ndividual is unknown, it can occur in patients appropriately prescribed oxycodone hydrochloride and acetaminophen oral solution. 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 oxycodone hydrochloride and acetaminophen oral solution, and monitor all patients receiving oxycodone hydrochloride and acetaminophen oral solution 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 oxycodone hydrochloride and acetaminophen oral solution, but use in such patients necessitates intensive counseling about the risks and proper use of oxycodone hydrochloride and acetaminophen oral solution along with intensive monitoring for signs of addiction, abuse, and misuse. consider prescribing naloxone for the emergency treatment of opioid overdose [see warnings, life-threatening respiratory depression ; dosage and administration, patient access to naloxone for the emergency treatment of opioid overdose ]. opioids are sought by drug abusers and people with addiction disorders and are subject to criminal diversion. consider these risks when prescribing or dispensing oxycodone hydrochloride and acetaminophen oral solution. 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 ). 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. opioid analgesic risk evaluation and mitigation strategy (rems) to ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and misuse, the food and drug administration (fda) has required a risk evaluation and mitigation strategy (rems) for these products. under the requirements of rems, drug companies with approved opioid analgesic products must make rems-compliant education programs available to healthcare providers. healthcare providers are strongly encouraged to do all of the following: complete a rems-compliant education program offered by an accredited provider of continuing education (ce) or another education program that includes all the elements of the fda education blueprint for health care providers involved in the management or support of patients with pain. discuss the safe use, serious risks, and proper storage and disposal of opioid analgesics with patients and/or their caregivers every time these medicines are prescribed. the patient counseling guide (pcg) can be obtained at this link: www.fda.gov/opioidanalgesicremspcg . emphasize to patients and their caregivers the importance of reading the medication guide that they will receive from their pharmacist every time an opioid analgesic is dispensed to them. consider using other tools to improve patient, household, and community safety, such as patient-prescriber agreements that reinforce patient-prescriber responsibilities. to obtain further information on the opioid analgesic rems and for a list of accredited rems cme/ce, call 800-503-0784, or log on to www.opioidanalgesicrems.com . the fda blueprint can be found at www.fda.gov/opioidanalgesicremsblueprint . 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 (co 2 ) 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 oxycodone hydrochloride and acetaminophen oral solution, 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 to 72 hours of initiating therapy with and following dosage increases of oxycodone hydrochloride and acetaminophen oral solution. to reduce the risk of respiratory depression, proper dosing and titration of oxycodone hydrochloride and acetaminophen oral solution are essential (see dosage and administration ). overestimating the oxycodone hydrochloride and acetaminophen oral solution dosage when converting patients from another opioid product can result in a fatal overdose with the first dose. accidental ingestion of even one dose of oxycodone hydrochloride and acetaminophen oral solution, especially by children, can result in respiratory depression and death due to an overdose of oxycodone hydrochloride and acetaminophen oral solution. educate patients and caregivers on how to recognize respiratory depression and emphasize the importance of calling 911 or getting emergency medical help right away in the event of a known or suspected overdose [see precautions, information for patients ]. opioids can cause sleep-related breathing disorders including central sleep apnea (csa) and sleep-related hypoxemia. opioid use increases the risk of csa in a dose-dependent fashion. in patients who present with csa, consider decreasing the opioid dosage using best practices for opioid taper (see dosage and administration ). patient access to naloxone for the emergency treatment of opioid overdose discuss the availability of naloxone for the emergency treatment of opioid overdose with the patient and caregiver and assess the potential need for access to naloxone, both when initiating and renewing treatment with oxycodone hydrochloride and acetaminophen oral solution. inform patients and caregivers about the various ways to obtain naloxone as permitted by individual state naloxone dispensing and prescribing requirements or guidelines (e.g., by prescription, directly from a pharmacist, or as part of a community-based program). educate patients and caregivers on how to recognize respiratory depression and emphasize the importance of calling 