Tylenol with Codeine #3 (APAP 300 MG / codeine phosphate 30 MG) Oral Tablet
Generic Name: ACETAMINOPHEN AND CODEINE PHOSPHATE
Brand Name: TYLENOL with Codeine
- Substance Name(s):
- CODEINE PHOSPHATE
- ACETAMINOPHEN
WARNINGS
Addiction, Abuse, and Misuse TYLENOL® with Codeine contains codeine.
Codeine in combination with acetaminophen, is a Schedule III controlled substance.
As an opioid, TYLENOL® with Codeine tablets expose users to the risks of addiction, abuse, and misuse (see DRUG ABUSE and DEPENDENCE ).
Although the risk of addiction in any individual is unknown, it can occur in patients appropriately prescribed TYLENOL® with Codeine tablets.
Addiction can occur at recommended dosages and if the drug is misused or abused.
Assess each patient’s risk for opioid addiction, abuse, or misuse prior to prescribing TYLENOL® with Codeine tablets, and monitor all patients receiving TYLENOL® with Codeine tablets for the development of these behaviors and conditions.
Risks are increased in patients with a personal or family history of substance abuse (including drug or alcohol abuse or addiction) or mental illness (e.g., major depression).
The potential for these risks should not, however, prevent the proper management of pain in any given patient.
Patients at increased risk may be prescribed opioids such as TYLENOL® with Codeine tablets, but use in such patients necessitates intensive counseling about the risks and proper use of TYLENOL® with Codeine tablets along with intensive monitoring for signs of addiction, abuse, and misuse.
Opioids are sought by drug abusers and people with addiction disorders and are subject to criminal diversion.
Consider these risks when prescribing or dispensing TYLENOL® with Codeine.
Strategies to reduce these risks include prescribing the drug in the smallest appropriate quantity and advising the patient on the proper disposal of unused drug (see PRECAUTIONS; Information for Patients/Caregivers ).
Contact local state professional licensing board or state controlled substances authority for information on how to prevent and detect abuse or diversion of this product.
Life-Threatening Respiratory Depression Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended.
Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death.
Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical status (see OVERDOSAGE ).
Carbon dioxide (CO2) retention from opioid-induced respiratory depression can exacerbate the sedating effects of opioids.
While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of TYLENOL® with Codeine, the risk is greatest during the initiation of therapy or following a dosage increase.
Monitor patients closely for respiratory depression, especially within the first 24–72 hours of initiating therapy with and following dosage increases of TYLENOL® with Codeine.
To reduce the risk of respiratory depression, proper dosing and titration of TYLENOL® with Codeine are essential (see DOSAGE AND ADMINISTRATION ).
Overestimating the TYLENOL® with Codeine dosage when converting patients from another opioid product can result in a fatal overdose with the first dose.
Accidental ingestion of TYLENOL® with Codeine, especially by children, can result in respiratory depression and death due to an overdose of codeine.
Ultra-Rapid Metabolism of Codeine and Other Risk Factors for Life-Threatening Respiratory Depression in Children Life-threatening respiratory depression and death have occurred in children who received codeine.
Codeine is subject to variability in metabolism based upon CYP2D6 genotype (described below), which can lead to an increased exposure to the active metabolite morphine.
Based upon post-marketing reports, children younger than 12 years of age appear to be more susceptible to the respiratory depressant effects of codeine, particularly if there are risk factors for respiratory depression.
For example, many reported cases of death occurred in the post-operative period following tonsillectomy and/or adenoidectomy, and many of the children had evidence of being ultra-rapid metabolizers of codeine.
Furthermore, children with obstructive sleep apnea who are treated with codeine for post-tonsillectomy and/or adenoidectomy pain may be particularly sensitive to its respiratory depressant effects.
Because of the risk of life-threatening respiratory depression and death: TYLENOL® with Codeine tablets are contraindicated for all children younger than 12 years of age (see CONTRAINDICATIONS ).
TYLENOL® with Codeine tablets are contraindicated for post-operative management in pediatric patients younger than 18 years of age following tonsillectomy and/or adenoidectomy (see CONTRAINDICATIONS ).
Avoid the use of TYLENOL® with Codeine tablets in adolescents 12 to 18 years of age who have other risk factors that may increase their sensitivity to the respiratory depressant effects of codeine unless the benefits outweigh the risks.
Risk factors include conditions associated with hypoventilation, such as post-operative status, obstructive sleep apnea, obesity, severe pulmonary disease, neuromuscular disease, and concomitant use of other medications that cause respiratory depression (see ).
As with adults, when prescribing codeine for adolescents, healthcare providers should choose the lowest effective dose for the shortest period of time and inform patients and caregivers about these risks and the signs of morphine overdose (see OVERDOSAGE ).
Nursing Mothers At least one death was reported in a nursing infant who was exposed to high levels of morphine in breast milk because the mother was an ultra-rapid metabolizer of codeine.
Breastfeeding is not recommended during treatment with TYLENOL® with Codeine tablets.
CYP2D6 Genetic Variability: Ultra-Rapid Metabolizers Some individuals may be ultra-rapid metabolizers because of a specific CYP2D6 genotype (e.g., gene duplications denoted as *1/*1×N or *1/*2×N).
The prevalence of this CYP2D6 phenotype varies widely and has been estimated at 1 to 10% for Whites (European, North American), 3 to 4% for Blacks (African Americans), 1 to 2% for East Asians (Chinese, Japanese, Korean), and may be greater than 10% in certain racial/ethnic groups (i.e., Oceanian, Northern African, Middle Eastern, Ashkenazi Jews, Puerto Rican).
These individuals convert codeine into its active metabolite, morphine, more rapidly and completely than other people.
This rapid conversion results in higher than expected serum morphine levels.
Even at labeled dosage regimens, individuals who are ultra-rapid metabolizers may have life-threatening or fatal respiratory depression or experience signs of overdose (such as extreme sleepiness, confusion, or shallow breathing) (see OVERDOSAGE ).
Therefore, individuals who are ultra-rapid metabolizers should not use TYLENOL® with Codeine tablets.
