overdose may include: , , diaphoresis and general malaise. Clinical and laboratory evidence of hepatic toxicity may not be apparent until 48 to 72 hours post-ingestion. Treatment: A single or multiple overdose with hydrocodone and acetaminophen is a potentially lethal polydrug overdose, and consultation with a regional poison control center is recommended. Immediate treatment includes support of cardiorespiratory function and measures to reduce drug absorption. Oxygen, intravenous fluids, vasopressors, and other supportive measures should be employed as indicated. Assisted or controlled ventilation should also be considered. For hydrocodone overdose, primary attention should be given to the reestablishment of adequate respiratory exchange through provision of a patent airway and the institution of assisted or controlled ventilation. The antagonist hydrochloride is a specific antidote against respiratory depression which may result from overdosage or unusual sensitivity to , including hydrocodone. Since the duration of action of hydrocodone may exceed that of the antagonist, the patient should be kept under continued surveillance, and repeated doses of the antagonist should be administered as needed to maintain adequate respiration. A narcotic antagonist should not be administered in the absence of clinically significant respiratory or cardiovascular depression. Gastric decontamination with activated charcoal should be administered just prior to N- (NAC) to decrease systemic absorption if acetaminophen ingestion is known or suspected to have occurred within a few hours of presentation. Serum acetaminophen levels should be obtained immediately if the patient presents 4 hours or more after ingestion to assess potential risk of hepatotoxicity; acetaminophen levels drawn less than 4 hours post-ingestion may be misleading. To obtain the best possible outcome, NAC should be administered as soon as possible where impending or evolving injury is suspected. Intravenous NAC may be administered when circumstances preclude . Vigorous supportive therapy is required in severe intoxication. Procedures to limit the continuing absorption of the drug must be readily performed since the hepatic injury is dependent and occurs early in the course of intoxication. DOSAGE AND ADMINISTRATION Dosage should be adjusted according to the severity of the and the response of the patient. However, it should be kept in mind that tolerance to hydrocodone can develop with continued use and that the incidence of untoward effects is dose related. The usual adult dosage is one or two tablets every four to six hours as needed for pain. The total daily dosage should not exceed 8 tablets. HOW SUPPLIED NORCO® 5/325 tablets (Hydrocodone and Acetaminophen Tablets, USP 5 mg/325 mg) contain hydrocodone bitartrate 5 mg and acetaminophen 325 mg. They are supplied as white with orange specks, capsule-shaped, bisected tablets, debossed WATSON on one side and 913 on the other side, in bottles of 100 tablets, NDC 52544-913-01, in bottles of 500 tablets, NDC 52544-913-05, and in hospital unit-dose cartons of 100 tablets (25 tablets x 4 cards), NDC 52544-913-48. Storage: Store at controlled room temperature 15°-30°C (59°-86°F). Dispense in a tight, light-resistant container with a child-resistant closure. A Schedule CII Narcotic.

Manufactured by: Distributed by: Mikart, Inc. Actavis Pharma, Inc. Atlanta, GA 30318 Parsippany, NJ 07054 USA

Rev. 08/2014

Code 667C00 BOXED WARNING The risk of acute liver failure is higher in individuals with underlying bitartrate and acetaminophen tablets should be used during liver disease and in individuals who ingest while taking only if the potential benefit justifies the potential risk to the fetus. Hepatotoxicity acetaminophen. Acetaminophen has been associated with cases of acute liver Nonteratogenic Effects: Babies born to mothers who have been failure, at times resulting in liver transplant and death. Most of Instruct patients to look for acetaminophen or APAP on package taking regularly prior to delivery will be physically the cases of liver injury are associated with the use of labels and not to use more than one product that contains dependent. The withdrawal signs include irritability and excessive acetaminophen at doses that exceed 4000 milligrams per day, and acetaminophen. Instruct patients to seek medical attention crying, tremors, hyperactive reflexes, increased respiratory rate, often involve more than one acetaminophen-containing product. immediately upon ingestion of more than 4000 milligrams of increased stools, sneezing, yawning, vomiting, and fever. The acetaminophen per day, even if they feel well. intensity of the syndrome does not always correlate with the DESCRIPTION Serious skin reactions: Rarely, acetaminophen may cause serious duration of maternal use or dose. There is no consensus on Hydrocodone bitartrate and acetaminophen is supplied in tablet form skin reactions such as acute generalized exanthematous pustulosis the best method of managing withdrawal. for oral administration. (AGEP), Stevens-Johnson Syndrome (SJS), and toxic epidermal Labor and Delivery: As with all narcotics, administration of this Hydrocodone bitartrate is an opioid and antitussive and occurs necrolysis (TEN), which can be fatal. Patients should be informed product to the mother shortly before delivery may result in some as fine, white crystals or as a crystalline powder. It is affected by light. about the signs of serious skin reactions, and use of the drug should degree of respiratory depression in the newborn, especially if higher The chemical name is 4,5α-Epoxy-3-methoxy-17-methylmorphinan-6- be discontinued at the first appearance of skin rash or any other sign doses are used. one tartrate (1:1) hydrate (2:5). It has the following structural formula: of hypersensitivity. Nursing Mothers: Acetaminophen is excreted in breast milk in small

