Co-Codamol 30/500mg Effervescent Tablets
1 NAME OF THE MEDICINAL PRODUCT
Co-codamol 30 mg/500 mg effervescent tablets.
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Each effervescent tablet contains 30 mg codeine phosphate hemihydrate and 500 mg paracetamol.
Excipients with known effects:
Each effervescent tablet contains 5 mg of aspartame
Each effervescent tablet contains 438 mg of sodium.
For the full list of excipients see section 6.1.
3 PHARMACEUTICAL FORM
Effervescent tablet.
White circular, flat bevelled edge tablet, plain on both sides.
4
CLINICAL PARTICULARS
For the relief of severe pain.
Co-codamol is indicated in patients older than 12 years of age for the treatment of acute moderate pain which is not considered to be relieved by other analgesics such as paracetamol or ibuprofen (alone).
4.2 Posology and method of administration
Posology
Co-codamol should be used at the lowest effective dose for the shortest period of time. This dose may be taken, up to 4 times a day at intervals of not less than 6 hours. Maximum daily dose of codeine should not exceed 240 mg.
The duration of treatment should be limited to 3 days and if no effective pain relief is achieved the patients/carers should be advised to seek the views of a physician.
Adults
Two tablets dissolved in water not more frequently than every 4 hours, up to a maximum of 8 tablets in any 24-hour period.
Elderly
As adults, however a reduced dose may be required (see section 4.4).
Paediatric population
Children aged 12 years to 15 years:
The recommended Co-codamol dose for children 12 years old to 15 years old is 1 tablet dissolved in water every 4 to 6 hours when necessary up to a maximum of 4 tablets in 24 hours.
Children aged 16 years to 18 years:
The recommended Co-codamol dose for children 16 years old to 18 years is one to two tablets dissolved in water every six hours when necessary up to a maximum of eight tablets in any 24 hour period.
Children aged less than 12 years:
Co-codamol should not be used in children below the age of 12 years because of the risk of opioid toxicity due to the variable and unpredictable metabolism of codeine to morphine (see sections 4.3 and 4.4).
Method of administration
Co-codamol is for oral administration.
• Hypersensitivity to codeine or paracetamol or to any of the excipients listed in section 6.1.
• In all paediatric patients (0-18 years of age) who undergo tonsillectomy and/or adenoidectomy for obstructive sleep apnoea syndrome due to an increased risk of developing serious and life-threatening adverse reactions (see section 4.4)
• In patients for whom it is known they are CYP2D6 ultra-rapid metabolisers
• Condition where morphine and opioids are contraindicated e. g: o acute asthma,
o respiratory depression, o acute alcoholism, o head injuries, o raised intra-cranial pressure o following biliary tract surgery, o breast-feeding (see section 4.6).
• In patients currently receiving or within 14 days of stopping monoamine oxidase inhibitor therapy.
4.4 Special warnings and precautions for use
These tablets contain 438 mg sodium per tablet and should be avoided by patients on a low sodium diet.
The tablets contain aspartame and so should not be taken by patients with phenylketonuria.
CYP2D6 metabolism
Codeine is partially metabolised by the liver enzyme CYP2D6 into morphine, its active metabolite. If a patient has a deficiency or is completely lacking this enzyme they will not obtain adequate analgesic effect. Estimates indicate that up to 7% of the Caucasian population may have this deficiency. However, if the patient is an extensive or ultra-rapid metaboliser there is an increased risk of developing side effects of opioid toxicity even at commonly prescribed doses. These patients convert codeine into morphine rapidly resulting in higher than expected serum morphine levels.
General symptoms of opioid toxicity include confusion, somnolence, shallow breathing, small pupils, nausea, vomiting, constipation and lack of appetite. In severe cases this may include symptoms of circulatory and respiratory depression, which may be life-threatening and very rarely fatal.
Estimates of prevalence of ultra-rapid metabolisers in different populations are summarized below:
|
Population |
Prevalence % |
|
African/Ethiopian |
29% |
|
African American |
3.4% to 6.5% |
|
Asian |
1.2% to 2% |
|
Caucasian |
3.6% to 6.5% |
|
Greek |
6.0% |
|
Hungarian |
1.9% |
|
Northern European |
1%-2% |
Post-operative use in children
There have been reports in the published literature that codeine given post-operatively in children after tonsillectomy and/or adenoidectomy for obstructive sleep apnoea, led to rare, but life-threatening adverse events including death (see section 4.3). All children received doses of codeine that were within the appropriate dose range; however there was evidence that these children were either ultra-rapid or extensive metabolisers in their ability to metabolise codeine to morphine.
