Codeine Phosphate Syrup Product Monograph

1 INDICATIONS

CODEINE PHOSPHATE SYRUP is indicated for the symptomatic treatment of mild to moderate pain.

1.1 Pediatrics

Pediatrics < 12 years of age: Regardless of clinical setting, the use of codeine is contraindicated in patients 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 CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS, Special Populations, Pediatrics; also, DOSING AND ADMINISTRATION)

Pediatrics (12 - 18 years of age): The safety and efficacy of CODEINE PHOSPHATE SYRUP has not been studied in the pediatric population. Therefore, the use of CODEINE PHOSPHATE SYRUP is not recommended in patients over 12 and under 18 years of age.

1.2 Geriatrics

Geriatrics >65 years of age: Evidence from clinical studies and experience suggests that use in the geriatric population is associated with differences in safety or effectiveness. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, concomitant disease or other drug therapy (see ACTION AND CLINICAL PHARMACOLOGY, Special Populations and Conditions, Geriatrics).

2 CONTRAINDICATIONS

CODEINE PHOSPHATE SYRUP is contraindicated in patients who are hypersensitive to this drug or to any ingredient in the formulation, including any non-medicinal ingredient, or component of the container. For a complete listing, see DOSAGE FORMS, STRENGTHS, COMPOSITION AND PACKAGING.

• Patients who are hypersensitive to the active substance codeine phosphate or other opioid analgesics or to any ingredient in the formulation. For a complete listing, see DOSAGE FORMS, COMPOSITION AND PACKAGING.
• In patients with known or suspected mechanical gastrointestinal obstruction (e.g., bowel obstruction or strictures) or any diseases/conditions that affect bowel transit (e.g., ileus of any type).
• Patients with suspected surgical abdomen (e.g., acute appendicitis or pancreatitis).
• Patients with mild pain that can be managed with other pain medications.
• Patients with acute or severe bronchial asthma, chronic obstructive airway, or status asthmaticus.
• Patients with acute respiratory depression, elevated carbon dioxide levels in the blood and cor pulmonale.
• Patients with acute alcoholism, delirium tremens, and convulsive disorders.
• Patients with severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury.
• CYP2D6 ultra-rapid metabolizers who convert codeine into its active metabolite more rapidly and completely than other people (see WARNINGS AND PRECAUTIONS, Risk of Death in Ultra-Rapid Metabolizers of Codeine; SYMPTOMS AND TREATMENT OF OVERDOSAGE, Codeine)
• Patients taking monoamine oxidase (MAO) inhibitors (or within 14 days of such therapy).

• Women who are breast-feeding, pregnant or during labour and delivery (see SERIOUS

  WARNINGS AND PRECAUTIONS, and WARNINGS AND PRECAUTIONS).

• Pediatric patients <12 years of age
• Pediatric patients (<18 years of age) who have undergone tonsillectomy and/or adenoidectomy for obstructive sleep apnoea syndrome

3 SERIOUS WARNINGS AND PRECAUTIONS BOX

Serious Warnings And Precautions

Limitations of Use

Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the risks of overdose and death with immediate release opioid formulations, CODEINE PHOSPHATE SYRUP should only be used in patients for whom alternative treatment options (e.g., non-opioid analgesics) are ineffective, not tolerated, or would be otherwise inadequate to provide appropriate management of pain (see DOSAGE AND ADMINISTRATION).

Addiction, Abuse, and Misuse

CODEINE PHOSPHATE SYRUP poses risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Each patient’s risk should be assessed prior to prescribing CODEINE PHOSPHATE SYRUP, and all patients should be monitored regularly for the development of these behaviours or conditions (see WARNINGS AND PRECAUTIONS). CODEINE PHOSPHATE SYRUP should be stored securely to avoid theft or misuse.

Life-threatening Respiratory Depression: OVERDOSE

Serious, life-threatening, or fatal respiratory depression may occur with use of CODEINE PHOSPHATE SYRUP. Infants exposed in-utero or through breast milk are at risk of life-threatening respiratory depression upon delivery or when nursed. Patients should be monitored for respiratory depression, especially during initiation of CODEINE PHOSPHATE SYRUP or following a dose increase. Further, instruct patients of the hazards related to taking opioids including fatal overdose.

Accidental Exposure

Accidental ingestion of even one dose of CODEINE PHOSPHATE SYRUP, especially by children, can result in a fatal overdose of Codeine phosphate (see DOSAGE AND ADMINISTRATION, Disposal, for instructions on proper disposal).

Neonatal Opioid Withdrawal Syndrome

Prolonged maternal use of CODEINE PHOSPHATE SYRUP during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening (see

WARNINGS AND PRECAUTIONS).

Interaction with Alcohol

The co-ingestion of alcohol with CODEINE PHOSPHATE SYRUP should be avoided as it may result in dangerous additive effects, causing serious injury or death (see WARNINGS AND PRECAUTIONS and DRUG INTERACTIONS).

Risks From Concomitant Use With Benzodiazepines Or Other CNS Depressants 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 (see WARNINGS AND PRECAUTIONS, Neurologic and DRUG INTERACTIONS).

• Reserve concomitant prescribing of CODEINE PHOSPHATE SYRUP and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate.
• Limit dosages and durations to the minimum required.
• Follow patients for signs and symptoms of respiratory depression and sedation.

4 DOSAGE AND ADMINISTRATION

CODEINE PHOSPHATE SYRUP should only be used in patients for whom alternative treatment options are ineffective or not tolerated (e.g., non-opioid analgesics) or would be otherwise inadequate to provide appropriate management of pain (see DOSAGE AND ADMINISTRATION)

For acute pain, it is recommended that CODEINE PHOSPHATE SYRUP be used for a maximum of 7 days at the lowest dose that provides adequate pain relief.

