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differences in renal function, gastrointestinal function, and distribution sites can further complicate the unpredictable pharmacokinetics of codeine.
The practical implication of this black-boxed label is manifested as codeine products being removed from hospital formularies for pediatrics regardless of indication. Many physicians both surgeons and anesthesiologists are utilizing alternative medications for analgesia including hydrocodone and oxycodone as oral opioids in their practices. This is not without risk because the potency of oxycodone in the opioid naive and metabolism issues with hydrocodone can still occur. Anesthetic techniques are also being tailored to minimize the need for postoperative oral opioids by utilizing IV acetaminophen, dexmedetomidine, IV opioids and prescribing alternating doses of oral acetaminophen and ibuprofen for home use. The
Priscilla J. Garcia, MD, MHA Pediatrics Editor
oral NSAID combination for home pain management will also increase with the triplicate requirement for hydrocodone and undoubtedly decrease the number of outpatient hydrocodone prescriptions by surgeons.
Alternative analgesics should be evaluated carefully for post-operative pain control in children undergoing tonsillectomy and/or adenoidectomy. Codeine should not be used.
References:
Jerome J, Solodiuk J, Sethna N et al. A single institution’s effort to translate codeine knowledge into specific clinical practice. J Pain Symptom Manage 2013: available online 7 November 2013.
Kelly K, Rieder M, van den Anker J, et al. More codeine fatalities after tonsillectomy in North American children. Pediatrics 2012; 129: e1343-e1347.
Niesters M, Overdyk F, Smith T, et al. Opioid-induced respiratory depression in paediatrics: a review of case reports. Br J Anaes 2013; 110(2): 175-82.
Tremlett M. Editorial: Wither codeine? Pediatric Anes 2013; 23: 677-683.
http://www.fda.gov/forconsumers/consumerupdates/
ucm315497.htm