Neonatal Opioid Withdrawal Syndrome Prolonged use of TYLENOL® with Codeine tablets during pregnancy can result in withdrawal in the neonate.
Neonatal opioid withdrawal syndrome, unlike opioid withdrawal syndrome in adults, may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts.
Observe newborns for signs of neonatal opioid withdrawal syndrome and manage accordingly.
Advise pregnant women using opioids for a prolonged period of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available (see PRECAUTIONS, Information for Patients/Caregivers, Pregnancy ).
Interactions with Drugs Affecting Cytochrome P450 Isoenzymes The effects of concomitant use or discontinuation of CYP3A4 inducers, CYP3A4 inhibitors, or CYP2D6 inhibitors with codeine are complex.
Use of CYP3A4 inducers, CYP3A4 inhibitors, or CYP2D6 inhibitors with TYLENOL® with Codeine requires careful consideration of the effects on the parent drug, codeine, and the active metabolite, morphine.
CYP3A4 Interaction The concomitant use of TYLENOL® with Codeine with all CYP3A4 inhibitors, such as macrolide antibiotics (e.g., erythromycin), azole-antifungal agents (e.g., ketoconazole), and protease inhibitors (e.g., ritonavir) or discontinuation of a CYP3A4 inducer such as rifampin, carbamazepine, and phenytoin, may result in an increase in codeine plasma concentrations with subsequently greater metabolism by CYP2D6, resulting in greater morphine levels, which could increase or prolong adverse reactions and may cause potentially fatal respiratory depression.
The concomitant use of TYLENOL® with Codeine with all CYP3A4 inducers or discontinuation of a CYP3A4 inhibitor may result in lower codeine levels, greater norcodeine levels, and less metabolism via CYP2D6 with resultant lower morphine levels.
This may be associated with a decrease in efficacy, and in some patients, may result in signs and symptoms of opioid withdrawal.
Follow patients receiving TYLENOL® with Codeine and any CYP3A4 inhibitor or inducer for signs and symptoms that may reflect opioid toxicity and opioid withdrawal when TYLENOL® with Codeine are used in conjunction with inhibitors and inducers of CYP3A4 (see , Drug Interactions ).
If concomitant use of a CYP3A4 inhibitor is necessary or if a CYP3A4 inducer is discontinued, consider dosage reduction of TYLENOL® with Codeine until stable drug effects are achieved.
Monitor patients for respiratory depression and sedation at frequent intervals.
If concomitant use of a CYP3A4 inducer is necessary or if a CYP3A4 inhibitor is discontinued, consider increasing the TYLENOL® with Codeine dosage until stable drug effects are achieved.
Monitor for signs of opioid withdrawal (see PRECAUTIONS, Drug Interactions ).
Risks of Concomitant Use or Discontinuation of CYP2D6 Inhibitors The concomitant use of TYLENOL® with Codeine with all CYP2D6 inhibitors (e.g., amiodarone, quinidine) may result in an increase in codeine plasma concentrations and a decrease in active metabolite morphine plasma concentration which could result in an analgesic efficacy reduction or symptoms of opioid withdrawal.
Discontinuation of a concomitantly used CYP2D6 inhibitor may result in a decrease in codeine plasma concentration and an increase in active metabolite morphine plasma concentration which could increase or prolong adverse reactions and may cause potentially fatal respiratory depression.
Follow patients receiving TYLENOL® with Codeine and any CYP2D6 inhibitor for signs and symptoms that may reflect opioid toxicity and opioid withdrawal when TYLENOL® with Codeine tablets are used in conjunction with inhibitors of CYP2D6.
If concomitant use with a CYP2D6 inhibitor is necessary, follow the patient for signs of reduced efficacy or opioid withdrawal and consider increasing the TYLENOL® with Codeine dosage.
After stopping use of a CYP2D6 inhibitor, consider reducing the TYLENOL® with Codeine dosage and follow the patient for signs and symptoms of respiratory depression or sedation (see PRECAUTIONS, Drug Interactions ).
Hepatotoxicity Acetaminophen has been associated with cases of acute liver failure, at times resulting in liver transplant and death.
Most of the cases of liver injury are associated with the use of acetaminophen at doses that exceed 4,000 milligrams per day, and often involve more than one acetaminophen-containing product.
The excessive intake of acetaminophen may be intentional to cause self-harm or unintentional as patients attempt to obtain more pain relief or unknowingly take other acetaminophen-containing products.
The risk of acute liver failure is higher in individuals with underlying liver disease and in individuals who ingest alcohol while taking acetaminophen.
Instruct patients to look for acetaminophen or APAP on package labels and not to use more than one product that contains acetaminophen.
Instruct patients to seek medical attention immediately upon ingestion of more than 4,000 milligrams of acetaminophen per day, even if they feel well.
Risks from Concomitant Use with Benzodiazepines or Other CNS Depressants Profound sedation, respiratory depression, coma, and death may result from the concomitant use of TYLENOL® with Codeine tablets with benzodiazepines and/or other CNS depressants (e.g., non-benzodiazepine sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, other opioids, alcohol).
Because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate.
Observational studies have demonstrated that concomitant use of opioid analgesics and benzodiazepines increases the risk of drug-related mortality compared to use of opioid analgesics alone.
Because of similar pharmacological properties, it is reasonable to expect similar risk with the concomitant use of other CNS depressant drugs with opioid analgesics (see PRECAUTIONS; Drug Interactions ).
If the decision is made to prescribe a benzodiazepine or other CNS depressant concomitantly with an opioid analgesic, prescribe the lowest effective dosages and minimum durations of concomitant use.
In patients already receiving an opioid analgesic, prescribe a lower initial dose of the benzodiazepine or other CNS depressant than indicated in the absence of an opioid, and titrate based on clinical response.
If an opioid analgesic is initiated in a patient already taking a benzodiazepine or other CNS depressant, prescribe a lower initial dose of the opioid analgesic, and titrate based on clinical response.
Follow patients closely for signs and symptoms of respiratory depression and sedation.
Advise both patients and caregivers about the risks of respiratory depression and sedation when TYLENOL® with Codeine tablets are used with benzodiazepines or other CNS depressants (including alcohol and illicit drugs).