Children with compromised respiratory function
Codeine is not recommended for use in children in whom respiratory function might be compromised including neuromuscular disorders, severe cardiac or respiratory conditions, upper respiratory or lung infections, multiple trauma or extensive surgical procedures. These factors may worsen symptoms of morphine toxicity.
Hepatic and renal impairment
Care is advised in the administration of paracetamol to patients with severe hepatic or renal impairment. The hazards of overdose are greater in those with alcoholic liver disease.
Elderly patients
Care should be observed in administering the medicinal product to any patients whose condition may be exacerbated by opioid, particularly the elderly, who may be sensitive to their central and gastro-intestinal effects, those on concurrent CNS depressant medicinal products, those with prostatic hypertrophy and those with inflammatory or obstructive bowel disorders.
Care should be observed if prolonged therapy is contemplated.
Monoamine oxidase inhibitor (MAOI)
Caution is advised when taking codeine with monoamine oxidase inhibitor (MAOI) therapy. Co-codamol Effervescent Tablets should not be taken concurrently or within 14 days of MAOI’s.
Patients should be advised not to exceed the recommended dose and not take other paracetamol containing products concurrently. Keep the medicinal product out of the sight and reach of children.
The leaflet will state in the “pregnancy and breast-feeding” subsection of the section 2 “What you need to know before take Co-codamol”:
Co-codamol is contraindicated in breast-feeding.
The leaflet will state in a prominent position in the ‘What you need to know before take Co-codamol section:
• Do not take for longer than directed by your prescriber.
• Taking codeine regularly for a long time can lead to addiction, which might cause you to feel restless and irritable when you stop the tablets.
• Taking a painkiller for headaches too often or for too long can make them worse.
The label will state (To be displayed prominently on outer pack - not boxed):
• Do not take for longer than directed by your prescriber as taking codeine regularly for a long time can lead to addiction.
4.5 Interaction with other medicinal products and other forms of interaction
The effect of CNS depressants (including alcohol) may be potentiated by codeine.
Paracetamol may increase the elimination half-life of chloramphenicol. Oral contraceptives may increase its rate of clearance. The speed of absorption of paracetamol may be increased by metoclopramide or domperidone and absorption reduced by colestyramine.
Patients on anticoagulants may take occasional doses of Co-codamol but the anticoagulant effect of warfarin and other coumarins may be enhanced by prolonged regular administration of paracetamol with increased risk of bleeding; occasional doses have no significant effect.
4.6 Fertility, pregnancy and lactation
Pregnancy
There is inadequate evidence of the safety of codeine in human pregnancy, but there is epidemiological evidence for the safety of paracetamol. Both substances have been used for many years without apparent ill consequences and animal studies have not shown any hazard. Careful consideration should be given before prescribing the medicinal product for pregnant patients. Opioid analgesics may depress neonatal respiration and cause withdrawal effects in neonates of dependent mothers.
A large amount of data on pregnant women indicate neither malformative, nor feto/neonatal toxicity. Paracetamol can be used during pregnancy if clinically needed however it should be used at the lowest effective dose for the shortest possible time and at the lowest possible frequency.
As a precautionary measure, use of Co-codamol should be avoided during the third trimester of pregnancy and during labor.
Breast-feeding
Paracetamol is excreted in breast milk but not in a clinically significant amount.
Codeine should not be used during breast-feeding (see section 4.3).
At normal therapeutic doses codeine and its active metabolites may be present in breast milk at very low doses and is unlikely to adversely affect the breast fed infant. However, if the patient is an ultra-rapid metaboliser of CYP2D6, higher levels of the active metabolites, morphine, may be present in breast milk and on very rare occasions may result in symptoms of opioid toxicity in the infant, which may be fatal.
If symptoms of opioid toxicity develop in either the mother or the infant, then all codeine containing medicines should be stopped and alternative non-opioid analgesics prescribed. In severe cases consideration should be given to prescribing naloxone to reverse these effects.
