Codeine for Cough Suppression: Name and Dosing
Codeine is NOT recommended for cough suppression due to its significant adverse effect profile (drowsiness, nausea, constipation, physical dependence) and lack of efficacy advantage over safer alternatives like dextromethorphan. 1, 2
Why Codeine Should Be Avoided
- Codeine has no greater efficacy than dextromethorphan but carries a much worse adverse side effect profile, making it an inferior choice for cough suppression 1, 2, 3
- Current evidence finds codeine to be no more effective than placebo for acute cough, particularly in children 4
- The risks of respiratory suppression, opioid toxicity, and physical dependence outweigh any potential benefits 5, 6
- International guidelines and regulatory authorities (USA, Europe, Canada, New Zealand, Australia) now recommend against codeine use in children under 12 years and those 12-18 years with respiratory conditions 5
If Codeine Must Be Used (Historical Reference Only)
Product name: Codeine linctus (15 mg/5 mL) or codeine phosphate tablets (15 mg, 30 mg) 1
Dosing regimen:
- Initial dose: 15-30 mg every 4 hours as required, up to four doses in 24 hours 1
- Maximum dose: 30-60 mg four times daily (maximum 240 mg in 24 hours) 1
- The FDA-approved formulation contains codeine phosphate 10 mg per 5 mL when combined with guaifenesin 7
Recommended Alternative: Dextromethorphan
Instead of codeine, use dextromethorphan, which has equivalent efficacy with superior safety 1, 2, 3:
- Optimal dose: 60 mg for maximum cough reflex suppression (higher than most over-the-counter preparations) 2, 3, 8
- Standard dosing: 10-15 mg three to four times daily, maximum 120 mg per day 2
- Key advantage: Non-sedating opioid with better safety profile and no physical dependence risk 2, 8
First-Line Non-Pharmacological Approach
Before any medication, consider:
- Honey and lemon as effective as many pharmacological treatments for benign viral cough 1, 2, 8
- Voluntary cough suppression techniques through central modulation 2, 8
Critical Pitfalls to Avoid
- Do not prescribe codeine when dextromethorphan is available - no efficacy advantage with worse side effects 1, 3
- Avoid cough suppressants in chronic bronchitis and bronchiectasis - can cause dangerous sputum retention 1
- Never use codeine in children under 12 years due to respiratory suppression and opioid toxicity risks 5, 6
- Do not continue antitussive therapy beyond 3 weeks without full diagnostic workup 2