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Zohydro ER

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Zohydro ER


The following serious adverse reactions are discussed elsewhere in the labeling:

Respiratory depression [see WARNINGS AND PRECAUTIONS]

Misuse and abuse [see WARNINGS AND PRECAUTIONS and Drug Abuse and Dependence]

CNS depressant effects [see WARNINGS AND PRECAUTIONS]

Clinical Trial Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. The safety of Zohydro ER was evaluated in a total of 1148 subjects in Phase 3 clinical trials.

Table 2 lists the most frequently occurring adverse reactions occurring at a greater frequency than placebo from the placebo-controlled trial in subjects with moderate-to-severe chronic lower back pain.

Table 2: Treatment-Emergent Adverse Events in ≥ 2% of Subjects During the Open-Label Titration Period and/or the Double-Blind Treatment Period, by Preferred Term —Number (%) of Treated Subjects (Placebo-Controlled Study in Opioid-Experienced Subjects With Moderate-to-Severe Chronic Lower Back Pain)

Preferred Term Open-Label Titration Period Double-Blind Treatment Period
Zohydro ER
(N = 510)
Zohydro ER
(n = 151)
(n = 151)
Constipation 56 (11%) 12 (8%) 0 (0%)
Nausea 50 (10%) 11 (7%) 5 (3%)
Somnolence 24 (5%) 1 (1%) 0 (0%)
Fatigue 21 (4%) 1 (1%) 2 (1%)
Headache 19 (4%) 0 (0%) 2 (1%)
Dizziness 17 (3%) 3 (2%) 1 (1%)
Dry Mouth 16 (3%) 0 (0%) 0 (0%)
Vomiting 14 (3%) 7 (5%) 1 (1%)
Pruritus 13 (3%) 0 (0%) 0 (0%)
Abdominal Pain 8 (2%) 4 (3%) 0 (0%)
Edema peripheral 7 (1%) 4 (3%) 0 (0%)
Upper respiratory tract infection 7 (1%) 5 (3%) 1 (1%)
Muscle spasms 6 (1%) 4 (3%) 2 (1%)
Urinary Tract Infection 4 (1%) 8 (5%) 3 (2%)
Back Pain 4 (1%) 6 (4%) 5 (3%)
Tremor 1 (0%) 4 (3%) 1 (1%)

The common ( ≥ 1% to < 10%) adverse drug reactions reported at least once by subjects treated with Zohydro ER in the Phase 3 clinical trials and not represented in Table 2 were:

Gastrointestinal Disorders: abdominal discomfort, abdominal pain, gastroesophageal reflux disease

General Disorders and Administration Site Conditions: non-cardiac chest pain, pain, peripheral edema, pyrexia,

Injury, Poisoning and Procedural Complications: contusion, fall, foot fracture, joint injury, joint sprain, muscle strain, skin laceration

Investigations: increased blood cholesterol, increased gamma-glutamyltransferase

Metabolism and Nutrition Disorders: dehydration, hypokalemia

Musculoskeletal and Connective Tissue Disorders: arthralgia, musculoskeletal pain, myalgia, neck pain, osteoarthritis, pain in extremity

Nervous System Disorders: lethargy, migraine, paresthesia

Psychiatric Disorders: anxiety, depression, insomnia

Respiratory, Thoracic and Mediastinal Disorders: cough, dyspnea

Skin and Subcutaneous Tissue Disorders: hyperhidrosis, night sweats, rash

Vascular Disorders: hot flush

Read the Zohydro ER (hydrocodone bitartrate extended release capsules) Side Effects Center for a complete guide to possible side effects



Concomitant use of alcohol with Zohydro ER can result in an increase of hydrocodone plasma levels and potentially fatal overdose of hydrocodone. Instruct patients not to consume alcoholic beverages or use prescription or non-prescription products containing alcohol while on Zohydro ER therapy [see CLINICAL PHARMACOLOGY].

Drugs Affecting Cytochrome P450 Isoenzymes

Inhibitors of CYP3A4

Because the CYP3A4 isoenzyme plays a major role in the metabolism of hydrocodone, drugs that inhibit CYP3A4 activity may cause decreased clearance of hydrocodone which could lead to an increase in hydrocodone plasma concentrations and result in increased or prolonged opioid effects. These effects could be more pronounced with concomitant use of CYP 3A4 inhibitors. If co-administration with Zohydro ER is necessary, monitor patients for respiratory depression and sedation at frequent intervals and consider dose adjustments until stable drug effects are achieved [see CLINICAL PHARMACOLOGY].

Inducers of CYP3A4

CYP450 inducers may induce the metabolism of hydrocodone and, therefore, may cause increased clearance of the drug which could lead to a decrease in hydrocodone plasma concentrations, lack of efficacy or, possibly, development of a withdrawal syndrome in a patient who had developed physical dependence to hydrocodone. If co-administration with Zohydro ER is necessary, monitor for signs of opioid withdrawal and consider dose adjustments until stable drug effects are achieved [see CLINICAL PHARMACOLOGY].

