Ibuprofen, codeine (Nurofen plus)
How does it work?
Nurofen plus tablets contain two active ingredients, ibuprofen and codeine phosphate. Both are pain-relieving medicines.
Ibuprofen is a type of medicine called a non-steroidal anti-inflammatory drug (NSAID). It relieves pain and inflammation. Ibuprofen works by blocking the action of a substance in the body called cyclo-oxygenase. Cyclo-oxygenase is an enzyme involved in the production of various chemicals in the body. Some of these natural chemicals are known as prostaglandins. They are produced by cyclo-oxygenase in response to injury or certain diseases and conditions. Prostaglandins cause pain, swelling and inflammation. By blocking the action of cyclo-oxygenase, ibuprofen stops the production of these inflammatory prostaglandins and therefore reduces inflammation and pain.
Codeine phosphate is a type of painkiller called an opioid. It is related to morphine but is not as strong. Opioid painkillers work by mimicking the action of naturally occurring pain-reducing chemicals called endorphins. Endorphins are found in the brain and spinal cord and reduce pain by combining with opioid receptors.
Codeine phosphate mimicks the action of natural endorphins by combining with the opioid receptors in the brain and spinal cord. This blocks the transmission of pain signals sent by the nerves to the brain. Therefore, even though the cause of the pain may remain, less pain is actually felt.
Nurofen plus tablets contain 12.8mg of codeine, which in combination with the ibuprofen, is effective at relieving mild to moderate pain.
What is it used for?
- Short-term (up to three days) relief of acute mild to moderate pain, including headaches, migraine, non-serious arthritic and rheumatic pain, soft tissue injuries such as sprains and strains, tendonitis, backache, nerve pain (neuralgia), toothache and period pain. Nurofen plus should only be used if the pain has not been relieved by paracetamol, ibuprofen or aspirin alone.
How do I take it?
- Nurofen plus tablets should preferably be taken either with or after food.
- Adults aged 18 years and over can take one or two Nurofen plus up to three times a day as needed to relieve pain. Leave at least four hours between doses and do not take more than six tablets in 24 hours.
- Adolescents aged 12 to 18 years can take one or two Nurofen plus up to three times a day as needed to relieve pain. Leave at least six hours between doses and do not take more than six tablets in 24 hours.
- Do not take more than the recommended dose.
- Do not take this medicine for longer than three days without consulting your doctor. Taking codeine regularly for more than three days can lead to addiction to the medicine and withdrawal symptoms when you stop taking it.
- Consult your doctor if your symptoms persist despite taking this medicine.
- The information in this factsheet may differ from that found in the leaflet that is provided with the medicine. This is because this factsheet has been updated with the latest advice (released 28 June 2013) from the medicines watchdog, the MHRA, regarding the use of codeine in children. It follows a European safety review of the use of codeine in children. The product information leaflets for medicines affected by the advice will be updated in due course, but in the meantime if you are confused about any of our information, or want further advice, then you should talk to your pharmacist.
- Codeine can cause drowsiness, although at the dose contained in this medicine this is very unlikely. However, if you do find this medicine makes you feel sleepy or dizzy you should not drive or operate machinery and avoid drinking alcohol.
- Do not take this medicine for longer than three days without consulting your doctor. If codeine is taken regularly for long periods of time, the body can become tolerant to it and it may become less effective at relieving pain. With prolonged use, the body may also become dependent on the codeine. As a result, when you then stop taking the medicine you may get withdrawal symptoms such as restlessness and irritability.
- If you need to use this medicine for longer than three days you should consult your doctor or pharmacist for advice.
- Taking a painkiller for headaches too often or for too long can actually make the headaches worse.
- People can vary considerably in the way that their body metabolises codeine. For some people this may lead to an increased chance of getting side effects, such as reduced levels of consciousness; sleepiness; slow, shallow breathing; pin-point pupils; lack of appetite; constipation; or nausea and vomiting. If you experience any of these you should stop using this medicine and get medical advice straight away. For other people it may mean that the codeine is less effective, so if you find this medicine doesn't relieve your symptoms well enough you should consult your doctor or pharmacist.
- Ibuprofen is generally well-tolerated and most people do not experience any side effects. The most common side effects are related to stomach irritation and include abdominal pain, indigestion and nausea. These can mainly be avoided by taking the ibuprofen with food. Rarely, serious side effects such as ulceration or bleeding in the stomach or intestines may occur. These are more likely with high doses and in elderly people. If you experience any sign of bleeding from the stomach or bowels after taking this medicine, such as vomiting blood and/or passing black/tarry/bloodstained stools, you should stop taking this medicine and consult your doctor immediately.