CH3 Hypersensitivity/anaphylaxis: There have been post-marketing amounts, but the significance of its effects on nursing infants is not COOH H N CH2 reports of hypersensitivity and anaphylaxis associated with use of known. It is not known whether hydrocodone is excreted in human H C OH acetaminophen. Clinical signs included swelling of the face, mouth, and milk. Because many are excreted in human milk and because 1 H •2 /2H O 2 throat, respiratory distress, urticaria, rash, pruritus, and vomiting. There of the potential for serious adverse reactions in nursing infants from CH HO C H 2 were infrequent reports of life-threatening anaphylaxis requiring hydrocodone and acetaminophen, a decision should be made COOH O emergency medical attention. Instruct patients to discontinue whether to discontinue nursing or to discontinue the drug, taking CH3O O Hydrocodone Bitartrate and Acetaminophen Tablets, USP immediately into account the importance of the drug to the mother. C H NO •C H O •21/2H O MW=494.49 18 21 3 6 6 2 and seek medical care if they experience these symptoms. Do not Acetaminophen, 4´-Hydroxyacetanilide, a slightly bitter, white, Pediatric Use: Safety and effectiveness in pediatric patients have prescribe Hydrocodone Bitartrate and Acetaminophen Tablets, USP for not been established. 05913202 odorless, crystalline powder, is a non-, non-salicylate analgesic patients with acetaminophen allergy. and antipyretic. It has the following structural formula: Geriatric Use: Clinical studies of hydrocodone bitartrate 5 mg and Respiratory Depression: At high doses or in sensitive patients, acetaminophen 500 mg did not include sufficient numbers of subjects hydrocodone may produce dose-related respiratory depression by aged 65 and over to determine whether they respond differently from CH3CONH OH acting directly on the brain stem respiratory center. Hydrocodone younger subjects. Other reported clinical experience has not identified also affects the center that controls respiratory rhythm, and may differences in responses between the elderly and younger patients. In C H NO MW=151.16 8 9 2 produce irregular and periodic breathing. general, dose selection for an elderly patient should be cautious, usually Each tablet contains: Head Injury and Increased Intracranial Pressure: The respiratory starting at the low end of the dosing range, reflecting the greater Hydrocodone Bitartrate ...... 5 mg effects of narcotics and their capacity to elevate frequency of decreased hepatic, renal, or cardiac function, and of Acetaminophen ...... 325 mg cerebrospinal fluid pressure may be markedly exaggerated in the concomitant disease or other drug therapy. In addition, each tablet contains the following inactive ingredients: presence of head injury, other intracranial lesions or a pre-existing ADVERSE REACTIONS colloidal silicon dioxide, croscarmellose sodium, crospovidone, increase in intracranial pressure. Furthermore, narcotics produce The most frequently reported adverse reactions are , microcrystalline cellulose, povidone, pregelatinized starch, stearic adverse reactions which may obscure the clinical course of patients , sedation, nausea and vomiting. These effects seem to be more acid and sugar spheres which are composed of starch derived from with head injuries. prominent in ambulatory than in nonambulatory patients, and some of corn, sucrose, and FD&C Yellow #6. Acute Abdominal Conditions: The administration of narcotics may Hydrocodone these adverse reactions may be alleviated if the patient lies down. Meets USP Dissolution Test 1. obscure the diagnosis or clinical course of patients with acute Bitartrate and Other adverse reactions include: CLINICAL PHARMACOLOGY abdominal conditions. Acetaminophen Central Nervous System: Tablets USP Hydrocodone is a semisynthetic narcotic analgesic and antitussive with PRECAUTIONS Drowsiness, mental clouding, lethargy, impairment of mental and 5 mg/325 mg multiple actions qualitatively similar to those of . Most of these General: Special Risk Patients: As with any narcotic analgesic agent, physical performance, , fear, dysphoria, psychic dependence, only involve the central nervous system and smooth muscle. The precise hydrocodone bitartrate and acetaminophen tablets should be used mechanism of action of hydrocodone and other is not known, mood changes. Code 667D00 Rev. 08/2014 with caution in elderly or debilitated patients and those with severe although it is believed to relate to the existence of opiate receptors in impairment of hepatic or renal function, hypothyroidism, Addison’s Gastrointestinal System: the central nervous system. In addition to analgesia, narcotics may disease, prostatic hypertrophy or urethral stricture. The usual Prolonged administration of hydrocodone bitartrate and acetaminophen produce drowsiness, changes in mood and mental clouding. precautions