What are the guidelines for using codeine-containing cough medicine?

Guidelines for Using Codeine-Containing Cough Medicine

Codeine-containing cough medicines are recommended only for short-term symptomatic relief of coughing in patients with chronic bronchitis, and are not recommended for cough due to upper respiratory infections (URIs) due to limited efficacy. 1

Appropriate Indications

• Codeine is recommended specifically for short-term symptomatic relief of coughing in patients with chronic bronchitis 1
• Codeine is not recommended for cough due to upper respiratory infections (URIs) as evidence shows limited efficacy 1
• Dextromethorphan is preferred over codeine as a first-line antitussive agent due to its superior safety profile 2
• For patients with lung cancer experiencing cough, codeine may be considered if other treatments are ineffective 1

Dosing Guidelines

• For adults and children 12 years and over: 10 mL (2 teaspoons) every 4 hours 3
• For children 6 to under 12 years: 5 mL (1 teaspoon) every 4 hours 3
• Do not exceed 6 doses in 24 hours 3
• Children under 6 years: Consult a doctor (generally not recommended) 3, 4

Contraindications and Warnings

• Do not use for persistent cough that may indicate a serious condition 3
• Avoid in patients with cough accompanied by excessive phlegm (mucus) 3
• Not recommended for patients with chronic pulmonary disease or shortness of breath 3
• Contraindicated in children under 12 years of age due to risk of respiratory depression 4
• May cause or aggravate constipation 3
• Stop use if symptoms do not improve within 7 days or are accompanied by fever, rash, or persistent headache 3

Safety Considerations

• Codeine has a greater side effect profile compared to other antitussives, including drowsiness, nausea, constipation, and risk of physical dependence 2, 5
• Codeine is a prodrug that is bioactivated by CYP2D6 into morphine in the liver, with opioid effects related to plasma morphine concentrations 5
• There have been reports of acute confusional states in adolescents attributed to inappropriate codeine use 6
• Codeine dependence is a common problem among adults and has been reported among adolescents 6

Alternative Approaches

• Ipratropium bromide is the recommended inhaled anticholinergic agent for cough suppression in URI or chronic bronchitis 1
• Dextromethorphan at appropriate doses (60 mg) provides optimal cough suppression with a better safety profile than codeine 2
• Simple home remedies like honey and lemon may be as effective as pharmacological treatments for benign viral cough 2
• For nocturnal cough, first-generation antihistamines with sedative properties may be beneficial 2
• Menthol by inhalation can provide acute but short-lived cough suppression 2

Evidence Quality and Limitations

• Evidence supporting codeine for cough suppression is of fair quality with intermediate benefit 1
• The recommendation for codeine in chronic bronchitis is graded as B (fair evidence, intermediate benefit) 1
• The recommendation against codeine for URI cough is graded as D (good evidence, no benefit) 1
• There is a lack of high-quality randomized controlled trials evaluating codeine for chronic cough in children 4

Clinical Decision Algorithm

1. Determine if the cough is due to chronic bronchitis or URI

   • If chronic bronchitis: Consider codeine for short-term relief 1
   • If URI: Avoid codeine due to limited efficacy 1

2. Consider patient-specific factors:

   • Age (avoid in children under 12) 4
   • Presence of excessive phlegm (avoid codeine) 3
   • History of respiratory conditions (use with caution) 3

3. Try alternatives before codeine:

   • For all cough types: Consider dextromethorphan first 2
   • For URI or bronchitis: Consider ipratropium bromide 1
   • For benign viral cough: Try honey and lemon 2

4. If codeine is deemed necessary, use appropriate dosing and limit duration to avoid dependence 3, 6