Advise patients not to drive or operate heavy machinery until the effects of concomitant use of the benzodiazepine or other CNS depressant have been determined.
Screen patients for risk of substance use disorders, including opioid abuse and misuse, and warn them of the risk for overdose and death associated with the use of additional CNS depressants including alcohol and illicit drugs (see PRECAUTIONS; Drug Interactions, Information for Patients/Caregivers ).
Life-Threatening Respiratory Depression in Patients with Chronic Pulmonary Disease or Elderly, Cachectic, or Debilitated Patients The use of TYLENOL® with Codeine tablets in patients with acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment is contraindicated.
Patients with Chronic Pulmonary Disease TYLENOL® with Codeine-treated patients with significant chronic obstructive pulmonary disease or cor pulmonale, and those with a substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression are at increased risk of decreased respiratory drive including apnea, even at recommended dosages of TYLENOL® with Codeine tablets (see ; Life-Threatening Respiratory Depression ).
Elderly, Cachectic, or Debilitated Patients Life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients because they may have altered pharmacokinetics, including clearance, compared to younger, healthier patients (see ; Life-Threatening Respiratory Depression ).
Monitor such patients closely, particularly when initiating and titrating TYLENOL® with Codeine tablets and when TYLENOL® with Codeine tablets are given concomitantly with other drugs that depress respiration (see ; Life-Threatening Respiratory Depression ).
Alternatively, consider the use of non-opioid analgesics in these patients.
Interaction with Monoamine Oxidase Inhibitors Monoamine oxidase inhibitors (MAOIs) may potentiate the effects of morphine, codeine’s active metabolite, including respiratory depression, coma, and confusion.
TYLENOL® with Codeine tablets should not be used in patients taking MAOIs or within 14 days of stopping such treatment.
Adrenal Insufficiency Cases of adrenal insufficiency have been reported with opioid use, more often following greater than 1 month of use.
Presentation of adrenal insufficiency may include non-specific symptoms and signs including nausea, vomiting, anorexia, fatigue, weakness, dizziness, and low blood pressure.
If adrenal insufficiency is suspected, confirm the diagnosis with diagnostic testing as soon as possible.
If adrenal insufficiency is diagnosed, treat with physiologic replacement doses of corticosteroids.
Wean the patient off of the opioid to allow adrenal function to recover and continue corticosteroid treatment until adrenal function recovers.
Other opioids may be tried as some cases reported use of a different opioid without recurrence of adrenal insufficiency.
The information available does not identify any particular opioids as being more likely to be associated with adrenal insufficiency.
Severe Hypotension TYLENOL® with Codeine may cause severe hypotension including orthostatic hypotension and syncope in ambulatory patients.
There is increased risk in patients whose ability to maintain blood pressure has already been compromised by a reduced blood volume or concurrent administration of certain CNS depressant drugs (e.g., phenothiazines or general anesthetics) (see PRECAUTIONS; Drug Interactions ).
Monitor these patients for signs of hypotension after initiating or titrating the dosage of TYLENOL® with Codeine.
In patients with circulatory shock TYLENOL® with Codeine tablets may cause vasodilatation that can further reduce cardiac output and blood pressure.
Avoid the use of TYLENOL® with Codeine tablets with circulatory shock.
Serious Skin Reactions Rarely, acetaminophen may cause serious skin reactions such as acute generalized exanthematous pustulosis (AGEP), Stevens-Johnson Syndrome (SJS), and toxic epidermal necrolysis (TEN), which can be fatal.
Patients should be informed about the signs of serious skin reactions, and use of the drug should be discontinued at the first appearance of skin rash or any other sign of hypersensitivity.
Risks of Use in Patients with Increased Intracranial Pressure, Brain Tumors, Head Injury, or Impaired Consciousness In patients who may be susceptible to the intracranial effects of CO2 retention (e.g., those with evidence of increased intracranial pressure or brain tumors), TYLENOL® with Codeine tablets may reduce respiratory drive, and the resultant CO2 retention can further increase intracranial pressure.
Monitor such patients for signs of sedation and respiratory depression, particularly when initiating therapy with TYLENOL® with Codeine tablets.
Opioids may also obscure the clinical course in a patient with a head injury.
Avoid the use of TYLENOL® with Codeine tablets in patients with impaired consciousness or coma.
Hypersensitivity/Anaphylaxis There have been post-marketing reports of hypersensitivity and anaphylaxis associated with the use of acetaminophen.
Clinical signs included swelling of the face, mouth, and throat, respiratory distress, urticaria, rash, pruritus, and vomiting.
There were infrequent reports of life-threatening anaphylaxis requiring emergency medical attention.
Instruct patients to discontinue TYLENOL® with Codeine immediately and seek medical care if they experience these symptoms.
Do not prescribe TYLENOL® with Codeine tablets for patients with acetaminophen allergy (see PRECAUTIONS; Information for Patients/Caregivers ).
Risks of Use in Patients with Gastrointestinal Conditions TYLENOL® with Codeine tablets are contraindicated in patients with gastrointestinal obstruction, including paralytic ileus.
The administration of TYLENOL® with Codeine tablets or other opioids may obscure the diagnosis or clinical course in patients with acute abdominal conditions.
TYLENOL® with Codeine tablets may cause spasm of the sphincter of Oddi.
Opioids may cause increases in serum amylase.
Monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms.
Sulfite Sensitivity TYLENOL® with Codeine tablets contain sodium metabisulfite, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people.
The overall prevalence of sulfite sensitivity in the general population is unknown and probably low.
Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people.
Increased Risk of Seizures in Patients with Seizure Disorders The codeine in TYLENOL® with Codeine tablets may increase the frequency of seizures in patients with seizure disorders, and may increase the risk of seizures occurring in other clinical settings associated with seizures.
Monitor patients with a history of seizure disorders for worsened seizure control during TYLENOL® with Codeine tablets therapy.
Withdrawal Avoid the use of mixed agonist/antagonist (e.g, pentazocine, nalbuphine, and butorphanol) or partial agonist (e.g., buprenorphine) analgesics in patients who are receiving a full opioid agonist analgesic, including TYLENOL® with Codeine tablets.
