Hydrocodone vs Codeine as Antitussives
Hydrocodone is as effective as codeine for cough suppression and may be preferred due to its efficacy and safety profile in patients requiring opioid antitussives. 1
Comparative Efficacy
- Both hydrocodone and codeine are centrally-acting opioid antitussives that have been extensively studied and demonstrated to be effective cough suppressants 1
- The American College of Chest Physicians guidelines identify both medications as effective antitussives, with opioids considered the best cough suppressants in patients with lung cancer 1
- While codeine has traditionally been considered the standard antitussive against which other medications are compared, evidence suggests hydrocodone may be equally or more effective:
- Hydrocodone demonstrated a median 70% improvement in cough frequency in patients with advanced cancer at a median dose of 10 mg/day 2
- Studies comparing dextromethorphan to codeine found that patients considered dextromethorphan the better antitussive, suggesting codeine may not be superior to other options 3
- A placebo-controlled study found codeine was no more effective than placebo in reducing cough associated with acute upper respiratory tract infections 4
- Similarly, codeine showed no significant effect over placebo in patients with COPD complaining of cough 5
Dosing Considerations
- Hydrocodone: Typically started at 5 mg twice daily, with titration as needed up to 30 mg/day 1, 2
- Codeine: Usually dosed at 30-60 mg every 4 hours for cough suppression 6
- Most patients respond to hydrocodone within one day of treatment initiation 2
Side Effect Profile
- Both medications carry risks of respiratory depression and hypoventilation, requiring caution with graduated dosing 1
- Hydrocodone has a well-established safety profile with primarily mild side effects (dry mouth, nausea, drowsiness) 2
- Dihydrocodeine (related to codeine) showed higher rates of somnolence (22%) compared to non-opioid alternatives (8%) in comparative studies 1
- Codeine requires metabolic activation by CYP2D6 to morphine, leading to variable efficacy based on individual metabolism 7
Clinical Applications
- For patients with intractable cough, particularly in advanced cancer, both hydrocodone and codeine are appropriate options 1
- Hydrocodone may be preferred in patients who:
- Need rapid cough control (most patients improve within one day) 2
- Have poor response to codeine
- Experience excessive sedation with codeine
- Cough suppressants should only be used when cough is dry, non-productive, and interfering with rest or recovery 6
Important Caveats
- Avoid cough suppressants when the patient is coughing up significant sputum or when cough serves a physiological purpose 6
- Limit opioid antitussive use to short-term therapy (3-7 days) due to potential for physical dependence 6
- Monitor for adequate expectoration despite cough suppression 6
- Consider underlying causes of cough and treat appropriately before or alongside symptomatic management 6
In conclusion, hydrocodone appears to be at least as effective as codeine for cough suppression, with a comparable safety profile when used appropriately. The choice between these agents should consider individual patient factors, but hydrocodone represents a valid alternative to codeine with demonstrated efficacy in clinical studies.