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Should Codeine Be Used In Kids? – Case Study

I’m very appreciative of a great guest post that begs the question: Should codeine be used in kids? If you would like to contribute a guest case, please feel free to email me at mededucation101@gmail.com – The case:

Patient ES is a 9 year old male who presents to the clinic with his mother complaining of cough, runny nose, sore throat, and fever at night.

CC:  Cough

PMH:

  • Obesity
  • Hypercholesterolemia
  • Asthma

Allergies: NKDA

Medications:

  • Tylenol 325mg 2 tablets Q6H prn pain
  • Fluticasone propionate 50mcg 1-2 sprays each nostril BID
  • Ventolin 108mcg 1-2 puffs Q4H prn

At the clinic ES was prescribed Cheratussin AC 100-10mg/5ml take 10ml Q4-6H prn for cough

Cheratussin AC is a combination of guaifenesin and codeine used as an antitussive. Guaifenesin acts as an expectorant by loosening and thinning bronchial secretions and phlegm thus making it easier for expulsion via ciliary action.1 Codeine is a weak opioid analgesic, which must be converted by CYP2D6 to morphine to have analgesic properties. However at lower doses, codeine acts as a cough suppressant by depressing the cough reflex in the CNS.   Stimulation of the mu and kappa opioid receptors results in analgesia, but can also lead to adverse effects including respiratory depression.2

Receiving an order for codeine in children should always arouse caution. In April 2015 the European Medicines Agency (EMA) announced that codeine should not be used to treat cough and cold in children under 12 years, and that codeine is not recommended in children and adolescents between 12-18 years who have breathing problems. The FDA is currently considering EMA recommendations, but is yet to make a definitive statement regarding the safety of codeine.3 The product label for Cheratussin AC approves its use in children above the age of 6 years, but prohibits use in children with chronic pulmonary disease or shortness of breath.4

Some things to consider in the case of ES:

  • Asthma management: Considering ES’s medical history and symptoms, his asthma might be cough-variant asthma or allergy related. Regardless, further tests should be performed to assess level of control to determine if his symptoms are appropriately managed by an as-needed rapid-acting Beta2-agonist (Ventolin) or if he needs to step up in therapy with the addition of a low-dose inhaled corticosteroid.

 

  • Use of Cheratussin AC: Considering ES’s asthma status and the risk of respiratory depression associated with codeine, I would recommend against the use of Cheratussin AC as an antitussive. The EMA discourages its use in children less than 12 years and the product label prohibits use in children with chronic pulmonary disease or shortness of breath. Depending on whether the cough is productive or a dry hacking cough, guaifenesin and dextromethorphan respectively provide alternatives. Ultimately I think that ES’s cough is linked to his asthma, and optimizing asthma control would result in reduced severity of symptoms.

Ibrahim Ahsan,  B.Sc. (Hons.)
D’Youville College School of Pharmacy
Pharm.D.  Candidate Class of 2016

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References

  1. Clinical Pharmacology. www.clinicalpharmacology.com. Accessed 12 Feb 2016.
  2. Clinical Pharmacology. www.clinicalpharmacology.com. Accessed 12 Feb 2016.
  3. LexiComp. www.lexi.com. Accessed 12 Feb 2016.
  4. Cheratussin AC package insert. Larken Laboratories, MS: Deltex Pharmaceuticals; 2008.

Written By Eric Christianson

February 21, 2016

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