Codeine, phenylephrine, and promethazine (Oral)
Generic name: codeine, phenylephrine, and promethazine [ KOE-deen-FOS-fate, fen-il-EF-rin-hye-droe-KLOR-ide, proe-METH-a-zeen-hye-droe-KLOR-ide ]
Drug class: Upper respiratory combinations
Medically reviewed by Drugs.com. Last updated on Sep 28, 2023.
Warning: Addiction, Abuse, and Misuse; Life-Threatening Respiratory Depression; Accidental Ingestion; Ultra-Rapid Metabolism of Codeine and Other Risk Factors for Life-Threatening Respiratory Depression in Children; Promethazine and Respiratory Depression in Children; Medication Errors; Interactions with Drugs Affecting Cytochrome P450 Isoenzymes; Concomitant Use with Benzodiazepines or Other CNS Depressants; Neonatal Opioid Withdrawal Syndromepromethazine hydrochloride/phenylephrine hydrochloride/codeine phosphate oral solution exposes users to risks of addiction, abuse, and misuse, which can lead to overdose and death. Assess patient’s risk before prescribing and monitor closely for these behaviors and conditions.
Serious, life-threatening, or fatal respiratory depression may occur. Monitor closely, especially upon initiation o when used in patients at higher risk.
Accidental ingestion of promethazine hydrochloride/phenylephrine hydrochloride/codeine phosphate oral solution, especially by children, can result in a fatal overdose of codeine.
Life-threatening respiratory depression and death have occurred in children who received codeine; most cases followed tonsillectomy and/or adenoidectomy, and many of the children had evidence of being an ultra-rapid metabolizer of codeine due to a CYP2D6 polymorphism. Promethazine hydrochloride/phenylephrine hydrochloride/codeine phosphate oral solution is contraindicated in children younger than 12 years of age and in children younger than 18 years of age following tonsillectomy and/or adenoidectomy. Avoid the use of promethazine hydrochloride/phenylephrine hydrochloride/codeine phosphate oral solution in adolescents 12 to 18 years of age who have other risk factors that may increase their sensitivity to the respiratory depressant effects of codeine.
Postmarketing cases of respiratory depression, including fatalities have been reported with use of promethazine in pediatric patients. Children may be particularly sensitive to the additive respiratory depressant effects when promethazine is combined with other respiratory depressants, including codeine.
Ensure accuracy when prescribing, dispensing, and administering promethazine hydrochloride/phenylephrine hydrochloride/codeine phosphate oral solution. Dosing errors can result in accidental overdose and death.
The effects of concomitant use or discontinuation of cytochrome P450 3A4 inducers, 3A4 inhibitors, or 2D6 inhibitors with codeine are complex, requiring careful consideration of the effects on the parent drug, codeine, and the active metabolite, morphine. Avoid the use of promethazine hydrochloride/phenylephrine hydrochloride/codeine phosphate oral solution in patients who are taking a CYP3A4 inhibitor, CYP3A4 inducer, or 2D6 inhibitor.
Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Avoid the use of promethazine hydrochloride/phenylephrine hydrochloride/codeine phosphate oral solution in patients taking benzodiazepines, other CNS depressants, or alcohol.
Promethazine hydrochloride/phenylephrine hydrochloride/codeine phosphate oral solution n is not recommended for use in pregnant women. Prolonged use of promethazine hydrochloride/phenylephrine hydrochloride/codeine phosphate oral solution during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated. If promethazine hydrochloride/phenylephrine hydrochloride/codeine phosphate oral solution is used for a prolonged period in a pregnant woman, advise the patient o f the risk o f neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available .
Uses for codeine, phenylephrine, and promethazine
Codeine, phenylephrine, and promethazine combination is used for the temporary relief of cough, runny or stuffy nose, sneezing, or other symptoms caused by allergies or the common cold.
Codeine belongs to the group of medicines called narcotic analgesics (pain medicines). It acts on the central nervous system (CNS) to relieve pain. Phenylephrine is a decongestant. It works by narrowing the blood vessels and leads to the clearing of nasal congestion.
Promethazine is an antihistamine. It works by preventing the effects of a substance called histamine, which is produced by the body. Histamine can cause itching, sneezing, runny nose, and watery eyes. It can sometimes close up the bronchial tubes (air passages of the lungs) and make breathing difficult.
When codeine is used for a long time or in large doses, it may become habit-forming, causing mental or physical dependence. Physical dependence may lead to withdrawal side effects when you suddenly stop taking the medicine.
