What are the current recommendations regarding codeine (methylmorphine) cough suppressant use?

From the Guidelines

Codeine cough suppressant use is not recommended in children under 12 years old and should be used with caution in adolescents between 12 and 18 years old who are obese or have conditions that increase the risk of serious breathing problems.

Current Recommendations

• The FDA guidelines, as endorsed by the expert panel opinion in 1, state that codeine is contraindicated to treat pain or cough in children younger than 12 years.
• The CHEST guideline and expert panel report in 1 suggests avoiding the use of codeine-containing medications in children with acute cough due to the potential for serious side effects, including respiratory distress.
• A strong recommendation against the use of codeine in children under 12 years old after tonsillectomy is made in 1, with the added contraindication that codeine should not be used to treat pain or cough in children younger than 12 years.

Rationale

• Multiple FDA advisories and warnings have been issued regarding the use of codeine in the pediatric population, including an initial safety warning regarding the use of codeine attributable to the finding of respiratory depression in rapid metabolizers 1.
• The use of OTC cough medications, including those containing codeine, has been associated with significant morbidity and even mortality in children 1.
• The American Academy of Pediatrics has advised against the use of codeine and dextromethorphan for treating any type of cough in children 1.

Alternatives

• Honey may offer more relief for cough symptoms than no treatment, diphenhydramine, or placebo in children with acute cough, but it is not better than dextromethorphan 1.
• Ipratropium bromide is recommended as an inhaled anticholinergic agent for cough due to URI or bronchitis in the current guidelines 1.

From the FDA Drug Label

Warnings Ask your doctor before use if you have a persistent cough, this may be a sign of a serious condition you have a persistent cough such as occurs with smoking, asthma, chronic bronchitis or emphysema you have a cough that is accompanied by excessive phlegm (mucus) you have chronic pulmonary disease or shortness of breath Stop use and ask a doctor if symptoms do not improve within 7 days, tend to recur or are accompanied by fever and rash or persistent headache These may be symptoms of a serious condition.

The current recommendations regarding codeine (methylmorphine) cough suppressant use are to:

• Consult a doctor before use if you have a persistent cough or certain underlying conditions such as smoking, asthma, chronic bronchitis, emphysema, chronic pulmonary disease, or shortness of breath.
• Stop use and ask a doctor if symptoms do not improve within 7 days or are accompanied by fever, rash, or persistent headache. 2

From the Research

Current Recommendations for Codeine Cough Suppressant Use

• The use of codeine as a cough suppressant is no longer recommended due to its limited efficacy and potential for abuse and dependence 3, 4.
• Studies have shown that codeine is no more effective than a placebo in suppressing cough caused by upper respiratory disorders or chronic obstructive pulmonary disease 4.
• The World Health Organization (WHO) removed codeine from the essential medicines list for children in 2011, and it is suggested that it should also be removed from the list for adults due to its limited efficacy and safety concerns 3.
• Codeine may only be effective in suppressing cough in specific situations, and its use should be limited to only when and as long as it is clinically necessary, particularly in children 5.
• Alternative treatments for cough are available, including antihistamines, decongestants, and expectorants, which can be used alone or in combination with codeine or other antitussives 6.
• There is a need for new therapies for cough, including disease-specific and symptom-related antitussives, as current treatments often have limited efficacy and are associated with side effects 7.

Safety and Efficacy Concerns

• Codeine use has the potential to lead to abuse and dependence, particularly through its active metabolite morphine 3.
• The efficacy of codeine in suppressing cough is highly variable and depends on individual factors, such as the biotransformation of codeine to morphine 3.
• Codeine may have significant side effects, particularly at high doses, and its use should be carefully monitored and limited to only when necessary 7.

Alternative Treatments

• Antihistamines, such as chlorpheniramine, and centrally acting opioid derivatives, such as dextromethorphan, are often used alone or in combination for the management of nonspecific cough 6.
• New agents, such as nociceptin or antagonists of transient receptor potential vanniloid-1, may have antitussive effects and are being researched as potential treatments for cough 7.