What is the equivalent to Tylenol (acetaminophen) with codeine?

Equivalent Alternatives to Tylenol with Codeine

Hydrocodone/acetaminophen (e.g., Vicodin, Lortab) is the most direct equivalent to Tylenol with codeine, offering similar or superior pain relief with a comparable side effect profile. 1

Equivalent Medication Options

First-Line Alternatives

• Hydrocodone/acetaminophen (5-7.5mg/325mg): Schedule II opioid combination that provides equivalent or better analgesia than codeine/acetaminophen 1, 2
• Oxycodone/acetaminophen (5mg/325mg): Schedule II opioid combination with similar efficacy to hydrocodone combinations 1

Second-Line Alternatives

• Hydrocodone/ibuprofen (7.5mg/200mg): Studies show this may provide better pain relief than codeine/acetaminophen combinations 2
• Tramadol (50-100mg): Lower risk of respiratory depression but still effective for moderate pain 3

Efficacy Comparison

Randomized controlled trials have directly compared these alternatives:

• A study comparing hydrocodone/acetaminophen (5mg/500mg) with codeine/acetaminophen (30mg/300mg) found both medications decreased pain scores by approximately 50%, with no statistically significant differences in efficacy 4

• However, another study found that two tablets of hydrocodone/ibuprofen (7.5mg/200mg) provided significantly better pain relief than two tablets of codeine/acetaminophen (30mg/300mg) for chronic pain 2

• Even a single tablet of hydrocodone/ibuprofen (7.5mg/200mg) was found to be as effective as two tablets of codeine/acetaminophen (30mg/300mg) 2

Pharmacological Considerations

Potency

• Codeine is a prodrug that must be metabolized to morphine by CYP2D6 enzyme
• Approximately 7-10% of Caucasians and up to 30% of Asians have genetic polymorphisms affecting CYP2D6, making codeine less effective for these patients 1, 3
• Hydrocodone and oxycodone have more predictable metabolism and efficacy

Side Effect Profiles

• All opioid combinations carry risks of:

  • Respiratory depression
  • Sedation
  • Constipation
  • Nausea/vomiting
  • Risk of dependence and addiction

• The side effect profiles between codeine/acetaminophen and hydrocodone/acetaminophen are generally similar 4

Prescribing Considerations

Dosing Guidelines

• Codeine/acetaminophen: Typically 30mg/300mg per tablet, 1-2 tablets every 4-6 hours
• Hydrocodone/acetaminophen: 5-7.5mg/325mg per tablet, 1 tablet every 4-6 hours
• Oxycodone/acetaminophen: 5mg/325mg per tablet, 1 tablet every 4-6 hours

Important Cautions

• Limit acetaminophen to less than 4000mg daily to prevent hepatotoxicity 1
• The FDA has required manufacturers to limit acetaminophen to 325mg per tablet in combination products 1
• Avoid in patients with significant respiratory disease or sleep apnea 5
• Consider drug interactions, particularly with benzodiazepines or other CNS depressants 5

Clinical Decision Making

When selecting an alternative to Tylenol with codeine:

1. For opioid-naïve patients with moderate pain: Start with hydrocodone/acetaminophen 5mg/325mg, 1 tablet every 4-6 hours as needed

2. For patients with prior opioid exposure: Consider hydrocodone/acetaminophen 7.5mg/325mg or oxycodone/acetaminophen 5mg/325mg

3. For patients with CYP2D6 polymorphisms: Avoid codeine-containing products and use hydrocodone or oxycodone combinations instead 1, 3

4. For patients with renal impairment: Hydromorphone or fentanyl may be safer options than morphine or codeine 3

Remember that equianalgesic doses of opioids have similar efficacy regardless of their DEA classification 1, so selection should be based on patient factors and side effect profiles rather than presumed differences in efficacy.