IV Tylenol

[bentrider]

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Does anyone know if IV Tylenol is any better than PO Tylenol?

 

[PMPMD]

Does anyone know if IV Tylenol is any better than PO Tylenol?

what do you mean by "better"?

It could potentially be useful for postop surgical pts that are strict NPO, who I'm not thrilled about giving opioids to (OSA, etc.), have contraindications to toradol, or who could benefit from multimodal analgesia.

 

[cchoukal]

I was wondering if anyone had started using this yet. Obviously, IV paracetamol has been in use in Europe for years, so there should be data on efficacy, but I haven't looking into this myself.

I was surprised to find that this stuff doesn't cost thousands of dollars per dose. I looked up IV APAP and IV ibuprofen and it looks like they're trying to stay close to the dose for IV ketorolac (as the comparator, under $10). Still not as cheap as PO, but not ridiculous either.

 

[bentrider]

My question is:

Is there any benefit to giving 1 gram of IV Tylenol($10.) if the patient can take 1 gram PO Tylenol which only costs pennies?

 

[lane]

what ever happened to good ole per rectum?

 

[rsgillmd]

Bentrider, last year (2/2010) at the TSA (Tennessee chapter of ASA not the supposed security behemoth) meeting I ran into a rep. At that time it wasn't available in the U.S. market yet, but they were close to final approval.

Is it available now?

Anyway to get back to your original question, per this rep the dosing was the same as PO. 1 gm PO = equianalgesic to 1 gm IV. However the onset of action was faster with IV. This is all per my conversation with the rep. I do not have a monograph to back this up. The PDR may or may not provide info about equivalence between routes.

It seems useful as an adjunct to opiates in patients who are NPO or have relative/absolute contraindications to Toradol. Otherwise, on a per-cost basis PO is better.

 

[proman]

FDA has approved the IV form, Omfirmev but we don't yet have it on formulary. It has a definite opioid sparing effect (and lower PONV likely due to less opioid). I haven't seen anything comparing the clinical efficacy of IV to PO. The Medical Letter has a summary on Omfirmev. Peak serum levels are 70% higher with IV vs PO with onset of analgesia at 10 minutes, peak at 1 hour and last 4-6 hours. These likely outperform PO route. PR pharmacokinetics are unreliable, so IV route would definitely be preferred. Wholesale cost is $10.75, within a dollar of ketorolac. I plan on using it when available and I wonder if combining it with ketorolac will have additive opioid-sparing effect.

 

[rsgillmd]

FDA has approved the IV form, Omfirmev but we don't yet have it on formulary. It has a definite opioid sparing effect (and lower PONV likely due to less opioid). I haven't seen anything comparing the clinical efficacy of IV to PO. The Medical Letter has a summary on Omfirmev. Peak serum levels are 70% higher with IV vs PO with onset of analgesia at 10 minutes, peak at 1 hour and last 4-6 hours. These likely outperform PO route. PR pharmacokinetics are unreliable, so IV route would definitely be preferred. Wholesale cost is $10.75, within a dollar of ketorolac. I plan on using it when available and I wonder if combining it with ketorolac will have additive opioid-sparing effect.

I'm thinking along your lines also -- ketorolac + tylenol. As you said, I think the affect will be additive.

10 minutes sounds nice for acute pain, but even PO Tylenol starts to have an effect in about 30 minutes (at least in my experience). Ketorolac seems to kick in around 15 minutes and takes about 30 minutes to peak.

 

[cchoukal]

Yeah, I can't imagine anyone's gonna use this is people who could take PO (or even PR) unless there was some other absorption issue.

 

[proman]

Yeah, I can't imagine anyone's gonna use this is people who could take PO (or even PR) unless there was some other absorption issue.

How many people here use PO acetaminophen preop? I'm guessing not many.

 

[periopdoc]

If it was available to me, I would use it on just about every patient except those with clear contraindications to acetaminophen. Anything that I can do to reduce opiate utilization and its side effects is a good thing in my book. Especially if it is something that won't leave the patient with abrupt onset of severe pain in 8-12 hours (single shot nerve block). The only reason I don't use more toradol is surgeon preference.

- pod

 

[pgg]

How many people here use PO acetaminophen preop? I'm guessing not many.

How many here use PO Motrin preop? Nobody, I bet. How many use IV Toradol? Lots of people, I bet.

The argument that IV Tylenol isn't useful because PO Tylenol exists doesn't make sense to me.

