Hycofenix (ANTITUSSIVE EXPECTORANT_OPIOID)

Dosage And Sterngths

Oral solution: Each 5 mL contains hydrocodone bitartrate, USP, 2.5 mg; pseudoephedrine hydrochloride, USP, 30 mg; and guaifenesin, USP, 200 mg.

Storage And Handling

HYCOFENIX (hydrocodone bitartrate, pseudoephedrine hydrochloride, and guaifenesin) oral solution is supplied as a violet-colored, black raspberry flavored liquid containing 2.5 mg hydrocodone bitartrate, 30 mg pseudoephedrine hydrochloride, and 200 mg guaifenesin in each 5 mL. It is available in:

White HDPE bottles of 16 fl. oz. (473 mL): NDC 24470-915-16
White HDPE bottles of 4 fl. oz. (118 mL): NDC 24470-915-04

Store solution at 20° to 25°C (68° to 77°F). Dispense in a tight, light-resistant container, as defined in the USP, with a child-resistant closure.

Manufactured for: MISSION PHARMACAL COMPANY San Antonio, TX 78230 1355. Revised: Jan 2017

HYCOFENIX is indicated for symptomatic relief of cough, nasal congestion, and to loosen mucus associated with the common cold.

Important Limitations Of Use

Not indicated for pediatric patients under 18 years of age.

Recommended Dosage

Adults And adolescents 18 Years Of Age And Older

10 mL every 4 to 6 hours, not to exceed 4 doses (40 mL) in 24 hours.

Administer HYCOFENIX by the oral route only. Measure HYCOFENIX with an accurate milliliter measuring device. Do not use a household teaspoon to measure the dose.

HYCOFENIX is contraindicated in:

• Patients with known hypersensitivity to hydrocodone bitartrate, pseudoephedrine hydrochloride, guaifenesin, or any of the inactive ingredients of HYCOFENIX.
• Patients receiving MAOI therapy or within 14 days of stopping such therapy.
• Patients with narrow angle glaucoma, urinary retention, severe hypertension, or severe coronary artery disease.

WARNINGS

Included as part of the "PRECAUTIONS" Section

PRECAUTIONS

Risks From Concomitant Use With Benzodiazepines Or Other CNS Depressants

Concomitant use of opioids, including HYCOFENIX, with benzodiazepines, or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Because of these risks, avoid use of opioid cough medications in patients taking benzodiazepines, other CNS depressants, or alcohol.

Observational studies have demonstrated that concomitant use of opioid analgesics and benzodiazepines increases the risk of drug-related mortality compared to use of opioids alone. Because of similar pharmacologic properties, it is reasonable to expect similar risk with concomitant use of opioid cough medications and benzodiazepines, other CNS depressants, or alcohol.

Advise both patients and caregivers about the risks of respiratory depression and sedation if HYCOFENIX is used with benzodiazepines, alcohol, or other CNS depressants.

Respiratory Depression

Hydrocodone bitartrate, one of the active ingredients in HYCOFENIX, produces dose-related respiratory depression by directly acting on brain stem respiratory centers. Overdose of hydrocodone bitartrate has been associated with fatal respiratory depression, and the use of hydrocodone bitartrate in children less than 6 years of age has been associated with fatal respiratory depression. Exercise caution when administering HYCOFENIX because of the potential for respiratory depression. If respiratory depression occurs, it may be antagonized by the use of naloxone hydrochloride and other supportive measures when indicated.

Drug Dependence

Hydrocodone can produce drug dependence of the morphine type and therefore, has the potential for being abused. Psychic dependence, physical dependence, and tolerance may develop upon repeated administration of HYCOFENIX. Prescribe and administer HYCOFENIX with the same degree of caution appropriate to the use of other opioid drugs.

