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CO-CODAMOL 30/500MG TABLETS BP
Active substance(s): CODEINE PHOSPHATE / PARACETAMOL
NAME OF THE MEDICINAL PRODUCT
Co-codamol 30/500 mg Tablets BP
QUALITATIVE AND QUANTITATIVE COMPOSITION
Each tablet contains: Paracetamol 500 mg
and Codeine Phosphate 30 mg.
For excipients, see 6.1
Off white, round, flat bevel-edged embossed tablets.
For the relief of severe pain
Codeine 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).
Posology and 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.
One or two tablets not more frequently than every 4- 6 hours, up to a maximum of 8 tablets in any
24 hour period.
Same as for adults, however a reduced dose may be required (see section 4.4).
Children aged 16-18 years: One or two tablets every 6 hours when necessary up to a maximum of 8
tablets in 24 hours.
Children aged 12 – 15 years: One tablet every 6 hours when necessary up to a maximum of 4
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 section 4.3 and 4.4).
Dosage should be adjusted accordingly to the severity of the pain and the response of the
patient. However, it should be kept in mind that tolerance to codeine can develop with
continued use and that the incidence of untoward effects is dose related. Doses of codeine
higher than 60 mg fail to give commensurate relief of pain but merely prolong analgesia
and are associated with an appreciable increased incidence of undesirable side effects.
Known hypersensitivity to paracetamol, codeine or other opioid analgesics or to any of
Moderate to severe renal failure.
Moderate to severe liver disease.
Acute respiratory depression and obstructive airways disease.
Bronchial asthma attack or heart failure secondary to chronic lung disease.
Raised intracranial pressure or head injuries (in addition to the risk of respiratory
depression and increased intracranial pressure, may affect papillary and other responses
vital for neurological assessment).
Where there is a risk of paralytic ileus.
In acute diarrhoeal conditions such as acute ulcerative colitis or antibiotic associated
colitis (e.g. pseudomembranous colitis) or
diarrhoea caused by poisoning until the toxic material has been eliminated from the
Not to be used in infants.
Following biliary tract surgery; monoamine oxidase inhibitor therapy, concurrent or
within 14 days.
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
Special warnings and precautions for use
Caution is advised in the administration of both paracetamol and codeine to patients with
impaired kidney or liver function. The hazard of overdose with paracetamol is greater in
those with alcoholic liver disease.
Care should be observed in administering the product to any patient whose condition
may be exacerbated by opioids, including the elderly, who may be sensitive to their
central and gastro-intestinal effects.
Co-codamol 30mg/500mg Tablets should be given with caution or in reduced doses to
elderly patients or debilitated patients or to patients with hypotension, hypothyroidism,
decreased respiratory reserve , adrenocortical insufficiency, prostatic hypertrophy,
shock, inflammatory or obstructive bowel disorders, urethral stricture, acute abdominal
conditions, recent gastrointestinal surgery, gallstones, myasthenia gravis, a history of
cardiac arrhythmias or convulsions and in patients with a history of drug abuse or
Avoid use during an acute asthma attack.
Care should be observed in those on concurrent CNS depressant drugs.
Opioid analgesics should be avoided in patients with biliary tract disorders or used in
conjunction with an antispasmodic.
Administration of pethidine and possibly other opioid analgesics to patients taking a
monoamine oxidase inhibitor (MAOI) has been associated with very severe and sometimes
fatal reactions. If the use of codeine is considered essential then great care should be taken
in patients taking MAOIs or within 14 days of stopping MAOIs (see section 4.5).
Caution should be exercised when using paracetamol prior to (less than 72 hours) or
concurrently with intravenous busulfan (see section 4.5 Interactions).
Patients should be advised that immediate medical advice should be sought in the event of
an overdose, because of the risk of delayed, serious liver damage
Care should also be observed if prolonged therapy is contemplated. Prolonged use of
codeine may lead to dependence and should be avoided.
Abrupt withdrawal of opioids from persons physically dependent on them precipitates a
withdrawal syndrome, the severity of which depends on the individual, the drug used, the
size and frequency of the dose, and the duration of drug use. Discontinuation should be
carried out gradually in patients who may have developed physical dependence, to avoid
precipitating withdrawal symptoms.
Codeine may induce faecal impaction, producing incontinence, spurious diarrhoea,
abdominal pain, and rarely, colonic obstruction. Elderly patients may metabolise or
eliminate opioid analgesics more slowly than younger adults.