In these patients, mixed agonist/antagonist and partial analgesics may reduce the analgesic effect and/or precipitate withdrawal symptoms.
When discontinuing TYLENOL® with Codeine, gradually taper the dosage (see DOSAGE AND ADMINISTRATION ).
Do not abruptly discontinue TYLENOL® with Codeine tablets (see DRUG ABUSE AND DEPENDENCE ).
DRUG INTERACTIONS
Drug Interactions CYP2D6 Inhibitors Codeine is metabolized by CYP2D6 to form morphine.
The concomitant use of TYLENOL® with Codeine and CYP2D6 inhibitors (e.g., paroxetine, fluoxetine, bupropion, quinidine) can increase the plasma concentration of codeine, but can decrease the plasma concentration of active metabolite morphine, which could result in reduced analgesic efficacy or symptoms of opioid withdrawal, particularly when an inhibitor is added after a stable dose of TYLENOL® with Codeine is achieved (see CLINICAL PHARMACOLOGY ).
After stopping a CYP2D6 inhibitor, as the effects of the inhibitor decline, the codeine plasma concentration will decrease but the active metabolite morphine plasma concentration will increase, which could increase or prolong adverse reactions and may cause potentially fatal respiratory depression (see CLINICAL PHARMACOLOGY ).
If concomitant use with a CYP2D6 inhibitor is necessary, or if a CYP2D6 inhibitor is discontinued after concomitant use, consider dosage adjustment of TYLENOL® with Codeine and monitor patients closely at frequent intervals.
If concomitant use with CYP2D6 inhibitors is necessary, follow the patient for reduced efficacy or signs and symptoms of opioid withdrawal and consider increasing the dosage of TYLENOL® with Codeine as needed.
After stopping use of a CYP2D6 inhibitor, consider reducing the dosage of TYLENOL® with Codeine and monitor the patient for signs and symptoms of respiratory depression or sedation.
CYP3A4 Inhibitors The concomitant use of TYLENOL® with Codeine tablets and CYP3A4 inhibitors, such as macrolide antibiotics (e.g., erythromycin), azole-antifungal agents (e.g.
ketoconazole), and protease inhibitors (e.g., ritonavir), may result in an increase in codeine plasma concentrations , with subsequently greater metabolism by CYP2D6, resulting in greater morphine levels, which could increase or prolong adverse reactions and may cause potentially fatal respiratory depression, particularly when an inhibitor is added after a stable dose of TYLENOL® with Codeine is achieved (see WARNINGS ).
After stopping a CYP3A4 inhibitor, as the effects of the inhibitor decline, it may result in lower codeine levels, greater norcodeine levels, and less metabolism via CYP2D6 with resultant lower morphine levels (see CLINICAL PHARMACOLOGY ), resulting in decreased opioid efficacy or a withdrawal syndrome in patients who had developed physical dependence to codeine.
If concomitant use of CYP3A4 inhibitor is necessary, consider dosage reduction of TYLENOL® with Codeine until stable drug effects are achieved.
Monitor patients for respiratory depression and sedation at frequent intervals.
If a CYP3A4 inhibitor is discontinued, consider increasing the TYLENOL® with Codeine tablets dosage until stable drug effects are achieved.
Monitor for signs of opioid withdrawal.
CYP3A4 Inducers The concomitant use of TYLENOL® with Codeine tablets and CYP3A4 inducers (e.g., rifampin, carbamazepine, phenytoin) can result in lower codeine levels, greater norcodeine levels, and less metabolism via CYP2D6 with resultant lower morphine levels (see CLINICAL PHARMACOLOGY ), resulting in decreased efficacy or onset of a withdrawal syndrome in patients who have developed physical dependence (see WARNINGS ).
After stopping a CYP3A4 inducer, as the effects of the inducer decline, codeine plasma concentrations may increase, with subsequently greater metabolism by cytochrome CYP2D6, resulting in greater morphine levels (see CLINICAL PHARMACOLOGY ), which could increase or prolong both the therapeutic effects and adverse reactions, and may cause serious respiratory depression.
If concomitant use of a CYP3A4 inducer is necessary, follow the patient for reduced efficacy and signs of opioid withdrawal and consider increasing the TYLENOL® with Codeine dosage as needed.
If a CYP3A4 inducer is discontinued, consider a TYLENOL® with Codeine tablets dosage reduction and monitor for signs of respiratory depression and sedation at frequent intervals.
Benzodiazepines and Other Central Nervous System (CNS) Depressants Due to additive pharmacologic effect, the concomitant use of benzodiazepines or other CNS depressants, including alcohol, other sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics and other opioids, can increase the risk of hypotension, respiratory depression, profound sedation, coma, and death.
Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate.
Limit dosages and durations to the minimum required.
Follow patients closely for signs of respiratory depression and sedation (see WARNINGS ).
Serotonergic Drugs The concomitant use of opioids with other drugs that affect the serotonergic neurotransmitter system has resulted in serotonin syndrome.
Examples of these drugs include, selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), triptans, 5-HT3 receptor antagonists, drugs that effect the serotonin neurotransmitter system (e.g., mirtazapine, trazodone, tramadol), and monoamine oxidase (MAO) inhibitors (used to treat psychiatric disorders and also others, such as linezolid and intravenous methylene blue) (see PRECAUTIONS; Information for Patients/Caregivers ).
If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation and dose adjustment.
Discontinue TYLENOL® with Codeine tablets immediately if serotonin syndrome is suspected.
Monoamine Oxidase Inhibitors (MAOIs) The concomitant use of opioids and MAOIs, such as phenelzine, tranylcypromine, linezolid, may manifest as serotonin syndrome or opioid toxicity.
Advise patients taking TYLENOL® with Codeine tablets not to use MAOIs or within 14 days of stopping such treatment.
If urgent use of an opioid is necessary, use test doses and frequent titration of small doses of other opioids (such as oxycodone, hydrocodone, oxymorphone, hydrocodone, or buprenorphine) to treat pain while closely monitoring blood pressure and signs and symptoms of CNS and respiratory depression.
