a-t 2016; 47: 59

Codeine-based pain and cough medicines - caution following cholecystectomy: A 43-year old woman with a respiratory tract infection suffered hours of painful upper abdominal cramps radiating into the back after a single dose of a codeine-based cough medicine (e.g. CODICOMPREN). This cholecystectomised patient had a history of earlier instances of suffering colic-like pain after taking codeine (NETZWERK Report 11.607). Another patient experienced severe tightness in the chest, developed shortness of breath and fear of dying shortly after taking a codeine-based medication that she had tolerated well before removal of her gallbladder (NETZWERK Report 17.018). According to the Summary of Product Characteristics (SPC) of, for example, CODICAPS MONO, codeine can trigger heart attack-like symptoms or exacerbate the symptoms of pre-existing pancreatitis in cholecystectomised patients (1). The literature furthermore contains several reports of upper abdominal pain under codeine in patients who had their gallbladder removed, and which was alleviated quickly with the opioid antagonist naloxone (NALOXON-HAMELN among other generics) (2). Codeine and its metabolite morphine (e.g. SEVREDOL) can trigger a spasm of the sphincter of Oddi (2), the sphincter where the common bile and pancreatic duct enter the duodenum, that regulates bile and pancreatic juice flow to the small intestine. It is presumed that, without a gallbladder acting as a reservoir, the contraction of the sphincter can cause severe pain because of the increase in intraductal pressure and, by obstructing pancreatic juice flow, trigger acute pancreatitis. It is also possible that damage to nerve fibres leading to the sphincter caused during the cholecystectomy is involved (2,3). The SPCs' of a number of opioid analgesics recommend caution or monitoring patients with biliary tract diseases, but without special reference to the conditions following a cholecystectomy. Before prescribing a codeine-based pain or cough medicine it is important to check whether a patient's gallbladder has been removed. Such patients should be informed of the possibility of the above side effects and provided with information on when to seek medical help, -Ed.