All doses of opioids carry an inherent risk of fatal or non-fatal adverse events. This risk is increased with higher doses. The maximum recommended daily dose of CODEINE PHOSPHATE SYRUP is 480 mg (72 morphine milligram equivalent). Each patient should be assessed for their risk prior to prescribing CODEINE PHOSPHATE SYRUP, as the likelihood of experiencing serious adverse events can depend upon the type of opioid, duration of treatment, level of pain as well as the patient’s own level of tolerance. In addition, the level of pain should be assessed routinely to confirm the most appropriate dose and the need for further use of CODEINE PHOSPHATE SYRUP (see DOSAGE AND ADMINISTRATION - Adjustment or reduction of Dosage).

4.1 Dosing Considerations

• CODEINE PHOSPHATE SYRUP should be used with caution within 12 hours pre-operatively and within the first 12-24 hours post-operatively (see WARNINGS AND PRECAUTIONS, Peri-operative Considerations).
• CODEINE PHOSPHATE SYRUP is not indicated for rectal administration.
• CODEINE PHOSPHATE SYRUP may be taken with or without food with a glass of water.
• The dose initiation should follow a conservative approach in certain patients such as the debilitated and those with severe impairment of hepatic or renal function, hypothyroidism, Addison’s disease, prostatic hypertrophy or urethral stricture. The recommended adult starting dose in these patients should be at 1/3 to 1/2 the usual starting dose followed by careful dose titration to adequate pain control according to their

4.2 Recommended Dose and Dosage Adjustment

Individual dosing requirements vary considerably based on each patient's age, weight, severity of pain, and medical and analgesic history.

Codeine, including CODEINE PHOSPHATE SYRUP, should be prescribed at the lowest effective dose for the shortest period of time.

Adults: 3 to 12 mL every 3 to 6 hours as necessary.

Children under 12 years of age: Codeine is contraindicated in children less than 12 years old because of the risk of opioid toxicity due to the variable and unpredictable metabolism of codeine to morphine (see INDICATIONS) (see CONTRAINDICATIONS).

Patients Not Receiving Opioids at the Time of Initiation of Codeine Treatment: The usual initial adult dose is 15 to 30 mg, orally, every 4 to 6 hours as necessary.

Patients Currently Receiving Opioids: For patients who are currently receiving other opioids, please refer to the following table to determine the approximate analgesic equivalences of various opioid analgesics.

Conversion ratios for opioids are subject to variations in kinetics governed by genetics and other factors. When switching from one opioid to another, consider reducing the calculated dose by 25-50% to minimize the risk of overdose. Subsequently, up-titrate the dose, as required, to reach the appropriate maintenance dose.

Opioid conversion table

Opioids

To convert to oral morphine equivalent,

multiply by:

To convert from oral morphine, multiply

by:

90 MED Equivalent dose

Morphine 1 1 90 mg/d Codeine 0.15 6.67 600 mg/d Hydromorphone 5.0 0.2 18 mg/d Oxycodone 1.5 0.667 60 mg/d Tapentadol 0.3 - 0.4 2.5 - 3.33 300 Tramadol 0.1 - 0.2 6 *** Methadone Morphine dose equivalence is not reliably established *** The maximum recommended daily dose of tramadol is 300 mg - 400 mg depending on the formulation.

Busse J. The 2017 Canadian guideline for opioids for chronic non-cancer pain. Hamilton (ON): McMaster University; 2017

Geriatrics: Respiratory depression has occurred in the elderly following administration of large initial doses of opioids to patients who were not opioid-tolerant or when opioids were co-administered with other agents that can depress respiration. CODEINE PHOSPHATE SYRUP should be initiated at a low dose and slowly titrated to effect (see WARNINGS AND PRECAUTIONS and ACTION AND CLINICAL PHARMACOLOGY).

Use with Non-Opioid Medications: If a non-opioid analgesic is being provided, it may be continued. If the non-opioid is discontinued, consideration should be given to increasing the opioid dose to compensate for the non-opioid analgesic. CODEINE PHOSPHATE SYRUP can be safely used concomitantly with usual doses of other non-opioid analgesics.

Dose Titration: Dose titration is the key to success with opioid analgesic therapy. Proper optimization of doses scaled to the relief of the individual's pain should aim at administration of the lowest dose which will achieve the overall treatment goal of satisfactory pain relief with acceptable side effects.

Dosage adjustments should be based on the patient's clinical response.

Adjustment or Reduction of Dosage: Physical dependence with or without psychological dependence tends to occur with chronic administration of opioids, including CODEINE PHOSPHATE SYRUP. Withdrawal (abstinence) symptoms may occur following abrupt discontinuation of therapy. These symptoms may include body aches, diarrhea, gooseflesh, loss of appetite, nausea, nervousness or restlessness, runny nose, sneezing, tremors or shivering, stomach cramps, tachycardia, trouble with sleeping, unusual increase in sweating, palpitations, unexplained fever, weakness and yawning.

Following successful relief of moderate to severe pain, periodic attempts to reduce the opioid dose should be made. Smaller doses or complete discontinuation may become feasible due to a change in the patient’s condition or mental state. Patients on prolonged therapy should be withdrawn gradually from the drug if it is no longer required for pain control. In patients who are appropriately treated with opioid analgesics and who undergo gradual withdrawal for the drug, these symptoms are usually mild (see WARNINGS AND PRECAUTIONS). Tapering should be individualised and carried out under medical supervision.

Patient should be informed that reducing and/or discontinuing opioids decreases their tolerance to these drugs. If treatment needs to be re-initiated, the patient must start at the lowest dose and titrate up to avoid overdose.

4.3 Administration

CODEINE PHOSPHATE SYRUP must be taken orally.

4.4 Missed Dose

If the patient forgets to take one or more doses, they should take their next dose at the next scheduled time and in the normal amount.

4.5 Disposal

CODEINE PHOSPHATE SYRUP should be kept in a safe place, out of the sight and reach of children before, during and after use. CODEINE PHOSPHATE SYRUP should not be used in front of children, since they may copy these actions.

CODEINE PHOSPHATE SYRUP should never be disposed of in household trash. Disposal via a pharmacy take back program is recommended. Unused or expired CODEINE PHOSPHATE SYRUP should be properly disposed of as soon as it is no longer needed to prevent accidental exposure to others, including children or pets. If temporary storage is required before disposal, a sealed child-proof container, such as a biohazard waste container or a lockable medication box could be obtained from a pharmacy.