Head Injury And Increased Intracranial Pressure

The respiratory depression effects of opioids and their capacity to elevate cerebrospinal fluid pressure may be markedly exaggerated in the presence of head injury, other intracranial lesions, or a preexisting increase in intracranial pressure. Furthermore, opioids produce adverse reactions which may obscure the clinical course of patients with head injuries. The use of HYCOFENIX should be avoided in these patients.

Activities Requiring Mental Alertness

Hydrocodone bitartrate, one of the active ingredients in HYCOFENIX, may produce marked drowsiness and impair the mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery. Advise patients to avoid engaging in hazardous tasks requiring mental alertness and motor coordination after ingestion of HYCOFENIX. Concurrent use of HYCOFENIX with alcohol or other central nervous system depressants should be avoided because additional impairment of central nervous system performance may occur.

Acute Abdominal Conditions

HYCOFENIX should be used with caution in patients with acute abdominal conditions since the administration of hydrocodone may obscure the diagnosis or clinical course of patients with acute abdominal conditions. The concurrent use of other anticholinergics with hydrocodone may produce paralytic ileus.

Co-Administration With Anticholinergics

The concurrent use of anticholinergics with hydrocodone may produce paralytic ileus. Exercise caution when using HYCOFENIX in patients taking anticholinergic medications.

Co-Administration With Monoamine Oxidase Inhibitors (MAOIs) Or Tricyclic Antidepressants

HYCOFENIX should not be used in patients receiving MAOI therapy or within 14 days of stopping such therapy. The use of MAOIs or tricyclic antidepressants with hydrocodone bitartrate may increase the effect of either the antidepressant or hydrocodone.

Cardiovascular And Central Nervous System Effects

The pseudoephedrine hydrochloride contained in HYCOFENIX can produce cardiovascular and central nervous system effects in some patients such as insomnia, dizziness, weakness, tremor, or arrhythmias. In addition, central nervous system stimulation with convulsions or cardiovascular collapse with accompanying hypotension has been reported. Therefore, HYCOFENIX should be used with caution in patients with cardiovascular disorders, and should not be used in patients with severe hypertension or coronary artery disease.

Persistent Cough

HYCOFENIX should not be used in patients with a persistent or chronic cough such as occurs with smoking, asthma, chronic bronchitis, or emphysema, or where cough is accompanied by excessive phlegm (mucus).

Dosing

Patients should be advised to measure HYCOFENIX with an accurate milliliter measuring device. Patients should be informed that a household teaspoon is not an accurate measuring device and could lead to overdosage, which can result in serious adverse reactions. Patients should be advised to ask their pharmacist to recommend an appropriate measuring device and for instructions for measuring the correct dose.

Coexisting Conditions

HYCOFENIX should be used with caution in patients with diabetes, thyroid disease, Addison's disease, prostatic hypertrophy or urethral stricture, and asthma.

Renal Impairment

HYCOFENIX should be used with caution in patients with severe renal impairment.

Renal Impairment

HYCOFENIX should be used with caution in patients with severe hepatic impairment.

Patient Conseling Information

Overdosage

Advise patients not to increase the dose or dosing frequency of HYCOFENIX because serious adverse events such as respiratory depression may occur with overdosage.

Dosing

Advise patients to measure HYCOFENIX with an accurate milliliter measuring device. Patients should be informed that a household teaspoon is not an accurate measuring device and could lead to overdosage, especially when half a teaspoon is measured. Patients should be advised to ask their pharmacist to recommend an appropriate measuring device and for instructions for measuring the correct dose.

Interactions With Benzodiazepines And Other Central Nervous System Depressants

Inform patients and caregivers that potentially fatal additive effects may occur if HYCOFENIX is used with benzodiazepines or other CNS depressants, including alcohol. Because of this risk, patients should avoid concomitant use of HYCOFENIX with benzodiazepines or other CNS depressants, including alcohol.

Activities Requiring Mental Alertness

Advise patients to avoid engaging in hazardous tasks that require mental alertness and motor coordination such as operating machinery or driving a motor vehicle as HYCOFENIX may produce marked drowsiness.