This medicine is available only with your doctor's prescription.
Before using codeine, phenylephrine, and promethazine
In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For this medicine, the following should be considered:
Tell your doctor if you have ever had any unusual or allergic reaction to this medicine or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully.
Use of Promethazine VC with codeine oral liquid in children and Promethazine, phenylephrine, and codeine oral solution in children younger than 12 years of age is not recommended.
It should not be used to relieve pain after surgery to remove tonsils or adenoids in any children. Severe breathing problems and deaths have been reported in some children who received codeine after tonsil or adenoid surgery.
Appropriate studies performed to date have not demonstrated geriatric-specific problems that would limit the usefulness of codeine, phenylephrine, and promethazine combination in the elderly. However, elderly patients are more likely to have age-related liver, kidney, or heart problems, which may require caution and an adjustment in the dose for patients receiving codeine, phenylephrine, and promethazine combination.
Studies in women breastfeeding have demonstrated harmful infant effects. An alternative to this medication should be prescribed or you should stop breastfeeding while using this medicine.
Interactions with Medicines
Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are taking this medicine, it is especially important that your healthcare professional know if you are taking any of the medicines listed below. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.
Using this medicine with any of the following medicines is not recommended. Your doctor may decide not to treat you with this medication or change some of the other medicines you take.
- Calcium Oxybate
- Magnesium Oxybate
- Methylene Blue
- Potassium Citrate
- Potassium Oxybate
- Sodium Oxybate
Using this medicine with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.
- Abiraterone Acetate
- Aripiprazole Lauroxil
- Arsenic Trioxide
- Calcium Oxybate
- Chloral Hydrate
- Eslicarbazepine Acetate
- Ethacrynic Acid
- Gabapentin Enacarbil
- Glycopyrronium Tosylate
- Inotuzumab Ozogamicin
- Iobenguane I 123
- Iobenguane I 131
- Magnesium Oxybate
- Morphine Sulfate Liposome
- Nitrous Oxide
- Opium Alkaloids
- Oxitropium Bromide
- Pipenzolate Bromide
- Potassium Oxybate
- Ropeginterferon Alfa-2b-njft
- Secretin Human
- Sodium Oxybate
- Sodium Phosphate
- Sodium Phosphate, Dibasic
- Sodium Phosphate, Monobasic
- St John's Wort
- Tolonium Chloride
Using this medicine with any of the following medicines may cause an increased risk of certain side effects, but using both drugs may be the best treatment for you. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.
- Aminolevulinic Acid
- Belladonna Alkaloids
- Betel Nut
- Evening Primrose
Interactions with Food/Tobacco/Alcohol
Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.
Using this medicine with any of the following may cause an increased risk of certain side effects but may be unavoidable in some cases. If used together, your doctor may change the dose or how often you use this medicine, or give you special instructions about the use of food, alcohol, or tobacco.
Other Medical Problems
The presence of other medical problems may affect the use of this medicine. Make sure you tell your doctor if you have any other medical problems, especially:
- Addison's disease or
- Alcohol abuse, or history of or
- Bladder blockage or
- Brain tumor or
- Breathing problems (eg, COPD, sleep apnea) or
- Depression or
- Drug dependence, especially with narcotics, or history of or
- Enlarged prostate or
- Head injury or
- Hypothyroidism (underactive thyroid) or
- Nerve and muscle disease or
- Obesity (overweight) or
- Trouble urinating or
- Weakened physical condition—Use with caution. May increase risk for more serious side effects.
- Asthma, acute or severe or
- Respiratory depression (very slow breathing) or
- Heart or blood vessel problems (eg, arteriosclerosis, peripheral vascular insufficiency) or
- Hypertension (high blood pressure) or
- Urinary retention or
- Narrow-angle glaucoma or
- Stomach or bowel blockage (eg, paralytic ileus) or
- Surgery (eg, nasopharyngeal tonsils, tonsils)—Should not be used in patients with these conditions.
- Bone marrow problems (eg, agranulocytosis, leukopenia) or
- Diabetes or
- Hypotension (low blood pressure) or
- Seizures, or history of or
- Stomach or bowel problems (eg, peptic ulcer, ulcerative colitis) or
- Surgery (eg, stomach, urinary tract), recent—Use with caution. May make these conditions worse.
- Kidney disease, severe or
- Liver disease (eg, cholestatic jaundice)—Use with caution. The effects may be increased because of the slower removal of the medicine from the body.