5 OVERDOSAGE

For management of a suspected drug overdose, contact your regional poison control center.

5.1 Symptoms:

Euphoria, dysphoria visual disturbances, hypotension and coma or death from respiratory depression.

5.2 Treatment:

Symptomatic and supportive therapy. Maintain ventilation and administer oxygen as needed. The opioid antagonist naloxone should be administered. If the patient is conscious and has not lost the gag reflex, empty the stomach by inducing emesis with ipecac syrup. If the patient is extremely drowsy, unconscious, convulsing or has no gag reflex, perform gastric lavage. Follow with activate charcoal (50 to 100 g in adults) and a cathartic>

6 DOSAGE FORMS, STRENGTHS, COMPOSITION AND PACKAGING

Table – Dosage Forms, Strengths, Composition and Packaging.

7 WARNINGS AND PRECAUTIONS

General

Patients should be instructed not to give CODEINE PHOSPHATE SYRUP to anyone other than the patient for whom it was prescribed; as such inappropriate use may have severe medical consequences, including death. CODEINE PHOSPHATE SYRUP should be stored securely to avoid theft or misuse.

CODEINE PHOSPHATE SYRUP should only be prescribed by persons knowledgeable in the continuous administration of potent opioids, in the management of patients receiving potent opioids for the treatment of pain, and in the detection and management of respiratory depression, including the use of opioid antagonists.

Patients should be cautioned not to consume alcohol while taking CODEINE PHOSPHATE SYRUP as it may increase the chance of experiencing serious adverse events, including death.

Hyperalgesia that will not respond to a further dose increase of Codeine phosphate can occur at particularly high doses. A Codeine phosphate dose reduction or change in opioid may be required.

Patients should be counselled to discontinue codeine products and to seek urgent medical help at the earliest sign of codeine toxicity including symptoms such as confusion, shallow breathing, or extreme sleepiness which may be life threatening.

Abuse and Misuse

Like all opioids, CODEINE PHOSPHATE SYRUP is a potential drug of abuse and misuse, which can lead to overdose and death. Therefore, CODEINE PHOSPHATE SYRUP should be prescribed and handled with caution.

Patients should be assessed for their clinical risks for opioid abuse or addiction prior to being prescribed opioids. All patients receiving opioids should be routinely monitored for signs of misuse and abuse.

Opioids, such as CODEINE PHOSPHATE SYRUP, should be used with particular care in patients with a history of alcohol and illicit/prescription drug abuse. However, concerns about abuse, addiction, and diversion should not prevent the proper management of pain.

CODEINE PHOSPHATE SYRUP is intended for oral use only.

Use in Drug and Alcohol Addiction

CODEINE PHOSPHATE SYRUP is an opioid with no approved use in the management of addictive disorders. Its proper usage in individuals with drug or alcohol dependence, either active or in remission is for the management of pain requiring opioid analgesia. Patients with a history of addiction to drugs or alcohol may be at higher risk of becoming addicted to CODEINE PHOSPHATE SYRUP; extreme caution and awareness is warranted to mitigate the risk.

Cardiovascular

Codeine phosphate administration may result in severe hypotension in patients whose ability to maintain adequate blood pressure is compromised by reduced blood volume, or concurrent administration of drugs such as phenothiazines and other tranquilizers, sedative/hypnotics, tricyclic antidepressants or general anesthetics. These patients should be monitored for signs of hypotension after initiating or titrating the dose of CODEINE PHOSPHATE SYRUP.

The use of CODEINE PHOSPHATE SYRUP in patients with circulatory shock should be avoided as it may cause vasodilation that can further reduce cardiac output and blood pressure.

Driving and Operating Machinery

Due caution should be exercised when driving or operating a vehicle or potentially dangerous machinery. CODEINE PHOSPHATE SYRUP may impair the mental and/or physical abilities needed for certain potentially hazardous activities such as driving a car or operating machinery. Patients should be cautioned accordingly. Patients should also be cautioned about the combined effects of Codeine phosphate with other CNS depressants, including other opioids, phenothiazine, sedative/hypnotics and alcohol.

Dependence/Tolerance

As with other opioids, tolerance and physical dependence may develop upon repeated administration of CODEINE PHOSPHATE SYRUP and there is a potential for development of psychological dependence.

Physical dependence and tolerance reflect the neuroadaptation of the opioid receptors to chronic exposure to an opioid, and are separate and distinct from abuse and addiction. Tolerance, as well as physical dependence, may develop upon repeated administration of opioids, and are not by themselves evidence of an addictive disorder or abuse.

Patients on prolonged therapy should be tapered gradually from the drug if it is no longer required for pain control. Withdrawal symptoms may occur following abrupt discontinuation of therapy or upon administration of an opioid antagonist. Some of the symptoms that may be associated with abrupt withdrawal of an opioid analgesic include body aches, diarrhea, gooseflesh, loss of appetite, nausea, nervousness or restlessness, anxiety, runny nose, sneezing, tremors or shivering, stomach cramps, tachycardia, trouble with sleeping, unusual increase in sweating, palpitations, unexplained fever, weakness and yawning (see ADVERSE REACTIONS, DOSAGE AND ADMINISTRATION, Adjustment or Reduction of Dosage).

Endocrine and Metabolism

Adrenal Insufficiency: Cases of adrenal insufficiency have been reported with opioid use, more often following greater than one month of use. Presentation of adrenal insufficiency may include non-specific symptoms and signs including nausea, vomiting, anorexia, fatigue, weakness, dizziness, and low blood pressure. If adrenal insufficiency is suspected, confirm the diagnosis with diagnostic testing as soon as possible. If adrenal insufficiency is diagnosed, treat withphysiologic replacement doses of corticosteroids. Wean the patient off of the opioid to allow adrenal function to recover and continue corticosteroid treatment until adrenal function recovers. Other opioids may be tried as some cases reported use of a different opioid without recurrence of adrenal insufficiency. The information available does not identify any particular opioids as being more likely to be associated with adrenal insufficiency.

