Drugs List

Therapeutic Indications

Uses

For the treatment of moderate to severe pain

Anti-tussive

Not all strengths or formulations are licensed for all indications

Administration

For oral administration

Contraindications

Acute respiratory depression

Chronic obstructive airways disease

Acute asthma

Raised intracranial pressure

Acute alcoholism

Paralytic ileus and patients at risk of paralytic ileus

Head injury

Children under 1 year of age

Phaeochromocytoma

Biliary colic

Coma

Hepatic failure

Heart failure secondary to lung disease

Within 2 weeks of discontinuing MAOIs

Precautions and Warnings

Not all formulations are licensed for all ages

Not all strengths or formulations are licensed for all indications

Child 1 to 4 years (see Dosage - Children )

Use with caution and reduce dose in the following:
Elderly
Debilitation
Hypothyroidism
Adrenocortical insufficiency
Asthma
Chronic hepatic disease
Severe renal impairment
Hypotension

Breastfeeding (see Lactation)

Pregnancy (see Pregnancy)

History of drug dependence

Prostatic hypertrophy

Inflammatory bowel disease

Convulsive disorders

Shock

Myasthenia gravis

Biliary tract diseases

Reduced respiratory reserve

Urethral stricture

Circulatory failure

There is the potential for drug abuse as with other opioids

Potential for tolerance and dependence to occur

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

Patients should be advised to avoid alcohol.

Patients should be advised not to take this medication for longer than directed.

Patients should be advised that taking this medication regularly for a long time can lead to addiction.

Avoid abrupt withdrawal.

Withdraw gradually in patients who have developed physical dependence, in order to avoid precipitating withdrawal symptoms.

The risk-benefit of continued use should be assessed regularly by the prescriber.

Some formulations contain lactose - use with caution in patients with lactose intolerance, galactosaemia or glucose-galactose malabsorption.

Pregnancy and Lactation

Pregnancy

Use with caution in pregnancy.

There is little published evidence of safety in human pregnancy, however dihydrocodeine has been used for many years without apparent ill effects. Studies in animals have not yet demonstrated any hazard.

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

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 any of 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
Drowsiness
Constipation
Tolerance
Dependence
Dizziness
Vertigo
Confusion
Headache
Mood changes
Hypotension
Tachycardia
Palpitations
Bradycardia
Dry mouth
Biliary spasm
Urinary retention
Difficulty in micturition
Ureteric spasm
Erectile dysfunction
Blurred vision
Double vision
Rash
Pruritus
Urticaria
Sweating
Flushing
Paralytic ileus
Abdominal pain
Diarrhoea
Seizures
Paraesthesia
Muscle rigidity
Hypotension
Respiratory depression
Oedema
Postural hypotension
Hallucinations
Euphoria
Dysphoria
Sleep disturbances
Sexual dysfunction
Miosis
Changes in hepatic enzymes
Addiction
Anaphylaxis
Bronchospasm
Hypothermia
Cough reflex decreased

Presentation

Tablets containing 30mg dihydrocodeine tartrate
Tablets containing 40mg dihydrocodeine tartrate
Elixir containing 10mg/5ml dihydrocodeine tartrate

Drugs List

Therapeutic Indications

Uses

For the treatment of moderate to severe pain

Anti-tussive

Not all strengths or formulations are licensed for all indications

Dosage

Not all formulations are licensed for all ages.

Adults

Elderly

Children

Patients with Renal Impairment

Patients with Hepatic Impairment

Administration

For oral administration

Contraindications

Acute respiratory depression

Chronic obstructive airways disease

Acute asthma

Raised intracranial pressure

Acute alcoholism

Paralytic ileus and patients at risk of paralytic ileus

Head injury

Children under 1 year of age

Phaeochromocytoma

Biliary colic

Coma

Hepatic failure

Heart failure secondary to lung disease

Within 2 weeks of discontinuing MAOIs

Precautions and Warnings

Not all formulations are licensed for all ages

Not all strengths or formulations are licensed for all indications

Child 1 to 4 years (see Dosage - Children )

Use with caution and reduce dose in the following:
Elderly
Debilitation
Hypothyroidism
Adrenocortical insufficiency
Asthma
Chronic hepatic disease
Severe renal impairment
Hypotension

Breastfeeding (see Lactation)

Pregnancy (see Pregnancy)

History of drug dependence

Prostatic hypertrophy

Inflammatory bowel disease

Convulsive disorders

Shock

Myasthenia gravis

Biliary tract diseases

Reduced respiratory reserve

Urethral stricture

Circulatory failure

There is the potential for drug abuse as with other opioids

Potential for tolerance and dependence to occur

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

Patients should be advised to avoid alcohol.

Patients should be advised not to take this medication for longer than directed.

Patients should be advised that taking this medication regularly for a long time can lead to addiction.

Avoid abrupt withdrawal.

Withdraw gradually in patients who have developed physical dependence, in order to avoid precipitating withdrawal symptoms.

The risk-benefit of continued use should be assessed regularly by the prescriber.

Some formulations contain lactose - use with caution in patients with lactose intolerance, galactosaemia or glucose-galactose malabsorption.

Pregnancy and Lactation

Pregnancy

Use with caution in pregnancy.

There is little published evidence of safety in human pregnancy, however dihydrocodeine has been used for many years without apparent ill effects. Studies in animals have not yet demonstrated any hazard.

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

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 any of 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

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

Patients should be advised to avoid alcohol

Patients should be advised not to take this medication for longer than directed, and that it can lead to addiction if used regularly for a long time.

Side Effects

Nausea
Vomiting
Drowsiness
Constipation
Tolerance
Dependence
Dizziness
Vertigo
Confusion
Headache
Mood changes
Hypotension
Tachycardia
Palpitations
Bradycardia
Dry mouth
Biliary spasm
Urinary retention
Difficulty in micturition
Ureteric spasm
Erectile dysfunction
Blurred vision
Double vision
Rash
Pruritus
Urticaria
Sweating
Flushing
Paralytic ileus
Abdominal pain
Diarrhoea
Seizures
Paraesthesia
Muscle rigidity
Hypotension
Respiratory depression
Oedema
Postural hypotension
Hallucinations
Euphoria
Dysphoria
Sleep disturbances
Sexual dysfunction
Miosis
Changes in hepatic enzymes
Addiction
Anaphylaxis
Bronchospasm
Hypothermia
Cough reflex decreased

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

Do not store above 25 degrees C
Protect from light

Further Information

Last Full Review Date: September 2011

Reference Sources

Summary of Product Characteristics: Dihydrocodeine tablets. Actavis UK Ltd. Revised June 2011
Summary of Product Characteristics: Dihydrocodeine tablets. Goldshield Group Limited. Revised March 2010
Summary of Product Characteristics: DF118 Forte tablets. Martindale Pharmaceuticals Ltd. Revised September 2005
Summary of Product Characteristics: Dihydrocodeine Elixir. Martindale Pharmaceuticals Ltd. Revised June 2002

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: 31 August 2017