Codeine Phosphate

EXACT SPC §4.2 WORDING FOR ADULT PAIN: 'Codeine should be used at the lowest effective dose for the shortest period of time. The dose may be taken, up to 4 times a day at intervals of not less than 6 hours. Maximum daily dose of codeine should not exceed 240mg. The duration of treatment should be limited to 3 days and if no effective pain relief is achieved the patients/carers should be advised to seek the views of a physician.' No adult per-dose milligram value is given for pain in this SPC — clinician to confirm the intended per-dose strength (the fetched product is Codeine phosphate 15 mg tablets). OTHER ADULT INDICATIONS STATED IN THE SAME SECTION: dry or painful cough — 15-30 mg three to four times daily; diarrhoea — 30 mg three to four times daily (range 15-60 mg). ELDERLY: dosage should be reduced. BEFORE STARTING: a discussion should be held with the patient to put in place a strategy for ending treatment, to minimise the risk of addiction and drug withdrawal syndrome. CYP2D6: codeine is metabolised to morphine by CYP2D6 — poor metabolisers get inadequate analgesia; ultra-rapid metabolisers are at increased risk of opioid toxicity even at commonly prescribed doses and codeine is contraindicated in known ultra-rapid metabolisers. OBSTETRIC RELEVANCE (this page's specialty): codeine is CONTRAINDICATED in women during breastfeeding — it may be secreted in breast milk and cause respiratory depression in the infant; if symptoms of opioid toxicity develop in mother or infant, stop all codeine-containing medicines and prescribe a non-opioid analgesic. Administration during labour may depress neonatal respiration and an antidote for the child should be readily available; opioids may cause gastric stasis during labour, increasing the risk of maternal inhalation pneumonia. Regular use in pregnancy may cause fetal dependence and neonatal withdrawal. PAEDIATRIC: contraindicated below 12 years of age (risk of opioid toxicity from variable, unpredictable metabolism to morphine, and contraindicated for cough below 12 years); not recommended in 12-18 year olds with compromised respiratory function for cough; contraindicated in all patients 0-18 years undergoing tonsillectomy and/or adenoidectomy for obstructive sleep apnoea. Not recommended for diarrhoea in children. Verify any paediatric use against a children's formulary.

RANGE, NOT A SINGLE VALUE — dosePerKg is deliberately null. Exact SPC §4.2 wording: 'The recommended codeine dose for children 12 years and older should be 30-60mg every 6 hours when necessary up to a maximum dose of codeine of 240mg daily. The dose is based on the body weight (0.5-1mg/kg).' STRICTLY CONTRAINDICATED IN CHILDREN UNDER 12 YEARS, and in all patients aged 0-18 years after tonsillectomy and/or adenoidectomy for obstructive sleep apnoea. Not recommended in 12-18 year olds with compromised respiratory function (neuromuscular disorders, severe cardiac or respiratory conditions, upper respiratory or lung infections, multiple trauma, extensive surgery). Verify against a children's formulary before use.