Dihydrocodeine serves as a key option for moderate cancer pain in UK clinical practice, particularly within the WHO analgesic ladder. Healthcare professionals often prescribe it alongside non-opioids for patients experiencing ongoing discomfort from cancer. This post explores its role, backed by NHS and palliative care guidelines.
Dihydrocodeine belongs to the opioid family, acting on the central nervous system to reduce moderate pain perception. Available in immediate-release tablets, liquid, or modified-release forms like DHC Continus, it suits both short-term and chronic use. In the UK, the NHS lists it for moderate to severe pain, including scenarios where stronger relief proves unnecessary initially.
Patients typically start with 30mg doses every four to six hours, up to 240mg daily, adjusted by doctors based on response. Unlike codeine, which varies in metabolism, dihydrocodeine offers more consistent effects, though caution applies in renal impairment due to metabolite buildup. Common brands include DF118, ensuring familiarity for UK prescribers.
Cancer pain affects up to 80% of advanced cases, ranging from mild aches to severe, debilitating episodes tied to tumours, treatments, or nerve damage. UK guidelines emphasise early, multimodal management to maintain quality of life, following the WHO three-step ladder: non-opioids first, weak opioids like dihydrocodeine next, then strong ones such as morphine.
Breakthrough pain—sudden flares atop baseline discomfort—demands flexible dosing, where dihydrocodeine fits as an accessible choice. Palliative care teams prioritise individual assessment, considering factors like renal function and prior opioid exposure, to avoid under- or over-treatment.
UK palliative guidelines position dihydrocodeine at step 2 for moderate cancer pain, combined with paracetamol or NSAIDs like ibuprofen. For instance, Scottish Palliative Care Guidelines recommend 30-60mg four times daily (maximum 240mg/24 hours), escalating to strong opioids if ineffective after 3-4 days.
NHS resources confirm its use for long-term conditions like cancer, unlike short post-operative needs. Macmillan Cancer Support explicitly names dihydrocodeine (DF118 Forte, DHC Continus) for mild-moderate cancer pain, highlighting its opioid status without the intensity of morphine. Evidence shows 60mg roughly equates to 6mg morphine, guiding safe transitions.​
| WHO Ladder Step | Pain Level | Example Meds | DHC Role |
|---|---|---|---|
| Step 1 | Mild | Paracetamol, Ibuprofen | Not primary; adjunct if needed |
| Step 2 | Moderate | Codeine, Dihydrocodeine | First-line weak opioid, 30-60mg QDS |
| Step 3 | Severe | Morphine, Oxycodone | Bridge to strong opioids if step 2 fails |
Standard starting dose for adults stands at 30mg every 4-6 hours, titrated to pain control without exceeding 240mg daily to minimise side effects. In palliative settings, modified-release versions like DHC Continus provide steady relief for chronic cancer pain, taken once or twice daily.
Breakthrough doses match the regular four-hourly amount, reviewed after 24 hours. patients over 65 or renal-impaired patients require lower starts (e.g., 15-30mg), with specialist input for eGFR below 60ml/min. Always take with food or milk to reduce nausea, and swallow tablets whole for modified-release forms.
Palliative care formularies endorse dihydrocodeine for stable moderate pain, noting equivalence to codeine but with potentially fewer metabolic issues. NHS Somerset guidelines affirm its licence for chronic severe pain, though stronger opioids dominate end-stage care.
Studies, though limited for single doses, support its moderate pain utility; a 30mg dose outperforms placebo but lags behind ibuprofen 400mg in acute settings—relevant for cancer flare-ups. In practice, it enhances quality of life metrics like appetite and sleep when tramadol alternatives falter, per oncology observations.
Common side effects include drowsiness, constipation, nausea, and dizziness, managed with laxatives like senna from day one and antiemetics like metoclopramide. Tolerance builds over time, risking dependence; guidelines advise gradual tapering for long-term users.
Respiratory depression risks rise with alcohol, sedatives, or overdose—carry naloxone for emergencies. Renal caution prevails: avoid in stage 4-5 CKD due to active metabolites. MHRA alerts stress avoiding prolonged-release opioids routinely post-op, but cancer pain remains indicated.
If dihydrocodeine fails after optimal dosing with adjuvants, switch to step 3 opioids like morphine (5-10mg four-hourly orally). Calculate total prior opioid use: 240mg dihydrocodeine daily approximates 24mg morphine. Renal patients may prefer alternatives like buprenorphine patches.
Specialists reassess unstable pain holistically, incorporating radiotherapy or nerve blocks. Patient education on reporting uncontrolled pain ensures timely adjustments.
Many UK cancer patients report dihydrocodeine eases daily activities without heavy sedation, per palliative feedback. Pair with non-drug strategies: heat packs, physiotherapy, or relaxation techniques amplify benefits.
Store securely at room temperature, track doses via apps, and inform GPs of use for seamless care transitions. For breastfeeding or pregnancy, low-dose use occurs under supervision, though alternatives like paracetamol prevail.
Dihydrocodeine shines for opioid-naïve patients, but comparisons guide choices:
| Medication | Strength | Key Advantages (UK Context) |
|---|---|---|
| Codeine | Weak opioid | Widely available co-codamol |
| Tramadol | Weak opioid | Dual action (opioid + serotonin) |
| Morphine IR | Strong | Gold standard for severe pain |
| Oxycodone | Strong | Renal-friendly option |
Select based on tolerance, comorbidities, and response—dihydrocodeine often bridges effectively.
Consult doctors before changes; self-adjusting risks harm. Regular reviews optimise therapy, balancing relief and wellbeing. UK resources like NHS.uk or Macmillan helplines offer personalised support