Gastrointestinal

Constipation: CODEINE PHOSPHATE SYRUP causes a reduction in gastrointestinal motility associated with an increase smooth muscle tone. Constipation is a frequently reported side effect of part of an opioid treatment. Patients should be advised of steps to prevent constipation and consider the prophylactic use of laxatives. You have to be particularly cautious in patients with chronic constipation.

Gastrointestinal transit: Clinical conditions or medical products that cause sudden shortening and marked gastrointestinal transit time may lead to decreased absorption of Codeine phosphate in CODEINE PHOSPHATE SYRUP and may cause withdrawal symptoms in patients with physical dependence on opioids.

Acute abdominal disorders: Opioid administration may overshadow the diagnosis or the clinical course of acute abdominal conditions. Therefore, it is important to make sure that the patient does not show bowel obstruction, or even Ileus, before initiating treatment.

Neonatal Opioid Withdrawal Syndrome (NOWS)

Use of CODEINE PHOSPHATE SYRUP is contraindicated in pregnant women (see CONTRAINDICATIONS). Prolonged maternal use of opioids during pregnancy can result in withdrawal signs in the neonate. Neonatal opioid withdrawal syndrome, unlike opioid withdrawal syndrome in adults, may be life-threatening. Neonatal opioid withdrawal syndrome presents as irritability, hyperactivity and abnormal sleep pattern, high pitched cry, tremor, vomiting, diarrhea and failure to gain weight. The onset, duration, and severity of neonatal opioid withdrawal syndrome vary based on the specific opioid used, duration of use, timing and amount of last maternal use, and rate of elimination of the drug by the newborn.

Neurologic

Interactions with Central Nervous System Depressants (including benzodiazepines and alcohol): CODEINE PHOSPHATE SYRUP should be used with caution and in a reduced dosage during concomitant administration of other opioid analgesics, general anesthetics, phenothiazines andother tranquilizers, sedative-hypnotics, tricyclic antidepressants, antipsychotics, antihistamines, benzodiazepines, centrally-active anti-emetics and other CNS depressants. Respiratory depression, hypotension and profound sedation, coma or death may result. Observational studies have demonstrated that concomitant use of opioid analgesics and benzodiazepines increases the risk of drug-related mortality compared to use of opioid analgesics alone. Because of similar pharmacological properties, it is reasonable to expect similar risk with the concomitant use of other CNS depressant drugs with opioid analgesics (see DRUG INTERACTIONS). If the decision is made to prescribe a benzodiazepine or other CNS depressant concomitantly with an opioid analgesic, prescribe the lowest effective dosages and minimum durations of concomitant use. In patients already receiving an opioid analgesic, prescribe a lower initial dose of the benzodiazepine or other CNS depressant than indicated in the absence of an opioid, and titrate based on clinical response. If an opioid analgesic is initiated in a patient already taking a benzodiazepine or other CNS depressant, prescribe a lower initial dose of the opioid analgesic, and titrate based on clinical response. Follow patients closely for signs and symptoms of respiratory depression and sedation.

Advise both patients and caregivers about the risks of respiratory depression and sedation when CODEINE PHOSPHATE SYRUP is used with benzodiazepines or other CNS depressants (including alcohol and illicit drugs). Advise patients not to drive or operate heavy machinery until the effects of concomitant use of the benzodiazepine or other CNS depressant have been determined. Screen patients for risk of substance use disorders, including opioid abuse and misuse, and warn them of the risk for overdose and death associated with the use of additional CNS depressants including alcohol and illicit drugs (see DRUG INTERACTIONS).

CODEINE PHOSPHATE SYRUP should not be consumed with alcohol as it may increase the chance of experiencing dangerous side effects, including death (see CODEINE PHOSPHATE SYRUP and ADVERSE REACTIONS, Sedation, and DRUG INTERACTIONS).

Severe pain antagonizes the subjective and respiratory depressant actions of opioid analgesics. Should pain suddenly subside, these effects may rapidly become manifest.

Serotonin Syndrome: CODEINE PHOSPHATE SYRUP could cause a rare but potentially life-threatening condition resulting from concomitant administration of serotonergic drugs (e.g. anti-depressants, migraine medications). Treatment with the serotoninergic drug should be discontinued if such events (characterized by clusters of symptoms such as hyperthermia, rigidity, myoclonus, autonomic instability with possible rapid fluctuations of vital signs, mental status changes including confusion, irritability, extreme agitation progressing to delirium and coma) occur and supportive symptomatic treatment should be initiated. CODEINE PHOSPHATE SYRUP should not be used in combination with MAO inhibitors or serotonin-precursors (such as L-tryptophan, oxitriptan) and should be used with caution in combination with other serotonergic drugs (triptans, certain tricyclic antidepressants, lithium, tramadol, St. John’s Wort) due to the risk of serotonergic syndrome (see DRUG INTERACTIONS).

Head Injury: The respiratory depressant effects of Codeine phosphate, and the capacity to elevate cerebrospinal fluid pressure, may be greatly increased in the presence of an already elevated intracranial pressure produced by trauma. Also, Codeine phosphate may produce confusion, miosis, vomiting and other side effects which obscure the clinical course of patients with head injury. In such patients, codeine phosphate must be used with extreme caution and only if it is judged essential (see CONTRAINDICATIONS).

Peri-Operative Considerations

CODEINE PHOSPHATE SYRUP is not indicated for pre-emptive analgesia (administration pre-operatively for the management of post-operative pain).

In the case of planned chordotomy or other pain-relieving operations, patients should not be treated with CODEINE PHOSPHATE SYRUP for at least 24 hours before the operation and CODEINE PHOSPHATE SYRUP should not be used in the immediate post-operative period.

Physicians should individualize treatment, moving from parenteral to oral analgesics as appropriate. Thereafter, if CODEINE PHOSPHATE SYRUP is to be continued after the patient recovers from the post-operative period; a new dosage should be administered in accordance with the changed need for pain relief. The risk of withdrawal in opioid-tolerant patients should be addressed as clinically indicated.

