Paracetamol And Codeine Tablets
Out of date information, search anotherSUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Co-Codamol 8mg/500mg Tablets Boots Paracetamol and Codeine Tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Paracetamol 500mg
Codeine phosphate 8mg
For excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Tablets
White tablets, broken breakline on one face. Debossed <AB> on other side.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
Codeine is indicated in patients older than 12 years of age for the short term treatment of acute moderate pain which is not considered to be relieved by other analgesics such as paracetamol or ibuprofen (alone).
For the symptomatic relief of pain including, headache, migraine, toothache, period pains, rheumatic pains, including muscle pains and backache.
4.2. Posology and method of administration
Posology
Adults over18 years:
One or two tablets to be swallowed with water. The dose should not be repeated more frequently than every four to six hours and not more than four times in any 24 hour period. Maximum dose is 8 tablets (4.0gm of paracetamol and 64mg of codeine in divided doses) per 24 hours.
Children aged 12 years to 18 years:
The recommended dose for children 12 years and older is 1 to 2 tablets every 6 hours when necessary up to a maximum of 8 tablets in 24 hours.
Children aged less than 12 years:
Codeine 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
For oral administration
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.
4.3. Contraindications
• Hypersensitivity to the active substances 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 women during breastfeeding (see section 4.6)
• In patients for whom it is known they are CYP2D6 ultra-rapid metabolisers
4.4. Special warnings and precautions for use
Paracetamol:
Care is advised in the administration of paracetamol to patients with renal or hepatic impairment. The hazards of overdose are greater in those with non-cirrhotic alcoholic liver disease
Leaflet:
Talk to a doctor at once if you take too much of this medicine even if you feel well. This is because too much paracetamol can cause delayed, serious liver damage.
Label:
1. Do not take more medicine than the label tells you to. If you do not get better, talk to your doctor
2. Do not take anything else containing Paracetamol
3. Talk to a doctor at once if you take too much of this medicine, even if you feel well
Codeine:
CYP2D6 metabolism
Codeine is metabolised by liver enzyme CYP2D6 into morphine, its active metabolite. If a patient has a deficiency or is completely lacking this enzyme an adequate analgesic effect will not be obtained. 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, shallow breathing, small pupils, nausea, vomiting, constipation, lack of appetite and somnolence. 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 poplations are summarized below
|
Population |
Prevalance % |
|
Afri can/Ethi opi an |
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 postoperatively in children after tonsillectomy and/or adenoidectomy for obstructive sleep apnoea, led to rare, but life-threatening adverse events including death (see also 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.”
The label will state:
Front of Pack
• Can cause addiction
• For three days use only
Back of Pack
List of indication as agreed in 4.1 of the SmPC
If you need to use this medicine for more than three days you should see your doctor or pharmacist.
This medicine contains codeine which can cause addiction if you take it continuously for more than three days. If you take this medicine for headaches for more than three days it can make them worse.
Leaflet:
Section 1: What the medicine is for
Succinct description of the indications from 4.1 of the SmPC Section 2: Before taking
• This medicine contains codeine [or dihydrocodeine] which can cause addiction if you take it continuously for more than three days. This can give you withdrawal symptoms from the medicine when you stop taking it
• If you take a painkiller for headaches for more than three days it can make them worse
Section 3: Dosage
• This medicine should not be taken for more than 3 days. If the pain does not improve after 3 days, talk to your doctor for advice.
• This medicine contains codeine [or dihydrocodeine] and can cause addiction if you take it continuously for more than three days. When you stop taking it you may get withdrawal symptoms. You should talk to your doctor or pharmacist if you think you are suffering from withdrawal symptoms
Section 4: Side effects Reporting of side effects
If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard. By reporting side effects you can help provide more information on the safety of this medicine.
How do I know if I am addicted?
