Combination Hydrocodone Products

[CosmoDaNP]

I have a question I'm hoping some of you fresh minds can answer.

I recently attended a confrence where they were touting the useage of a particular Hydrocodone/APAP combination product (Maxidone). Their claims were that with its higher amounts of APAP you would see more rapid analgesia.

I've always written Lorcet products simply because when I was in school that is what "everyone" used. Hospital forumlary didn't include anything else.

So, I'm just wondering... Is their any information supporting the useage of one brand of Hydrocodone/APAP products over another? Is the less APAP contained in Norco a lead in for less analgesia or is Maxidone superior because your "Prescribing the max"?

Thanks in advance,
Cosmo

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[Caverject]

I have a question I'm hoping some of you fresh minds can answer.

I recently attended a confrence where they were touting the useage of a particular Hydrocodone/APAP combination product (Maxidone). Their claims were that with its higher amounts of APAP you would see more rapid analgesia.

I've always written Lorcet products simply because when I was in school that is what "everyone" used. Hospital forumlary didn't include anything else.

So, I'm just wondering... Is their any information supporting the useage of one brand of Hydrocodone/APAP products over another? Is the less APAP contained in Norco a lead in for less analgesia or is Maxidone superior because your "Prescribing the max"?

Thanks in advance,
Cosmo

There really is not any info for comparison purposes, it's more or less how a physician feels. I do not like the idea of Maxidone because it has a formulation of 10/750 a patient can only take 5 tablets a day. (4g APAP limit) Even with Lorcet, you run into the same problem because the limit is 6 per day. Norco is good because there is not a whole lot of tylenol in the product. Of course, this always leads to the potential of abuse. In this case, my drug of choice is Lortab which is a formulation of 7.5/500mg.

 

[dgroulx]

I personally prefer Vicoprofen which is 7.5mg hydrocode and 200mg ibuprofen. In many cases you should be reducing inflammation. It all depends on why the pain med is being prescribed and how long your going to be on it.

 

[CosmoDaNP]

It all depends on why the pain med is being prescribed and how long your going to be on it.

Thats the issue I run in to with the APAP amounts. For acute pain Lorcet HD q4-6h PRN for a few days is fine. No worry there.

For mild-moderate chronic pain the physician I work with likes to use a combination of Lorcet and Ultracet. Ultracet 1 tab q6 RTC and Lorcet HD q6 PRN with #120 of each per month. It just concerns me because of the total amount of Tylenol that we're talking about there... it is a very high doseage.
For more severe chronic pain/cancer pain we use a long acting narcotic with Lorcet (10/650) TID PRN which seems to work well.

Can't say as I've ever written for Vicoprofen though. Once I think. I do know that there is a new formulation out called Xodol (I think that's it) that is 5mg Hydrocodone with 200mg Ibu.

At any rate I appreciate everyone's comments. I did quite a bit of searching and couldn't find anything that supported any one product. Glad to see I wasn't missing anything. Just goes to prove the golden rule "If in doubt, ask a pharmacist!"
Cosmo

 

[MNnaloxone]

Never saw any studies on different levels of APAP (never looked, either-but guessing they aren't there). Sounds like you got ahold of a drug rep.

If we're so concerned about rapid anagesia, how about a IM of Toradol in the practicioner's office?

Agreed that Vicoprofen is a nice replacement for a good chunk of the Vicodin scipts out there. Xodol is 10/300. Talk about turning up the volume... Not a fan of Tramadol. Too edgy about the SSRI effects.

Any other thoughts? Share, please. I've gotta start a pain clinic this year at the VA, too...

 

[bananaface]

I'm just going to thump a bit about chronic pain and acetaminophen.

If you assume that relief from APAP lasts 4 hours (conservative), you need to divide the daily max of 2.7g of APAP (for chronic use) evenly across the 6 doses. This means not over 450mg of APAP per dose. Norco products, all of which contain 325mg APAP, would be a good choice. (Interestingly, Vicodin 5/500 is a bit too high a dose for long term use if doses happen every 4 hours. If the dose lasts 4.5 hours, Vicodin 5/500 would be okay.)

How is a higher acetaminophen dose supposed to lead to more rapid analgesia?

 

[CosmoDaNP]

Actually we do IM Toradol in the office along with a few narcotic injections for pain.
Comes in handy alot of times. Ofcourse there are people who do try abuse the convience.