The administration of analgesics in the peri-operative period should be managed by healthcare providers with adequate training and experience (e.g., by an anesthesiologist).

Codeine phosphate and other morphine-like opioids have been shown to decrease bowel motility. Ileus is a common post-operative complication, especially after intra-abdominal surgery with opioid analgesia. Caution should be taken to monitor for decreased bowel motility in post- operative patients receiving opioids. Standard supportive therapy should be implemented.

CODEINE PHOSPHATE SYRUP should not be used in the early post-operative period (12 to 24 hours post- surgery) unless the patient is ambulatory and gastrointestinal function is normal.

Renal

Codeine should be given with caution and the initial dose should be reduced in certain patients such as the debilitated and those with severe impairment of hepatic or renal function, hypothyroidism, Addison’s disease, prostatic hypertrophy or urethral stricture (see DOSAGE AND ADMINISTRATION)

Respiratory

Respiratory Depression: Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression from opioid use, if not immediately recognized and treated, may lead to respiratory arrest and death. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical status. Codeine phosphate should be used with extreme caution in patients with substantially decreased respiratory reserve, pre- existing respiratory depression, hypoxia or hypercapnia (see CONTRAINDICATIONS). While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of CODEINE PHOSPHATE SYRUP, the risk is greatest during the initiation of therapy or following a dose increase. Patients should be closely monitored for respiratory depression when initiating therapy with CODEINE PHOSPHATE SYRUP and following dose increases.

Life-threatening respiratory depression is more likely to occur in the elderly, cachectic, or debilitated patients because they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients.

To reduce the risk of respiratory depression, proper dosing and titration of CODEINE PHOSPHATE SYRUP are essential. Overestimating the CODEINE PHOSPHATE SYRUP dose when converting patients from another opioid product can result in a fatal overdose with the first dose. In these patients, the use of non-opioid analgesics should be considered, if feasible (see WARNINGS AND PRECAUTIONS, Special Populations, Special Risk Groups, and DOSAGE AND ADMINISTRATION).

Respiratory depression and death have occurred in children who received codeine in the postoperative period following tonsillectomy and/or adenoidectomy and had evidence of being ultra-rapid metabolizers of codeine (i.e., multiple copies of the gene for cytochrome P450 isoenzyme 2D6 or high morphine concentrations). Children with obstructive sleep apnea who are treated with codeine for post-tonsillectomy and/or adenoidectomy pain may be particularly sensitive to the respiratory depressant effects of codeine that has been rapidly metabolized to morphine. Codeine-containing products are contraindicated for post-operative pain management in all pediatric patients undergoing tonsillectomy and/or adenoidectomy for obstructive sleep apnoea syndrome (see CONTRAINDICATIONS).

Use in Patients with Chronic Pulmonary Disease: Monitor patients with significant chronic obstructive pulmonary disease or cor pulmonale, and patients having a substantially decreased respiratory reserve, hypoxia, hypercapnia, or preexisting respiratory depression for respiratory depression, particularly when initiating therapy and titrating with CODEINE PHOSPHATE SYRUP, as in these patients, even usual therapeutic doses of CODEINE PHOSPHATE SYRUP may decrease respiratory drive to the point of apnea. In these patients, use of alternative non-opioid analgesics should be considered, if possible. The use of CODEINE PHOSPHATE SYRUP is contraindicated in Patients with acute or severe bronchial asthma, chronic obstructive airway, or status asthmaticus (see CONTRAINDICATIONS).

Risk of Death in Ultra-Rapid Metabolizers of Codeine

Some individuals may be ultra-rapid metabolizers due to a specific CYP2D6*2x2 genotype. These individuals convert codeine into its active metabolite, morphine, more rapidly and completely than other people. This rapid conversion results in higher than expected serum morphine levels. Even at labelled dosage regimens, individuals who are ultra-rapid metabolizers may have life-threatening or fatal respiratory depression or experience overdose symptoms such as extreme sleepiness, confusion, or shallow breathing. . (See also Labour, Delivery and Nursing Women in Special Populations).

The prevalence of this CYP2D6 phenotype varies widely and has been estimated at 0.5 to 1% in Chinese and Japanese, 0.5 to 1% in Hispanics, 1 to 10% in Caucasians, 3% in African Americans, and 16 to 28% in North Africans, Ethiopians, and Arabs. Data are not available for other ethnic groups. When physicians prescribe codeine-containing drugs, they should choose the lowest effective dose for the shortest period of time and inform their patients about these risks and the signs of morphine overdose (see DOSAGE AND ADMINISTRATION, Dosing Considerations).

Sensitivity/Resistance

Pruritus, urticaria, other skin rashes, edema, diaphoresis, wheal and flare over the vein with i.v. injection. Because of close structural similarities, patients exhibiting systemic allergy to morphine (e.g., generalized rash, shortness of breath) should not receive codeine, diamorphine, hydromorphone, oxycodone or oxymorphone.

Sexual Health

Long-term use of opioids may be associated with decreased sex hormone levels and symptoms such as low libido, erectile dysfunction, or infertility (see ADVERSE REACTIONS, Post- Marketing Experience).

7.1 Special Populations

7.1.1 Pregnant Women

Pregnant Women: Studies in human have not been conducted. CODEINE PHOSPHATE SYRUP crosses the placental barrier and is contraindicated in pregnant women and during labour and delivery. Women of childbearing potential who become or are planning to become pregnant should be advised to consult a physician prior to initiating or continuing therapy with CODEINE PHOSPHATE SYRUP.

Prolonged maternal use of opioids during pregnancy can result in withdrawal signs in the neonate. Neonatal Opioid Withdrawal Syndrome (NOWS), unlike opioid withdrawal syndrome in adults, may be life-threatening (see WARNINGS AND PRECAUTIONS, Neonatal Opioid Withdrawal Syndrome, ADVERSE REACTIONS, Post-marketing Experience).