should be observed and the possibility of respiratory tablets may produce . The analgesic action of acetaminophen involves peripheral depression should be kept in mind. Genitourinary System: influences, but the specific mechanism is as yet undetermined. Cough Reflex: Hydrocodone suppresses the cough reflex; as with Ureteral spasm, spasm of vesical sphincters and urinary retention Antipyretic activity is mediated through hypothalamic heat regulating all narcotics, caution should be exercised when hydrocodone have been reported with opiates. centers. Acetaminophen inhibits prostaglandin synthetase. bitartrate and acetaminophen tablets are used postoperatively and in Respiratory Depression: Therapeutic doses of acetaminophen have negligible effects on the patients with pulmonary disease. Hydrocodone bitartrate may produce dose-related respiratory cardiovascular or respiratory systems; however, toxic doses may Information for Patients/Caregivers: depression by acting directly on the brain stem respiratory center cause circulatory failure and rapid, shallow breathing. • Do not take Hydrocodone Bitartrate and Acetaminophen Tablets, (see OVERDOSAGE). : The behavior of the individual components is USP if you are allergic to any of its ingredients. Special Senses: described below. • If you develop signs of allergy such as a rash or difficulty breathing Hydrocodone: Following a 10 mg oral dose of hydrocodone stop taking Hydrocodone Bitartrate and Acetaminophen Tablets, USP Cases of hearing impairment or permanent loss have been reported administered to five adult male subjects, the mean peak and contact your healthcare provider immediately. predominantly in patients with chronic overdose. concentration was 23.6 ± 5.2 ng/mL. Maximum serum levels were • Do not take more than 4000 milligrams of acetaminophen per day. Dermatological: achieved at 1.3 ± 0.3 hours and the half-life was determined to be 3.8 Call your doctor if you took more than the recommended dose. Skin rash, pruritus. The following adverse drug events may be borne ± 0.3 hours. Hydrocodone exhibits a complex pattern of metabolism Hydrocodone, like all narcotics, may impair the mental and/or in mind as potential effects of acetaminophen: allergic reactions, including O-demethylation, N-demethylation and 6-keto reduction to rash, thrombocytopenia, agranulocytosis. Potential effects of high the corresponding 6-α- and 6-β- hydroxymetabolites. See physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery; dosage are listed in the OVERDOSAGE section. OVERDOSAGE for toxicity information. patients should be cautioned accordingly. DRUG ABUSE AND DEPENDENCE Acetaminophen: Acetaminophen is rapidly absorbed from the gastrointestinal tract and is distributed throughout most body tissues. Alcohol and other CNS may produce an additive CNS Controlled Substance: Hydrocodone Bitartrate and Acetaminophen The plasma half-life is 1.25 to 3 hours, but may be increased by liver depression, when taken with this combination product, and should Tablets are classified as a Schedule II controlled substance. damage and following overdosage. Elimination of acetaminophen is be avoided. Abuse and Dependence: Psychic dependence, physical dependence, principally by liver metabolism (conjugation) and subsequent renal Hydrocodone may be habit-forming. Patients should take the drug and tolerance may develop upon repeated administration of narcotics; of metabolites. Approximately 85% of an oral dose appears only for as long as it is prescribed, in the amounts prescribed, and therefore, this product should be prescribed and administered with in the within 24 hours of administration, most as the glucuronide no more frequently than prescribed. caution. However, psychic dependence is unlikely to develop when conjugate, with small amounts of other conjugates and unchanged Laboratory Tests: In patients with severe hepatic or renal disease, hydrocodone bitartrate and acetaminophen tablets are used for a short drug. See OVERDOSAGE for toxicity information. effects of therapy should be monitored with serial liver and/or renal time for the treatment of pain. INDICATIONS AND USAGE function tests. Physical dependence, the condition in which continued administration of Hydrocodone bitartrate and acetaminophen tablets are indicated for Drug Interactions: Patients receiving other narcotics, , the drug is required to prevent the appearance of a withdrawal syndrome, the relief of moderate to moderately severe pain. , antianxiety agents, or other CNS depressants (including assumes clinically significant proportions only after several weeks of alcohol) concomitantly with hydrocodone bitartrate and acetaminophen continued narcotic use, although some mild degree of physical CONTRAINDICATIONS tablets may exhibit an additive CNS depression. When combined therapy dependence may develop after a few days of narcotic therapy. Tolerance, This product should not be administered to patients who have previously is contemplated, the dose of one or both agents should be reduced. in which increasingly large doses are required in order to produce the exhibited hypersensitivity to hydrocodone or acetaminophen. same degree of analgesia, is manifested initially by a shortened duration The use of MAO inhibitors or tricyclic antidepressants with hydrocodone of analgesic effect, and subsequently by decreases in the