More Codeine Fatalities After Tonsillectomy in North American Children

TLDR

Codeine use after adenotonsillectomy in children with obstructive sleep apnea has been linked to fatal outcomes due to ultra‑rapid CYP2D6 metabolism. This study reports three additional fatal or life‑threatening cases of codeine use in North American children. The cases revealed that CYP2D6 gene duplications produced excessive morphine, causing fatal respiratory depression, indicating that codeine analgesia post‑adenotonsillectomy is unsafe for young children with obstructive sleep apnea.

Abstract

In 2009 we reported the fatal case of a toddler who had received codeine after adenotonsillectomy for obstructive sleep apnea syndrome. The child was an ultra-rapid metabolizer of cytochrome P4502D6 (CYP2D6). We now report 3 additional fatal or life-threatening cases from North America. In the 2 fatal cases, functional gene duplications encoding for CYP2D6 caused a significantly greater production of potent morphine from its parent drug, codeine. A severe case of respiratory depression in an extensive metabolizer is also noted. These cases demonstrate that analgesia with codeine or other opioids that use the CYP2D6 pathway after adenotonsillectomy may not be safe in young children with obstructive sleep apnea syndrome.