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How to select cold medicines part three: cough suppressants

Patients often consult your Intrepid Pharmacist over troubles with cough related to cold, flu or allergies..

As a reminder to the reader, the five drug areas examined this series are:

Antihistamines: take one of these many flavors if you have a runny nose that needs drying up, itchy watery, eyes, sneezing, etc. or a rash or poison ivy/oak/sumac. It can also help you sleep.

Cough Suppressant: take this for a mild cough

Decongestant: does just what it says and opens up and drains the sinus (so your nose will run).

Expectorant: helps loosen “Crud” (e.g. mucus) in the chest so you can cough it up.

Pain and Fever: antipyretic (fancy med-speak for “lowers your fever”) and anti-inflammatory drugs do just what they say, but which one do you need and where all are they found??

Let’s get this out of the way now: Only one over-the-counter cough suppressant exists and it is called dextromethorphan. Any of the pretty boxes of cold medicines claiming the help cough nearly always contain this drug. The exception: in cases where the cough is caused by nasal discharge running down the back of the throat (altogether now: ewww!) an antihistamine (see previous column) is listed as the cough suppressant as it will dry up the post nasal drip causing the cough.

When do you need a cough suppressant? If you are suffering from the “dry,” hacking non-productive cough (meaning you cough a lot but do not cough up anything) or you are coughing so much you cannot sleep, then you need a medication containing a cough suppressant. Remember, though, coughs are a good thing—to a point—and help removed unwanted material (that think yellow phlegm stuff—once again everybody: ewww!) from the lungs. That said, when you cough (as with when you sneeze), your Intrepid Pharmacist asks—nay, begs!— that you cough into the corner of your shirt sleeve as in the picture above. Nothing helps spread germs faster than coughing into your hand…and then grabbing a door handle or door knob or shopping cart.

Rules of Purchase: Obviously this is a medication you want to use if you are coughing a lot, especially if the cough is unproductive. If you try it in one product, though, and do not attain any relief do not go buy a different product; it will not work any better than the first one. Do not let the pretty boxes and colorful marketing mislead you. You can obtain dextromethorphan as a standalone medication in Delsym (or your store’s own brand. And yes it is the same chemical in both). Most often, however, patients take this drug as part of a multi-symptom (or what your Intrepid Pharmacist likes to call the mix-and match products, since that is what the manufacturers do to create the illusion of lots of medications when there are really only a limited set of drugs they are working with).

Muti-Symptom Medications: Frequently you will find the cough suppressant paired with an expectorant (see part four) in things like Mucinex DM (pill form) and Robitussin DM (liquid form). Again, do not let the pretty colors and different dose forms mislead you! Turn the boxes and bottles over and read the Active Ingredients list! The drugs in both these products are the same, only the dose form has changed from a tablet into liquid that tastes suspiciously like un-carbonated Dr. Pepper/Cherry Coke.

Likewise on other multi-symptom mix and match cold, allergy and flu medications (NyQuil, Theraflu, etc.), ignore the pretty colors and consult the Active Ingredients list on the box. Your Intrepid Pharmacist emphasizes this point so much because he is amazed how many people come to him who succumb to the marketing and pretty colors and never look at the Active Ingredient list to see the same drugs in both the products they are holding. So, if the Over-the- Counter cough suppressant brand of your choice does not provide any relief, contact your prescriber for something stronger.

Cautions and Side Effects: Dextromethorphan is a codeine analogue of levorphanol though it has no actual effect on the opioid receptors in the body the way codeine and its synthetic variants do. As with antihistamines, drowsiness is the biggest side effect concern, doubly so if you are taking a multi-symptom product that also contains an antihistamine. Still overdose can yield exciting results including hallucinations, coma and death, which is why so many teen ages have rushed out to engage in the much reported on pastime called “Robotripping,” wherein they drink an entire bottle of Robitussin DM…for the sheer fun of it. Your Intrepid Pharmacist was previously unaware that hallucinations, coma and death were fun, but apparently they are, since the plethora of video gaming, actual sports activities, television channels and internet sites are not enough to keep young adults entertained or challenged. Not only does this entire practiceannoy your Intrepid Pharmacist, it also has led to laws limiting the sale of dextromethorphan containing products to people 18 or older. The FDA has also flirted with making dextromethorphan go the way of pseudoephedrine or outright making it prescription only. In spite of revisiting this issue several times over the last twenty years (including 2010), no change has been made.

Pregnancy: and Children: As with many medications, dextromethorphan is rated pregnancy category C by the FDA. In these situations it is best to consult with your OB or physician handling your pregnancy. Your Intrepid Pharmacist has seen this on “use” and “don’t use” lists. This medication is not indicated for use in children under age four and in many cases you will not find dosing for under age six. If you have a child who is under the listed dosing age for this medication, do not guess and try to halve the dose or something like that, as the metabolic processes in small children and infants is not the same as with older children and adults. So, a little bit can go a very long way. The medication must be dosed for the child’s body weight or body surface area.

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