911 or getting emergency medical help, even if naloxone is administered [see precautions, information for patients ]. consider prescribing naloxone, based on the patient’s risk factors for overdose, such as concomitant use of other cns depressants, a history of opioid use disorder, or prior opioid overdose. the presence of risk factors for overdose should not prevent the proper management of pain in any given patient. also consider prescribing naloxone if the patient has household members (including children) or other close contacts at risk for accidental ingestion or overdose. if naloxone is prescribed, educate patients and caregivers on how to treat with naloxone [see warnings, addiction, abuse, and misuse , risks from concomitant use with benzodiazepines or other cns depressants ; precautions, information for patients ]. neonatal opioid withdrawal syndrome prolonged use of oxycodone hydrochloride and acetaminophen oral solution 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 , pregnancy ). risks of concomitant use or discontinuation of cytochrome p450 3a4 inhibitors and inducers concomitant use of oxycodone hydrochloride and acetaminophen oral solution with a cyp3a4 inhibitor, such as macrolide antibiotics (e.g., erythromycin), azole-antifungal agents (e.g., ketoconazole), and protease inhibitors (e.g., ritonavir), may increase plasma concentrations of oxycodone hydrochloride and prolong opioid adverse reactions, which may cause potentially fatal respiratory depression (see warnings ), particularly when an inhibitor is added after a stable dose of oxycodone hydrochloride and acetaminophen oral solution is achieved. similarly, discontinuation of a cyp3a4 inducer, such as rifampin, carbamazepine, and phenytoin, in oxycodone hydrochloride and acetaminophen oral solution-treated patients may increase oxycodone plasma concentrations and prolong opioid adverse reactions. when using oxycodone hydrochloride and acetaminophen oral solution with cyp3a4 inhibitors or discontinuing cyp3a4 inducers in oxycodone hydrochloride and acetaminophen oral solution-treated patients, monitor patients closely at frequent intervals and consider dosage reduction of oxycodone hydrochloride and acetaminophen oral solution until stable drug effects are achieved (see precautions, drug interactions ). concomitant use of oxycodone hydrochloride and acetaminophen oral solution with cyp3a4 inducers or discontinue of a cyp3a4 inhibitor could decrease oxycodone hydrochloride plasma concentrations, decrease opioid efficacy or, possibly, lead to a withdrawal syndrome in a patient who had developed physical dependence to oxycodone hydrochloride. when using oxycodone hydrochloride and acetaminophen oral solution with cyp3a4 inducers or discontinuing cyp3a4 inhibitors, monitor patients closely at frequent intervals and consider increasing the opioid dosage if needed to maintain adequate analgesia or if symptoms of opioid withdrawal occur (see precautions, drug interactions ). risks from concomitant use with benzodiazepines or other cns depressants profound sedation, respiratory depression, coma, and death may result from the concomitant use of oxycodone hydrochloride and acetaminophen oral solution with benzodiazepines 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. if concomitant use is warranted, consider prescribing naloxone for the emergency treatment of opioid overdose [see warnings, life-threatening respiratory depression ; dosage and administration, patient access to naloxone for the emergency treatment of opioid overdose ]. advise both patients and caregivers about the risks of respiratory depression and sedation when oxycodone hydrochloride and acetaminophen oral solution is 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. life-threatening respiratory depression in patients with chronic pulmonary disease or in elderly, cachectic, or debilitated patients the use of oxycodone hydrochloride and acetaminophen oral solution 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- oxycodone hydrochloride and acetaminophen oral solution-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 oxycodone hydrochloride and acetaminophen oral solution (see warnings, life-threatening respiratory depression ). elderly, cachetic, or debilitated patients- life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients because they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients (see warnings, life-threatening respiratory depression ). monitor such patients closely, particularly when initiating and titrating oxycodone hydrochloride and acetaminophen oral solution and when oxycodone hydrochloride and acetaminophen oral solution is given concomitantly with other drugs that depress respiration (see warnings, life-threatening respiratory depression ). alternatively, consider the use of non-opioid analgesics in these patients. adrenal insufficiency cases of adrenal insufficiency have been reported with opioid use, more often following greater than one 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 oxycodone hydrochloride and acetaminophen oral solution 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 oxycodone hydrochloride and acetaminophen oral solution. in patients with circulatory shock oxycodone hydrochloride and acetaminophen oral solution may cause vasodilatation that can further reduce cardiac output and blood pressure. avoid the use of oxycodone hydrochloride and acetaminophen oral solution with circulatory shock. 