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Compound Analgesic (Paracetamol + Codeine)

Co-codamol 30/500

Brand names: Kapake, Solpadol, Tylex

Adult dose

Dose: 1–2 tablets (codeine 30mg/paracetamol 500mg per tablet) every 4–6 hours as required
Route: Oral
Frequency: Every 4–6h PRN
Max: 8 tablets/day (codeine 240mg + paracetamol 4000mg/day); duration: acute use only — risk of dependence with prolonged use
WHO analgesic ladder step 2. For moderate orthopaedic pain (post-fracture, post-operative). Do not exceed 4g paracetamol/day total (including other paracetamol sources). Weaker co-codamol strengths: 8/500 and 15/500 — prescription-only (30/500 is CD Schedule 5).

Paediatric dose

Route: Oral
Frequency: N/A
Max: Not recommended <12 years (MHRA restriction 2013)
MHRA 2013: codeine is contraindicated for pain in children <12 years and in children <18 years post-tonsillectomy/adenoidectomy. Ultra-rapid CYP2D6 metabolisers convert codeine to morphine rapidly — fatal respiratory depression reported.

Dose adjustments

Renal

Reduce frequency and dose in renal impairment — codeine metabolites accumulate; avoid in eGFR <30

Hepatic

Avoid in severe hepatic impairment — paracetamol component hepatotoxic; codeine impaired metabolism

Clinical pearls

  • 30/500 strength is Schedule 5 CD in UK — can be prescribed on standard FP10 prescription; note on controlled drug register if dispensing >5 days supply
  • Laxative prophylaxis (senna or macrogol) should be prescribed alongside for any regular use — opioid-induced constipation is universal
  • Codeine is a prodrug — converted to morphine by CYP2D6; 6–10% of Caucasians are poor metabolisers (reduced analgesia); 1–2% are ultra-rapid metabolisers (toxicity risk)
  • Limit to acute use only (maximum 3–5 days for acute pain) — risk of dependence with prolonged use
  • If inadequate analgesia on co-codamol 30/500, step up to low-dose oral morphine rather than doubling dose

Contraindications

  • Children <12 years (MHRA contraindication)
  • Post-tonsillectomy/adenoidectomy pain in children <18 years
  • Known ultra-rapid CYP2D6 metaboliser
  • Acute respiratory depression
  • Paralytic ileus
  • Concurrent MAOI use

Side effects

  • Constipation (very common — laxative prophylaxis recommended for regular use)
  • Nausea and vomiting
  • Drowsiness
  • Codeine dependence (with prolonged use)
  • Respiratory depression (rare at standard doses; significant in ultra-rapid metabolisers)
  • Paracetamol hepatotoxicity (if maximum dose exceeded)

Interactions

  • MAOIs — contraindicated
  • CNS depressants — additive sedation
  • Gabapentin/pregabalin — increased respiratory depression risk
  • Alcohol — additive CNS and hepatic effects

Monitoring

  • Bowel function (constipation)
  • Pain scores
  • Signs of opioid dependence
  • Total daily paracetamol intake

Reference: BNFc; BNF; NICE NG59; WHO Analgesic Ladder; MHRA Drug Safety Update (codeine in children, 2013). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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