What is an alternative to Cotridin (codeine) for cough suppression?

Alternatives to Cotridin (Codeine) for Cough Suppression

Dextromethorphan is the recommended first-line alternative to codeine for cough suppression due to its better safety profile and similar efficacy. 1

First-Line Options

Dextromethorphan

• Mechanism: Non-sedating opiate that acts centrally to suppress cough reflex
• Efficacy: Shown to suppress acute cough in meta-analyses 1
• Dosing: 10-15 mg three to four times daily; maximum cough reflex suppression occurs at 60 mg 1
• Advantages: Extended-release formulations provide 12-hour relief 2
• Caution: Higher doses may be more effective but combined preparations may contain other ingredients like paracetamol 1

Menthol

• Acts as a peripherally acting antitussive
• Can be prescribed as menthol crystals or proprietary capsules
• Provides acute but short-lived cough suppression 1
• Can be used in combination with dextromethorphan for enhanced effect

Second-Line Options

Sedative Antihistamines

• First-generation antihistamines with sedative properties
• Particularly suitable for nocturnal cough 1
• Main side effect is drowsiness, which can be beneficial at night

Levodropropizine

• Peripherally acting antitussive
• Comparable efficacy to dihydrocodeine or moguisteine
• May provide earlier cough reduction than dextromethorphan 1
• Limited availability in some countries

For Severe or Intractable Cough

Morphine or Other Opioids

• Consider only when other approaches have failed
• Low-dose morphine (5-10 mg slow-release twice daily) 1
• Reserved for severe cases, particularly in palliative care settings
• Significant side effect profile including constipation, drowsiness, and potential for dependence 3

Practical Approach to Cough Management

1. Start with over-the-counter preparations:

   • Dextromethorphan-containing products (most effective alternative to codeine) 1, 2
   • Glycerol-based cough syrups or simple honey and lemon preparations 1

2. If inadequate response, consider:

   • Higher doses of dextromethorphan (up to 60 mg) 1
   • Adding menthol for additional relief 1
   • First-generation antihistamines for nighttime cough 1

3. For persistent cough despite above measures:

   • Levodropropizine (where available) 1
   • Consider opioid alternatives only in severe cases 1

Important Considerations

• Codeine disadvantages: Guidelines specifically note that codeine has no greater efficacy than dextromethorphan but has a much greater adverse side effect profile 1
• Pholcodine: Similar limitations to codeine with significant side effects 1
• Patient factors: Consider comorbidities, potential drug interactions, and risk of respiratory depression with centrally acting agents
• Duration: Limit use of antitussives to short-term symptomatic relief when possible

Special Situations

• Nocturnal cough: First-generation antihistamines or dextromethorphan at bedtime 1
• Chronic cough: Address underlying causes first (asthma, GERD, etc.) before symptomatic treatment 4
• Palliative care: More liberal use of opioids may be appropriate when quality of life is the primary concern 1, 5

The evidence clearly supports dextromethorphan as the most appropriate alternative to codeine-containing preparations like Cotridin, offering similar efficacy with a significantly better safety profile.