I'm trying to think what that 5/200 combo was. Your right, Zydone is a Hydro/APAP combo. Actually has less APAP than Norco.

We work really close with a univeristy pain clinic and basically do the same thing with meds that they do.
Patients with mild-moderate pain get
Lorcet HD (5/500) qid PRN #120
Ultracet 37.5/325 qid RTC #120
Usually some sort of muscle relaxer as well. We also use alot of TCA's, Neurontin/Keppra/Lamactil/Topamax as well as Effexor XR (and now Cymbalta).

As far as strong narcotics the pain clinic we work with likes Methadone for your neuropathic pain, Fibromyalgia and back pain. For arthritis, "head" pain and other mus/ske issues its Oxycontin. For cancer pain and things not aforementioned its Duragesic first, Oxycontin next. They also always want Lorcet (10/650) TID PRN #90 for Breakthrough pain. We consult with them before putting any patient on a RTC strong opioid plan. Not to discount my own training but I'm not putting a patient on tons of narcotics unless a well trained pain management physician endorses the idea. No way, no how.

Good luck at the pain clinic... it'll be... interesting.

Cosmo

 

[CosmoDaNP]

I'm just going to thump a bit about chronic pain and acetaminophen.

If you assume that relief from APAP lasts 4 hours (conservative), you need to divide the daily max of 2.7g of APAP (for chronic use) evenly across the 6 doses. This means not over 450mg of APAP per dose. Norco products, all of which contain 325mg APAP, would be a good choice. (Interestingly, Vicodin 5/500 is a bit too high a dose for long term use if doses happen every 4 hours. If the dose lasts 4.5 hours, Vicodin 5/500 would be okay.)

In no case do I give more than 4 tablets of a Hydrocodone product per day. Every pain specialist I've ever talked to says if your needing more than 40mg of Hydrocodone per day then you either need to be on a long acting medicine with the Hydrocodone just for breakthrough pain or you have an addiction problem.

For patients with mild-moderate chronic pain I give Lorcet HD qid PRN along Ultracet qid. Thats 3.5g of APAP per day. That would be quite a bit more than the amount your quoting for chronic use which I agree, is too much. I use this combination on the suggestion for several pain mgmt specialists in my area. They use the combo extensively in their practice. I guess I could always switch the patients to Norco...and that would get them closer to the goal amount.

For the more severe chronic pain and cancer pain, I give Lorcet (10/650) tid PRN which would just total out 1.95g/day. I like the way that sounds better.

How is a higher acetaminophen dose supposed to lead to more rapid analgesia?

The way it was explained to me by the pain specialist I talked to (Board Certified MDA with a fellowship in pain). He told me that the APAP component of the tablet was important because it is what provides the inital analgesia. After you get the inital onset of pain relief THEN the Hydrocodone kicks in but because it takes a fair amount of time to onset APAP must be included and a higher doseage of APAP would result in more analgesia sooner.

 

[Caverject]

In no case do I give more than 4 tablets of a Hydrocodone product per day. Every pain specialist I've ever talked to says if your needing more than 40mg of Hydrocodone per day then you either need to be on a long acting medicine with the Hydrocodone just for breakthrough pain or you have an addiction problem.

For patients with mild-moderate chronic pain I give Lorcet HD qid PRN along Ultracet qid. Thats 3.5g of APAP per day. That would be quite a bit more than the amount your quoting for chronic use which I agree, is too much. I use this combination on the suggestion for several pain mgmt specialists in my area. They use the combo extensively in their practice. I guess I could always switch the patients to Norco...and that would get them closer to the goal amount.

For the more severe chronic pain and cancer pain, I give Lorcet (10/650) tid PRN which would just total out 1.95g/day. I like the way that sounds better.


The way it was explained to me by the pain specialist I talked to (Board Certified MDA with a fellowship in pain). He told me that the APAP component of the tablet was important because it is what provides the inital analgesia. After you get the inital onset of pain relief THEN the Hydrocodone kicks in but because it takes a fair amount of time to onset APAP must be included and a higher doseage of APAP would result in more analgesia sooner.

not to mock you or anything, but I thought NP's couldn't write for narcotics? Or maybe that is a Georgia thing?