Mixed Agonist/Antagonist and Partial Agonist Opioid Analgesics The concomitant use of opioids with other opioid analgesics, such as butorphanol, nalbuphine, pentazocine, may reduce the analgesic effect of TYLENOL® with Codeine tablets and/or precipitate withdrawal symptoms.
Advise patient to avoid concomitant use of these drugs.
Muscle Relaxants TYLENOL® with Codeine tablets may enhance the neuromuscular blocking action of skeletal muscle relaxants and produce an increased degree of respiratory depression.
If concomitant use is warranted, monitor patients for signs of respiratory depression that may be greater than otherwise expected and decrease the dosage of TYLENOL® with Codeine tablets and/or the muscle relaxant as necessary.
Diuretics Opioids can reduce the efficacy of diuretics by inducing the release of antidiuretic hormone.
If concomitant use is warranted, monitor patients for signs of diminished diuresis and/or effects on blood pressure and increase the dosage of the diuretic as needed.
Anticholinergic Drugs The concomitant use of anticholinergic drugs may increase risk of urinary retention and/or severe constipation, which may lead to paralytic ileus.
If concomitant use is warranted, monitor patients for signs of urinary retention or reduced gastric motility when TYLENOL® with Codeine tablets are used concomitantly with anticholinergic drugs.
OVERDOSAGE
Following an acute overdosage, toxicity may result from codeine or acetaminophen.
Clinical Presentation Codeine Acute overdosage with codeine can be manifested by respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, constricted pupils, and, in some cases, pulmonary edema, bradycardia, hypotension, partial or complete airway obstruction, atypical snoring, and death.
Marked mydriasis rather than miosis may be seen with hypoxia in overdose situations.
Acetaminophen Dose-dependent, potentially fatal hepatic necrosis is the most serious adverse effect of acetaminophen overdose.
Renal tubular necrosis, hypoglycemic coma, and coagulation defects may also occur.
Early symptoms following a potentially hepatotoxic overdose may include; anorexia, nausea, vomiting, diaphoresis, pallor and general malaise.
Clinical and laboratory evidence of hepatic toxicity may not be apparent until 48 to 72 hours post-ingestion.
Treatment of Overdose Codeine In case of overdose, priorities are the reestablishment of a patent and protected airway and institution of assisted or controlled ventilation, if needed.
Employ other supportive measures (including oxygen and vasopressors) in the management of circulatory shock and pulmonary edema as indicated.
Cardiac arrest or serious arrhythmias will require advanced life-support measures.
The opioid antagonists, naloxone or nalmefene, are specific antidotes to respiratory depression resulting from opioid overdose.
For clinically significant respiratory or circulatory depression secondary to TYLENOL® with Codeine tablets overdose, administer an opioid antagonist.
Opioid antagonists should not be administered in the absence of clinically significant respiratory or circulatory depression secondary to codeine overdose.
Because the duration of opioid reversal is expected to be less than the duration of action of codeine in TYLENOL® with Codeine tablets, carefully monitor the patient until spontaneous respiration is reliably reestablished.
If the response to an opioid antagonist is suboptimal or only brief in nature, administer additional antagonist as directed by the product’s prescribing information.
In an individual physically dependent on opioids, administration of the recommended usual dosage of the antagonist will precipitate an acute withdrawal syndrome.
The severity of the withdrawal symptoms experienced will depend on the degree of physical dependence and the dose of the antagonist administered.
If a decision is made to treat serious respiratory depression in the physically dependent patient, administration of the antagonist should be begun with care and by titration with smaller than usual doses of the antagonist.
Acetaminophen Gastric decontamination with activated charcoal should be administered just prior to N-acetylcysteine (NAC) to decrease systemic absorption if acetaminophen ingestion is known or suspected to have occurred within a few hours of presentation.
Serum acetaminophen levels should be obtained immediately if the patient presents 4 hours or more after ingestion to assess potential risk of hepatotoxicity; acetaminophen levels drawn less than 4 hours post-ingestion may be misleading.
To obtain the best possible outcome, (NAC) should be administered as soon as possible where impending or evolving liver injury is suspected.
Intravenous NAC may be administered when circumstances preclude oral administration.
Vigorous supportive therapy is required in severe intoxication.
Procedures to limit the continuing absorption of the drug must be readily performed since the hepatic injury is dose-dependent and occurs early in the course of intoxication.
DESCRIPTION
TYLENOL® with Codeine is supplied in tablet form for oral administration.
Acetaminophen, 4′-hydroxyacetanilide, a slightly bitter, white, odorless, crystalline powder, is a non-opiate, non-salicylate analgesic and antipyretic.
It has the following structural formula: C8 H9 NO2 M.W.
151.16 Codeine phosphate, 7,8-didehydro-4, 5α-epoxy-3-methoxy-17-methylmorphinan-6α-ol phosphate (1:1) (salt) hemihydrate, a white crystalline powder, is a narcotic analgesic and antitussive.
It has the following structural formula: C18H21NO3∙H3PO4∙1/2 H2O M.W.
406.37 Each Tylenol with Codeine No.
3 tablet, USP (300 mg/30 mg) contains: Acetaminophen 300 mg Codeine Phosphate 30 mg Each Tylenol with Codeine No.
4 tablet, USP (300 mg/60 mg) contains: Acetaminophen 300 mg Codeine Phosphate 60 mg In addition, each tablet contains the following inactive ingredients: TYLENOL® with Codeine No.
3 contains powdered cellulose, magnesium stearate, sodium metabisulfiteSee WARNINGS , pregelatinized starch (corn), and modified starch (corn).
TYLENOL® with Codeine No.
4 contains powdered cellulose, magnesium stearate, sodium metabisulfite, pregelatinized starch (corn), and corn starch.
Chemical Structure Chemical Structure
HOW SUPPLIED
Product: 50090-0006 NDC: 50090-0006-2 20 TABLET in a BOTTLE
GERIATRIC USE
Geriatric Use Elderly patients (aged 65 years or older) may have increased sensitivity to TYLENOL® with Codeine tablets.
