Drugs List

Therapeutic Indications

Uses

Relief of severe pain

Administration

For administration by intramuscular or deep subcutaneous injection.

Contraindications

Respiratory depression

Obstructive airways disease

Acute asthma

Raised intracranial pressure

Head injury

Phaeochromocytoma (risk of pressor response to histamine release)

Risk of paralytic ileus

Prostatic hypertrophy

Coma

Children under 1 year

Within 2 weeks of discontinuing MAOIs

Convulsive disorders

Precautions and Warnings

Reduce the dose patients with the following:
Elderly
Debilitated
Hypothyroidism
Chronic hepatic disease
Renal impairment
Hypotension
Adrenal insufficiency

Use with caution in patients with the following conditions:
Asthma (dihydrocodeine may cause histamine release)
Shock
Myasthenia gravis
Obstructive or inflammatory bowel disease
Biliary tract disorders

Pregnancy (see Pregnancy )

Lactation (see Lactation )

Children aged 1 to 4 years (see Dosage - Children ).

Alcohol should be avoided whilst receiving dihydrocodeine.

Dihydrocodeine may cause drowsiness, and so patients should be advised not to drive or operate machinery if affected.

Pregnancy and Lactation

Pregnancy

Use with caution in pregnancy.

There is inadequate evidence of safety in human pregnancy, however dihydrocodeine has been used for many years without apparent ill effects.

Opioids are known to depress neonatal respiration, and withdrawal effects have been seen in infants of dependant mothers.

If administered during labour, gastric stasis and inhalational pneumonia may occur in the mother.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use with caution in lactation.

It is not known whether dihydrocodeine or its metabolites are excreted in breast milk.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Nausea
Vomiting
Constipation
Drowsiness
Difficulty in micturition
Dry mouth
Sweating
Headache
Facial flushing
Vertigo
Postural hypotension
Hallucinations
Mood changes
Miosis
Pruritus
Respiratory depression
Dysphoria
Dependence
Rash
Paralytic ileus
Abdominal pain
Diarrhoea
Seizures
Paraesthesia

Presentation

Solution for injection containing 50mg/ml of dihydrocodeine tartrate

Drugs List

Therapeutic Indications

Uses

Relief of severe pain

Dosage

Dihydrocodeine should be given parenterally when oral administration is not appropriate.

Adults

Elderly

Children

Patients with Renal Impairment

Patients with Hepatic Impairment

Administration

For administration by intramuscular or deep subcutaneous injection.

Contraindications

Respiratory depression

Obstructive airways disease

Acute asthma

Raised intracranial pressure

Head injury

Phaeochromocytoma (risk of pressor response to histamine release)

Risk of paralytic ileus

Prostatic hypertrophy

Coma

Children under 1 year

Within 2 weeks of discontinuing MAOIs

Convulsive disorders

Precautions and Warnings

Reduce the dose patients with the following:
Elderly
Debilitated
Hypothyroidism
Chronic hepatic disease
Renal impairment
Hypotension
Adrenal insufficiency

Use with caution in patients with the following conditions:
Asthma (dihydrocodeine may cause histamine release)
Shock
Myasthenia gravis
Obstructive or inflammatory bowel disease
Biliary tract disorders

Pregnancy (see Pregnancy )

Lactation (see Lactation )

Children aged 1 to 4 years (see Dosage - Children ).

Alcohol should be avoided whilst receiving dihydrocodeine.

Dihydrocodeine may cause drowsiness, and so patients should be advised not to drive or operate machinery if affected.

Pregnancy and Lactation

Pregnancy

Use with caution in pregnancy.

There is inadequate evidence of safety in human pregnancy, however dihydrocodeine has been used for many years without apparent ill effects.

Opioids are known to depress neonatal respiration, and withdrawal effects have been seen in infants of dependant mothers.

If administered during labour, gastric stasis and inhalational pneumonia may occur in the mother.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use with caution in lactation.

It is not known whether dihydrocodeine or its metabolites are excreted in breast milk.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Effects on Ability to Drive and Operate Machinery

This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988 (England and Wales). When prescribing this medicine: Advise patient the medicine can affect cognitive function and is likely to affect ability to drive. Advise patient not to drive until they know how the medicine affects them.

Counselling

Advise patients to avoid alcohol whilst receiving dihydrocodeine.

Advise patients that dihydrocodeine may cause drowsiness, and they should not to drive or operate machinery if affected.

Side Effects

Nausea
Vomiting
Constipation
Drowsiness
Difficulty in micturition
Dry mouth
Sweating
Headache
Facial flushing
Vertigo
Postural hypotension
Hallucinations
Mood changes
Miosis
Pruritus
Respiratory depression
Dysphoria
Dependence
Rash
Paralytic ileus
Abdominal pain
Diarrhoea
Seizures
Paraesthesia

Effects on Laboratory Tests

Opioids may interfere with gastric emptying studies as they delay gastric emptying. Hepatobiliary imaging using technetium Tc 99m disofenin may also be affected as opioid treatment may cause constriction of the sphincter of Oddi and increase biliary tract pressure.

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Shelf Life and Storage

Protect from light.

Further Information

Last Full Review Date: September 2012

Reference Sources

Summary of Product Characteristics: Dihydrocodeine injection. Martindale Pharmaceuticals Ltd. Revised June 2003

Gov.uk. Government departments. Department for Transport. Publications. Drug driving and medicine: advice for healthcare professionals. Drug driving: Guidance for healthcare professionals on drug driving. Available at: https://www.gov.uk Last accessed: 6 January 2015
New drug driving offence implications for medicines packaging. Medicines Regulatory News. 10 December 2013. Available at: https://www.mhra.gov.uk Last accessed: 6 January 2015

NICE Evidence Services Available at: www.nice.org.uk Last accessed: 17 August 2017