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 4000 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 4000 milligrams of acetaminophen per day, even if they feel well. 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. hypersensitivity/anaphylaxis there have been post-marketing reports of hypersensitivity and anaphylaxis associated with 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 oxycodone hydrochloride and acetaminophen oral solution immediately and seek medical care if they experience these symptoms. do not prescribe oxycodone hydrochloride and acetaminophen oral solution for patients with acetaminophen allergy (see precautions, information for patients ). 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 co 2 retention (e.g., those with evidence of increased intracranial pressure or brain tumors), oxycodone hydrochloride and acetaminophen oral solution may reduce respiratory drive, and the resultant co 2 retention can further increase intracranial pressure. monitor such patients for signs of sedation and respiratory depression, particularly when initiating therapy with oxycodone hydrochloride and acetaminophen oral solution. opioids may also obscure the clinical course in a patient with a head injury. avoid the use of oxycodone hydrochloride and acetaminophen oral solution in patients with impaired consciousness or coma. risks of use in patients with gastrointestinal conditions oxycodone hydrochloride and acetaminophen oral solution is contraindicated in patients with known or suspected gastrointestinal obstruction, including paralytic ileus. the administration of oxycodone hydrochloride and acetaminophen oral solution, or other opioids may obscure the diagnosis or clinical course in patients with acute abdominal conditions. the oxycodone in oxycodone hydrochloride and acetaminophen oral solution 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. increased risk of seizures in patients with seizure disorders the oxycodone in oxycodone hydrochloride and acetaminophen oral solution 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 oxycodone hydrochloride and acetaminophen oral solution therapy. withdrawal do not abruptly discontinue oxycodone hydrochloride and acetaminophen oral solution in a patient physically dependent on opioids. when discontinuing oxycodone hydrochloride and acetaminophen oral solution in a physically dependent patient, gradually taper the dosage. rapid tapering of oxycodone hydrochloride and acetaminophen oral solution in a patient physically dependent on opioids may lead to a withdrawal syndrome and return of pain (see dosage and administration , drug abuse and dependence ). additionally, 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 oxycodone hydrochloride and acetaminophen oral solution. in these patients, mixed agonist/antagonist and partial agonist analgesics may reduce the analgesic effect and/or precipitate withdrawal symptoms. (see precautions, drug interactions ).

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 to 72 hours of initiating therapy and following dosage increases with oxycodone hydrochloride and acetaminophen oral solution and adjust the dosage accordingly (see warnings ). patient access to naloxone for the emergency treatment of opioid overdose discuss the availability of naloxone for the emergency treatment of opioid overdose with the patient and caregiver and assess the potential need for access to naloxone, both when initiating and renewing treatment with oxycodone hydrochloride and acetaminophen oral solution [see warnings, life-threatening respiratory depression ; precautions, information for patients ]. inform patients and caregivers about the various ways to obtain naloxone as permitted by individual state naloxone dispensing and prescribing regulations (e.g., by prescription, directly from a pharmacist, or as part of a community-based program). consider prescribing naloxone, based on the patient’s risk factors for overdose, such as concomitant use of cns depressants, a history of opioid use disorder, or prior opioid overdose. the presence of risk factors for overdose should not prevent the proper management of pain in any given patient [see warnings, addiction, abuse, and misuse, life-threatening respiratory depression, risks from concomitant use with benzodiazepines or other cns depressants ]. consider prescribing naloxone when the patient has household members (including children) or other close contacts at risk for accidental ingestion or overdose initial dosage initiating treatment with oxycodone hydrochloride and acetaminophen oral solution the usual adult dosage is 5 ml (one teaspoonful) every 6 hours as needed for pain. the total daily dose of acetaminophen should not exceed 4 grams. (maximum daily dose is 12 teaspoonfuls or 