if symptoms of allergic or hypersensitivity reactions occur. Use with caution in patients with hypersensitivity reactions to other phenanthrene derivative opioid agonists (codeine, hydromorphone, levorphanol, oxycodone, oxymorphone).

• Hypotension: May cause hypotension; use with caution in patients with hypovolemia, cardiovascular disease (including acute MI), or drugs which may exaggerate hypotensive effects (including phenothiazines or general anesthetics).

• G6PD deficiency: Use with caution in patients with known G6PD deficiency.

• Head trauma: Use with extreme caution in patients with head injury, intracranial lesions, or elevated intracranial pressure; exaggerated elevation of ICP may occur.

• Psychosis: Use with caution in patients with toxic psychosis.

• Renal impairment: Use with caution in patients with renal impairment.

• Respiratory disease: Use hydrocodone with caution in patients with pre-existing respiratory compromise (hypoxia and/or hypercapnia), COPD or other obstructive pulmonary disease, and kyphoscoliosis or other skeletal disorder which may alter respiratory function; critical respiratory depression may occur, even at therapeutic dosages. May suppress cough reflex; use with caution postoperatively and in patients with pulmonary disease.

• Seizures: Use with caution in patients with a history of seizure disorders.

• Thyroid dysfunction: Use with caution in patients with thyroid dysfunction.

Standard Dosing: Oral (doses should be titrated to appropriate analgesic effect): Analgesic:

Children 2-13 years or <50 kg: Hydrocodone 0.1-0.2 mg/kg/dose every 4-6 hours; do not exceed 6 doses/day or the maximum recommended dose of acetaminophen

Children and Adults ≥50 kg: Average starting dose in opioid naive patients: Hydrocodone 5-10 mg 4 times/day; the dosage of acetaminophen should be limited to ≤4 g/day (and possibly less in patients with hepatic impairment or ethanol use).

Dosage ranges (based on specific product labeling): Hydrocodone 2.5-10 mg every 4-6 hours (maximum dose of hydrocodone may be limited by the acetaminophen content of specific product)

Elderly: Doses should be titrated to appropriate analgesic effect; 2.5-5 mg of the hydrocodone component every 4-6 hours. Do not exceed 4 g/day of acetaminophen.

Drug interactions: Link: http://www.drugs.com/drug-interactions/acetaminophen-hydrocodone.html

A total of 627 drugs (3722 brand and generic names) are known to interact with acetaminophen / hydrocodone.