- Very rarely, NSAIDS may cause serious blistering or peeling skin reactions (eg Stevens-Johnson syndrome, toxic epidermal necrolysis, exfoliative dermatitis). For this reason, you should stop taking this medicine and consult your doctor if you get a skin rash or sores inside your mouth while taking this medicine.
Use with caution in
- Elderly people.
- Decreased kidney function.
- Decreased liver function.
- Heart failure.
- High blood pressure (hypertension).
- People with blood clotting problems or taking anticoagulant medicines.
- People with reduced lung function, eg due to asthma.
- People with a condition called bronchiectasis, in which there is persistent widening of the airways as a result of lung disease, eg infection, inflammation, tumours or cystic fibrosis.
- People with disorders affecting the stomach or intestines.
- People who have recently had surgery on the stomach, intestines or urinary tract.
- People with constipation or potential for blockage in the gut.
- People with inflammatory bowel disorders such as Crohn's disease or ulcerative colitis.
- People with biliary tract disorders, eg gallstones or recent surgery on the biliary tract.
- People who have difficulty passing urine, for example men with an enlarged prostate gland (prostatic hypertrophy).
- People with an underactive thyroid gland (hypothyroidism).
- People with underactive adrenal glands, eg Addison's disease.
- People with low blood pressure (hypotension) or shock.
- A condition involving abnormal muscle weakness called myasthenia gravis.
- People with a history of convulsions or fits, eg epilepsy.
- People with an irregular heartbeat (arrhythmia).
- People with a history of allergies.
- Diseases affecting connective tissue, eg systemic lupus erythematosus.
- People with a history of drug abuse or dependence.
Not to be used in
- Children under 12 years of age.
- Relieving pain in children and adolescents under 18 years of age who have had surgery to remove their tonsils or adenoids (tonsillectomy or adenoidectomy or both) for obstructive sleep apnoea.
- People who are known to have a genetic variation of a liver enzyme called CYP2D6, which metabolises codeine into morphine (CYP2D6 ultra-rapid metabolisers). These people are more likely to experience side effects after taking codeine, because they convert more codeine into morphine than other people. See the warning section above.
- Codeine is not recommended for adolescents aged 12 to 18 years whose breathing might be compromised, including those with neuromuscular disorders; severe heart or lung conditions; upper airway or lung infections; multiple trauma; or who have had extensive surgical procedures.
- People with very slow, shallow breathing (respiratory depression).
- Chronic obstructive pulmonary disease (COPD).
- People having an asthma attack.
- People with raised pressure inside the skull (intracranial pressure).
- People with a head injury.
- People in whom aspirin or other NSAIDs, eg ibuprofen, cause allergic reactions such as asthma attacks, itchy rash (urticaria), nasal inflammation (rhinitis) or swelling of the lips, tongue and throat (angioedema).
- People with an active peptic ulcer or bleeding in the gut.
- People who have had recurrent peptic ulcers or bleeding from the gut (two or more episodes).
- People who have ever experienced bleeding or perforation of the gut as a result of previous treatment with an NSAID.
- People with or at risk of paralysis or inactivity in the intestines that prevents material moving through the gut (paralytic ileus).
- Severe heart failure.
- Liver failure.
- Severe kidney failure.
- People taking other NSAIDs, including COX-2 inhibitors (see end of factsheet for more details).
This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy.
If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately.
Pregnancy and breastfeeding
Certain medicines should not be used during pregnancy or breastfeeding. However, other medicines may be safely used in pregnancy or breastfeeding providing the benefits to the mother outweigh the risks to the unborn baby. Always inform your doctor if you are pregnant or planning a pregnancy, before using any medicine.
- If you are pregnant or trying for a baby you should not use this medicine without consulting your doctor first. This medicine is not recommended for use in pregnancy unless considered essential by your doctor. This is particularly important in the first and third trimesters. If codeine is used regularly in the third trimester it may cause withdrawal symptoms in the baby after birth. If used during labour it may cause breathing difficulties in the baby after birth. If ibuprofen is taken in the third trimester it may delay labour, increase the length of labour and cause complications in the newborn baby. Some evidence suggests that NSAIDs should also be avoided by women attempting to conceive, as they may temporarily reduce female fertility during treatment and may also increase the risk of miscarriage or malformations. Seek further medical advice from your doctor.
- Ibuprofen and codeine may pass into breast milk in amounts that are probably too small to be harmful in most people. However, because some people metabolise codeine in a slightly different way that can increase the risk of getting side effects from the medicine, it is recommended that women who are breastfeeding do not take codeine. It is impossible to predict which women and babies will metabolise codeine differently. Potential side effects in a nursing baby may include drowsiness or sedation, difficulty breastfeeding, vomiting, breathing difficulties and floppiness. If you are breastfeeding you should not take this medicine.
Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Just because a side effect is stated here does not mean that all people using this medicine will experience that or any side effect.
- Indigestion or abdominal pain.
- Nausea and vomiting.
- Dry mouth.
- Skin rash.
- Hearing disturbances.
- Difficulty passing urine.
- Ulceration or bleeding in the stomach or intestine.
- Codeine can cause drowsiness, although at the dose contained in this medicine this is very unlikely. However, if you do find this medicine makes you feel sleepy or dizzy you should not drive or operate machinery and avoid alcoholic drink.
- Dependence on the medicine if used regularly or for long periods of time (see warning section above).
- Hypersensitivity reactions such as narrowing of the airways (bronchospasm), swelling of the lips, throat and tongue (angioedema), itchy blistering rash or anaphylactic shock.
- Kidney, liver or blood disorders.
The side effects listed above may not include all of the side effects reported by the medicine's manufacturer. For more information about any other possible risks associated with this medicine, please read the information provided with the medicine or consult your doctor or pharmacist.
How can this medicine affect other medicines?
It is important to tell your doctor or pharmacist what medicines you are already taking, including those bought without a prescription and herbal medicines, before taking this medicine. Similarly, check with your doctor or pharmacist before taking any new medicines while taking this one, to make sure that the combination is safe.
Ibuprofen should not be taken in combination with painkilling doses of aspirin or any other NSAID, (eg naproxen, diclofenac) that is taken by mouth, as this increases the risk of side effects on the stomach and intestines. People taking selective inhibitors of COX-2 such as celecoxib or etoricoxib should not take ibuprofen for the same reason.
There may be an increased risk of ulceration or bleeding from the gut if ibuprofen is taken with corticosteroids such as prednisolone.
There may also be an increased risk of bleeding from the gut if ibuprofen is taken with the following medicines:
- anti-blood-clotting (anticoagulant) medicines such as warfarin, dabigatran
- antiplatelet medicines to reduce the risk of blood clots or 'thin the blood', eg low-dose aspirin, dipydridamole, clopidogrel
- SSRI antidepressants, eg fluoxetine, paroxetine, citalopram
There may be an increased risk of side effects on the kidneys if ibuprofen is taken in combination with any of the following medicines:
- ACE inhibitors, eg enalapril
- diuretics, eg furosemide
Ibuprofen may reduce the removal of the following medicines from the body and so may increase the blood levels and risk of side effects of these medicines:
Ibuprofen may oppose the blood pressure lowering effects of certain medicines to treat high blood pressure, such as the following:
- ACE inhibitors such as captopril
- beta-blockers such as atenolol.
If ibuprofen is used in combination with quinolone antibiotics, such as ciprofloxacin or norfloxacin there may be an increased risk of seizures (fits). This may occur in people with or without a previous history of epilepsy or convulsions.
This medicine should not be used by people who are currently taking a monoamine oxidase inhibitor (MAOI) or who have taken one of these medicines in the last 14 days. MAOIs include the antidepressants phenelzine, tranylcypromine, isocarboxazid and moclobemide and the anti-Parkinson's medicine selegiline.
The dose of codeine in this medicine is unlikely to cause drowsiness, but this is more likely if the medicine is taken in combination with any of the following, which can also cause drowsiness:
- antipsychotics, eg haloperidol, chlorpromazine
- benzodiazepines, eg temazepam, diazepam
- sedating antihistamines, eg chlorphenamine, promethazine, triprolidine, hydroxyzine (some of these may be found in non-prescription cough and cold or hayfever remedies)
- sleeping tablets, eg zopiclone
- other strong opioid painkillers, eg dihydrocodeine, morphine, tramadol
- tricyclic antidepressants, eg amitriptyline.
Codeine phosphate can reduce the muscular activity in the gut and so may oppose the effect of the following medicines on the gut:
There may be an increased risk of side effects such as constipation, dry mouth and blurred vision if codeine is taken with antimuscarinic medicines that can cause these type of side effects, such as the following:
- antimuscarinic medicines for Parkinson's symptoms, eg procyclidine, orphenadrine, trihexiphenidyl
- antimuscarinic medicines for urinary incontinence, eg oxybutynin, flavoxate, tolterodine, propiverine, trospium
- antispasmodics, eg atropine, hyoscine.
There is a risk of severe constipation if codeine is used with antimotility medicines for diarrhoea, such as loperamide.
Quinidine reduces the painkilling effect of codeine.
Rifampicin and ritonavir may also reduce the effects of codeine.
Other medicines containing the same active ingredients
- Cuprofen plus.
- Solpadeine migraine.