 

[CosmoDaNP]

not to mock you or anything, but I thought NP's couldn't write for narcotics? Or maybe that is a Georgia thing?

Actually there are six states in which NP's cannot write for any controlled substances. In one state they can prescribe anything but only under a physicians license. In 28 states NP's can prescribe anything including ?V-II substances. The rest of the states allow some degree of NP prescribing varying from just non-controlled drugs up to ?III drugs.

Cosmo

 

[bananaface]

For patients with mild-moderate chronic pain I give Lorcet HD qid PRN along Ultracet qid. Thats 3.5g of APAP per day.

It would be 3.3g of APAP per day, still over the recommended amount for chronic use. Per UpToDate: "chronic daily dosing in adults of...3-4 g/day of acetaminophen for one year have resulted in liver damage." I will hunt down a more detailed reference on that one.

I would rather see better pain control at 6 tabs/day on a lower dose per tab than 4/day at a higher dose. Since APAP gives relief for 4-6 hours, many patients are going to get into an unneeded cycle of pain and relief.

Ultracet is only indicated for acute pain. Per page 5 of the .pdf file of the package insert as posted on the FDA website, "ULTRACET is only indicated for the short term (5 days or less) management of acute pain." This information is not well known amongst pharmacists or prescribers.

 

[MNnaloxone]

Ultracet is only indicated for acute pain. Per page 5 of the .pdf file of the package insert as posted on the FDA website, "ULTRACET is only indicated for the short term (5 days or less) management of acute pain." This information is not well known amongst pharmacists or prescribers.

Wow-you learn something everyday. Thanks, banana!

I'm still gonna call it Grandma's Vicodin, though. Oh where, oh where did Darvocet go?

 

[jdpharmd?]

I have a question I'm hoping some of you fresh minds can answer.

I recently attended a confrence where they were touting the useage of a particular Hydrocodone/APAP combination product (Maxidone). Their claims were that with its higher amounts of APAP you would see more rapid analgesia.

I've always written Lorcet products simply because when I was in school that is what "everyone" used. Hospital forumlary didn't include anything else.

So, I'm just wondering... Is their any information supporting the useage of one brand of Hydrocodone/APAP products over another? Is the less APAP contained in Norco a lead in for less analgesia or is Maxidone superior because your "Prescribing the max"?

Thanks in advance,
Cosmo

Slightly off-topic, but I think this is a heck of a good question. I'm sure there are countless practitioners who could care less, and just write for the standard "vicodin 5/500mg, 1-2q 4-6h prn pain" regardless of the situation. I'll do a little research and try to give my .02, just as soon as I can cut down on my 57+ hour weeks. Kudos to you for wanting the absolute best for your pt.

 

[CosmoDaNP]

Kudos to you for wanting the absolute best for your pt.

I like to think that we ALL try. Takes a major team effort.

Cosmo

 

[futoi]

Ultracet is only indicated for acute pain. Per page 5 of the .pdf file of the package insert as posted on the FDA website, "ULTRACET is only indicated for the short term (5 days or less) management of acute pain." This information is not well known amongst pharmacists or prescribers.[/QUOTE]


indications don't necessarily dictate how a medication will be prescribed. many patients take tramadol chronically, regardless of the fda's blessing. most noted example of this type of prescribing is probably neurontin - only has fda approval for partial seizures and post-herpetic neuralgia (clinical pharmacology online). however it is used for just about everything, including ALS.

every reference I've seen has set a ceiling for APAP at 4g/d for chronic use. not sure where the 2.7g/d comes from; maybe for chronic alcoholics or people with significant liver damage?

 

[GravyRPH]

Off-Label Use of Neurontin May Be Dangerous....to your pocketbook.

 

[ultracet]

Actually there are six states in which NP's cannot write for any controlled substances. In one state they can prescribe anything but only under a physicians license. In 28 states NP's can prescribe anything including ?V-II substances. The rest of the states allow some degree of NP prescribing varying from just non-controlled drugs up to ?III drugs.

Cosmo

OFF TOPIC for the majority of this post... here in AL when we fill NPs prescriptions we always look for the doctor's name at the top of the rx and that's what we imput into the computer.
we ignore the NPs name and pretend that the rx was written completely by the doctor...

