Codeine

Indications

  • Mild to moderate pain (includes fixed-dose combinations with aspirin, ibuprofen, paracetamol)
  • Cough suppression
  • Diarrhoea

Precautions

  • Renal – avoid use in renal impairment
  • Breastfeeding – avoid use
  • See precautions from Opioid Analgesics

Dose

  • Oral, 30–60 mg every 4 hours if needed; maximum 240 mg in 24 hours.

Fixed-dose combination with aspirin

  • 1–2 tablets every 4 hours if needed, up to a maximum of 8 tablets daily.

Fixed-dose combination with ibuprofen

  • 1–2 tablets (of ibuprofen 200 mg and codeine 12.8 mg) every 4 hours if needed, up to a maximum of 6 tablets daily.

Fixed-dose combination with paracetamol

  • 1–2 tablets (of paracetamol 500 mg and codeine 8, 15 or 30 mg) every 4–6 hours if needed, up to a maximum of 8 tablets daily.

Practice considerations

  • codeine is not recommended for the management of severe pain

  • codeine (a prodrug) is metabolised to morphine; people with normal codeine metabolism metabolise 30 mg of codeine to approximately 4.5 mg of morphine

  • codeine is metabolised by CYP2D6:

    • some people are unlikely to obtain analgesia with codeine due to a genetic lack of CYP2D6, e.g. 6–10% of Caucasians and 1–2% of Asians
    • some people are ultra-rapid metabolisers, e.g. up to 10% of Caucasians, 1–2% of Asians and 29% of Ethiopians, and may achieve higher morphine concentrations, increasing their risk of toxicity

  • beware of the potential for misuse leading to dependence and over-use of OTC codeine fixed-dose combinations; this has resulted in toxicity from the non-opioid analgesic, e.g. acute renal failure and GI perforation from ibuprofen

  • there is no conclusive evidence that products containing 8–15 mg of codeine per tablet with paracetamol, aspirin or ibuprofen have any benefits over these non-opioids alone

Available brands

  • Codeine phosphate 30 mg – tablet
  • Aspirin 300 mg + codeine phosphate 8 mg - tablet
  • Paracetamol 500 mg + codeine phosphate 30 mg – tablet