intensity of Patients known to be hypersensitive to other opioids may exhibit preparations may increase the effect of either the antidepressant or analgesia. The rate of development of tolerance varies among patients. cross-sensitivity to hydrocodone. hydrocodone. OVERDOSAGE WARNINGS Drug/Laboratory Test Interactions: Acetaminophen may produce Hepatotoxicity: Acetaminophen has been associated with cases of false-positive test results for urinary 5-hydroxyindoleacetic acid. Following an acute overdosage, toxicity may result from acute liver failure, at times resulting in liver transplant and death. hydrocodone or acetaminophen. Carcinogenesis, Mutagenesis, Impairment of Fertility: No Most of the cases of liver injury are associated with the use of Signs and Symptoms: acetaminophen at doses that exceed 4000 milligrams per day, and adequate studies have been conducted in animals to determine often involve more than one acetaminophen-containing product. The whether hydrocodone or acetaminophen have a potential for Hydrocodone: Serious overdose with hydrocodone is characterized excessive intake of acetaminophen may be intentional to cause self- carcinogenesis, mutagenesis, or impairment of fertility. by respiratory depression (a decrease in respiratory rate and/or tidal harm or unintentional as patients attempt to obtain more pain relief Pregnancy: Teratogenic Effects: C: There are no volume, Cheyne-Stokes respiration, cyanosis), extreme or unknowingly take other acetaminophen-containing products. adequate and well-controlled studies in pregnant women. Hydrocodone progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, and sometimes bradycardia and . In severe overdosage, apnea, circulatory collapse, cardiac arrest and death may occur. Acetaminophen: In acetaminophen overdosage: dose-dependent, potentially fatal hepatic necrosis is the most serious adverse effect. Renal tubular necrosis, hypoglycemic coma, and coagulation defects may also occur. Early symptoms following a potentially hepatotoxic overdose may include: nausea, vomiting, diaphoresis and general malaise. Clinical and laboratory evidence of hepatic toxicity may not be apparent until 48 to 72 hours post-ingestion. Treatment: A single or multiple with hydrocodone and acetaminophen is a potentially lethal polydrug overdose, and consultation with a regional poison control center is recommended. Immediate treatment includes support of cardiorespiratory function and measures to reduce drug absorption. Oxygen, intravenous fluids, vasopressors, and other supportive measures should be employed as indicated. Assisted or controlled ventilation should also be considered. For hydrocodone overdose, primary attention should be given to the reestablishment of adequate respiratory exchange through provision of a patent airway and the institution of assisted or controlled ventilation. The narcotic antagonist naloxone hydrochloride is a specific antidote against respiratory depression which may result from overdosage or unusual sensitivity to narcotics, including hydrocodone. Since the duration of action of hydrocodone may exceed that of the antagonist, the patient should be kept under continued surveillance, and repeated doses of the antagonist should be administered as needed to maintain adequate respiration. A narcotic antagonist should not be administered in the absence of clinically significant respiratory or cardiovascular depression. Gastric decontamination with activated charcoal should be administered just prior to N-acetylcysteine (NAC) to decrease systemic absorption if acetaminophen ingestion is known or suspected to have occurred within a few hours of presentation. Serum acetaminophen levels should be obtained immediately if the patient presents 4 hours or more after ingestion to assess potential risk of hepatotoxicity; acetaminophen levels drawn less than 4 hours post-ingestion may be misleading. To obtain the best possible outcome, NAC should be administered as soon as possible where impending or evolving liver injury is suspected. Intravenous NAC may be administered when circumstances preclude oral administration. Vigorous supportive therapy is required in severe intoxication. Procedures to limit the continuing absorption of the drug must be readily performed since the hepatic injury is dose dependent and occurs early in the course of intoxication. DOSAGE AND ADMINISTRATION Dosage should be adjusted according to the severity of the pain and the response of the patient. However, it should be kept in mind that tolerance to hydrocodone can develop with continued use and that the incidence of untoward effects is dose related. The usual adult dosage is one or two tablets every four to six hours as needed for pain. The total daily dosage should not exceed 8 tablets. HOW SUPPLIED Hydrocodone Bitartrate and Acetaminophen Tablets USP, contain hydrocodone bitartrate 5 mg and acetaminophen 325 mg. They are supplied as white with orange specks, capsule-shaped, bisected tablets, debossed WATSON on one side and 3202 on the other side, in bottles of 100 and 500. Storage: Store at controlled room temperature 15°-30°C (59°-86°F). Dispense in a tight, light-resistant container with a child-resistant closure. A Schedule CII Narcotic. Manufactured by: Mikart, Inc. Atlanta, GA 30318

Distributed by: Watson Pharma, Inc. Parsippany, NJ 07054 USA Rev. 08/2014 Code 667D00