60 ml.) it is of utmost importance that the dose of oxycodone hydrochloride and acetaminophen oral solution be administered accurately. a household teaspoon or tablespoon is not an adequate measuring device, especially when one-half or three-fourths of a teaspoonful is to be measured. given the variability of the household spoon measure and the possibility of mistakenly using a tablespoon instead of a teaspoon, which could lead to overdosage, it is strongly recommended that caregivers obtain and use a calibrated measuring device. health care providers should recommend a calibrated measuring device that can measure and deliver the prescribed dose accurately, and instruct caregivers to use extreme caution in measuring the dosage. conversion from oxycodone hydrochloride and acetaminophen to extended-release oxycodone the relative bioavailability of oxycodone hydrochloride and acetaminophen oral solution compared to extended-release oxycodone is unknown, so conversion to extended-release oxycodone must be accompanied by close observation for signs of excessive sedation and respiratory depression. titration and maintenance of therapy individually titrate oxycodone hydrochloride and acetaminophen oral solution to a dose that provides adequate analgesia and minimizes adverse reactions. continually reevaluate patients receiving oxycodone hydrochloride and acetaminophen oral solution 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 oxycodone hydrochloride and acetaminophen oral solution 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. safe reduction or discontinuation of oxycodone hydrochloride and acetaminophen oral solution do not abruptly discontinue oxycodone hydrochloride and acetaminophen oral solution in patients who may be physically dependent on opioids. rapid discontinuation of opioid analgesics in patients who are physically dependent on opioids has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide. rapid discontinuation has also been associated with attempts to find other sources of opioid analgesics, which may be confused with drug-seeking for abuse. patients may also attempt to treat their pain or withdrawal symptoms with illicit opioids, such as heroin, and other substances. when a decision has been made to decrease the dose or discontinue therapy in an opioid-dependent patient taking oxycodone hydrochloride and acetaminophen oral solution, there are a variety of factors that should be considered, including the dose of oxycodone hydrochloride and acetaminophen oral solution the patient has been taking, the duration of treatment, the type of pain being treated, and the physical and psychological attributes of the patient. it is important to ensure ongoing care of the patient and to agree on an appropriate tapering schedule and follow-up plan so that the patient and provider goals and expectations are clear and realistic. when opioid analgesics are being discontinued due to a suspected substance use disorder, evaluate and treat the patient, or refer for evaluation and treatment of the substance use disorder. treatment should include evidence-based approaches, such as medication assisted treatment of opioid use disorder. complex patients with co-morbid pain and substance use disorders may benefit from referral to a specialist. there are no standard opioid tapering schedules that are suitable for all patients. good clinical practice dictates a patient-specific plan to taper the dose of the opioid gradually. for patients on oxycodone hydrochloride and acetaminophen oral solution who are physically opioid-dependent, initiate the taper by a small enough increment (e.g., no greater than 10% to 25% of the total daily dose) to avoid withdrawal symptoms, and proceed with dose-lowering at an interval of every 2 to 4 weeks. patients who have been taking opioids for briefer periods of time may tolerate a more rapid taper. it may be necessary to provide the patient with lower dosage strengths to accomplish a successful taper. reassess the patient frequently to manage pain and withdrawal symptoms, should they emerge. common withdrawal symptoms include restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis. other signs and symptoms also may develop, including irritability, anxiety, bachache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate. if withdrawal symptoms arise, it may be necessary to pause the taper for a period of time or raise the dose of the opioid analgesic to the previous dose, and then proceed with a slower taper. in addition, monitor patients for any changes in mood, emergence of suicidal thoughts, or use of other substances. when managing patients taking opioids analgesics, particularly those who have been treated for a long duration and/or with high doses for chronic pain, ensure that a multimodal approach to pain management, including mental health support (if needed), is in place prior to initiating an opioid analgesic taper. a multimodal approach to pain management may optimize the treatment of chronic pain, as well as assist with the successful tapering of the opioid analgesic (see warnings, withdrawal , drug abuse and dependence ).