Codeine is metabolised by the 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, 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 lifethreatening and very rarely fatal.
Estimates of prevalence of ultra-rapid metabolisers in different populations are
3.4% to 6.5%
1.2% to 2%
3.6% to 6.5%
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 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 risk-benefit of continued use should be assessed regularly by the prescriber.
The leaflet will state in a prominent position in the ‘before taking’ 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.
• Under ‘Pregnancy and Breastfeeding’:
Do not take codeine while you are breast feeding. Codeine and morphine pass into
• In Section 3 ‘How to take Co-codamol tablets’:
Talk to your 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.
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
• Do not take more medicine than the label tells you to. If you do not get better talk to
• Do not take anything else containing paracetamol while taking this medicine.
• Talk to a doctor at once if you take too much of this medicine, even if you feel well.
Do not exceed the stated dose.
Patients should be advised not to take other paracetamol or codeine containing products
If symptoms persist, consult your doctor. Keep out of the sight and reach of children.
Interaction with other medicinal products and other forms of interaction
The speed of absorption of paracetamol may be increased by metoclopramide or
domperidone and absorption reduced by colestyramine.
The anticoagulant effect of warfarin and other coumarins may be enhanced by prolonged
regular daily use of paracetamol with increased risk of bleeding; occasional doses have
no significant effect.
The risk of paracetamol toxicity may be increased in patients receiving other potentially
hepatotoxic drugs or drugs that induce liver microsomal enzymes. The plasmaparacetamol concentrations considered an indication for antidote treatment should be
halved in patients receiving enzyme-inducing drugs such as carbamazepine,
phenobarbital, phenytoin, primidone or rifampicin.
Excretion of paracetamol may be reduced and plasma concentrations increased when
given with probenecid.
Hepatotoxicity at therapeutic doses of paracetamol has been reported in patients
The depressant effects of codeine are enhanced by depressants of the central nervous
system such as alcohol, hypnotics, sedatives, tricyclic antidepressants and
Anaesthetics: concomitant administration of codeine and anaesthetics may cause
increased CNS depression and/or respiratory depression and/or hypotension.
Alcohol: the hypotensive, sedative and respiratory depressive effects of alcohol may be
The hypotensive actions of diuretics and antihypertensive agents may be potentiated
when used concurrently with opioid analgesics.
Concurrent use of hydroxyzine with codeine may result in increased analgesia as well as
increased CNS depressant and hypotensive effects.
Concurrent use of codeine with antidiarrhoeal and antiperistaltic agents such as
loperamide and kaolin may increase the risk of severe constipation.
Concomitant use of antimuscarinics or medications with antimuscarinic action may result
in an increased risk of severe constipation which may lead to paralytic ileus and/or
The respiratory depressant effects caused by neuromuscular blocking agents may be
additive to the central respiratory depressant effects of opioid analgesics.
Antidepressants: The depressant effects of opioid analgesics may be enhanced by tricyclic
antidepressants. MAOIs taken with pethidine have been associated with severe CNS
excitation or depression (including hypertension or hypotension). Although this has not
been documented with codeine, it is possible that a similar interaction may occur and
therefore the use of codeine should be avoided while the patient is taking MAOIs and for 2
weeks after MAOI discontinuation.
Quinidine can inhibit the analgesic effect of codeine.
Codeine may delay the absorption of flecainide and mexiletine and thus reduce the
antiarrhythmic effect of the latter.
Codeine may antagonise the gastrointestinal effects of metoclopramide, cisapride and
Ulcer-healing drugs: Cimetidine inhibits the metabolism of opioid analgesics resulting in
increased plasma concentrations.
Naloxone antagonises the analgesic, CNS and respiratory depressant effects of opioid
analgesics. Naltrexone also blocks the therapeutic effect of opioids.
Antihistamines: concomitant administration of codeine and antihistamines with sedative
properties may cause increased CNS depression and/or respiratory depression and/or
Paracetamol may increase the elimination half-life of chloramphenicol. Oral contraceptives
may increase its rate of clearance.
Codeine potentiates the effect of hypnotics and anxiolytics.
Cytotoxic drugs: Paracetamol possibly inhibits metabolism of intravenous busulfan
(manufacturer of intravenous busulfan advises caution within 72 hours of paracetamol).