Pregnant women using opioids should not discontinue their medication abruptly as this can cause pregnancy complication such as miscarriage or still-birth. Tapering should be slow and under medical supervision to avoid serious adverse events to the fetus.

Labour and Delivery and Nursing Women: Life-threatening respiratory depression can occur in the infant if opioids are administered to the mother. Naloxone, a drug that counters the effects of opioids, should be readily available if CODEINE PHOSPHATE SYRUP is used in this population.

7.1.2 Breast-feeding

Since opioids can cross the placental barrier and are excreted in breast milk, CODEINE PHOSPHATE SYRUP is not recommended to be used in nursing women and during labour and delivery unless, in the judgement of the physician, the potential benefits outweigh the risks. Life-threatening respiratory depression can occur in the infant if opioids are administered to the mother. Naloxone, a drug that counters the effects of opioids, should be readily available if CODEINE PHOSPHATE SYRUP is used in this population.

Codeine is secreted into human milk. In women with normal codeine metabolism (normal CYP2D6 activity), the amount of codeine secreted into human milk is low and dose-dependent. However, some women are ultra-rapid metabolisers of codeine (see CONTRAINDICATIONS, Ultra-Rapid Metabolisers of Codeine; and WARNINGS AND PRECAUTIONS, Risk of Death in Ultra-rapid Metabolizers of Codeine). These women achieve higher-than-expected serum levels of codeine’s active metabolite, morphine, leading to higher-than-expected levels of morphine in breast milk and potentially dangerously high serum morphine levels in their breast-fed infants. Therefore, maternal use of codeine can potentially lead to serious adverse reactions, including death in nursing infants.

Since there is a risk of infant exposure to codeine and morphine through breast milk, CODEINE PHOSPHATE SYRUP is contraindicated in breast-feeding. Prescribers should closely monitor mother-infant pairs and notify treating pediatricians about any use of codeine during breast-feeding.

7.1.3 Pediatrics

Pediatrics (<12 years of age): Regardless of clinical setting; the use of codeine is contraindicated in patients 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

CONTRAINDICATIONS).

Pediatrics (12-18 years of age): The safety and efficacy of codeine has not been studied in the pediatric population. Therefore, use of codeine is not recommended in patients over 12 and under 18 years of age.

7.1.4 Geriatrics

In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range and titrate slowly, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy (see DOSAGE AND ADMINISTRATION and ACTION AND CLINICAL PHARMACOLOGY, Special Populations and Conditions, Geriatrics).

7.1.5 Special Risk Groups

Codeine phosphate should be administered with caution to patients with a history of alcohol and drug abuse and in a reduced dosage to debilitated patients, and in patients with severely impaired pulmonary function, Addison’s disease, hypothyroidism, myxedema, toxic psychosis, prostatic hypertrophy or urethral stricture.

7.1.6 Patients with Hepatic and/or Renal Impairment

Codeine should be given with caution and the initial dose should be reduced in certain patients such as the debilitated and those with severe impairment of hepatic or renal function, hypothyroidism, Addison’s disease, prostatic hypertrophy or urethral stricture (see DOSAGE AND ADMINISTRATION.

8 ADVERSE REACTIONS

8.1 Adverse Reaction Overview

Adverse effects of CODEINE PHOSPHATE SYRUP are similar to those of other opioid analgesics, and represent an extension of pharmacological effects of the drug class. The major hazards of opioids include respiratory and central nervous system depression and to a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest.

The most frequently observed adverse effects of CODEINE PHOSPHATE SYRUP are: Sedation, nausea and vomiting, constipation and sweating. These effects seem to be more prominent in ambulatory patients and in those not experiencing severe pain. In such individuals, lower doses are advisable. Some adverse reactions may be alleviated if the patient lies down.

Sedation: Sedation is a common side effect of opioid analgesics, especially in opioid naïve individuals. Sedation may also occur partly because patients often recuperate from prolonged fatigue after the relief of persistent pain. Most patients develop tolerance to the sedative effects of opioids within three to five days and, if the sedation is not severe, will not require any treatment except reassurance. If excessive sedation persists beyond a few days, the dose of the opioid should be reduced and alternate causes investigated. Some of these are: concurrent CNS depressant medication, hepatic or renal dysfunction, brain metastases, hypercalcemia and respiratory failure. If it is necessary to reduce the dose, it can be carefully increased again after three or four days if it is obvious that the pain is not being well controlled. Dizziness and unsteadiness may be caused by postural hypotension, particularly in elderly or debilitated patients, and may be alleviated if the patient lies down.

Nausea and Vomiting: Nausea is a common side effect on initiation of therapy with opioid analgesics and is thought to occur by activation of the chemoreceptor trigger zone, stimulation of the vestibular apparatus and through delayed gastric emptying. The prevalence of nausea declines following continued treatment with opioid analgesics. When instituting therapy with an opioid for chronic pain, the routine prescription of an antiemetic should be considered. In the cancer patient, investigation of nausea should include such causes as constipation, bowel obstruction, uremia, hypercalcemia, hepatomegaly, tumor invasion of celiac plexus and concurrent use of drugs with emetogenic properties. Persistent nausea which does not respond to dosage reduction may be caused by opioid-induced gastric stasis and may be accompanied by other symptoms including anorexia, early satiety, vomiting and abdominal fullness. These symptoms respond to chronic treatment with gastrointestinal prokinetic agents.

Constipation: Practically all patients become constipated while taking opioids on a persistent basis. In some patients, particularly the elderly or bedridden, fecal impaction may result. It is essential to caution the patients in this regard and to institute an appropriate regimen of bowel management at the start of prolonged opioid therapy. Stimulant laxatives, stool softeners, and other appropriate measures should be used as required. As fecal impaction may present as overflow diarrhea, the presence of constipation should be excluded in patients on opioid therapy prior to initiating treatment for diarrhea.

The following adverse effects occur less frequently with opioid analgesics and include those reported in CODEINE PHOSPHATE SYRUP clinical trials, whether related or not to Codeine phosphate.

Cardiovascular: Supraventricular tachycardia, bradycardia, palpitations, faintness, syncope, postural hypotension and hypertension, and phlebitis following i.v. injection.