Proper use of codeine, phenylephrine, and promethazine
Take this medicine only as directed by your doctor. Do not take more of it, do not take it more often, and do not take it for a longer time than your doctor ordered. This is especially important for elderly patients, who may be more sensitive to the effects of pain medicines. If too much of this medicine is taken for a long time, it may become habit-forming (causing mental or physical dependence).
Measure the oral liquid with a marked measuring spoon, oral syringe, or medicine cup. The average household teaspoon may not hold the right amount of liquid.
This medicine should come with a Medication Guide. Read and follow the instructions carefully. Ask your doctor if you have any questions.
The dose of this medicine will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of this medicine. If your dose is different, do not change it unless your doctor tells you to do so.
The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.
- For symptoms of cough or stuffy nose caused by allergies:
- For oral dosage forms (elixir or syrup):
- Adults—5 milliliters (mL) every 4 to 6 hours as needed. Do not take more than 30 mL in 24 hours.
- Children—Use is not recommended.
- For oral dosage form (syrup):
- Adults and children 12 years of age and older—5 milliliters (mL) or 1 teaspoonful every 4 to 6 hours. Do not take more than 30 mL in 24 hours.
- Children younger than 12 years of age—Use is not recommended.
- For oral dosage forms (elixir or syrup):
If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.
Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.
Keep out of the reach of children.
Do not keep outdated medicine or medicine no longer needed.
Ask your healthcare professional how you should dispose of any medicine you do not use.
Drop off any unused narcotic medicine at a drug take-back location right away. If you do not have a drug take-back location near you, flush any unused narcotic medicine down the toilet. Check your local drug store and clinics for take-back locations. You can also check the DEA web site for locations. Here is the link to the FDA safe disposal of medicines website: www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm
Precautions while using codeine, phenylephrine, and promethazine
It is very important that your doctor check your or your child's progress while using this medicine. This will allow your doctor to see if the medicine is working properly and to decide if you or your child should continue to take it. Blood tests may be needed to check for unwanted effects.
If your or your child's symptoms (eg, cough) do not improve or become worse within 5 days, check with your doctor right away.
Do not use this medicine if you or your child is using or has used an MAO inhibitor (MAOI) such as isocarboxazid [Marplan®], linezolid [Zyvox®], phenelzine [Nardil®], selegiline [Eldepryl®], tranylcypromine [Parnate®]) within the past 14 days.
Codeine is changed to morphine in the body. Some people change codeine to morphine more quickly than others. These individuals are called "ultra-rapid metabolizers of codeine". Contact your doctor immediately if you have extreme drowsiness, sleepiness, confusion, or shallow breathing. These symptoms may indicate that you are an "ultra-rapid metabolizer of codeine". As a result, there is too much morphine in the body and more side effects of morphine than usual. Children may be especially sensitive to this effect. Do not give this medicine to:
- Children younger than 12 years of age.
- Children younger than 18 years of age who have had surgery removal of tonsils or adenoids.
- Children 12 to 18 years of age who have a high risk for breathing problems (eg, obstructive sleep apnea, obesity, lung disease).
If a nursing mother is an ultra-rapid metabolizer of codeine, it could lead to morphine overdose in the nursing baby and cause very serious side effects.
For nursing mothers taking this medicine:
- Talk to your doctor if you have any questions about using codeine or about how this medicine may affect your baby.
- Call your doctor if you become extremely tired and have difficulty caring for your baby.
- Your baby should generally nurse every 2 to 3 hours and should not sleep for more than 4 hours at a time.
- Check with your doctor, hospital emergency room, or local emergency services (eg, "call 9-1-1") immediately if your baby shows signs of increased sleepiness (more than usual), difficulty breastfeeding, difficulty breathing, or limpness. These may be symptoms of an overdose and need immediate medical attention.
Using this medicine while you are pregnant may cause serious unwanted effects, including neonatal opioid withdrawal syndrome in your newborn baby. Tell your doctor right away if you think you are pregnant or if you plan to become pregnant while using this medicine.
If you think you or someone else may have taken an overdose of this medicine, get emergency help at once. Signs of an overdose include: dark urine, difficult or troubled breathing, irregular, fast or slow, or shallow breathing, nausea, vomiting, pain in the upper stomach, pale or blue lips, fingernails, or skin, pinpoint pupils of the eyes, or yellow eyes or skin.