• If you take the medicine according to the instructions on the pack it is unlikely that you will become addicted to the medicine. However, if the following apply to you it is important that you talk to your doctor:
• You need to take the medicine for longer periods of time
• You need to take more than the recommended dose
• When you stop taking the medicine you feel very unwell but you feel better if you start taking the medicine again
Important information regarding the ingredients of this medicine Co-codamol 8mg/500mg Tablets contain parahydroxybenzoates (E218, E214 and E216), which may cause allergic reactions (possibly delayed).
4.5. Interaction with other medicinal products and other forms of interaction
Paracetamol:
Alcohol: Paracetamol should be given with care to patients with alcohol dependence (see Section 4.4).
Analgesics: Diflunisal increases blood concentrations of paracetamol.
Anion-exchange resins: Absorption reduced by cholestyramine; administration should be separated by at least 1 hour.
Antibacterials: Isoniazid may increase the risk of hepatotoxicity with therapeutic doses of paracetamol.
Anticoagulants: The anticoagulant effect of warfarin and other coumarins may be enhanced by prolonged regular use of paracetamol with increased risk of bleeding; occasional doses have no significant effect.
Antiepileptics: Carbamazepine, phenobarbital, phenytoin and primidone can reduce the effects of paracetamol and increase the risk of hepatotoxicity.
Motility stimulants: The speed of absorption of paracetamol may be increased by metoclopramide or domperidone.
Oral Contraceptives: Paracetamol is cleared from the body more quickly in women taking oral contraceptives and the analgesic effects may be reduced.
Uricosurics: Probenecid can reduce the loss of paracetamol from the body.
Codeine:
Alcohol: the effects of alcohol may be enhanced.
Anti-arrhythmics: codeine delays the absorption of mexiletine. The analgesic activity of codeine is likely to be significantly impaired by quinidine in extensive metabolisers of codeine.
Antidepressants: Severe CNS excitation or depression (including hypertension or hypotension) has been reported with the concurrent use of monoamine oxidase inhibitors (MAOIs) and pethidine. It is therefore possible that a similar interaction may occur with other opioid analgesics. The depressant effects of opioid analgesics may be enhanced by tricyclic antidepressants.
Antipsychotics: enhanced sedative and hypotensive effect.
Anxiolytics and hypnotics: enhanced sedative effect.
Domperidone and metoclopramide: codeine antagonises the effect of metoclopramide and domperidone on gastrointestinal activity.
Antidiarrhoeal and antiperistaltic agents: Concurrent use of codeine with agents such as loperamide and kaolin may increase the risk of severe constipation.
Ulcer-healing drugs: cimetidine inhibits the metabolism of opioid analgesics resulting in increased plasma concentrations.
Interference with laboratory tests
Opioid analgesics interfere with a number of laboratory tests including plasma amylase, lipase, bilirubin, alkaline phosphatase, lactate dehydrogenase, alanine aminotransferase and aspartate aminotransferase. Opioids may also interfere with gastric emptying studies as they delay gastric emptying and with hepatobiliary imaging using technetium Tc 99m disofenin as opioid treatment may cause constriction of the sphincter of Oddi and increase biliary tract pressure.
4.6 Fertility, pregnancy and lactation
Paracetamol:
Epidemiological studies in human pregnancy have shown no ill effects due to paracetamol use in the recommended dosage, but patients should follow the advice of their doctor regarding its use.
Paracetamol is excreted in breast milk, but not in a clinically significant amount. Available published data do not contraindicate breast-feeding.
Codeine:
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 metabolite, 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.
4.7. Effect on ability to drive and use machines
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
• 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.
Codeine can produce typical opioid effects including constipation, nausea, vomiting, dizziness, light-headedness, 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.
There have been very rare occurrences of pancreatitis.
Adverse effects of paracetamol are rare:
Immune system disorders
- Hypersensitivity including skin rash may occur.
- Frequency not known: anaphylactic shock, angioedema
There have been a few reports of blood dyscrasias including thrombocytopenia and agranulocytosis but these were not necessarily causally related to paracetamol.