Gastrointestinal: Dry mouth, nausea, vomiting, constipation, biliary tract spasm, laryngospasme, anorexia, diarrhea, cramps, dyspepsia, taste alterations.

General and CNS: Drowsiness, sedation, euphoria, dysphoria, weakness, headache, agitation, seizures, uncoordinated muscle movements, alterations of mood, dreams, hallucinations and disorientation, visual disturbances, insomnia, miosis, toxic psychoses. Genitourinary: Urinary retention or hesitance, antidiuretic effect, reduced libido and/or potency.

Respiratory: Codeine, including CODEINE PHOSPHATE SYRUP is not recommended for use in any patient in whom respiratory function might be compromised including neuromuscular disorders, severe cardiac or respiratory conditions, lung infections, multiple trauma or extensive surgical procedures.

Before prescribing medication to suppress or modify cough, it is important to ascertain that the underlying cause of the cough is identified, that modification of the cough does not increase the risk of clinical or physiologic complications, and that appropriate therapy for the primary disease is provided.

Use with extreme caution in patients having an acute asthmatic attack, patients with chronic obstructive pulmonary disease or cor pulmonale, patients having a substantially decreased respiratory reserve and patients with preexisting respiratory depression, hypoxia or hypercapnia. Usual therapeutic doses may decrease respiratory drive while simultaneously, increasing airway resistance to the point of apnea. In patients with asthma or pulmonary emphysema, codeine may, due to its drying action on the respiratory mucusa, increase viscosity of bronchial secretions and suppress the cough reflex.

Use with caution in sedated or debilitated patients, in patients who have undergone thoracotomies or laparotomies, since suppression of the cough reflex may lead to retention of secretions postoperatively in these patients.

The respiratory depressant effects of codeine and its capacity to elevate cerebrospinal fluid pressure may be markedly exaggerated in the presence of head injury or intracranial lesions or pre-existing increase in intracranial pressure. Opioids produce adverse reactions which may obscure the clinical course of a patient with head injuries. In such patients, codeine must be used with extreme caution and only if its use is deemed essential.

Use with caution in patients with seizures as they may be exacerbated or induced by opioids. Use with caution in patients with cardiac arrhythmias due to the cholinergic effects of the drug. Codeine should be given with caution and the initial dose should be reduced in certain patients such as the debilitated and those with severe impairment of hepatic or renal function, hypothyroidism, Addison’s disease, prostatic hypertrophy or urethral stricture.

Hypersensitivity: Pruritus, urticaria, other skin rashes, edema, diaphoresis, wheal and flare over the vein with i.v. injection. Because of close structural similarities, patients exhibiting systemic allergy to morphine (e.g., generalized rash, shortness of breath) should not receive codeine, diamorphine, hydromorphone, oxycodone or oxymorphone.

Nausea and Vomiting: Occur frequently after single doses of narcotics or as an early unwanted effect of regular opioid analgesic therapy.

Withdrawal Syndrome: Physical dependence with or without psychological dependence tends to occur with chronic administration. An abstinence syndrome may be precipitated when an opioid analgesic is abruptly discontinued or opioid antagonists are administered. The following withdrawal symptoms may be observed after abrupt discontinuation of an opioid analgesic: body aches, diarrhea, gooseflesh, loss of appetite, nervousness or restlessness, runny nose, sneezing, tremors or shivering, stomach cramps, nausea, sleep disturbances, unusual increase in sweating and yawning, weakness, tachycardia and unexplained fever. With appropriate medical use and gradual withdrawal from opioid analgesics, these symptoms are usually mild.

Other: Abnormal liver function test results (propoxyphene flushing/warmth).

8.2 Post-Market Adverse Reactions

Androgen deficiency: Chronic use of opioids may influence the hypothalamic-pituitary-gonadal axis, leading to androgen deficiency that may manifest as low libido, impotence, erectile dysfunction, amenorrhea, or infertility. The causal role of opioids in the clinical syndrome of hypogonadism is unknown because the various medical, physical, lifestyle, and psychological stressors that may influence gonadal hormone levels have not been adequately controlled for in studies conducted to date. Patients presenting with symptoms of androgen deficiency should undergo laboratory evaluation.

9 DRUG INTERACTIONS

9.1 Serious Drug Interactions Box

Serious Drug Interactions

Neuromuscular Blocking Agents:

Opioid analgesics may enhance the effects of neuromuscular blocking agents resulting in increased respiratory depression.

9.2 Overview

Interaction with Benzodiazepines and Other Central Nervous System (CNS) Depressants: Due to additive pharmacologic effect, the concomitant use of benzodiazepines or other CNS depressants (e.g. other opioids, sedatives/hypnotics, antidepressants, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, phenothiazines, neuroleptics, antihistamines, antiemetics, and alcohol) and beta-blockers, increases the risk of respiratory depression, profound sedation, coma, and death. Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients closely for signs of respiratory depression and sedation (see WARNINGS AND PRECAUTIONS, Neurologic, Interactions with Central Nervous System Depressants (including benzodiazepines and alcohol) and Psychomotor Impairment). CODEINE PHOSPHATE SYRUP should not be consumed with alcohol as it may increase the chance of experiencing dangerous side effects.

Coadministration of codeine phosphate with a serotonergic agent, such as a Selective Serotonin Re-uptake Inhibitor or a Serotonin Norepinephrine Re-uptake Inhibitor, may increase the risk of serotonin syndrome, a potentially life-threatening condition (see WARNINGS AND PRECAUTIONS).

9.3 Drug-Drug Interactions

Anticholinergics: Concomitant use of drugs with antimuscarinic activity may increase the risk of severe constipation and/or urinary retention.

Cimetidine: Concurrent administration of cimetidine may lead to increased effect or toxicity of opioid analgesics.

CNS Agents: Concomitant administration of other CNS drugs such as sedatives, hypnotics, phenothiazines, anesthetics and alcohol may increase the sedative and depressant effects of opioid analgesics. If the concomitant use of these drugs is considered necessary, their doses should be reduced accordingly.