In general, use caution when selecting a dosage for an elderly patient, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function and of concomitant disease or other drug therapy.
Respiratory depression is the chief risk for elderly patients treated with opioids, and has occurred after large initial doses were administered to patients who were not opioid-tolerant or when opioids were co-administered with other agents that depress respiration.
Titrate the dosage of TYLENOL® with Codeine tablets slowly in geriatric patients and monitor closely for signs of central nervous system depression (see WARNINGS ).
These drugs are known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function.
Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.
MECHANISM OF ACTION
Mechanism of Action Codeine is an opioid agonist relatively selective for the mu-opioid receptor, but with a much weaker affinity than morphine.
The analgesic properties of codeine have been speculated to come from its conversion to morphine, although the exact mechanism of analgesic action remains unknown.
The precise mechanism of the analgesic properties of acetaminophen is not established but is thought to involve central actions.
INDICATIONS AND USAGE
TYLENOL® with Codeine (acetaminophen and codeine phosphate) tablets are indicated for the management of mild to moderate pain, where treatment with an opioid is appropriate and for which alternative treatments are inadequate.
Limitations of Use Because of the risks of addiction, abuse, and misuse, with opioids, even at recommended doses (see WARNINGS ), reserve TYLENOL® with Codeine tablets for use in patients for whom alternative treatment options [e.g., non-opioid analgesics] Have not provided adequate analgesia, or are not expected to provide adequate analgesia, Have not been tolerated, or are not expected to be tolerated.
PEDIATRIC USE
Pediatric Use The safety and effectiveness of TYLENOL® with Codeine in pediatric patients below the age of 18 have not been established.
Life-threatening respiratory depression and death have occurred in children who received codeine (see WARNINGS ).
In most of the reported cases, these events followed tonsillectomy and/or adenoidectomy, and many of the children had evidence of being ultra-rapid metabolizers of codeine (i.e., multiple copies of the gene for CYP2D6 or high morphine concentrations).
Children with sleep apnea may be particularly sensitive to the respiratory depressant effects of codeine.
Because of the risk of life-threatening respiratory depression and death: TYLENOL® with Codeine tablets are contraindicated for all children younger than 12 years of age (see CONTRAINDICATIONS ).
TYLENOL® with Codeine tablets are contraindicated for post-operative management in pediatric patients younger than 18 years of age following tonsillectomy and/or adenoidectomy (see CONTRAINDICATIONS ).
Avoid the use of TYLENOL® with Codeine tablets in adolescents 12 to 18 years of age who have other risk factors that may increase their sensitivity to the respiratory depressant effects of codeine unless the benefits outweigh the risks.
Risk factors include conditions associated with hypoventilation, such as post-operative status, obstructive sleep apnea, obesity, severe pulmonary disease, neuromuscular disease, and concomitant use of other medications that cause respiratory depression (see WARNINGS ).
PREGNANCY
Pregnancy Teratogenic Effects Codeine A study in rats and rabbits reported no teratogenic effect of codeine administered during the period of organogenesis in doses ranging from 5 to 120 mg/kg.
In the rat, doses at the 120 mg/kg level, in the toxic range for the adult animal, were associated with an increase in embryo resorption at the time of implantation.
In another study a single 100 mg/kg subcutaneous dose of codeine administered to pregnant mice reportedly resulted in delayed ossification in the offspring.
There are no adequate and well-controlled studies in pregnant women.
TYLENOL® with Codeine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Nonteratogenic Effects Fetal/Neonatal Adverse Reactions Prolonged use of opioid analgesics during pregnancy for medical or nonmedical purposes can result in physical dependence in the neonate and neonatal opioid withdrawal syndrome shortly after birth.
Neonatal opioid withdrawal syndrome presents as irritability, hyperactivity and abnormal sleep pattern, high pitched cry, tremor, vomiting, diarrhea and failure to gain weight.
The onset, duration, and severity of neonatal opioid withdrawal syndrome vary based on the specific opioid used, duration of use, timing and amount of last maternal use, and rate of elimination of the drug by the newborn.
Observe newborns for symptoms of neonatal opioid withdrawal syndrome and manage accordingly (see WARNINGS ).
NUSRING MOTHERS
Nursing Mothers Codeine and its active metabolite, morphine, are present in human milk.
There are published studies and cases that have reported excessive sedation, respiratory depression, and death in infants exposed to codeine via breast milk.
Women who are ultra-rapid metabolizers of codeine achieve higher than expected serum levels of morphine, potentially leading to higher levels of morphine in breast milk that can be dangerous in their breastfed infants.
In women with normal codeine metabolism (normal CYP2D6 activity), the amount of codeine secreted into human milk is low and dose-dependent.
There is no information on the effects of codeine on milk production.
Because of the potential for serious adverse reactions, including excess sedation, respiratory depression, and death in a breastfed infant, advise patients that breastfeeding is not recommended during treatment with TYLENOL® with Codeine tablets (see WARNINGS ).
Acetaminophen is excreted in breast milk in small amounts, but the significance of its effect on nursing infants is not known.
Because of the potential for serious adverse reactions in nursing infants from acetaminophen, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.
Clinical Considerations If infants are exposed to TYLENOL® with Codeine tablets through breast milk, they should be monitored for excess sedation and respiratory depression.
Withdrawal symptoms can occur in breastfed infants when maternal administration of an opioid analgesic is stopped, or when breastfeeding is stopped.
BOXED WARNING
WARNING: ADDICTION, ABUSE, AND MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL INGESTION; ULTRA-RAPID METABOLISM OF CODEINE AND OTHER RISK FACTORS FOR LIFE-THREATENING RESPIRATORY DEPRESSION IN CHILDREN; NEONATAL OPIOID WITHDRAWAL SYNDROME; INTERACTIONS WITH DRUGS AFFECTING CYTOCHROME P450 ISOENZYMES; HEPATOTOXICITY; and RISKS FROM CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS Addiction, Abuse and Misuse TYLENOL® with Codeine exposes patients and other users to the risks of opioid addiction, abuse and misuse, which can lead to overdose and death.