y reactions may include: skin eruptions, urticarial, erythematous skin reactions. hematologic reactions may include: thrombocytopenia, neutropenia, pancytopenia, hemolytic anemia. rare cases of agranulocytosis has likewise been associated with acetaminophen use. in high doses, the most serious adverse effect is a dose-dependent, potentially fatal hepatic necrosis. renal tubular necrosis and hypoglycemic coma also may occur. other adverse reactions obtained from postmarketing experiences with oxycodone and acetaminophen are listed by organ system and in decreasing order of severity and/or frequency as follows: body as a whole anaphylactoid reaction, allergic reaction, malaise, asthenia, fatigue, chest pain, fever, hypothermia, thirst, headache, increased sweating, accidental overdose, non-accidental overdose cardiovascular hypotension, hypertension, tachycardia, orthostatic hypotension, bradycardia, palpitations, dysrhythmias central and peripheral nervous system stupor, tremor, paraesthesia, hypoaesthesia, lethargy, seizures, anxiety, mental impairment, agitation, cerebral edema, confusion, dizziness fluid and electrolyte dehydration, hyperkalemia, metabolic acidosis, respiratory alkalosis gastrointestinal dyspepsia, taste disturbances, abdominal pain, abdominal distention, sweating increased, diarrhea, dry mouth, flatulence, gastrointestinal disorder, nausea, vomiting, pancreatitis, intestinal obstruction, ileus hepatic transient elevations of hepatic enzymes, increase in bilirubin, hepatitis, hepatic failure, jaundice, hepatotoxicity, hepatic disorder hearing and vestibular hearing loss, tinnitus hematologic thrombocytopenia hypersensitivity acute anaphylaxis, angioedema, asthma, bronchospasm, laryngeal edema, urticaria, anaphylactoid reaction metabolic and nutritional hypoglycemia, hyperglycemia, acidosis, alkalosis musculoskeletal myalgia, rhabdomyolysis ocular miosis, visual disturbances, red eye psychiatric drug dependence, drug abuse, insomnia, confusion, anxiety, agitation, depressed level of consciousness, nervousness, hallucination, somnolence, depression, suicide respiratory system bronchospasm, dyspnea, hyperpnea, pulmonary edema, tachypnea, aspiration, hypoventilation, laryngeal edema skin and appendages erythema, urticaria, rash, flushing urogenital interstitial nephritis, papillary necrosis, proteinuria, renal insufficiency and failure, urinary retention postmarketing experience serotonin syndrome: cases of serotonin syndrome, a potentially life-threatening condition, have been reported during concomitant use of opioids with serotonergic drugs. adrenal insufficiency: cases of adrenal insufficiency have been reported with opioid use, more often following greater than one month of use. anaphylaxis: anaphylaxis has been reported with ingredients contained in oxycodone hydrochloride and acetaminophen oral solution. androgen deficiency: cases of androgen deficiency have occurred with chronic use of opioids (see clinical pharmacology ). to report suspected adverse reactions, contact nostrum laboratories, inc at (1-877-770-1288) or fda at 1-800-fda-1088 or www.fda.gov/medwatch.