MAO Inhibitors: Serious adverse reactions have been reported in patients who receive MAO inhibitors with pethidine. Other opioid analgesics should be used with extreme caution, if at all, in patients taking MAO inhibitors (including selegiline) or within 14 days of such therapy.

Opioid Antagonists: Naltrexone and agonist-antagonist opioid analgesics (i.e., pentazocine, nalbuphine, butorphanol) should not be administered to a patient who has received or is receiving a course of therapy with a pure opioid agonist analgesic. In these patients, mixed agonist-antagonists may reduce the analgesic effect or may precipitate withdrawal symptoms.

Other Opioids: The use of more than one opioid agonist at a time is usually inappropriate; additive CNS depressant, respiratory depressant and hypotensive effects may occur if 2 or more agonists are used concurrently. Potentiation of effects may occur with a previously administered long-acting opioid analgesic.

Tricyclic Antidepressants: Tricyclic antidepressants may enhance opioid-induced respiratory depression.

Warfarin: Opioid agonists may potentiate the anticoagulant effects of coumarin anticoagulants.

9.4 Drug-Laboratory Test Interactions

Opioid analgesics may interfere with certain diagnostic procedures, by increasing plasma amylase and lipase concentrations and by increasing CSF pressure. Gastric emptying is delayed by these drugs so gastric emptying studies will not be valid.

9.5 Drug-Lifestyle Interactions

The concomitant use of alcohol should be avoided (see WARNINGS AND PRECAUTIONS, General).

10 ACTION AND CLINICAL PHARMACOLOGY

10.1 Mechanism of Action

Codeine exerts its effect on opiate receptors, primarily in the CNS and smooth muscle. Its effects include: analgesia, respiratory depression, suppression of the cough reflex, decreased gastrointestinal motility. CNS changes and stimulation of the chemoreceptor trigger zone which causes nausea and vomiting.

Central Nervous System: Codeine phosphate produces respiratory depression by direct action on brain stem respiratory centres. The respiratory depression involves both a reduction in the responsiveness of the brain stem centres to increases in CO2 tension and to electrical stimulation.

Codeine phosphate depresses the cough reflex by direct effect on the cough centre in the medulla. Antitussive effects may occur with doses lower than those usually required for analgesia.

Codeine phosphate causes miosis, even in total darkness. Pinpoint pupils are a sign of opioid overdose but are not pathognomonic (e.g., pontine lesions of hemorrhagic or ischemic origin may produce similar findings). Marked mydriasis rather than miosis may be seen with hypoxia in the setting of codeine phosphate overdose.

Gastrointestinal Tract and Other Smooth Muscle: Codeine phosphate causes a reduction in motility associated with an increase in smooth muscle tone in the antrum of the stomach and duodenum. Digestion of food in the small intestine is delayed and propulsive contractions are decreased. Propulsive peristaltic waves in the colon are decreased, while tone may be increased to the point of spasm resulting in constipation. Other opioid-induced effects may include a reduction in gastric, biliary and pancreatic secretions, spasm of the sphincter of Oddi, and transient elevations in serum amylase.

Cardiovascular System: Codeine phosphate may produce release of histamine with or without associated peripheral vasodilation. Manifestations of histamine release and/or peripheral vasodilatation may include pruritus, flushing, red eyes, hyperhidrosis and/or orthostatic hypotension.

Endocrine System: Opioids may influence the hypothalamic-pituitary-adrenal or -gonadal axes. Some changes that can be seen include an increase in serum prolactin, and decreases in plasma cortisol and testosterone. Clinical signs and symptoms may be manifest from these hormonal changes.

Immune System: In vitro and animal studies indicate that opioids have a variety of effects on immune functions, depending on the context in which they are used. The clinical significance of these findings is unknown.

10.2 Pharmacodynamics

Codeine is well absorbed orally and from parenteral sites. Onset of analgesic action occurs in 10 to 30 minutes after parenteral administration or in up to 45 minutes following an oral dose. Peak effect is reached in 30 to 60 minutes after an i.m. or s.c. dose or 1 to 2 hours after oral dosing. Analgesia lasts 4 to 6 hours. Codeine’s antitussive effect peaks within 1 to 2 hours and lasts up to 4 hours. Its plasma half-life is approximately 3 to 4 hours but may be as long as 19 hours in anephric patients. Codeine is approximately 7% bound to plasma protein; its volume of distribution is 2.5 to 3.5 L/kg. It is primarily metabolized by the liver, and its metabolites, some active, are eliminated in the urine. Only a small fraction (0.01) is excreted unchanged.

10.3 Pharmacokinetics

Special Populations and Conditions

Pediatrics: The use of codeine is contraindicated in patients below the age of 12 years due to increased safety concerns (see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS, Special Populations, Pediatrics).

Geriatrics: Elderly patients may be more susceptible to adverse effects, especially respiratory depression and constipation. Caution is advised; the initial dose should be reduced and effects monitored. Elimination and metabolism may be slowed; lower doses or longer dosing intervals may be required.

11 STORAGE, STABILITY AND DISPOSAL

Store between 15 - 30 C.

12 SPECIAL HANDLING INSTRUCTIONS

Not applicable.

PART II: SCIENTIFIC INFORMATION

13 PHARMACEUTICAL INFORMATION

Drug Substance

Proper name: Codeine phosphate

Chemical name: 7,8-Didehydro-4,5α-epoxy-3-methoxy-17-methylmorphinan-

6α-ol phosphate hemihydrate

Molecular formula: C₁₈H₂₁NO₃,H₃PO₄,½H₂O

Molecular mass: 406.4

Structural formula:

https://www.pharmacopoeia.com/bp-2018/monographs/codeine-phosphate.html?date=2018-01-01&text=codeine+phosphate

Physicochemical properties: Hemihydrate, fine, white, needle-shaped crystals; a crystalline powder; odourless, affected by light.

Solubilité: Freely soluble in water, very soluble in hot water, slightly soluble in alcohol, more soluble in boiling alcohol.