 

[meister]

OFF TOPIC for the majority of this post... here in AL when we fill NPs prescriptions we always look for the doctor's name at the top of the rx and that's what we imput into the computer.
we ignore the NPs name and pretend that the rx was written completely by the doctor...

Here we put both the NP's and physician's name in the computer, in the format: Blah, NP Blah, MD.

 

[jdpharmd?]

OFF TOPIC for the majority of this post... here in AL when we fill NPs prescriptions we always look for the doctor's name at the top of the rx and that's what we imput into the computer.
we ignore the NPs name and pretend that the rx was written completely by the doctor...

Here, it's just the NP on our system, and they can write for controls. I don't know the extent of supervision required, but I can tell you that it's not much. Most of my experiences have been good.

 

[bananaface]

Here, it's just the NP on our system, and they can write for controls. I don't know the extent of supervision required, but I can tell you that it's not much. Most of my experiences have been good.

Same here.

 

[CosmoDaNP]

New question...
The physician I work for and I were talking today about a possibility of 12h Hydrocodone. He was pondering the useage of Tussionex as a way of giving RTC Hydrocodone therapy with BID dosing.

The way I read the information on Tussionex, despite its delivery system the half life of Hydrocodone is unchanged from the usual 4hrs. That would mean that despite the fact its suggested to be given BID you wouldn't be getting any extended benefit from the medication.

To my knowledge all other hydrocodone preps in that class work the same way? The only one I'm not too familiar with is Hycodan. Not a medicine I typically see or write for. I hate to tell him he's wrong on this one but... it does appear he is?

Finally... anyone know anything about any clinical trials or anything in the pipeline as far as contin forms of Hydrocodone? Maybe even an IV form (I believe IV is availble in Europe?)

TIA,
Cosmo

 

[jdpharmd?]

New question...
The physician I work for and I were talking today about a possibility of 12h Hydrocodone. He was pondering the useage of Tussionex as a way of giving RTC Hydrocodone therapy with BID dosing.

The way I read the information on Tussionex, despite its delivery system the half life of Hydrocodone is unchanged from the usual 4hrs. That would mean that despite the fact its suggested to be given BID you wouldn't be getting any extended benefit from the medication.

To my knowledge all other hydrocodone preps in that class work the same way? The only one I'm not too familiar with is Hycodan. Not a medicine I typically see or write for. I hate to tell him he's wrong on this one but... it does appear he is?

Finally... anyone know anything about any clinical trials or anything in the pipeline as far as contin forms of Hydrocodone? Maybe even an IV form (I believe IV is availble in Europe?)

TIA,
Cosmo

"Following multiple dosing with TUSSIONEX Pennkinetic Extended-Release Suspension, hydrocodone mean (S.D.) peak plasma concentrations of 22.8 (5.9) ng/mL occurred at 3.4 hours. Chlorpheniramine mean (S.D.) peak plasma concentrations of 58.4 (14.7) ng/mL occurred at 6.3 hours following multiple dosing. Peak plasma levels obtained with an immediate-release syrup occurred at approximately 1.5 hours for hydrocodone and 2.8 hours for chlorpheniramine. The plasma half-lives of hydrocodone and chlorpheniramine have been reported to be approximately 4 and 16 hours, respectively. "

IMHO - The low dose of Hydrocodone, the length of time for onset (long), and the addition of Chlorpheniramine (drowsy) all make Tussionex a poor choice for pain management. The absence of APAP/IBU is also a problem.

I would assume that hycodan is a poor choice becuase it's only hydrocodone. Vicodin is more efficacious than pure hydrocodone because of the synergism with the tylenol component. Hydrocodone (alone) is approx equal to morphine on a mg per mg basis. I don't know of too many oral 5mg doses of morphine.

I've never heard of an extended release form of hydrocodone for pain. Just out of curiosity, what would the percieved advantage of IV hydrocodone be?

All very good questions...

 

[MNnaloxone]

Tussionex! Dope on a rope!

My humble opinion, too-poor choice for pain management. Nice to think outside the box, but you can call your doc on this one. You are absolutely correct in your half-life reasoning. You get away with the low levels of hydrocodone in your system (12H dosing) because you need a lot less opiate in your system to suppress cough vs. acute pain.

Got me curious about IV hydrocodone as well. Anyone have a reason why we wouldn't just nail the patient with a fentanyl syringe?