When we get it, I plan to use it in just about everybody.

 

[sevo85288]

We just got it. It has some kick! Looking at the details, therapeutic threshold for acet is 10mcg/ml in plasma. Only 70% of PO pts achieve this. Around 0% of PR achieve it. IV on the other hand, has 100% of pt's achieving 10mcg/ml but most go as high as 27mcg/ml. So the amount of drug in the plasma is much higher. Therefore, the CNS concentration (where the drug actually works) is higher. In essence this is acetaminophen on steriods. My patients are seeing about 10-25% less pain, which is huge. I run it either in the middle or towards of end case depending on the duration of case. I have used it with and without ketoralac. I have done some cases with very old folks where I have only used 50 mcg of fentanyl and given 1000mg of Ofermiv. I like it.

 

[2ndyear]

what ever happened to good ole per rectum?

Most people never give enough to make a difference.

 

[dhb]

I've used it on most patients i've seen through the OR.
IMHO it a has a pretty weak effect. Patients are so variable in respect to pain (eg post-op thoracotomies barely using any morphine 😕 ) that it would be hard to notice it's effect: if there are studies on opiod sparring i haven't seen them.
What has been studied is the post-op plasma level between PO and iv and due to slower GI transit times the peak PO level is about half the iv.

 

[DipriFan]

Agree w/ sevo85288; anecdotally, this stuff works better than my expectations for it. I started using it specifically when the po route is unavailable, and/or the sturgeons have forbidden ketorolac.

As others have said, IV administration offers several advantages in terms of PK, i.e. shorter Tmax (i.e. more rapid onset), higher Cmax, and greater time above MEAC in the CNS (the site of action).

My initial reaction was: great, but what about the liver? Because iv route avoids 1st-pass metabolism, the liver sees about 2-fold LESS APAP initially, so iv route may in fact be safer. The mean Cmax after 1gm iv is about 29mg/L, whereas the threshold for potential hepatotoxicity which is about 150mg/L.

 

[sevo85288]

I've used it on most patients i've seen through the OR.
IMHO it a has a pretty weak effect. Patients are so variable in respect to pain (eg post-op thoracotomies barely using any morphine 😕 ) that it would be hard to notice it's effect: if there are studies on opiod sparring i haven't seen them.
What has been studied is the post-op plasma level between PO and iv and due to slower GI transit times the peak PO level is about half the iv.

A Randomized, Double-Blind, Placebo-Controlled, Multicenter, Repeat-Dose Study of Two Intravenous Acetaminophen Dosing Regimens for the Treatment of Pain After Abdominal Laparoscopic Surgery
Steven J. Wininger, MD1; Howard Miller, MD2; Harold S. Minkowitz, MD3; Mike A. Royal, MD, JD, MBA4; Robert Y. Ang, MD4; James B. Breitmeyer, MD, PhD4; and Neil K. Singla, MD5
1Precision Trials, LLC, Phoenix, Arizona; 2Woman’s Hospital of Texas, Houston, Texas; 3Department of Anesthesiology, Memorial Hermann Memorial City Medical Center, Houston, Texas; 4Clinical Development, Cadence Pharmaceuticals, Inc., San Diego, California; and 5Department of Anesthesia, Huntington Memorial Hospital, Pasadena, California

 

[sevo85288]

Agree w/ sevo85288; anecdotally, this stuff works better than my expectations for it. I started using it specifically when the po route is unavailable, and/or the sturgeons have forbidden ketorolac.

As others have said, IV administration offers several advantages in terms of PK, i.e. shorter Tmax (i.e. more rapid onset), higher Cmax, and greater time above MEAC in the CNS (the site of action).

My initial reaction was: great, but what about the liver? Because iv route avoids 1st-pass metabolism, the liver sees about 2-fold LESS APAP initially, so iv route may in fact be safer. The mean Cmax after 1gm iv is about 29mg/L, whereas the threshold for potential hepatotoxicity which is about 150mg/L.

Could you please provide a link or source to your last sentence. Thanks

 

[bonesmd]

Could you please provide a link or source to your last sentence. Thanks

Just left a Cadence dinner reporting the same, but I left the literature in the car.

 

[DipriFan]

Could you please provide a link or source to your last sentence. Thanks

Sure.

Jahr. Anesthesiology Clin 2010:614
http://www.ncbi.nlm.nih.gov/pubmed?term=21074742