CNS Depressants

The concomitant use of Zohydro ER with other CNS depressants including sedatives, hypnotics, tranquilizers, general anesthetics, phenothiazines, other opioids, and alcohol can increase the risk of respiratory depression, profound sedation, coma and death. Monitor patients receiving CNS depressants and Zohydro ER for signs of respiratory depression, sedation and hypotension.

When combined therapy with any of the above medications is considered, the dose of one or both agents should be reduced [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS].

Interactions with Mixed Agonist/Antagonist Opioid Analgesics

Mixed agonist/antagonist analgesics (i.e., pentazocine, nalbuphine, butorphanol, and buprenorphine) may reduce the analgesic effect of Zohydro ER or precipitate withdrawal symptoms in these patients. Avoid the use of mixed agonist/antagonist analgesics in patients receiving Zohydro ER.

MAO Inhibitors

Zohydro ER is not recommended for use in patients who have received MAO inhibitors within 14 days, because severe and unpredictable potentiation by MAO inhibitors has been reported with opioid analgesics. No specific interaction between hydrocodone and MAO inhibitors has been observed, but caution in the use of any opioid in patients taking this class of drugs is appropriate.


Anticholinergics or other drugs with anticholinergic activity when used concurrently with opioid analgesics may increase the risk of urinary retention or severe constipation, which may lead to paralytic ileus. Monitor patients for signs of urinary retention and constipation in addition to respiratory and central nervous system depression when Zohydro ER is used concurrently with anticholinergic drugs.

Drug Abuse And Dependence

Controlled Substance

Zohydro ER contains hydrocodone bitartrate, a Schedule II controlled substance with a high potential for abuse similar to fentanyl, methadone, morphine, oxycodone, and oxymorphone. Zohydro ER is subject to misuse, abuse, addiction and criminal diversion. The high drug content in the extended release formulation adds to the risk of adverse outcomes from abuse and misuse.


All patients treated with opioids require careful monitoring for signs of abuse and addiction, because use of opioid analgesic products carries the risk of addiction even under appropriate medical use.

Drug abuse is the intentional non-therapeutic use of an over-the-counter or prescription drug, even once, for its rewarding psychological or physiological effects. Drug abuse includes, but is not limited to the following examples: the use of a prescription or over-the-counter drug to get “high,” or the use of steroids for performance enhancement and muscle build up.

Drug addiction is a cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use and include: a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal.

“Drug-seeking” behavior is very common to addicts and drug abusers. Drug seeking tactics include, but are not limited to, emergency calls or visits near the end of office hours, refusal to undergo appropriate examination, testing or referral, repeated claims of “loss” of prescriptions, tampering with prescriptions and reluctance to provide prior medical records or contact information for other treating physician(s). “Doctor shopping” (visiting multiple prescribers) to obtain additional prescriptions is common among drug abusers, people with untreated addiction, and criminals seeking drugs to sell.

Abuse and addiction are separate and distinct from physical dependence and tolerance. Physicians should be aware that addiction may not be accompanied by concurrent tolerance and symptoms of physical dependence in all addicts. In addition, abuse of opioids can occur in the absence of true addiction and is characterized by misuse for non-medical purposes, often in combination with other psychoactive substances.

Zohydro ER can be diverted for non-medical use into illicit channels of distribution. Careful record-keeping of prescribing information, including quantity, frequency, and renewal requests, as required by law, is strongly advised.

Proper assessment of the patient, proper prescribing practices, periodic re-evaluation of therapy, and proper dispensing and storage are appropriate measures that help to limit abuse of opioid drugs.

Compromising the extended-release delivery system of Zohydro ER will result in the uncontrolled delivery of hydrocodone and pose a significant risk to the abuser that could result in overdose and death [see WARNINGS AND PRECAUTIONS]. The risk of fatal overdose is further increased when hydrocodone is abused concurrently with alcohol or other CNS depressants, including other opioids [see WARNINGS AND PRECAUTIONS].


Both tolerance and physical dependence can develop during chronic opioid therapy. Tolerance is the need for increasing doses of opioids to maintain a defined effect such as analgesia (in the absence of disease progression or other external factors). Tolerance may occur to both the desired and undesired effects of drugs, and may develop at different rates for different effects.

Physical dependence results in withdrawal symptoms after abrupt discontinuation or a significant dose reduction of a drug. Withdrawal also may be precipitated through the administration of drugs with opioid antagonist activity, e.g., naloxone, nalmefene, or mixed agonist/antagonist analgesics (pentazocine, butorphanol, buprenorphine, nalbuphine). Physical dependence may not occur to a clinically significant degree until after several days to weeks of continued opioid usage.

Zohydro ER should be discontinued by a gradual downward titration [see DOSAGE AND ADMINISTRATION]. If Zohydro ER is abruptly discontinued in a physically-dependent patient, an abstinence syndrome may occur. Some or all of the following can characterize this syndrome: restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, piloerection, myalgia, mydriasis, irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, increased blood pressure, respiratory rate, or heart rate.

Infants born to mothers physically dependent on opioids will also be physically dependent and may exhibit respiratory difficulties and withdrawal symptoms [see Use In Specific Populations].


a Sauberan, 2011

Last reviewed on RxList: 11/7/2013
This monograph has been modified to include the generic and brand name in many instances.


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