Is there an IV formulation of Percocet, and if not, what IV opioid dose provides analgesia equivalent to oral Percocet (5 mg oxycodone/325 mg acetaminophen)?

IV Equivalent to Percocet

There is no IV formulation of Percocet (oxycodone/acetaminophen combination), but the equivalent IV opioid dose to oral Percocet 5/325 mg is approximately 1.5-2 mg IV hydromorphone or 3-5 mg IV morphine, combined with 1 gram IV acetaminophen for multimodal analgesia. 1, 2

Understanding the Conversion

Percocet contains oxycodone 5 mg plus acetaminophen 325 mg as an oral fixed-dose combination. 3, 4 Since no IV oxycodone formulation exists in the United States, conversion requires selecting an appropriate IV opioid alternative. 5, 4

Opioid Component Conversion

For the opioid component:

• Hydromorphone is the preferred IV opioid with a recommended dose of 0.015 mg/kg (approximately 1-1.5 mg for a 70 kg adult) as it has quicker onset, less histamine release, and lower risk of dose stacking compared to morphine. 1

• Morphine is an acceptable alternative at 0.1 mg/kg IV (approximately 5-10 mg for a 70 kg adult), though it carries higher risk of toxicity in renal failure and has slower onset. 1

• The oral oxycodone to IV morphine conversion ratio during repeated dosing is approximately 3:1, meaning 5 mg oral oxycodone equals roughly 1.5-2 mg IV morphine. 5

• Since hydromorphone is approximately 5-7 times more potent than morphine, 1.5 mg IV hydromorphone provides equivalent analgesia to 5 mg oral oxycodone. 1

Acetaminophen Component

For the acetaminophen component:

• Administer 1 gram IV acetaminophen every 6 hours (maximum 4 grams daily) as the foundational component of multimodal analgesia. 2, 6

• IV acetaminophen ensures predictable plasma concentrations compared to oral routes, which may have unreliable absorption in acute conditions. 2

• The 325 mg acetaminophen in Percocet is subtherapeutic; IV dosing at 1 gram provides superior analgesia. 2, 6

Recommended IV Regimen

The optimal approach combines:

1. IV Hydromorphone 1-1.5 mg initially, then 1 mg after 15 minutes if pain persists (patient-driven protocol preferred). 1

2. IV Acetaminophen 1 gram every 6 hours as scheduled dosing, not as needed. 2, 6

3. Consider adding IV Ibuprofen 600-800 mg every 6-8 hours for synergistic multimodal analgesia, which provides superior pain control compared to opioids alone. 1, 2

Critical Clinical Considerations

Multimodal analgesia is superior to opioid monotherapy:

• Combining IV acetaminophen with IV NSAIDs reduces opioid requirements by 30-50% while improving pain scores. 1, 2

• Reserve opioids strictly as rescue medication after optimizing non-opioid analgesics. 2, 3

Common pitfalls to avoid:

• Premature opioid escalation before optimizing non-opioid analgesics increases side effects without improving outcomes. 2, 3

• Using morphine doses less than 5 mg leads to oligoanalgesia; the 1+1 mg hydromorphone protocol addresses physician reluctance to adequately dose opioids. 1

• Failing to account for acetaminophen from all sources can lead to unintentional overdose exceeding the 4-gram daily maximum. 2, 3

• Not monitoring for hypotension with IV acetaminophen, which may preclude use in hemodynamically unstable patients. 2

Special Population Adjustments

In patients with renal impairment:

• Hydromorphone is strongly preferred over morphine due to lower risk of toxic metabolite accumulation. 1

• IV NSAIDs should be avoided or used with extreme caution, typically limited to 48 hours. 2

In patients with liver disease:

• Reduce maximum daily acetaminophen to 2-3 grams and monitor liver enzymes closely. 2

For opioid-naive patients:

• Avoid initial continuous infusion or PCA; use bolus dosing with careful titration. 1

• Start with lower end of dosing range (1 mg hydromorphone or 5 mg morphine). 1