From the Guidelines
You should not give Norco to a patient allergic to codeine and morphine due to the high risk of cross-reactivity and potential for severe allergic reactions. Norco contains hydrocodone, which is chemically related to codeine and morphine as they are all opioid medications. According to the study by Marco et al 1, equianalgesic doses of opioids have similar efficacy in the treatment of acute pain, but this does not negate the risk of allergic reactions. The study also notes that schedule II and III opioids, including hydrocodone, have the potential for abuse and should be used with caution.
Key Considerations
- Cross-reactivity between opioid medications is common, and a patient allergic to one opioid has a significant risk of being allergic to others in the same class 1.
- The allergic reaction could range from mild symptoms like itching and hives to severe, potentially life-threatening reactions such as anaphylaxis.
- Non-opioid pain management options, such as acetaminophen or NSAIDs (like ibuprofen or naproxen), may be considered as alternatives to Norco.
- Consultation with an allergist about the possibility of opioid allergy testing may be necessary to determine if any specific opioids might be safe for the patient.
Alternative Pain Management Options
- Acetaminophen: a common over-the-counter pain reliever that can be used to manage mild to moderate pain.
- NSAIDs (like ibuprofen or naproxen): can be used to manage mild to moderate pain and reduce inflammation.
- Consultation with a pain management specialist: may be necessary for patients with multiple opioid allergies who require treatment for moderate to severe pain.
It is essential to document the patient's allergies clearly in their medical record and consider a pain management consultation to ensure the patient receives safe and effective pain management. The study by Swarm et al 2 highlights the importance of individualized pain management and the need for caution when prescribing opioids, especially in patients with a history of allergies or sensitivities.
From the FDA Drug Label
Hydrocodone bitartrate and acetaminophen tablets are contraindicated in patients with: • Hypersensitivity to hydrocodone or acetaminophen (e.g., anaphylaxis) Do not prescribe Hydrocodone Bitartrate and Acetaminophen Tablets for patients with acetaminophen allergy
The patient is allergic to codeine and morphine, but the provided drug labels do not directly address cross-reactivity between these opioids and hydrocodone. Hypersensitivity to hydrocodone is a contraindication, but there is no information on whether an allergy to codeine or morphine increases the risk of a hypersensitivity reaction to hydrocodone.
- The labels do mention hypersensitivity to hydrocodone or acetaminophen, but do not provide information on cross-reactivity with other opioids.
- Therefore, it is unclear whether it is safe to give Norco (hydrocodone) to a patient allergic to codeine and morphine, and a conservative clinical decision would be to avoid its use in this patient due to the potential risk of hypersensitivity reaction 3, 4.
From the Research
Opioid Allergy and Cross-Reactivity
- The study 5 found that the incidence of opioid allergy cross-reactivity in hospitalized patients with historical opioid allergies is low, with cross-reactivity rates ranging from 0% to 6.7%.
- This suggests that a patient allergic to codeine and morphine may not necessarily be allergic to other opioids, such as hydrocodone (found in Norco).
Norco and Opioid Allergy
- Norco is a combination of hydrocodone and acetaminophen, and hydrocodone is an opioid that is different from codeine and morphine.
- The study 6 discusses the use of combination analgesics, including those with hydrocodone, but does not specifically address the issue of opioid allergy cross-reactivity.
- However, the study 7 notes that all "weak" opioids, including hydrocodone, can have the same dose-dependent adverse effects as morphine, and that there is no evidence that they carry a lower risk of addiction or other adverse effects.
Administration of Norco to Patients with Opioid Allergy
- Given the low incidence of opioid allergy cross-reactivity found in the study 5, it may be possible to administer Norco to a patient allergic to codeine and morphine, but with caution and careful monitoring.
- The study 7 emphasizes the need for vigilance when using any opioid, including hydrocodone, due to the risk of serious adverse effects, including respiratory depression and addiction.