4.7 Effects on ability to drive and use machines
Patients should be warned not to drive or operate machinery if they become dizzy or sedated while taking Co-codamol.
This medicine can impair cognitive function and can affect a patient’s ability to drive safely. This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988. When prescribing this medicine, patients should be told:
• The medicine is likely to affect your ability to drive
• Do not drive until you know how the medicine affects you
• It is an offence to drive while under the influence of this medicine
• However, you would not be committing an offence (called ‘statutory defence’) if: o The medicine has been prescribed to treat a medical or dental problem and
o You have taken it according to the instructions given by the prescriber and in the information provided with the medicine and o It was not affecting your ability to drive safely
4.8 Undesirable effects
Adverse effects of paracetamol are rare:
Blood and lymphatic system disorders
Very rare: thrombocytopenia, neutropenia, leucopenia
Not known: agranulocytosis
Immune system disorders
Hypersensitivity including skin rash may occur.
Not known: Anaphylactic shock, angioedema. Respiratory, thoracic and mediastinal disorders Not known: bronchospasm (see section 4.4)
Skin and subcutaneous disorders
Very rare cases of serious skin reactions have been reported.
Very rare occurrence of pancreatitis.
Codeine can produce typical opioid effects including vomiting, constipation, nausea, light-headedness, dizziness, confusion, drowsiness and urinary retention. The frequency and severity are determined by dosage, duration of treatment and individual sensitivity. Tolerance and dependence can occur, especially with prolonged high dosage of codeine.
• Regular prolonged use of codeine is known to lead to addiction and tolerance. Symptoms of restlessness and irritability may result when treatment is then stopped.
• Prolonged use of a painkiller for headaches can make them worse.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via Yellow Card Scheme at: www.mhra.gov.uk/yellowcard
4.9 Overdose
Paracetamol
Liver damage is possible in adults who have taken 10 g or more of paracetamol. Ingestion of 5 g or more of paracetamol may lead to liver damage if the patient has risk factors (see below).
Risk factors
If the patient
a. Is on long term treatment with carbamazepine, phenobarbital, phenytoin, primidone, rifampicin, St John’s Wort or other medicinal products that induce liver enzymes.
or
b. Regularly consumes ethanol in excess of recommended amounts. or
c. Is likely to be glutathione deplete e.g. eating disorders, cystic fibrosis, HIV infection, starvation, cachexia.
Symptoms
Symptoms of paracetamol overdose in the first 24 hours are pallor, nausea, vomiting, anorexia, and abdominal pain. Liver damage may become apparent 12 to 48 hours after ingestion. Increased levels of hepatic transaminases, lactate dehydrogenase and bilicubin may occur and the INR may increase. Abnormalities of glucose metabolism and metabolic acidosis may occur. In severe poisoning, hepatic failure may progress to encephalopathy, haemorrhage, hypoglycaemia, cerebral oedema, gastrointestinal bleeding and death. Acute renal failure with acute tubular necrosis strongly suggested by loin pain, haematuria and proteinuria, may develop even in the absence of severe liver damage. Cardiac arrhythmias, pancreatitis and pancytopenia have been reported.
Management
Immediate treatment is essential in the management of paracetamol overdose. Despite a lack of significant early symptoms, patients should be referred to hospital urgently for immediate medical attention. Symptoms may be limited to nausea or vomiting and may not reflect the severity of overdose or the risk of organ damage. Management should be in accordance with established treatment guidelines, see BNF overdose section.
Treatment with activated charcoal should be considered if the overdose has been taken within 1 hour. Plasma paracetamol concentration should be measured at 4 hours or later after ingestion (earlier concentrations are unreliable). Treatment with N-acetylcysteine may be used up to 24 hours after ingestion of paracetamol; however, the maximum protective effect is obtained up to 8 hours post-ingestion. The effectiveness of the antidote declines sharply after this time. If required the patient should be given intravenous N-acetylcysteine, in line with the established dosage schedule. If vomiting is not a problem, oral methionine may be a suitable alternative for remote areas, outside hospital. Management of patients who present with serious hepatic dysfunction beyond 24h from ingestion should be discussed with the NPIS or a liver unit.
