Cough Treatment Remains a Challenge

Cold symptoms are a common patient complaint, and coughing is cited as one of the most irritating and persistent symptoms.¹ Patients often ask pharmacists and pharmacists about the best way to stop coughing, but it can be difficult to provide effective advice.

Consider that the CHEST Expert Cough Panel met in 2017 to review the guidelines developed in 2006, addressing six key clinical questions (table 1²) for the treatment of acute cough associated with colds.^2,3 Unfortunately, the panel’s overall findings were that clinical trials in this condition have not yielded significant results since 2006.²

What’s not working?

The panel’s work has yielded disastrous results, so the question remains of what works. overflowing with Most new prescription drugs approved by the FDA since 2006 are new combinations of previously approved products, including:^4-8:

• Extended Release Codeine Polystyrene and Chlorpheniramine (Tuzistra XR)
• Oral solution of guaifenesin and hydrocodone bitartrate (Flowtuss, Obredon)
• Guaifenesin/hydrocodone bitartrate and chlorpheniramine maleate (Vituz)
• Oral solution of guaifenesin, hydrocodone bitartrate, and pseudoephedrine hydrochloride (Hycophoenix).

Additionally, the FDA has issued drug safety warnings for the use of some products in certain populations. Perhaps most importantly, pharmacists should avoid giving over-the-counter cold and cough products to infants and children under the age of two because of the potential for serious and potentially life-threatening side effects (AEs). I strongly recommend against using it. “⁹ Additionally, the FDA warns against using codeine-containing medicines to treat colds and coughs in children under the age of 18.^Ten

Finally, pharmacy staff should remember that some individuals abuse certain OTC and prescription drugs. For example, high doses of dextromethorphan, often informally referred to as robot tripping, can cause dissociative effects and euphoria.¹¹ Some young people started the “purple drink” craze popularized by some celebrities by mixing promethazine and codeine syrup with alcohol, candy, fruit, or soda to cause euphoria and addiction. We are hiring.¹² Unfortunately, such abuse can lead to serious complications, including death.

what works?

Due to the lack of or even negative evidence for many products, we are answering the question, “What is the best way to stop an acute cough?” It’s not simple. The first step is to screen for red flags (Table 2¹³).

Basic counseling begins with encouraging patients to drink fluids, especially hot drinks, gargle with salt water, humidify the air, and remove irritants (such as fragrances and perfumes) from the home. .^3,13 Non-smokers should avoid tobacco smoke, and patients who smoke should consider quitting. Nasal irrigators and saline sprays can help if you have nasal congestion or postnasal drip. Cough drops are also helpful and may help soothe a sore throat.^3,13

OTC options include combination cough products containing pain relievers, antihistamines and decongestants. cough suppressants such as dextromethorphan; eucalyptus oil; guaifenesin, an expectorant that thins mucus; topical camphor; topical menthol, which can reduce the amount of coughing.

Patients should choose products that address only their specific symptoms. If the cough is intrusive or persistent, the patient may see the prescribing doctor for something stronger.

Generally, prescription options include codeine, but codeine cough syrup is available without a prescription in some states.^3,13

Conclusion

Although there are a considerable number of cough suppressant products available, few have been evaluated in head-to-head or well-designed clinical trials. This is an unmet need. Nonpharmacologic treatments are often as effective as over-the-counter (OTC) and prescription drugs. Doing nothing can be just as helpful as doing something. An important concept for patients needing cough products to remember is that more is not always better.

References

1. Colds: Protect yourself and others. CDC. Updated 11/29/2021. Accessed 10 January 2023. http://www.cdc.gov/features/rhinoviruses/

2. Marescar MA, Callahan Lyon P, Ireland B, Irwin RS. CHEST Expert Cough panel. Pharmacological and non-pharmacological treatments for acute cold-associated cough: A report from the CHEST Expert Panel. chest. 2017;152(5):1021-1037. doi:10.1016/j.chest.2017.08.009

3. Mr. Platter. Coughs and Colds: ACCP Evidence-Based Clinical Practice Guidelines. chest. 2006;129(suppl 1):72S-74S. doi:10.1378/chest.129.1_suppl.72S

4. Vitus. Prescribing Information. Hawthorn Pharmaceuticals Inc; 2017. Accessed January 10, 2023.

5. Obredon. Prescribing Information. ABER Pharmaceuticals LLC; 2016. Accessed 10 January 2023.

6. Floatus. Prescribing Information. Mission Pharmaceutical Company; accessed 10 January 2018, 2023.

7. Tuzistra XR. Prescribing Information. Tris Pharma K.K.; accessed 10 January 2018, 2023.

8. Hycophoenix. Prescribing Information. Mission Pharmacal; accessed January 10, 2023, 2018.

9. Should children be given cough and cold medicine? FDA. https://www.fda.gov/consumers/consumer-updates/should-you-give-kids-medicine-coughs-and-colds#:~:text=But% 20%20children%20will%20get, in%20infants %20 and %20 young %20 children.

10. FDA Drug Safety Communication: FDA is evaluating the potential risks of using codeine cough and cold medicines in children. FDA. March 6, 2018. Accessed January 20, 2023. https://www.fda.gov/drugs/drug-safe-ty-and-availability/fda-drug-safety-communication-fda-evaluating-potential-risks-using – codeine – cough and cold medicine

11. Lynn KA, Long MT, Pagel PS. “Robotripping”: Dextromethorphan abuse and its effects on anesthesia. Anesthetic2014;4(5):e20990. doi:10.5812/aapm.20990

12. Barnes JM, Boyer EW. Antitussives and Substance Abuse. substance abuse rehabilitation2013; 4:75-82.

13. Tietze KJ. cough. : Krinsky DL, Ferreri SP, Hemstreet BA, Hume AL, Rollins CJ, Tietze KJ, eds. Handbook of OTC Medicines: An Interactive Approach to Self-Care.20th ed. American Pharmacists Association; 2020:237-250.

About the author

Janet Y. Wick, MBA, RPh, FASCP, is Director of Pharmaceutical Professional Development in the Department of Pharmacy Practicum at the University of Connecticut School of Pharmacy at Storrs.