What is the recommended dose and frequency of Tylenol 3 (acetaminophen and codeine) per day?

Tylenol 3 Dosing and Frequency

Tylenol 3 (acetaminophen 300 mg/codeine 30 mg) should be dosed as 1-2 tablets every 4 hours as needed for pain, not exceeding 12 tablets (3600 mg acetaminophen) in 24 hours, though you should prescribe the minimum quantity needed—typically no more than a 3-7 day supply for acute pain. 1

Standard Dosing Regimen

• Take 1-2 tablets every 4 hours as needed for moderate pain, not around the clock 1
• Maximum of 6 doses in 24 hours per FDA labeling for codeine-containing products 2
• Do not exceed 12 tablets daily (equivalent to 3600 mg acetaminophen), though the absolute maximum acetaminophen limit is 4000 mg/24 hours from all sources 1, 3
• Single dose maximum is 1000 mg acetaminophen (approximately 3 tablets), which should not be exceeded 1

Critical Safety Limits for Acetaminophen

• The daily acetaminophen maximum is 4000 mg from all acetaminophen-containing products combined 1, 3
• Patients often don't realize Tylenol 3 contains acetaminophen—studies show 49% of patients don't know if "Tylenol" contains acetaminophen, and 66-90% don't know about combination products like Vicodin or Percocet 4
• Only 7% of patients know the correct maximum daily acetaminophen dose, creating significant overdose risk 4

When Tylenol 3 Is Appropriate

• Tylenol 3 is a WHO Level II analgesic for moderate pain (numerical pain score 4-6) and should only be used after non-opioid analgesics like acetaminophen alone or NSAIDs have proven inadequate 3, 1
• First-line therapy should be acetaminophen alone (up to 1000 mg per dose) or NSAIDs, which are actually superior to codeine combinations for most acute pain 1
• Tylenol 3 represents a weak opioid option that is generally less effective than NSAIDs for most acute pain conditions 1

Special Population Adjustments

Geriatric Patients

• Start with 1 tablet every 4-6 hours rather than 2 tablets in older adults 1
• Lower starting doses and slower titration are recommended due to increased risk of adverse effects 3

Liver Disease

• Limit acetaminophen to 2000-3000 mg daily in patients with hepatic impairment or chronic alcohol use 1
• Daily doses of 2-3 g are generally recommended for patients with liver cirrhosis, as they are at risk of prolonged half-life 3
• Codeine should be avoided in patients with liver cirrhosis since metabolites may accumulate, causing respiratory depression 3

Renal Impairment

• Codeine is metabolized via the P450 pathway and requires dose adjustment in renal impairment 3

Prescribing Limitations and Risk Mitigation

• Prescribe the minimum quantity needed, typically no more than a 3-7 day supply for acute pain 1
• Maximum initial prescription should be limited to 20 tablets or less for acute pain episodes 1
• Check the prescription drug monitoring program (PDMP) before prescribing to identify patients at risk for opioid misuse 1
• Co-prescribe naloxone if the patient or household members have overdose risk factors 1

Common Pitfalls to Avoid

• Failing to account for acetaminophen from other sources: Patients may be taking over-the-counter acetaminophen, cold medications, or other prescription combinations containing acetaminophen 4
• Prescribing around-the-clock dosing: Tylenol 3 should be taken only when pain is moderate to severe, not scheduled 1
• Overlooking that NSAIDs are often more effective: For acute soft tissue injuries and low back pain, NSAIDs like ketorolac provide comparable or superior analgesia with fewer adverse effects than acetaminophen-codeine combinations 5
• Not educating patients about constipation: Codeine causes constipation in 21% of patients, significantly more than alternative analgesics 6