Antipsychotics: enhanced sedative and hypotensive effects
Sodium oxybate: concomitant administration of codeine and sodium oxybate may cause
increased CNS depression and/or respiratory depression and/or hypotension.
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 Tc99m disofenin as opioid treatment may cause
constriction of the Sphincter of Oddi and increases biliary tract pressure.
Fertility, pregnancy and lactation
Codeine crosses the placenta. There is no adequate evidence of safety in human pregnancy
and a possible association with respiratory and cardiac malformations has been reported.
Regular use during pregnancy may cause physical dependence in the foetus leading to
withdrawal symptoms in the neonate. Use during pregnancy should be avoided if possible.
Use of opioid analgesia during labour may cause respiratory depression in the neonate,
especially the premature neonate. These agents should not be given during the delivery of a
Opioid analgesics may cause gastric stasis during labour, increasing the risk of inhalation
pneumonia in the mother.
There is epidemiological evidence of safety in human pregnancy when paracetamol is used
in normal stated dosages.
Paracetamol is excreted in breast milk but not in clinically significant quantities.
Codeine should not be used during breastfeeding (see section 4.3).
At normal therapeutic doses codeine and its active metabolite 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.
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.
Effects on ability to drive and use machines
Codeine may cause drowsiness, changes in vision, including blurred or double vision. If
affected patients should be advised not to drive or operate machinery. The effects of
alcohol are enhanced by opioid analgesics.
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’)
- The medicine has been prescribed to treat a medical or dental problem
- You have taken it according to the instructions given by the prescriber and
in the information provided with the medicine and
- It was not affecting your ability to drive safely
The frequency and severity of side effects 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
Prolonged use of a painkiller for headaches can make them worse.
Tolerance and some of the most common side effects – drowsiness, nausea and vomiting,
and confusion – generally develops with long term use.
Immune system disorders: maculopapular rash has been seen as part of a hypersensitivity
syndrome associated with oral codeine phosphate; fever, splenomegaly and
lymphadenopathy also occurred.
Endocrine disorders: hyperglycaemia
Metabolism and nutrition disorders: anorexia
Psychiatric disorders: hallucinations, nightmares, confusion, restlessness, mood changes,
mental depression, dysphoria, euphoria (The euphoric activity of codeine may lead to its
abuse and dependence).
Nervous system disorders: convulsions (especially in infants and children), dizziness,
headache, drowsiness, light-headedness.
Eye disorders: miosis, blurred or double vision, other visual disturbances
Ear and labyrinth disorders: vertigo
Cardiac disorders: orthostatic hypotension, palpitations, tachycardia and bradycardia
Vascular disorders: Postural hypotension, facial flushing. Large doses produce hypotension.
Respiratory, thoracic and mediastinal disorders: dyspnoea, larger doses produce respiratory
Gastrointestinal disorders: nausea, vomiting, constipation, dry mouth and stomach cramps.
There have been very rare occurrences of pancreatitis.
Hepatobiliary disorders: biliary spasm (may be associated with altered liver enzyme values)
Skin and subcutaneous tissue disorders: allergic reactions such as urticaria, pruritus, skin
rash, sweating and facial oedema.
Musculoskeletal and connective tissue disorders: uncontrolled muscle movements, muscular
rigidity may occur after high doses.
Renal and urinary disorders: urinary retention, uretic spasm, difficulties in micturition
(dysuria, increased frequency, decrease in amount) An antidiuretic effect may also occur
Reproductive system and breast disorders: sexual dysfunction, erectile dysfunction,
decreased potency, decreased libido.
General disorders and administration site conditions: malaise, tiredness, hypothermia.
The paracetamol component of Co-codamol 30/500 mg Tablets is relatively free of sideeffects but immune system disorders, hypersensitivity including skin rash, urticaria,
anaphylactic shock or angioedema may occur. Very rare cases of serious skin reactions such
as Toxic Epidermal Necrolysis (TEN), Stevens-Johnson syndrome (SJS), acute generalized
exanthematous pustulosis, fixed drug eruption have been reported.
Haematological side-effects including thrombocytopenia, agranulocytosis, neutropenia,
pancytopenia and leucopenia have occurred in isolated cases, but these were not necessarily
causally related to paracetamol.
Renal damage may occur rarely with long term use.
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.
Symptoms of paracetamol overdosage in the first 24 hours are sweating, 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, hypotension, cerebral oedema, coma and death. Prothrombin time may
increase with deteriorating liver function.
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.