rect action on brain stem respiratory centers. the respiratory depression involves a reduction in the responsiveness of the brain stem respiratory centers to both increases in carbon dioxide tension and electrical stimulation. oxycodone causes miosis, even in total darkness. pinpoint pupils are a sign of opioid overdose but are not pathognomonic (e.g., pontine lesions of hemorrhagic or ischemic origins may produce similar findings). marked mydriasis rather than miosis may be seen due to hypoxia in overdose situations. therapeutic doses of acetaminophen have negligible effects on the cardiovascular or respiratory systems; however, toxic doses may cause circulatory failure and rapid, shallow breathing. effects on the gastrointestinal tract and other smooth muscle oxycodone causes a reduction in motility associated with an increase in smooth muscle tone in the antrum of the stomach and duodenum. digestion of food in the small intestine is delayed and propulsive contractions are decreased. propulsive peristaltic waves in the colon are decreased, while tone may be increased to the point of spasm, resulting in constipation. other opioid-induced effects may include a reduction in biliary and pancreatic secretions, spasm of sphincter of oddi, and transient elevations in serum amylase. effects on the cardiovascular system oxycodone produces peripheral vasodilation which may result in orthostatic hypotension or syncope. manifestations of histamine release and/or peripheral vasodilation may include pruritus, flushing, red eyes, sweating, and/or orthostatic hypotension. effects on the endocrine system opioids inhibit the secretion of adrenocorticotropic hormone (acth), cortisol, and luteinizing hormone (lh) in humans (see adverse reactions ). they also stimulate prolactin, growth hormone (gh) secretion, and pancreatic secretion of insulin and glucagon. chronic use of opioids may influence the hypothalamic-pituitary-gonadal axis, leading to androgen deficiency that may manifest as symptoms as low libido, impotence, erectile dysfunction, amenorrhea, or infertility. the causal role of opioids in the syndrome of hypogonadism is unknown because the various medical, physical, lifestyle, and psychological stressors that may influence gonadal hormone levels have not been adequately controlled for in studies conducted to date (see adverse reactions ). effects on the immune system opioids have been shown to have a variety of effects on components of the immune system. the clinical significance of these findings is unknown. overall, the effects of opioids appear to be modestly immunosuppressive. concentration-efficacy relationships the minimum effective analgesic concentration will vary widely among patients, especially among patients who have been previously treated with potent agonist opioids. the minimum effective analgesic concentration of oxycodone for any individual patient may increase over time due to an increase in pain, the development of a new pain syndrome, and/or the development of analgesic tolerance (see dosage and administration ). concentration-adverse reaction relationships there is a relationship between increasing oxycodone plasma concentration and increasing frequency of dose-related opioid adverse reactions such as nausea, vomiting, cns effects, and respiratory depression. in opioid-tolerant patients, the situation may be altered by the development of tolerance to opioid-related adverse reactions (see dosage and administration ). pharmacokinetics absorption and distribution the mean absolute oral bioavailability of oxycodone in cancer patients was reported to be about 87%. oxycodone has been shown to be 45% bound to human plasma proteins in vitro . the volume of distribution after intravenous administration is 211.9 ±186.6 l. absorption of acetaminophen is rapid and almost complete from the gi tract after oral administration. with overdosage, absorption is complete in 4 hours. acetaminophen is relatively uniformly distributed throughout most body fluids. binding of the drug to plasma proteins is variable; only 20% to 50% may be bound at the concentrations encountered during acute intoxication. metabolism and elimination oxycodone in humans, oxycodone is extensively metabolized to noroxycodone by means of cyp3a-mediated n-demethylation, oxymorphone by means of cyp2d6-mediated o-demethylation, and their glucuronides (see precautions, drug interactions ). acetaminophen acetaminophen is rapidly absorbed from the gastrointestinal tract and is distributed throughout most body tissues. a small fraction (10-25%) of acetaminophen is bound to plasma proteins. the plasma half-life is 1.25 to 3 hours, but may be increased by liver damage and following overdosage. elimination of acetaminophen is principally by liver metabolism (conjugation) and subsequent renal excretion of metabolites. acetaminophen is primarily metabolized in the liver by first-order kinetics and involves three principal separate pathways: conjugation with glucuronide; conjugation with sulfate; and oxidation via the cytochrome, p450-dependent, mixed-function oxidase enzyme pathway to form a reactive intermediate metabolite, which conjugates with glutathione and is then further metabolized to form cysteine and mercapturic acid conjugates. the principal cytochrome p450 isoenzyme involved appears to be cyp2e1, with cyp1a2 and cyp3a4 as additional pathways. approximately 85% of an oral dose appears in the urine within 24 hours of administration, most as the glucuronide conjugate, with small amounts of other conjugates and unchanged drug (see overdosage ) for toxicity information.