Drug Dependence

Caution patients that HYCOFENIX contains hydrocodone bitartrate and can produce drug dependence.

MAOIs

Patients should be informed that due to its pseudoephedrine component, they should not use HYCOFENIX with an MAOI or within 14 days of stopping use of an MAOI .

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

Carcinogenicity, mutagenicity, and reproductive studies have not been conducted with HYCOFENIX; however, published information is available for the individual active ingredients or related active ingredients.

Hydrocodone

Carcinogenicity studies were conducted with codeine, an opiate related to hydrocodone. In 2 year studies in F344/N rats and B6C3F1 mice, codeine showed no evidence of tumorigenicity at dietary doses up to 70 and 400 mg/kg/day, respectively (approximately 30 and 80 times, respectively, the MRHDD of hydrocodone on a mg/m² basis).

Pseudoephedrine

Two-year feeding studies in rats and mice demonstrated no evidence of carcinogenic potential with ephedrine sulfate, a structurally related drug with pharmacological properties similar to pseudoephedrine, at dietary doses up to 10 and 27 mg/kg, respectively (approximately 0.3 and 0.5 times, respectively, the MRHDD of pseudoephedrine hydrochloride on a mg/m² basis).

Guaifenesin

Carcinogenicity, genotoxicity, or reproductive toxicology studies have not been conducted with guaifenesin.

Use In Specific Populations

Pregnancy

Teratogenic Effects

Pregnancy Category C

There are no adequate and well controlled studies of HYCOFENIX in pregnant women. Reproductive toxicity studies have not been conducted with HYCOFENIX; however, studies are available with an individual active ingredient or related active ingredient. Hydrocodone was teratogenic in hamsters. Codeine, an opiate related to hydrocodone, increased resorptions and decreased fetal weight in rats. Because animal reproduction studies are not always predictive of human response, HYCOFENIX should be used during pregnancy only if the benefit justifies the potential risk to the fetus.

Hydrocodone

Hydrocodone has been shown to be teratogenic in hamsters when given in a dose approximately 35 times the maximum recommended human daily dose (MRHDD) (on a mg/m² basis at a single subcutaneous dose of 102 mg/kg on gestation day 8). Reproductive toxicology studies were also conducted with codeine, an opiate related to hydrocodone. In a study in which pregnant rats were dosed throughout organogenesis, a dose of codeine approximately 50 times the MRHDD of hydrocodone (on a mg/m² basis at an oral dose of 120 mg/kg/day of codeine) increased resorptions and decreased fetal weight; however, these effects occurred in the presence of maternal toxicity. In studies in which rabbits and mice were dosed throughout organogenesis, doses of codeine up to approximately 25 and 120 times, respectively, the MRHDD of hydrocodone (on a mg/m² basis at oral doses of 30 and 600 mg/kg/day, respectively), produced no adverse developmental effects.

Non-Teratogenic Effects

Babies born to mothers who have been taking opioids regularly prior to delivery will be physically dependent. The withdrawal signs include irritability and excessive crying, tremors, hyperactive reflexes, increased respiratory rate, increased stools, sneezing, yawning, vomiting, and fever. The intensity of the syndrome does not always correlate with the duration of maternal opioid use or dose.

Labor And Delivery

As with all opioids, administration of HYCOFENIX to the mother shortly before delivery may result in some degree of respiratory depression in the newborn, especially if higher doses are used.

Nursing Mothers

Caution should be exercised when HYCOFENIX is administered to nursing mothers. Hydrocodone and pseudoephedrine are known to be excreted in human milk. No studies have been performed to determine if guaifenesin is excreted into breastmilk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from HYCOFENIX, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Pediatric Use

Safety and effectiveness of HYCOFENIX in pediatric patients under 18 years of age has not been established. The use of hydrocodone in children less than 6 years of age is associated with fatal respiratory depression.