Codeine
Nausea and vomiting are prominent symptoms of codeine toxicity, with circulatory and respiratory depression in severe overdose.
The effects of codeine over-dosage will be potentiated by simultaneous ingestion of alcohol and psychotropic drugs.
Symptoms
Central nervous system depression, including respiratory depression, may develop but is unlikely to be severe unless other sedative agents have been co-ingested, including alcohol, or the overdose is very large. The pupils may be pin-point in size; nausea and vomiting are common. Hypotension and tachycardia are possible but unlikely.
Management
Management should include general symptomatic and supportive measures including a clear airway and monitoring of vital signs until stable. Consider activated charcoal if an adult presents within one hour of ingestion of more than 350 mg or a child more than 5 mg/kg.
Give naloxone if coma or respiratory depression is present. Naloxone is a competitive antagonist and has a short half-life so large and repeated doses may be required in a seriously poisoned patient. Observe for at least four hours after ingestion, or eight hours if a sustained release preparation has been taken.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Anilides, Paracetamol combinations ATC Code: NO2B E51
Paracetamol is an analgesic which acts peripherally, probably by blocking impulse generation at the bradykinin sensitive chemo-receptors which evoke
pain. Although it is a prostaglandin synthetase inhibitor, the synthetase system in the CNS rather than the periphery appears to be more sensitive to it. This may explain paracetamol's lack of appreciable anti-inflammatory activity. Paracetamol also exhibits antipyretic activity.
Codeine is a centrally acting weak analgesic.
Codeine exerts its effect through p opioid receptors, although codeine has low affinity for these receptors, and its analgesic effect is due to its conversion to morphine. Codeine, particularly in combination with other analgesics such as paracetamol, has been shown to be effective in acute nociceptive pain.
5.2 Pharmacokinetic properties
Following oral administration of two effervescent tablets (i.e., a dose of paracetamol 1000 mg and codeine 60 mg) the mean maximum plasma concentrations of paracetamol and codeine were 20.4 pg/ml and 218.8 ng/ml respectively. The mean times to maximum plasma concentrations were 0.34 hours for paracetamol and 0.42 hours for codeine phosphate.
The mean AUC for the 10 hours following administration was 50.0 pg/ml per hour for paracetamol and 450.0 ng/ml per hour for codeine.
The bioavailabilities of paracetamol and codeine phosphate when given as the combination are similar to those when they are given separately.
Codeine is mainly metabolized by glucuronidation to codeine-6-glucuronide. Minor routes of metabolism include O-demethylation leading to morphine, N-demethylation to norcodeine and after both O-and N-demethylation formation of normorphine. Morphine and norcodeine are further transformed in glucuroconjugates. Unchanged codeine and its metabolites are mainly excreted by urinary route within 48h (84.4±15.9%).
The O-demethylation of codeine to morphine is catalyzed by the cytochrome P450 isozyme 2D6 (CYP2D6) which shows genetic polymorphism that may affect the efficacy and toxicity of codeine.
Genetic polymorphism in CYP2D6 leads to ultra-rapid, extensive and poor metaboliser phenotypes.
5.3 Preclinical safety data
There are no preclinical data of relevance which are additional to that already included in other sections of the SPC.
PHARMACEUTICAL PARTICULARS
6
6.1. List of excipients
Sodium hydrogen carbonate, Citric acid anhydrous,
Sodium carbonate anhydrous, Povidone,
Simeticone,
Sodium saccharin, Aspartame,
Polysorbate 80.
6.2 Incompatibilities
Not applicable
6.3 Shelf life
3 years
6.4 Special precautions for storage
Do not store above 25°C. Store in the original package.
6.5 Nature and contents of container
Aluminium / Aluminium foil strips
Pack sizes: 30, 32, 56, 60, 84, 90 and 100 tablets.
Special precautions for disposal
6.6.
Co-codamol Effervescent Tablets should be dissolved in half a tumbler full of water before taking.
7 MARKETING AUTHORISATION HOLDER
Cipla (EU) Limited
Hillbrow House
Hillbrow Road
Esher
Surrey
KT10 9NW
8 MARKETING AUTHORISATION NUMBER(S)
PL 36390/0006
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE
AUTHORISATION
06/10/2011
10 DATE OF REVISION OF THE TEXT
14/11/2016