Assess each patient’s risk prior to prescribing TYLENOL® with Codeine tablets, and monitor all patients regularly for the development of these behaviors and conditions (see WARNINGS).
Life-Threatening Respiratory Depression Serious, life-threatening, or fatal respiratory depression may occur with use of TYLENOL® with Codeine tablets.
Monitor for respiratory depression, especially during initiation of TYLENOL® with Codeine tablets or following a dose increase (see WARNINGS).
Accidental Ingestion Accidental ingestion of TYLENOL® with Codeine tablets, especially by children, can result in a fatal overdose of TYLENOL® with Codeine tablets (see WARNINGS).
Ultra-Rapid Metabolism of Codeine and Other Risk Factors for Life-Threatening Respiratory Depression in Children Life-threatening respiratory depression and death have occurred in children who received codeine.
Most of the reported cases occurred following tonsillectomy and/or adenoidectomy and many of the children had evidence of being ultra-rapid metabolizers of codeine due to a cytochrome P450 (CYP) 2D6 polymorphism (see WARNINGS, PRECAUTIONS; Information for Patients/Caregivers, Nursing Mothers).
TYLENOL® with Codeine is contraindicated in children younger than 12 years of age and in children younger than 18 years of age following tonsillectomy and/or adenoidectomy (see CONTRAINDICATIONS).
Avoid the use of TYLENOL® with Codeine tablets in adolescents 12 to 18 years of age who have other risk factors that may increase their sensitivity to the respiratory depressant effects of codeine (see WARNINGS, PRECAUTIONS).
Neonatal Opioid Withdrawal Syndrome Prolonged use of TYLENOL® with Codeine tablets during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts.
If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available (see WARNINGS, PRECAUTIONS).
Interactions with Drugs Affecting Cytochrome P450 Isoenzymes The effects of concomitant use or discontinuation of CYP3A4 inducers, CYP3A4 inhibitors, or CYP2D6 inhibitors with codeine are complex.
Use of CYP3A4 inducers, CYP3A4 inhibitors, or CYP2D6 inhibitors with TYLENOL® with Codeine tablets requires careful consideration of the effects on the parent drug, codeine, and the active metabolite, morphine (see WARNINGS, PRECAUTIONS: DRUG INTERACTIONS).
Hepatotoxicity Acetaminophen has been associated with cases of acute liver failure, at times resulting in liver transplant and death.
Most of the cases of liver injury are associated with the use of acetaminophen at doses that exceed 4,000 milligrams per day, and often involve more than one acetaminophen-containing product (see WARNINGS).
Risks from Concomitant Use with Benzodiazepines or Other CNS Depressants Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death (see WARNINGS, Drug Interactions).
Reserve concomitant prescribing of TYLENOL® with Codeine tablets and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate.
Limit dosages and durations to the minimum required.
Follow patients for signs and symptoms of respiratory depression and sedation.
INFORMATION FOR PATIENTS
Information for Patients/Caregivers Advise the patient to read the FDA-approved patient labeling (Medication Guide).
Addiction, Abuse and Misuse Inform patients that the use of TYLENOL® with Codeine tablets, even when taken as recommended, can result in addiction, abuse, and misuse, which can lead to overdose and death (see WARNINGS ).
Instruct patients not to share TYLENOL® with Codeine tablets with others and to take steps to protect TYLENOL® with Codeine tablets from theft or misuse.
Life-Threatening Respiratory Depression Inform patients of the risk of life-threatening respiratory depression, including information that the risk is greatest when starting TYLENOL® with Codeine tablets or when the dosage is increased, and that it can occur even at recommended dosages (see WARNINGS ).
Advise patients how to recognize respiratory depression and to seek medical attention if breathing difficulties develop.
Accidental Ingestion Inform patients that accidental ingestion, especially by children, may result in respiratory depression or death (see WARNINGS ).
Instruct patients to take steps to store TYLENOL® with Codeine tablets securely.
Advise patients to properly dispose of TYLENOL® with Codeine tablets in accordance with local state guidelines and/or regulations.
Ultra-Rapid Metabolism of Codeine and Other Risk Factors for Life-Threatening Respiratory Depression in Children Advise caregivers that TYLENOL® with Codeine is contraindicated in all children younger than 12 years of age and in children younger than 18 years of age following tonsillectomy and/or adenoidectomy.
Advise caregivers of children 12 to 18 years of age receiving TYLENOL® with Codeine to monitor for signs of respiratory depression (see WARNINGS ).
Interactions with Benzodiazepines and Other CNS Depressants Inform patients and caregivers that potentially fatal additive effects may occur if TYLENOL® with Codeine is used with benzodiazepines or other CNS depressants, including alcohol, and not to use these drugs concomitantly unless supervised by a healthcare provider (see WARNINGS, PRECAUTIONS; Drug Interactions ).
Serotonin Syndrome Inform patients that opioids could cause a rare but potentially life-threatening condition resulting from concomitant administration of serotonergic drugs.
Warn patients of the symptoms and signs of serotonin syndrome and to seek medical attention right away if symptoms develop.
Instruct patients to inform their healthcare provider if they are taking, or plan to take serotonergic medications (see PRECAUTIONS; Drug Interactions ).
MAOI Interaction Inform patients not to take TYLENOL® with Codeine tablets while using any drugs that inhibit monoamine oxidase.
Patients should not start MAOIs while taking TYLENOL® with Codeine tablets (see WARNINGS, Drug Interactions ).
Adrenal Insufficiency Inform patients that opioids could cause adrenal insufficiency, a potentially life-threatening condition.
Adrenal insufficiency may present with non-specific symptoms and signs such as nausea, vomiting, anorexia, fatigue, weakness, dizziness, and low blood pressure.
Advise patients to seek medical attention if they experience a constellation of these symptoms (see WARNINGS ).
Important Administration Instructions Instruct patients how to properly take TYLENOL® with Codeine tablets (see DOSAGE AND ADMINISTRATION ).
Advise patients not to adjust the dose of TYLENOL® with Codeine without consulting a physician or other healthcare professional.