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 the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
4.9. Overdose
Liver damage is possible in adults who have taken 10g or more of paracetamol. Ingestion of 5g 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, phenobarbitone, phenytoin, primidone, rifampicin, St John’s Wort or other drugs 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 overdosage in the first 24 hours are pallor, nausea, vomiting, anorexia and abdominal pain. Liver damage may become apparent 12 to 48 hours after ingestion. Abnormalities of glucose metabolism and metabolic acidosis may occur. In severe poisoning, hepatic failure may progress to encephalopathy, haemorrhage, hypoglycaemia, cerebral oedema 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 and pancreatitis have been reported.
Treatment
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:
Symptoms
Central nervous system depression, including respiratory depression, may develop but is unlikely to be severe unless other sedative agents have been coingested, including alcohol, or the overdose is very large. The triad of coma, pinpoint pupils and respiratory depression is considered indicative of opioid overdosage with dilation of the pupils occurring as hypoxia develops.
Nausea and vomiting are common Other opioid overdose symptoms include hypothermia, confusion, convulsions, severe dizziness, severe drowsiness, hypotension and tachycardia (possible but unlikely), nervousness or restlessness, excitement, hallucinations, bradycardia, circulatory failure, slow or troubled breathing, severe weakness, convulsions, especially in infants and children. Rhabdomyolysis, progressing to renal failure, has been reported in overdosage with opioids.
The effects in overdosage will be potentiated by simultaneous ingestion of alcohol and psychotropic drugs.
Treatment
This 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 350mg or a child more than 5mg/kg. In acute overdosage with respiratory depression or coma, the specific opioid antagonist naloxone is indicated using one of the recommended dose regimens- repeated doses may be required in a seriously poisoned patient as naloxone is a competitive antagonist with a short half-life. Patients should be observed closely 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
Paracetamol:
Paracetamol has analgesic and antipyretic actions.
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 particulars
Paracetamol:
Paracetamol is readily absorbed from the gastro-intestinal tract with peak plasma concentrations occurring 30 minutes to two hours after ingestion. It is metabolised in the liver and excreted in the urine, mainly as the glucuronide and sulphate conjugates. Less than 5% is excreted as unchanged paracetamol. The elimination half-life varies from about one hour to four hours. At usual therapeutic concentrations plasma protein binding is negligible.
Codeine:
Codeine is well absorbed from the gastrointestinal tract following oral administration. It is metabolised in the liver to morphine, and norcodeine which are both excreted in the urine partly as conjugates with glucuronic acid. Most of the excretion products appear in the urine within 6 hours and up to 86% of the dose is excreted in 24 hours. About 70% of the dose is excreted as free codeine, 10% as free and conjugated morphine and a further 10% as free or conjugated norcodeine. Only traces are found in the faeces. The plasma half life is between approximately three and four hours.
5.3. Preclinical safety data
There is no pre-clinical data of relevance to the prescriber which is additional to that already included in the other sections of the SmPC.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Potato starch Maize starch Talc
Povidone Stearic acid Magnesium stearate
* Nipasept consists of methyl-p-hydroxybenzoate (E218), ethyl-p-hydroxy benzoate (E214) and propyl-p-hydroxybenzoate (E216).
6.2 Incompatibilities
None
6.3 Shelf life
3 years.
6.4 Special precautions for storage
Do not store above 25oC
Blisters: Store in the original package
6.5 Nature and contents of container
Blister packs:
8, 10, 12, 16, 20, 24, 28, 30, 32 as Pharmacy packs
Blister strips consist of a 35gsm paper/9p soft tempered aluminium foil lid and 250p PVC film base in cartons.
Or
Blister strips consist of a 250p hard aluminium foil laminated to 15 p rigid PVC film and 250p PVC film base in cartons.
6.6 Special precautions for disposal
No special requirements.
7 MARKETING AUTHORISATION HOLDER
Bristol Laboratories Ltd,
Unit 3, Canalside,
Northbridge Road Berkhamsted HP4 1EG UK
8 MARKETING AUTHORISATION NUMBER(S)
PL 17907/0162
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
25/07/2006
10 DATE OF REVISION OF THE TEXT
11/08/2014