This medicine will add to the effects of alcohol and other CNS depressants (medicines that can make you drowsy or less alert). Some examples of CNS depressants are antihistamines or medicine for allergies or colds, sedatives, tranquilizers, or sleeping medicine, other prescription pain medicine or narcotics, medicine for seizures or barbiturates, muscle relaxants, or anesthetics, including some dental anesthetics. Check with your doctor before taking any of these medicines while you or your child are using this medicine.
This medicine may be habit-forming. If you feel that the medicine is not working as well, do not use more than your prescribed dose. Call your doctor for instructions.
Using narcotics for a long time can cause severe constipation. To prevent this, your doctor may direct you to take laxatives or stool softeners, drink a lot of fluids, or increase the amount of fiber in your diet. Be sure to follow the directions carefully, because continuing constipation can lead to more serious problems.
This medicine may make you dizzy, drowsy, or less alert than they are normally. Do not drive or do anything else that could be dangerous until you know how this medicine affects you.
Dizziness, lightheadedness, or fainting may occur when you get up suddenly from a lying or sitting position. Getting up slowly may help. Also, lying down for a while may relieve dizziness or lightheadedness.
Promethazine may increase your risk for convulsions (seizures). It may also cause dystonia (movement disorder). This is more likely in sick children with diarrhea. Talk to your doctor if you have any concerns.
Check with your doctor right away if you or your child are having convulsions, difficulty with breathing, fast heartbeat, high fever, high or low blood pressure, increased sweating, loss of bladder control, severe muscle stiffness, unusually pale skin, or tiredness. These could be symptoms of a serious condition called neuroleptic malignant syndrome (NMS).
This medicine may cause adrenal insufficiency. Check with your doctor right away if you have darkening of the skin, diarrhea, dizziness, fainting, loss of appetite, mental depression, nausea, skin rash, unusual tiredness or weakness, or vomiting.
If you are especially sensitive to the effects of this medicine, do not suddenly stop using it without first checking with your doctor. Your doctor may want you to gradually reduce the amount you are using before stopping it completely. This may help reduce the possibility of withdrawal symptoms, such as abdominal or stomach cramps, anxiety, fever, nausea, runny nose, sweating, tremors, or trouble sleeping.
Using too much of this medicine may cause infertility (unable to have children). Talk with your doctor before using this medicine if you plan to have children.
Make sure any doctor or dentist who treats you knows that you are using this medicine. You or your child may need to stop using this medicine several days before you have surgery or medical tests.
This medicine may make your skin more sensitive to sunlight. Use sunscreen when you are outdoors. Avoid sunlamps and tanning beds.
Do not take other medicines unless they have been discussed with your doctor. This includes prescription or nonprescription (over-the-counter [OTC]) medicines and herbal or vitamin supplements.
Side Effects of codeine, phenylephrine, and promethazine
Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.
Check with your doctor immediately if any of the following side effects occur:
Incidence not known
- Black, tarry stools
- bleeding gums
- blood in the urine or stools
- blurred vision
- chest pain
- clay-colored stools
- cold sweats
- dark urine
- decrease in the frequency of urination
- decrease in urine volume
- difficult or troubled breathing
- difficulty in passing urine (dribbling)
- dizziness, faintness, or lightheadedness when getting up from a lying or sitting position
- fast or slow, pounding, or irregular heartbeat or pulse
- high fever
- increased sweating
- irregular, fast or slow, or shallow breathing
- loss of appetite
- loss of bladder control
- painful or difficult urination
- pale or blue lips, fingernails, or skin
- pinpoint red spots on the skin
- pounding in the ears
- rash or itching
- severe muscle stiffness
- shakiness in the legs, arms, hands, or feet
- sore throat
- sores, ulcers, or white spots on the lips or in the mouth
- stomach pain
- swollen glands
- trembling or shaking of the hands or feet
- unpleasant breath odor
- unusual bleeding or bruising
- unusual tiredness or weakness
- unusually pale skin
- vomiting of blood
- yellow eyes or skin
Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:
Incidence not known
- blurred or loss of vision
- confusion about identity, place, and time
- disturbed color perception
- double vision
- dry mouth
- false or unusual sense of well-being
- halos around lights
- increased sensitivity of the skin to sunlight
- night blindness
- overbright appearance of lights
- redness or other discoloration of the skin
- relaxed and calm feeling
- seeing, hearing, or feeling things that are not there
- severe sunburn
- sleepiness or unusual drowsiness
- trouble sleeping
- tunnel vision
Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.
Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.
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