If patients have been receiving treatment with TYLENOL® with Codeine tablets for more than a few weeks and cessation of therapy is indicated, counsel them on the importance of safely tapering the dose and that abruptly discontinuing the medication could precipitate withdrawal symptoms.
Provide a dose schedule to accomplish a gradual discontinuation of the medication (see WARNINGS ).
Maximum Daily Dose of Acetaminophen Inform patients not to take more than 4,000 milligrams of acetaminophen per day.
Advise patients to call their healthcare provider if they have taken more than the recommended dose.
Hypotension Inform patients that TYLENOL® with Codeine may cause orthostatic hypotension and syncope.
Instruct patients how to recognize symptoms of low blood pressure and how to reduce the risk of serious consequences should hypotension occur (e.g., sit or lie down, carefully rise from a sitting or lying position) (see WARNINGS; Hypotension ).
Anaphylaxis Inform patients that anaphylaxis has been reported with ingredients contained in TYLENOL® with Codeine.
Advise patients how to recognize such a reaction, and if they develop signs of allergy such as a rash or difficulty breathing to stop taking TYLENOL® with Codeine and seek medical attention.
(see CONTRAINDICATIONS, ADVERSE REACTIONS ).
Pregnancy Neonatal Opioid Withdrawal Syndrome Inform female patients of reproductive potential that prolonged use of TYLENOL® with Codeine during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated (see WARNINGS, Pregnancy ).
Embryo-Fetal Toxicity Inform female patients of reproductive potential that TYLENOL® with Codeine can cause fetal harm and to inform the prescriber of a known or suspected pregnancy (see PRECAUTIONS; Pregnancy ).
Lactation Advise women that breastfeeding is not recommended during treatment with TYLENOL® with Codeine tablets (see PRECAUTIONS; Nursing Mothers).
Infertility Inform patients that chronic use of opioids may cause reduced fertility.
It is not known whether these effects on fertility are reversible.
Driving or Operating Heavy Machinery Inform patients that TYLENOL® with Codeine tablets may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery and to avoid such tasks while taking this product, until they know how they will react to the medication.
Constipation Advise patients of the potential for severe constipation, including management instructions and when to seek medical attention (see ADVERSE REACTIONS, CLINICAL PHARMACOLOGY ).
Disposal of Unused TYLENOL® with Codeine Advise patients to properly dispose of TYLENOL® with Codeine tablets.
Advise patients to throw the drug in the household trash following these steps: Remove them from their original containers and mix them with an undesirable substance, such as used coffee grounds or kitty litter (this makes the drug less appealing to children and pets, and unrecognizable to people who may intentionally go through the trash seeking drugs).
Place the mixture in a sealable bag, empty can, or other container to prevent the drug from leaking or breaking out of a garbage bag, or dispose of unused tablets in accordance with local state guidelines and/or regulations.
DOSAGE AND ADMINISTRATION
Important Dosage and Administration Instructions Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals (see WARNINGS ).
Initiate the dosing regimen for each patient individually, taking into account the patient’s severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse (see WARNINGS ).
Monitor patients closely for respiratory depression, especially within the first 24–72 hours of initiating therapy and following dosage increases with TYLENOL® with Codeine tablets and adjust the dosage accordingly (see WARNINGS ).
Initial Dosage Initiating Treatment with TYLENOL® with Codeine Tablets Dosage should be adjusted according to severity of pain and response of the patient.
However, it should be kept in mind that tolerance to codeine can develop with continued use and that the incidence of untoward effects is dose related.
Adult doses of codeine higher than 60 mg are associated with an increased incidence of adverse reactions and are not associated with greater efficacy.
The usual adult dosage is: TYLENOL® with Codeine Tablets (codeine 30 mg and acetaminophen 300 mg): Take 1 to 2 tablets every 4 hours as needed for pain.
TYLENOL® with Codeine Tablets (codeine 60 mg and acetaminophen 300 mg): Take one tablet every 4 hours as needed for pain.
Single Doses (Range) Maximum 24-Hour Dose Codeine Phosphate 30 mg to 60 mg 360 mg Acetaminophen 300 mg to 1,000 mg 4,000 mg The prescriber must determine the number of tablets per dose, and the maximum number of tablets per 24 hours, based upon the above dosage guidance.
This information should be conveyed in the prescription.
Conversion from Other Opioids to TYLENOL® with Codeine Tablets There is inter-patient variability in the potency of opioid drugs and opioid formulations.
Therefore, a conservative approach is advised when determining the total daily dosage of TYLENOL® with Codeine tablets.
It is safer to underestimate a patient’s 24-hour TYLENOL® with Codeine tablets dosage than to overestimate the 24-hour TYLENOL® with Codeine tablets dosage and manage an adverse reaction due to overdose.
Titration and Maintenance of Therapy Individually titrate TYLENOL® with Codeine tablets to a dose that provides adequate analgesia and minimizes adverse reactions.
Continually reevaluate patients receiving TYLENOL® with Codeine tablets to assess the maintenance of pain control and the relative incidence of adverse reactions, as well as monitoring for the development of addiction, abuse, or misuse (see WARNINGS ).
Frequent communication is important among the prescriber, other members of the healthcare team, the patient, and the caregiver/family during periods of changing analgesic requirements, including initial titration.
If the level of pain increases after dosage stabilization, attempt to identify the source of increased pain before increasing the TYLENOL® with Codeine tablets dosage.
If unacceptable opioid-related adverse reactions are observed, consider reducing the dosage.
Adjust the dosage to obtain an appropriate balance between management of pain and opioid-related adverse reactions.
Discontinuation of TYLENOL® with Codeine When a patient who has been taking TYLENOL® with Codeine tablets regularly and may be physically dependent no longer requires therapy with TYLENOL® with Codeine tablets, taper the dose gradually, by 25% to 50% every 2 to 4 days, while monitoring carefully for signs and symptoms of withdrawal.
If the patient develops these signs or symptoms, raise the dose to the previous level and taper more slowly, either by increasing the interval between decreases, decreasing the amount of change in dose, or both.
Do not abruptly discontinue TYLENOL® with Codeine tablets in a physically-dependent patient (see WARNINGS, DRUG ABUSE AND DEPENDENCE ).