Geriatric Use

Clinical studies have not been conducted with HYCOFENIX in geriatric populations. Other reported clinical experience with the individual active ingredients of HYCOFENIX has not identified differences in responses between the elderly and patients younger than 65 years of age. In general, dose selection for an elderly patient should be made with caution, 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. The pseudoephedrine contained in HYCOFENIX is known to be substantially excreted by the kidney and the risk of toxic 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.

Renal Impairment

HYCOFENIX should be given with caution in patients with severe impairment of renal function. Pseudoephedrine is primarily excreted unchanged in the urine as unchanged drug with the remainder apparently being metabolized in the liver. Therefore, pseudoephedrine may accumulate in patients with renal impairment.

Hepatic Impairment

HYCOFENIX should be given with caution in patients with severe impairment of hepatic function.

When guaifenesin, pseudoephedrine, and hydrocodone were administered in combination, the pharmacokinetics for each component was similar to those observed when each component was administered separately.

Teratogenic Effects

Pregnancy Category C

There are no adequate and well controlled studies of HYCOFENIX in pregnant women. Reproductive toxicity studies have not been conducted with HYCOFENIX; however, studies are available with an individual active ingredient or related active ingredient. Hydrocodone was teratogenic in hamsters. Codeine, an opiate related to hydrocodone, increased resorptions and decreased fetal weight in rats. Because animal reproduction studies are not always predictive of human response, HYCOFENIX should be used during pregnancy only if the benefit justifies the potential risk to the fetus.

Hydrocodone

Hydrocodone has been shown to be teratogenic in hamsters when given in a dose approximately 35 times the maximum recommended human daily dose (MRHDD) (on a mg/m² basis at a single subcutaneous dose of 102 mg/kg on gestation day 8). Reproductive toxicology studies were also conducted with codeine, an opiate related to hydrocodone. In a study in which pregnant rats were dosed throughout organogenesis, a dose of codeine approximately 50 times the MRHDD of hydrocodone (on a mg/m² basis at an oral dose of 120 mg/kg/day of codeine) increased resorptions and decreased fetal weight; however, these effects occurred in the presence of maternal toxicity. In studies in which rabbits and mice were dosed throughout organogenesis, doses of codeine up to approximately 25 and 120 times, respectively, the MRHDD of hydrocodone (on a mg/m² basis at oral doses of 30 and 600 mg/kg/day, respectively), produced no adverse developmental effects.

Non-Teratogenic Effects

Babies born to mothers who have been taking opioids regularly prior to delivery will be physically dependent. The withdrawal signs include irritability and excessive crying, tremors, hyperactive reflexes, increased respiratory rate, increased stools, sneezing, yawning, vomiting, and fever. The intensity of the syndrome does not always correlate with the duration of maternal opioid use or dose.

Use of hydrocodone bitartrate is associated with the following:

• Respiratory depression
• Drug dependence
• Increased intracranial pressure
• Decreased mental alertness with impaired mental and/or physical abilities
• Paralytic ileus

Use of pseudoephedrine, a sympathomimetic amine, may result in the following:

• Central nervous system effects such as insomnia, dizziness, weakness, tremor, or convulsions
• Cardiovascular system effects such as arrhythmias, or increased blood pressure, cardiovascular collapse with accompanying hypotension

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

The most common adverse reactions experienced by subjects taking a single dose of HYCOFENIX in the clinical setting include the following: Central Nervous System: headache, dizziness, sedation (somnolence); Gastrointestinal System: nausea, diarrhea; Cardiovascular System: decreased blood pressure; Vascular System: hot flush.

No human overdosage data are available for HYCOFENIX.

Hydrocodone

Overdosage with hydrocodone is characterized by respiratory depression (a decrease in respiratory rate and/or tidal volume, Cheyne-Stokes respiration, cyanosis), extreme somnolence progressing to stupor or coma, skeletal muscle flaccidity, dizziness, ringing in the ears, confusion, blurred vision, eye problems, cold and clammy skin, and sometimes bradycardia and hypotension. In severe overdose, apnea, circulatory collapse, cardiac arrest and death may occur.

