What is the recommended dosing for Hycodan (hydrocodone)?

Hycodan Dosing

For adults, Hycodan (hydrocodone bitartrate/homatropine) is dosed at 5-10 mg of hydrocodone every 4-6 hours as needed, with a maximum daily dose not exceeding 60 mg of hydrocodone (or 6 tablets of the 10 mg strength). 1

Standard Dosing Regimens

For immediate-release hydrocodone/acetaminophen combinations:

• 5 mg/325 mg strength: 1-2 tablets every 4-6 hours as needed; maximum 8 tablets daily 1
• 7.5 mg/325 mg strength: 1 tablet every 4-6 hours as needed; maximum 6 tablets daily 1
• 10 mg/325 mg strength: 1 tablet every 4-6 hours as needed; maximum 6 tablets daily 1

The FDA label explicitly states these are the usual adult dosages, with total daily limits designed to prevent acetaminophen toxicity while providing adequate analgesia. 1

Initiation Strategy

Start with the lowest effective dose and titrate upward based on pain response within 24-72 hours. 1 The FDA emphasizes using the lowest effective dosage for the shortest duration consistent with treatment goals, as respiratory depression risk is highest during initial therapy and dose escalation. 1

For opioid-naive patients with moderate pain, beginning with hydrocodone 5 mg every 4-6 hours is appropriate. 1 If inadequate relief occurs, increase to 7.5-10 mg per dose rather than shortening the dosing interval. 1

Special Clinical Applications

For cough suppression in advanced cancer:

• Initial dose: 5 mg twice daily 2
• Titrate daily by 5 mg increments until ≥50% improvement in cough frequency 2
• Median effective dose: 10 mg/day (range 5-30 mg/day) 2
• Maximum studied dose: 60 mg/24 hours 3, 2

This indication demonstrates that lower total daily doses (10-20 mg) often suffice for antitussive effects compared to analgesic requirements. 2 Most patients achieve cough control within one day of reaching their effective dose. 2

Conversion from Other Opioids

When converting from other opioids to hydrocodone, use a conservative approach and reduce the calculated equivalent dose by 25-50% to account for incomplete cross-tolerance. 4, 1

Hydrocodone is approximately equipotent with oral morphine (1:1 ratio), though this equivalence is not fully substantiated. 4, 5 The CDC assigns hydrocodone a morphine milligram equivalent (MME) conversion factor of 1.0. 6

Critical conversion principle: It is safer to underestimate the 24-hour hydrocodone dose than to overestimate and manage overdose-related adverse reactions. 1

Titration and Maintenance

Continually reassess patients to maintain pain control while minimizing adverse reactions. 1 If pain increases after dose stabilization, identify the source of increased pain before escalating the hydrocodone dose. 1

For patients requiring dose adjustments:

• Increase by 25-50% of the current dose if analgesia is inadequate 1
• Decrease the dose if unacceptable opioid-related adverse reactions occur 1
• Frequent communication between prescriber and patient is essential during titration 1

Discontinuation Protocol

Never abruptly discontinue hydrocodone in patients who may be physically dependent. 1 Rapid discontinuation has resulted in serious withdrawal symptoms, uncontrolled pain, suicide, and attempts to obtain illicit opioids. 1

Taper gradually by reducing the daily dose by 10-25% every few days while monitoring for withdrawal symptoms. 1

Safety Monitoring

Monitor closely for respiratory depression, especially within the first 24-72 hours of initiating therapy and following dose increases. 1 Respiratory depression is the primary risk with all opioid therapy and requires immediate dose adjustment if detected. 1

Common adverse effects include constipation (29-36%), dizziness (19-24%), vomiting (16-24%), and dry mouth (15-18%), with no significant differences between hydrocodone and codeine combinations. 7 These effects are generally mild and tolerable. 2, 8

Clinical Efficacy Context

Hydrocodone demonstrates comparable analgesic efficacy to codeine in acute musculoskeletal pain, but with significantly fewer treatment failures and fewer CNS side effects. 9 In cancer-related pain, hydrocodone/acetaminophen combinations provide equivalent pain relief to codeine/acetaminophen over 23 days of treatment. 7

The subjective effects of hydrocodone are dose-related, with significant pleasant and unpleasant effects primarily limited to doses ≥20 mg. 8 At 20 mg, hydrocodone produces effects similar to 40 mg oral morphine. 8