What are the indications for Codeine + Paracetamol?

From the Guidelines

Codeine + paracetamol combination is indicated for moderate pain relief, particularly in patients with cancer or cancer treatment, as noted in the most recent guideline by the American Society of Clinical Oncology (ASCO) 1. The typical adult dose is 1-2 tablets every 4-6 hours as needed, not exceeding 8 tablets in 24 hours, with each tablet usually containing 30mg codeine and 500mg paracetamol. This combination provides effective pain relief through two mechanisms:

• Codeine, an opioid, acts on the central nervous system to reduce pain perception.
• Paracetamol (acetaminophen) reduces pain and fever by inhibiting prostaglandin synthesis. Important considerations:
• Do not use for more than 3 days without consulting a doctor.
• Avoid alcohol while taking this medication.
• May cause drowsiness; do not drive or operate machinery until you know how it affects you.
• Can be habit-forming if used long-term; follow prescribed dosage carefully.
• Not recommended for children under 12 years old. Side effects may include constipation, nausea, and dizziness, as reported in various studies, including those by the European Society for Medical Oncology (ESMO) 1. However, the most recent ASCO guideline 1 suggests that the use of codeine + paracetamol may be limited by the "ceiling effect" and genetic polymorphism of CYP2D6, which may affect the efficacy of codeine in some patients. In such cases, alternative opioids like morphine or methadone may be considered, but the decision should be made on a case-by-case basis, taking into account the individual patient's needs and medical history.

From the Research

Indications for Codeine + Paracetamol

The combination of codeine and paracetamol is indicated for the treatment of:

• Moderate to severe pain in various settings, including postoperative, osteoarticular, and post-traumatic pain 2
• Cancer pain, with codeine being more effective than placebo, but with increased risk of nausea, vomiting, and constipation 3
• Acute postoperative pain in adults, with the combination providing good analgesia to half of those treated, comparable to commonly used non-steroidal anti-inflammatory drugs, with the benefit of longer duration of action 4

Specific Pain Conditions

The combination is effective in:

• Headache 2
• Postoperative pain, with the best results in terms of safety and efficacy obtained in this setting 2
• Osteoarticular pain 2
• Post-traumatic pain 2
• Cancer pain, with codeine being more effective than placebo, but with increased risk of adverse events 3

Comparison with Other Analgesics

The efficacy of codeine + paracetamol is:

• Not inferior to NSAIDs in the treatment of pain 2
• Comparable to commonly used non-steroidal anti-inflammatory drugs in acute postoperative pain, with the benefit of longer duration of action 4