Pseudoephedrine

Overdosage with sympathomimetics such as pseudoephedrine may give rise to giddiness, headache, nausea, vomiting, sweating, thirst, tachycardia, precordial pain, palpitations, difficulty in micturition, muscle weakness and tenseness, anxiety, restlessness, and insomnia. Many patients can present a toxic psychosis with delusion and hallucinations. Some may develop cardiac arrhythmias, circulatory collapse, convulsion, coma, and respiratory failure.

Guaifenesin

Overdosage with guaifenesin can cause depression of the central nervous system. While present in polypharmacy overdoses, one case of overdose with only significant levels of guaifenesin has been reported. Symptoms included slurred speech, shallow respirations, reduced heart rate with rhythm sinus bradycardia, followed by asystole.

Treatment of overdosage consists of discontinuation of HYCOFENIX together with institution of appropriate therapy. Primary attention should be given to the reestablishment of adequate respiratory exchange through provision of a patent airway and the institution of assisted or controlled ventilation. The opioid antagonist naloxone hydrochloride is a specific antidote for respiratory depression which may result from overdosage or unusual sensitivity to opioids including hydrocodone. Therefore, an appropriate dose of naloxone hydrochloride should be administered, preferably by the intravenous route, simultaneously with efforts at respiratory resuscitation. For further information, see full prescribing information for naloxone hydrochloride. An antagonist should not be administered in the absence of clinically significant respiratory depression. Oxygen, intravenous fluids, vasopressors, and other supportive measures should be employed as indicated. Gastric emptying may be useful in removing unabsorbed drug.

Systemic exposure (in terms of peak plasma concentrations and area under plasma concentration versus time curve) of hydrocodone bitartrate, pseudoephedrine hydrochloride, and guaifenesin after a single 10 mL oral dose administration of 5 mg hydrocodone bitartrate, 60 mg pseudoephedrine hydrochloride, and 400 mg guaifenesin are equivalent to the respective reference solutions of 5 mL hydrocodone bitartrate (5 mg/5 mL), 5 mL pseudoephedrine hydrochloride (30 mg/5 mL), and 10 mL guaifenesin (200 mg/5 mL).

Hydrocodone

Following a single 10 mL oral dose administration of 5 mg hydrocodone bitartrate, 60 mg pseudoephedrine hydrochloride, and 400 mg guaifenesin administered to 37 healthy adults, the geometric mean Cmax and AUC0-inf for hydrocodone were 9.0 ng/mL and 61.2 ng•hr/mL, respectively. The median time to maximum concentration for hydrocodone was about 1.67 hours. Food has no significant effect on the extent of absorption of hydrocodone. The mean plasma half-life of hydrocodone is approximately 4 hours.

Pseudoephedrine

Following a single 10 mL oral dose administration of 5 mg hydrocodone bitartrate, 60 mg pseudoephedrine hydrochloride, and 400 mg guaifenesin administered to 37 healthy adults, the geometric mean Cmax and AUC0-inf for pseudoephedrine were 0.19 mcg/mL and 1.9 mcg•hr/mL, respectively. The median time to maximum concentration for pseudoephedrine was about 2.5 hours. Food has no significant effect on the extent of absorption of pseudoephedrine. The mean plasma half-life of pseudoephedrine is approximately 6 hours.

Guaifenesin

Following a single 10 mL oral dose administration of 5 mg hydrocodone bitartrate, 60 mg pseudoephedrine hydrochloride, and 400 mg guaifenesin administered to 36 healthy adults, the geometric mean Cmax and AUC0-inf for guaifenesin were 2.0 mcg/mL and 2.6 mcg•hr/mL, respectively. The median time to maximum concentration was about 25 minutes. The effect of food on guaifenesin systemic exposure is not considered to be clinically meaningful. The mean plasma half-life of guaifenesin is approximately 1 hour.