What is Nurofen plus 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 does Nurofen plus work?

• Nurofen plus tablets contain two active ingredients, ibuprofen and codeine phosphate.
• Ibuprofen is a type of medicine called a non-steroidal anti-inflammatory drug (NSAID). It works by blocking the action of an enzyme in the body called cyclo-oxygenase (COX). COX is involved in the production of prostaglandins, which cause pain, swelling and inflammation. By blocking the action of COX, ibuprofen stops the production of these inflammatory prostaglandins and so 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 in the brain and spinal cord. They reduce pain by combining with opioid receptors and blocking the transmission of pain signals sent by the nerves to the brain. This means that 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.

How do I take Nurofen plus?

• 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 Nurofen plus 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 pain doesn't get better despite taking Nurofen plus.

What should I know before I take Nurofen plus?

• Codeine can cause drowsiness, although at the dose contained in Nurofen plus 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.
• In March 2015 a new 'drug driving' law came into force that allows police to use roadside drug tests to check for the presence of prohibited drugs in a driver's saliva. The medicines prohibited by the law include morphine. Codeine is converted into morphine by the liver, which means it may be an offence to drive while you are taking Nurofen plus. You should not drive if you think this medicine affects your ability to drive safely, for example if it makes you feel sleepy, dizzy, unable to concentrate or make decisions, or if you have blurred or double vision.
• 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 taking Nurofen plus 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.
• Do not take Nurofen plus 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.
• Taking a painkiller for headaches too often or for too long can actually make the headaches worse.

Who should not take Nurofen plus?

• 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 above.
• People with very slow, shallow breathing (respiratory depression), people having  an asthma attack and people with chronic obstructive pulmonary disease (COPD).
• People with a head injury or raised pressure inside the skull (intracranial pressure).
• People who have had an allergic reaction after taking aspirin or other NSAIDs such as diclofenac in the past, for example asthma attacks, itchy rash (urticaria), nasal inflammation (rhinitis) or swelling of the lips, tongue and throat (angioedema).
• People with an active stomach or intestinal ulcer or bleeding in the gut, particularly those who have had two or more episodes of this, or who have experienced this when taking an NSAID in the past.
• People who have or who are at risk of getting a blockage in the gut (paralytic ileus).
• People with severe heart failure, liver failure or kidney failure.
• People already taking any other NSAIDs by mouth, including COX-2 inhibitors (see end of factsheet for more details).
• People who have taken the antidepressants phenelzine, tranylcypromine, isocarboxazid or moclobemide, or the anti-Parkinson's medicine selegiline in the last 14 days.
• Women who are pregnant or breastfeeding.
• Children under 12 years of age.
• 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.
• 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.
• Nurofen plus should not be used if you are allergic to any of its ingredients. If you feel you have experienced an allergic reaction, stop using Nurofen plus and inform your doctor or pharmacist immediately.

Who should get medical advice before taking Nurofen plus?

• Elderly people.
• People with kidney or liver problems.
• People with heart failure.
• People with high blood pressure (hypertension).
• People with blood clotting problems or taking anticoagulant medicines.
• People with lung problems such as asthma or 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 problems affecting the stomach or intestines, such as constipation or inflammatory bowel disorders such as Crohn's disease or ulcerative colitis.
• People who have recently had surgery on their stomach, intestines or urinary tract.
• 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.
• People with an underactive thyroid gland (hypothyroidism).
• People with underactive adrenal glands, eg Addison's disease.
• People with low blood pressure (hypotension) or shock.
• People with 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.
• People with diseases affecting connective tissue, eg systemic lupus erythematosus.
• People with a history of drug abuse or dependence.

Can I take Nurofen plus while pregnant or breastfeeding?

• If you are pregnant or trying for a baby you should not use Nurofen plus 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. Ask you doctor or midwife for further advice.
• 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 Nurofen plus.

What are the possible side effects of Nurofen plus?

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 ibuprofen and codeine. Just because a side effect is stated here does not mean that all people using Nurofen plus will experience that or any side effect.

• Constipation.
• Indigestion or abdominal pain. Usually avoided by taking the medicine with food.
• Nausea and vomiting.
• Dry mouth.
• Dizziness.
• Sweating.
• Itching.
• Skin rash. Stop taking Nurofen plus and consult your doctor if you get a skin rash or sores inside your mouth while taking it.
• Headache.
• Hearing disturbances.
• Difficulty passing urine.
• Ulceration or bleeding in the stomach or intestine. If you experience any sign of bleeding from the stomach or bowels after taking Nurofen plus, such as vomiting blood and/or passing black/tarry/bloodstained stools, you should stop taking it and consult your doctor immediately.
• Codeine can cause drowsiness, although at the dose in Nurofen plus this is very unlikely.
• Dependence on the medicine if used regularly or for long periods of time (see 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.

Talk to your doctor, nurse or pharmacist if you want any more information about the possible side effects of Nurofen plus. 

Can I take Nurofen plus with other medicines?

• If you are already taking any medicines, including those bought without a prescription and herbal medicines, you should check with your pharmacist before taking Nurofen plus as well, to make sure that the combination is safe. This is especially important if you are taking any of the medicines mentioned below.
• Nurofen plus should not be taken by people who have taken the antidepressants phenelzine, tranylcypromine, isocarboxazid or moclobemide, or the anti-Parkinson's medicine selegilinee in the last 14 days.
• Don't take Nurofen plus if you are already taking painkilling doses of aspirin or any other NSAID, (eg naproxen, diclofenac) taken by mouth, including selective inhibitors of COX-2 such as celecoxib or etoricoxib, as this increases the risk of side effects on the stomach and intestines.

There may be an increased risk of ulceration or bleeding in the gut if ibuprofen is taken with corticosteroids such as prednisolone.

There may also be an increased risk of bleeding 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
• erlotinib
• iloprost
• SSRI antidepressants, eg fluoxetine, paroxetine, citalopram
• venlafaxine.

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
• ciclosporin
• diuretics, eg furosemide
• tacrolimus.

Ibuprofen may reduce the removal of the following medicines from the body and so may increase the risk of side effects of these medicines:

• digoxin
• lithium
• methotrexate.

Ibuprofen may oppose the blood pressure lowering effects of certain medicines to treat high blood pressure, such as the following:

• amlodipine
• 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.

The dose of codeine in Nurofen plus is unlikely to cause drowsiness, but this is more likely if you take it with any of the following, which can also cause drowsiness:

• alcohol
• 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:

• domperidone
• metoclopramide.

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, rifampicin and ritonavir may reduce the painkilling effect of codeine.

References:

http://patient.info/forums/discuss/codeine-addiction-nurofen-plus--425842

http://www.nurofen.ie/?gclid=CJ2b7NqXy9ECFUOT7Qod3esIpg

http://www.nurofen.co.uk/our-products/pharmacy-strength/nurofen-plus/

http://www.netdoctor.co.uk/medicines/aches-and-pains/a8027/nurofen-plus-ibuprofen-and-codeine/