What is the recommended dosage of codeine (opioid cough suppressant) for adults and children?

Codeine Cough Syrup Dosage Recommendations

For adults, the recommended dosage of codeine cough syrup is 10 mL (2 teaspoons) containing approximately 30 mg of codeine every 4-6 hours, not exceeding 6 doses (120 mg total) in 24 hours. 1

Adult Dosing

• Standard adult dose: 10 mL (2 teaspoons) every 4 hours
• Maximum daily doses: Do not exceed 6 doses in 24 hours
• Duration of treatment: Limit to short-term use (3-7 days) due to potential for physical dependence 2
• Assessment: Evaluate response after 2-4 days; discontinue if no improvement 2

Pediatric Dosing

• Children 6-12 years: 5 mL (1 teaspoon) every 4 hours, not exceeding 6 doses in 24 hours 1
• Children under 6 years: Not recommended due to safety concerns 1, 3
• Adolescents 12+ years: Same as adult dosing (10 mL every 4 hours) 1

Important Considerations

Indications

• Use only for dry, non-productive cough that is bothersome and disruptive, especially at night 2
• Avoid when cough is productive or when clearance of secretions is needed for recovery 2
• Primary treatment for cough due to infection should be appropriate antibiotics, with cough suppressants as secondary symptomatic treatment 2

Contraindications and Cautions

• Avoid in patients with:
  • Productive cough with significant sputum 2
  • Renal impairment (morphine, codeine, and tramadol should be avoided) 4
  • Known CYP2D6 ultrarapid metabolizers (increased risk of toxicity) 4, 3
  • Children under 6 years 3

Pharmacological Considerations

• Codeine is a prodrug requiring CYP2D6 to be metabolized to morphine for analgesic effects 4
• Genetic polymorphism of CYP2D6 (more common among Asians) may result in variable response 4
• Drug interactions: Medications that inhibit or compete for CYP2D6 might reduce analgesic effects 4

Monitoring

• Monitor for adequate expectoration despite cough suppression 2
• Watch for signs of respiratory depression, especially in patients with risk factors 3
• Red flags requiring immediate attention: hemoptysis, increasing breathlessness, fever, purulent sputum 2

Alternative Options

If codeine is contraindicated or ineffective, consider:

• Dextromethorphan: 10-15 mg three to four times daily 2
• Benzonatate: 100-200 mg four times daily 2
• Levodropropizine: 75 mg three times daily 2
• Simple home remedies like honey and lemon for acute viral cough 2
• Ipratropium bromide inhaler for cough due to URI or bronchitis 2

Special Populations

• Elderly: Use lower doses due to increased sensitivity to side effects 2
• Pregnancy: Avoid, especially in third trimester 2
• Patients with substance use disorders: Collaborate with pain or substance use disorder specialists 4

Remember that while codeine can provide symptomatic relief for bothersome cough, evidence for its efficacy is limited 4, 2, and treatment should be short-term with careful monitoring for adverse effects.