What are alternative treatments to codeine (methylmorphine) cough syrup for a patient with a codeine allergy?

From the Guidelines

For patients with codeine allergies, dextromethorphan at 30mg every 6-8 hours is a first-line option for managing cough symptoms, as it works by suppressing the cough reflex in the brain without opioid properties 1.

Alternative Treatment Options

Other alternatives to codeine for cough suppression include:

• Benzonatate (Tessalon Perles) at 100-200mg three times daily, which works by numbing stretch receptors in the lungs
• Antihistamines like diphenhydramine (Benadryl) 25-50mg at bedtime for significant nighttime cough, particularly when the cough has an allergic component
• Guaifenesin (Mucinex) at 600-1200mg every 12 hours for productive coughs by thinning mucus
• Inhaled corticosteroids like budesonide or fluticasone for inflammatory coughs

Important Considerations

It's essential to treat the underlying cause of the cough while providing symptomatic relief and adjust treatment based on whether the cough is productive or non-productive. The recommended dosage of dextromethorphan may need to be adjusted, as some combined preparations contain other ingredients like paracetamol, and care must be taken to avoid excessive doses 1.

Evidence-Based Recommendations

The American College of Chest Physicians (ACCP) recommends peripheral cough suppressants, such as levodropropizine and moguisteine, for the short-term symptomatic relief of coughing in patients with chronic or acute bronchitis, with a grade of recommendation of A 1. However, for patients with codeine allergies, dextromethorphan is a suitable alternative, as it has been shown to suppress acute cough in a single meta-analysis 1.

From the FDA Drug Label

BENZONATATE is indicated for the symptomatic relief of cough. Package/Label Principal Display Panel Compare to Delsym® active ingredient Dextromethorphan Polistirex Extended-Release Oral Suspension Cough Suppressant

• Alternative treatments to codeine cough syrup for a patient with a codeine allergy are:
  • Benzonatate (PO) 2
  • Dextromethorphan (PO) 3 Note: Patient should be monitored for potential allergic reactions to the alternative treatments, especially since dextromethorphan contains sodium metabisulfite, a sulfite that may cause allergic-type reactions.

From the Research

Alternative Treatments to Codeine Cough Syrup

For a patient with a codeine allergy, several alternative treatments can be considered:

• Centrally acting opioids such as morphine and dextromethorphan 4, 5, 6
• Peripherally acting antitussives like moguisteine and levodropropizine 4
• Centrally acting drugs such as amitryptiline, paroxetine, gabapentin, and carbamezepine, which have shown success in case reports 4
• New opioids like nociceptin or antagonists of TRPV1, which may be more effective 4
• Guaifenesin, which has been shown to be equally effective as codeine and dextromethorphan in relieving cough symptoms 6

Comparison of Alternative Treatments

Studies have compared the effectiveness of different cough suppressants:

• Dextromethorphan was found to be similarly effective as codeine in reducing cough frequency, and was considered the better antitussive by patients due to its lack of side effects and non-narcotic status 5
• Guaifenesin, codeine, and dextromethorphan were found to be equally effective in relieving cough symptoms in patients with uncomplicated respiratory tract infections 6

Considerations for Treatment

When selecting an alternative treatment to codeine cough syrup, it is essential to consider the patient's specific needs and medical history:

• The use of other substances may result in no particular gain and probably no particular loss, except where analgesia, cough relief, and sedation are required simultaneously 7
• Caution is needed to limit the use of codeine and other opioids only when and as long as it is clinically necessary, particularly in children 8