Liver damage is possible in adults who have taken 10 g or more of paracetamol. It is
considered that excess quantities of a toxic metabolite (usually adequately detoxified by
glutathione when normal doses of Paracetamol are ingested), become irreversibly bound
to liver tissue.
Ingestion of 5g or more of paracetamol may lead to liver damage if the patient has any of
the following risk factors:
a) is on long term treatment with carbamazepine, phenobarbital, phenytoin,
primidone, rifampicin, St John’s Wort or other drugs that induce liver enzymes.
b) regularly consumes ethanol in excess of recommended amounts
c) is likely to be gluathine deplete e.g. eating disorders, cystic fibrosis, HIV, infection,
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 and any patient who has ingested around 7.5 g or more of
paracetamol in the proceeding 4 hours should undergo gastric lavage.. 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 at least 48 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 serious hepatic dysfunction beyond 24h
from ingestion should be discussed with the NPIS or a liver unit.
The effects in overdosage will be potentiated by simultaneous ingestion of alcohol and
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.
Symptoms of codeine overdosage include cold clammy skin, skeletal muscle flaccidity,
confusion, convulsions, dizziness, drowsiness, nervousness or restlessness, miosis,
bradycardia, dyspnoea, unconsciousness, circulatory failure and deepening coma. Nausea
and vomiting are common. Hypotension and tachycardia are possible but unlikely.
In severe overdose with codeine, apnoea, circulatory collapse, cardiac arrest and death may
occur (from respiratory failure).
This should include general symptomatic and supportive measures including a clear
airway and the institution of controlled ventilation 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. Oxygen, intravenous fluids, vasopressors
and other supportive measures should be employed as indicated.
Intensive support therapy may be required to correct respiratory failure and shock due to
the effects of codeine. In addition the specific narcotic antagonist, naloxone
hydrochloride, may be used to rapidly counteract the severe respiratory depression and
coma. Naloxone has a short half-life so large and repeated doses may be required in a
seriously poisoned patient. A dose of 0.4-2 mg is given intravenously or intramuscularly
to adults, this is repeated at intervals of 2-3 minutes if necessary. Up to a total of 10 mg
of naloxone may be given. In children doses of naloxone of 5-10 mcg/kg bodyweight
may be given intravenously or intramuscularly. Observe for at least four hours after
ingestion, or eight hours if a sustained release preparation has been taken.
Codeine is not dialysable.
Paracetamol has analgesic and antipyretic actions.
Codeine phosphate is an analgesic of the opioid class. Opioid analgesics bind with
stereospecific receptors at many sites within the CNS to alter processes affecting both the
perception of pain and the emotional response to it. It has been hypothesised that alterations
in release of various neurotransmitters from afferent nerves sensitive to painful stimuli may
be partially responsible for the analgesic effect.
Codeine is a centrally acting weak analgesic. Codeine exerts its effect through µ 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.
The drugs are additive and some workers suggest there may be synergy between the
Paracetamol is readily absorbed from the gastro-intestinal tract with peak plasma
levels occurring about 30 minutes to 2 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 unchanged.
The elimination half-life of paracetamol varies from about 1 to 4 hours. Plasma
protein binding is negligible at usual therapeutic doses.
Codeine phosphate is absorbed from the gastrointestinal tract and peak plasma
concentrations occur after about one hour. Codeine is metabolised by O-and Ndemethylation in the liver to morphine, and norcodeine and other metabolites. Codeine
and its metabolites are excreted almost entirely by the kidney, mainly as conjugates with
glucuronic acid. Most of the excretion products appear in the urine within six hours and
up to 80% 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.
Codeine is not extensively bound to plasma proteins. The plasma half-life varies from
about 3 to 4 hours.
Preclinical safety data
Both actives have been in clinical use separately and in combination products for many
years. Preclinical data has therefore been superseded by clinical data.
List of Excipients
Each tablet contains
Colloidal anhydrous silica
Special precautions for storage
Do not store above 25°C. Store in the original package.
Nature and contents of container
Blister pack strips, constructed from 250 micron PVC film lidded with aluminium foil
containing 10, 20, 30, 50 or 100 tablets per strip.
Instruction for use and handling
MARKETING AUTHORISATION HOLDER
M & A Pharmachem Ltd
Bolton BL5 2AL
MARKETING AUTHORISATION NUMBER
DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
16 August 2004
DATE OF REVISION OF THE TEXT