“The patient says she needs to use Tylox, not Percocet. What is that?”
When a new group of residents come for training at the hospital, we get all sorts of fun questions. This question is relatively easy, and I’ll answer it in a moment. For newbies, grasping the currently available oxycodone combination products might be a challenge. So I thought I would write a brief post to try and clarify the available products and their differences. I’m also concerned that any confusion about the true content of some of these products might lead to inappropriate prescribing or utilization, resulting in an adverse event.
I’ve entitled this article “The Difference between Percocet, Percodan and Tylox.” But I’ll actually give a quick review of all the currently used oxycodone combination products, since there aren’t too many. I am going to tell you what each drug is, what it contains, and how it is typically used. However – NOTE – this is not a comprehensive article intended to explain every clinical aspect related to the safe and effective use of these agents. Also, understand that these are all Schedule II controlled substances in the U.S. That means they fall into the category of having just about the highest potential for addiction and abuse. They should always be used cautiously and only as directed.
Note: Nothing in this article should be taken as prescribing advice. It is for information only.
A QUICK REVIEW OF OXYCODONE COMBINATIONS:
TYLOX – Getting back to the doctor’s question: Tylox no longer exists. It was a combination of oxycodone (5mg) and acetaminophen (500mg) in a capsule form by Jannsen pharmaceuticals. But they discontinued manufacturing it back in late 2012. When the FDA issued a requirement that all combination medications containing acetaminophen be limited to no more than 325mg per dose, all the generic manufacturers had to get out of the market as well. As of early 2014…there was no more Tylox or generic Tylox left on the market (unless a pharmacy happened to stockpile it).
PERCOCET TABLETS – A combination of oxycodone and acetaminophen. Percocet was originally approved for marketing in the U.S. back in 1976. It is currently owned by Endo pharmaceuticals and comes in the following strengths:
NOTE – The 5mg/325mg combination is by far the most frequently prescribed strength. This strength is used so frequently, that some prescribers forget that it comes in other strengths and neglect to indicate the strength on their prescription. The strength is important. Since all strengths have the same amount of acetaminophen, prescribers can identify which strength they want by simply writing “Percocet-5” for example.
Dosing: Since we want to keep most patients under 4 grams of acetaminophen daily, these products should be used at the lowest effective dose and never exceed 12 tablets per day (3,900mg of acetaminophen). Typical dosing ranges include 1-2 tablets every 6 hours as needed for moderate to severe pain. Warnings should be given to not drive within 6 hours of the dose and not to mix this product with alcohol or other acetaminophen containing products. I usually recommend all my patients who take any product with oxycodone to take a stool softener such as docusate sodium twice daily (with a full glass of water) while using this medication for pain.
Generic Names: Percocet is usually dispensed as a generic, and a variety of available generics are on the market. Generic manufacturers currently making versions of Percocet include companies like Actavis, American Health, Endo (they call it “Endocet”), Mallinckrodt (stamped with the infamous 512 on one side), Mylan and others).
PERCODAN TABLETS – A combination of oxycodone and aspirin by Endo pharmaceuticals. A tablet of Percodan contains 4.8355mg of oxycodone hydrochloride along with 325mg of aspirin. Due to the aspirin component, and the numerous drug interactions and safety risks associated with aspirin, this particular combination has largely fallen out of use. You will still find pockets of patients and physicians around the country who continue to utilize it, but it is far less frequently prescribed than Percocet.
Fun Fact: Prescribers and patients may wonder about the odd “4.8355mg” of oxycodone hydrochloride in Percodan. There is a bit of a story behind this. Originally Percodan contained 2 forms of oxycodone. Oxycodone hydrochloride 4.62 mg and Oxycodone terephthalate 0.38mg. Combined it formed a neat addition of exactly 5mg of oxycodone salts. But frankly there is no clinical benefit to the “terephthalate” version, and continuing that combination added cost without value. So back in 2005 they dropped the 0.38mg of oxycodone terephthalate. But rather than leaving only the 4.62mg of oxycodone, which would have resulted in a weaker product, the manufacturer had to add an equivalent amount of “free” oxycodone to make up for the loss of the 0.38mg of oxycodone terephthalate. It turns out that is about equal to 0.2155mg of oxycodone hydrochloride. So they added 0.2155mg oxycodone hydrochloride to the existing 4.62mg of oxycodone hydrochloride and the result was 4.8355mg of oxycodone hydrochloride.
Dosing: Percodan is recommended to be dosed at 1 tablet every 6 hours as needed for pain, and should not exceed 12 tablets per day to keep the aspirin dose below 4 grams daily. Patients should be told not to drive within 6 hours of their dose and not to mix this product with alcohol or other products containing aspirin.
Generic Names: Percodan comes in several generic formulations including Endodan (made by Endo as well), and version made by Actavis and Mylan.
Note: At the time of this writing, Percodan (brand name) is temporarily unavailable from the manufacturer. It hasn’t been discontinued, but I won’t be surprised to see it officially taken off the market due to lack of sales.
OTHER OXYCODONE COMBINATIONS:
Roxicet Solution – The only available LIQUID combination product containing oxycodone and acetaminophen is Roxicet solution. It comes in one strength: 5mg oxycodone/325mg acetaminophen per 5ml. For patients who cannot swallow tablets or for whom a liquid version is more appropriate, this is your only choice.
Primlev tablets– A unique combination of oxycodone and acetaminophen by Akrimax pharmaceuticals. Each tablet contains just 300mg of acetaminophen, thus it has a slightly lower risk (in theory) of acetaminophen toxicity. Primlev comes in 3 strengths: 5mg/300mg; 7.5mg/300mg; 10mg/300mg.
One might wonder how a brand name, relatively expensive, combination of oxycodone and acetaminophen could ever get any market share in a category dominated by generics. The answer is simple: copay cards. Patients with one of these manufacturer provided cards get the medication for free, because the makers of Primlev pick up the copay.
Xartemis XR tablets – A long-acting (typically taken as 2 tablets twice daily) combination of oxycodone (7.5mg) and acetaminophen (325mg) marketed by Mallinckrodt pharmaceuticals. Xartemis XR has been specially formulated to reduce the possibility of abuse by including ingredients that make it more difficult to extract the oxycodone component and inject or snort it.
Combunox tablets – A formerly available combination of oxycodone and ibuprofen. No longer on the market. Don’t bother.
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