Compound Analgesic (Codeine + Paracetamol — Weak Opioid Step-Down) Pregnancy: Caution — neonatal withdrawal and opioid effects; avoid near term

Co-codamol 30/500 (Post-Operative Step-Down Analgesia)

Brand names: Tylex, Kapake, Solpadol

Adult dose

Dose: 2 tablets (codeine 30 mg + paracetamol 500 mg per tablet = codeine 60 mg + paracetamol 1 g) four times daily

Route: Oral

Frequency: Four times daily (every 6 hours)

Max: 8 tablets/day (codeine 240 mg/day; paracetamol 4 g/day)

Step-down analgesia when transitioning from IV opioids. Standard post-operative analgesic ladder: IV morphine PCA → co-codamol 30/500 QDS → co-codamol 8/500 or ibuprofen → paracetamol alone. Always prescribe with a laxative to prevent codeine-induced constipation.

Paediatric dose

Route: N/A

Frequency: N/A

Max: N/A

MHRA 2013: codeine contraindicated in children <12 years and in children 12–18 years post-tonsillectomy/adenoidectomy. Do not use co-codamol in paediatric post-operative patients.

Dose adjustments

Renal

Reduce dose or avoid in renal impairment — morphine-6-glucuronide (active codeine metabolite) accumulates

Hepatic

Reduce dose in hepatic impairment

Clinical pearls

Co-codamol 30/500 contains 30 mg codeine: codeine is a prodrug converted to morphine by CYP2D6 — efficacy and risk vary with CYP2D6 phenotype
Always co-prescribe laxative: codeine causes constipation in virtually all patients — prescribe senna or lactulose from day 1
MHRA 2013: do NOT use codeine in children under 12 years; avoid in 12–18 year olds after tonsillectomy (deaths reported in ultra-rapid metabolisers)
Paracetamol component: do NOT prescribe additional paracetamol alongside co-codamol — maximum daily paracetamol 4 g
Dependence: short-term post-surgical use is appropriate; avoid prolonged courses >2 weeks (codeine dependence/overuse headache)

Contraindications

Children <12 years (MHRA — codeine)
Post-tonsillectomy in children 12–18 years
Ultra-rapid CYP2D6 metabolisers (life-threatening opioid toxicity)
Respiratory depression
Known paracetamol hepatotoxicity

Side effects

Constipation (very common — always co-prescribe laxative)
Nausea and vomiting
Sedation
Dizziness
Respiratory depression (ultra-rapid metabolisers)
Paracetamol toxicity (overdose — rare at therapeutic doses)

Interactions

MAOIs — serotonin and opioid interaction (avoid)
CNS depressants — additive sedation
CYP2D6 inhibitors (fluoxetine, paroxetine) — reduce codeine to morphine conversion (reduced analgesia)

Monitoring

Bowel function (constipation)
Pain score
Respiratory rate (overdose/ultra-rapid metabolisers)
Renal function (prolonged use)

Reference: BNFc; BNF; MHRA Drug Safety Update 2013 (codeine children); RCoA Acute Pain Handbook; WHO Analgesic Ladder. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways