Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. Narrator - ? 00:11 This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice, and should not be used in lieu of obtaining advice from a qualified health care provider. Unknown Speaker 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk. Episode 47 I'm your co host, Dr. Kane. I'm Dr. Schuman, and I'm Dr. Patel. And again, we have a special guest today. Hi. I'm Dr. Angelo. I'm glad to be here. So we had Dr. Angelo on previously for our gastrointestinal disorders, self care of Gi disorders. We've invited her back today for talking about cough and cold management for patients who are presenting in, you know, an outpatient setting for self care. Speaker 1 00:57 And one of the things, I think, just to kind of start off with any of these topics where we're looking at at self care and dealing with an individual coming complaining of certain symptoms, there's, I believe, a couple of mnemonics that we can use to start looking through maybe where those questions we should answer. So if you're you know, all of a sudden, you're faced with a patient. What are the things I need to know? Dr. Angel, what is one example of one of those mnemonics? Sure. Narrator - ? 01:19 So these follow the simple process we want to make sure we collect the information we need to be able to provide appropriate recommendations. And one of the big things when we talk about self care is whether these are even appropriate for self care need to be referred. So the mnemonics you bring up are a great way to go through that the things we teach in class, we've got two different ones we present to our students, pqrsta, which that stems from pain management, things that the EMTs and nurses came up with years ago to help quickly manage their pain patients, and we've applied that to self care. And the other one is the scholar Mac and so, I guess, briefly recapping what those stand for. So as you're working with your patients and going through your questions, making sure you do address all of these. So the pqrsta pneumonic first, we would find out what's causing the problem, P for precipitating or provoking, and then Q for quality, R for remitting factors. So what makes it better? What makes it worse? The s in pqrsta would be sight or severity. And then we want to talk about temporal factors, and then that A is any other symptoms? And I think Dr. shoeman, you mentioned you've used scholar Mac and some of the things that you've been doing, you're familiar with that. Speaker 1 02:30 Yeah, I really like using this one. Again, it's similar in how it's set up. So s for symptoms, you know, again, specific nature of it. You just say, for example, I have a cold. Okay, what are you talking are we talking about the nose? Are we talking about the throat? What do we mean? Characteristics? A little bit more specific, the history. When did it start, or how long has it been going on the onset? When did it first start? At least this particular episode, you know, but it hasn't been. Has it been periodic episodes throughout time? What's the location of the body? Aggravating factors, remitting factors, you know, those that make it worse, those things that make it better. And then the Mac portion medication, so our home medications that you're on to see if that can be contributing allergies. And then conditions, medical Dr. Sean Kane 03:11 conditions there. And again, Dr. Angelo, as you mentioned, the whole point of either of these acronyms is to make sure that we're asking the appropriate questions, to make sure we're covering all the bases, because sometimes there could be something extremely relevant, like a past medical history of hypertension, or they're on four antihypertensives, and if you recommend, let's say, Sudafed, that may not be the best recommendation, and you wouldn't know that they were an uncontrolled hypertensive patient had you not asked a question, because the patient doesn't know to divulge that to you without Any questions to kind of get the ball Narrator - ? 03:42 rolling right. And finding out how long something's been going on for is important because that could easily lead to referral if this is a chronic condition, also their symptoms. They may think it's one thing, but as they tell us more about what they're experiencing, we deduct it something more serious, and want to refer them. So this is really to help us better empower our patients from a self care perspective. Dr. Sean Kane 04:04 So before we get to the point of talking about non pharmacologic therapy and pharmacologic therapy, what are some of the characteristics of patients that we definitely should not be recommending self care for sure. Narrator - ? 04:14 So as we're talking about cough and cold in particular things that we want to be looking out for, we talked about chronic diseases and some other issues they might have, so asthma, COPD, heart failure, those are things we want to be very careful. If they also have cough or cold symptoms, if the cough is lasting more than seven days, or if it comes and goes it's recurring, we'd want to refer them so if they have a cough that was due to the flu or common cold symptoms, and the flu or the cold clears out, but this cough continues. A lot of times we think of a post infectious cough, and in many cases, those require prescription therapy to treat so it would refer those patients as well if you suspect a cough associated with drugs. One good example would be our ACE inhibitors, which we talk a lot about as causing a dry cough. Cough, anything that's related to inhalation issues, dust particles, irritants, objects that may remain in the lungs, if they're coughing and it's a productive cough. So they have secretions, and those secretions are a little bit odd in color. So we're looking at yellow, tan, even bloody or pus like secretions. We would definitely refer them patients who have a high fever, so as we get 103, degrees Fahrenheit and higher, we would refer, and then if we've got fever that doesn't resolve, and especially for children, we would be more sensitive to fever effects with cough, Dr. Sean Kane 05:33 like most things in self care, a lot of these exclusions to self care are, I would think, at least pretty like obvious, but sometimes they're not so obvious, if you don't know why you're saying we can't treat you. So most of these involve something like lung cancer, where they have a chronic cough over a long period of time, COPD, where they aren't diagnosed with COPD, pneumonias, flus, all of those things. Our medications are symptomatic management, but we have things that we do for those disease states that we would give a prescription for, for example, and that's why we're referring them to a healthcare provider, not trying to manage COPD with our guaifenesin, for example. Speaker 1 06:09 All right, so now that we've determined what you know, is maybe not appropriate for treatment, let's, let's look at what we can offer if somebody doesn't meet those criteria they're coming in. We think this is something that can be addressed. You know, be in this set, in this setting. What can we do? Non pharmacologically? Speaker 2 06:23 So usually, you know, first thing to start out with, we've heard this a lot too, is make sure you drink plenty of fluids, you know, to get rid of, even if it's a viral induced, you know, getting the viruses out too simple things as running the humidifiers and vaporizers, but cool temperature waters can help as well non medicated lozenges to help out the throat and maybe some help with the post nasal drip and then more controversial things like honey. So what can you offer here? As far as the honey is concerned? Narrator - ? 06:53 Dr. Angelo, sure, there are reports that honey has been used for cough and it's relatively safe if a patient wants to try that. We had a study a while back. It had a very small end. So as we know from our statistics, we do have to be careful. So I think there are 130 patients assessed in this study. But honey was compared to dextromethorphan for cough, and it was really based on subjective analysis and these children and whether or not their cough improved over a matter of a couple couple nights, and they took it before bedtime, and there was evidence that honey seemed to work better than the next German and placebo products. So again, I usually say it's worth a try, as long as we don't have a young child. So when we get under the age of 12 months, we worry about something called botulism with honey, and also patients, maybe with diabetes or those that would be sensitive to the sugar content in honey. Dr. Sean Kane 07:47 And were there any, let's say, limitations of this 130 patient study that are worth mentioning? Narrator - ? 07:53 What's interesting when you read the fine print of this particular trial, it was funded by the National honey board. Dr. Sean Kane 07:59 That sounds like a conflict of interest to me. Narrator - ? 08:01 Sometimes it might be, let's hope that this was a peer reviewed article and research study, and that maybe that was vetted before it hit the press. Dr. Sean Kane 08:11 So we have a lot of things that are fairly simple interventions, that are essentially no harm and very minimal cost to the patient. But if a patient needs pharmacologic therapy, what are some of the things that we can consider, at least, to recommend to the patient? Speaker 2 08:25 So we're talking about antitussives here, but even before we approach that point, we need to figure out whether this is more of a dry cough or whether this is more of a productive cough, because that's gonna segue your therapy in those directions. So let's say you have a patient coming in and you've asked the pqrsd question and figured out it's more of a dry cough. And then you can go ahead and approach with either systemic antitussives or topical antitussives. So we kind of have sections under, you know, subsections too, so a few agents fall under your systemic antitussives. And first and foremost, we can start off with codeine, everyone's favorite, right? So currently, codeine over the counter is scheduled as c5 and for it to be considered c5 or schedule five drug it, we need to make sure there is no more than 200 milligrams per 100 ml of the medication quantity. And another fact has to be true, that one other active ingredient has to be non coding, so we're not talking about flavoring agent or sweetener or anything like that. Dr. Sean Kane 09:35 So correct me if I'm wrong, but is codeine the only or codeine with another product, and that the only scheduled self care product that you would find over the counter. Or are there other over the counter scheduled products on the market as well, Speaker 1 09:46 though it honestly doesn't come up much in practice, codeine and dihydrocodeine are two products which you technically can get, you know, at certain concentrations, and which vary state to state, and which under that amount. For example, in Illinois. You can go up there, and as long as you provide two forms of identification, you can go up there, and you would be able to feasibly pick up an amount of the behind the counter. But these are medications that not generally are kept behind there. It's one of those artifacts for, you know, a trivia or for law classes we talk about that that can be done. But again, in practice, these quantities not usually kept, but feasibly you would be able to get. And every state differs in that, in terms of how old you have to be, what the concentration is, and how much you can get. Dr. Sean Kane 10:27 So in terms of how codeine works, as an example, is going to increase the threshold for coughing deep in the brainstem, just like any of our other opioids would. Just happens that this is one of the opioids that is more or less available over the counter. Narrator - ? 10:41 Well, I think why codeine is even being discussed with when we talk about a lot of these things, it's the gold standard by which other things are compared. And so when we look at dextromethorphan, for instance, that is compared to codeine as far as its efficacy as well as potency, Speaker 2 10:56 and as we talked about how it's working, in CNS, we're going to see lot of CNS related side effects. So things like sedation, dizziness comes along with that. We talked about the opioid like, nature of codeine as well, and that's where we're going to see some of the GI issues like constipation and nausea, vomiting come through. Speaker 1 11:12 And one of the things that has come up a lot is, as we've looked at, for example, at our facility, look at the opioid safety initiative, it's really come about the caution in terms of respiratory depression. So we talked about, again, the role in the medulla. But what they also can do is look at the body's ability to sense oxygen versus CO two levels. The way I always explain to my patients, it's like, just like your car, in a crude sense, has the ability to sense oxygen levels your body does as well, and to know when you should be increasing or decreasing respiration that can be suppressed a little bit. And so you do have to be aware of that for, you know, maybe a decreased respiratory drive and that CNS to suppression. So if you have somebody who has COPD asthma, something sleep apnea, for example, you have to be careful. Dr. Sean Kane 11:56 So, Dr. Patel, are we recommending codeine in children? Or is this more of an adult product, or does it vary? You know, what age group are we using this medication for? Speaker 2 12:05 So if you look at the labeling, they do have recommendation for dosing for kids six to 12. However, the safety and efficacy is not really established in children. So I'm going to say we're going to limit this to adult patient only, Dr. Sean Kane 12:20 and I will say just to get a plug in for genomics, codeine is one of those products that has to be activated to a more potent version of coding in the body through an enzyme system in the liver that has a lot of variability. So some patients will be very sensitive to coding. Some patients will be very not sensitive to coding, which, again, is kind of beyond the scope of the podcast, but it's an interesting thing about how coding acts in the body, hopefully we have safer medications, aside from coding that don't have some of this variability, some of the respiratory depression, things like that, that may be more available as a cost suppressant. Narrator - ? 12:51 I wouldn't necessarily call it safer, if you will. But dextromethorphan is available. The other issue with dextromethorphan is around efficacy, and does this even work or not? And so that's a very debatable topic, and I don't think we do have a good answer one way or the other. There are proponents that say, do not use dextromethorphan because its efficacy is not great, but it is very similar to codeine as far as its potency, as long as we dose it correctly, and has similar properties, but lacks the opioid like analgesic effects, doesn't cause the respiratory depression, but we still see dependence on this particular product, and it is a huge problem in our adolescent population and abuse potential. So many states have taken the measure of placing age limitations to be able to purchase dextromethorphan over the counter. So because there so Dr. Sean Kane 13:40 because there is an abuse potential for this particular medication, certain stores certain states may have restrictions based on age or need for identification to actually purchase the product. Pharmacists should be aware that you know, for anyone purchasing a large quantity of dextromethorphan containing products that it does have an abuse potential. And of course, you should use your own judgment, in addition to any restrictions that you have from your store, from your state, and a lot Speaker 1 14:06 of that is is due real quick, to some of the effects on certain neurotransmitters. That's also the same reason why there's a drug interaction with monoamine oxidase inhibitors or MAOIs, not only used too much again for some forms of depression and Parkinson's, but you need a 14 day washout. And that's the same thing for most antidepressants as well. And it's also in the as an interesting fact. It's also why it potentially shows up as a false positive for PCP, is due to some similarities there. Dr. Sean Kane 14:29 And you're going to see dextromethorphan in a lot of different combination products that are available in the cough and cold aisle, just to mention two. Specifically, one is Delsym, which is an extended release liquid product of dextromethorphan that lasts 12 hours, which is nice if you want to suppress cough over, you know, over a sleep of eight hours, let's say where the patient won't have to redose during the night. And then also, typically, when people say dextromethorphan, they're thinking of Robitussin. But you should know that Robitussin comes in a bunch of different ingredients of. Varieties and flavors and things like that. That's those line extensions, exactly. So you're not necessarily getting dextromethorphan with Robitussin, but classically, Robitussin was dextromethorphan before it came out into nine different variations Speaker 2 15:13 of it. Yep. And then, since we're talking about more, so of the liquid products, be always aware of the added sugar component for your diabetics, some of these products can be made as an elixir, which can also include a small amount of alcohol. So using certainly religiously sensitive people as well as religiously sensitive patients as well as children, should be also accounted for. Dr. Sean Kane 15:36 So another medication that commonly comes up with with as an antitussive is diphenhydramine or Benadryl. So is this any particular type of cough we mentioned, dry versus productive cough, so it's going Narrator - ? 15:48 to be used mostly for your dry cough. When you look at the American College Chest Physicians, what they attribute a lot of the dry cough symptoms to is post nasal drip, and this is one of their recommendations, is to combine a first generation antihistamine with a decongestant to treat cough. So it is FDA approved as an antitussive, again, mostly for the dry cough. It is important to note that only the first generations would work for this, second generation antihistamines are not recommended to treat cough. Dr. Sean Kane 16:16 When you say second generation, you mean loratadine, for example, or Narrator - ? 16:19 Claritin (loratadine), Zyrtec (cetirizine), and fexofenadine, so those would not be included. But I would argue, even the other agents that are not FDA approved but are still first generation antihistamines, chlorpheniramine and brompheniramine, would probably have similar action against cough. It's just we don't see that as an FDA approved option. Dr. Sean Kane 16:38 So again, in thinking of our PQRS ta question, you probably would be recommending this only for that post nasal drip patient, or would it be a blanket recommendation for you? Narrator - ? 16:47 I might use it really because of the sedative effects that we'll see with the first generation anti histamine, probably for nighttime cough that's keeping someone up, also maybe for that post nasal drip but I would be careful again, just because of the drowsiness, and so I would lean towards using this at night only, and then all of the same adverse effects and cautions would apply when we talk about the anticholinergic effects of the first generation antihistamines. Speaker 2 17:13 Yeah, what is interesting to make a distinction, as we all know that this is an antihistamine, but when we are dosing for its antitussive effect, that the dose is a little bit lower than the antihistamine effect. Speaker 1 17:26 And as Dr. Angelo alluded to, the one thing with this medication is we do have to watch for certain kind of side effects. Since it is a first generation antihistamine. What that means is this is one that has CNS penetration, which is why you have the antitussive effect. Then it also brings with the drowsiness, again, which could be a benefit or a side effect, depending upon how you're using it, respiratory depression, blurred vision, urinary retention, dry mouth, dry respiratory secretions, all those anti sludge effects owing to that anti muscarinic anticholinergic effect, again, that Dr. Angelo and Dr. Patel alluded to, Speaker 3 17:58 which means we would have certain patients we would avoid use in correct yes, definitely. Speaker 1 18:03 Again, a couple things we have to watch for would be those that, you know are having some some issues with, with urinary retention, for example, be a big population. Again, working at the VA, that's we think about a lot is so if that is a concern there, you know, we can potentially then have somebody with too much to the point of, you know, again, a block, for example, you have to watch for use in children as well some of that paradoxical excitation that can occasionally occur. Speaker 2 18:28 So that kind of concludes the section on oral antitrust, and we can move on to discuss some of the topical antitrustives that are available. So what kind of agents are available in this category. Dr. Sean Kane 18:41 So the two main topical anti tests that are FDA approved are camphor and menthol, and you're going to find this as a lozenge and inhalation ointments cream. So there's a lot of different dosage forms that are available for these topical products. Speaker 2 18:57 The big question is, you know, how do they really work? What is the underlying pharmacology of it, Speaker 1 19:03 we believe, is that some of the vapors there so as they as they dissolve or as they come out, you know, as you inhale them, the vapors there stimulate some of the sensory nerve endings within the nose and the mucosal so you end up with an anesthetic sensation. And you also get, subjectively, some improved air flow there. Is that cooling nature to them, and they come in a couple different formulations. As you mentioned, there's lozenges menthol, five to 10 milligrams every couple of hours that also use something called pectin in there as well. Speaker 2 19:32 And pectin's job is to basically relieve some of the irritation and inflammation that could be there, right? Narrator - ? 19:38 It doesn't have the same effect as camphor and menthol. We think of camphor and menthol. We're going to see that in a variety that in a variety of products. It's also a counter irritant. So I see hot for instance, comes to mind. Obviously the dose in an antitussives is going to be much lower, and when we get into the lower ranges, or the lower percentages with these two agents, we see more of that local anesthetic effect. Um, then we would the counter irritant effect, right, as Speaker 1 20:01 Dr. Patel said, with the pectin and kind of, also the coating effect is the most toggle. So that combination, so you get the antitussive, and then the other one too. So then, if it is a direct irritation there, you can kind of coat it, and then that's also some of that, that itchy, scratchy nature there as well. Dr. Sean Kane 20:16 So we mentioned that this camphor and menthol also comes as an inhalation product. How is this actually delivered to the patient? Narrator - ? 20:24 This is oftentimes, if we're using it from an inhalation perspective, in the liquid form, and we're going to add it to a vaporizer. So I think of sort of the Vicks products, or the Vicks line that has the liquid, and then as the vaporizer gets hot and starts releasing steam. It vaporizes the medication into the air, and so this is then what the individual ends up inhaling to help relieve cough and cold symptoms. Dr. Sean Kane 20:52 So patients would have to, we mentioned, kind of a cold vaporizer that wouldn't work. You really need this warmed vaporizer. Narrator - ? 20:58 Then usually we see these affiliated with the vaporizer. So the humidifiers, which are typically cold air. And then the other way, we when we look at inhalation, we think of it more as the Vicks VapoRub, or the cream that is supposed to be applied to the individual's chest. Again, it's relying, it's not absorbing through the chest and helping with any sort of lung effects. What's happening is it's it's allowing the child, or even the adult using it to inhale the vapors, to help relieve symptoms. Dr. Sean Kane 21:28 And of course, you know, with any product, you have to be careful where you're putting it, so putting that directly in the nose is probably not a great idea. Putting it on your mouth or anywhere that it would be absorbed, like open skin or open source, not a great idea. It's also flammable. You know, it's menthol. It has the potential to catch fire. Narrator - ? 21:46 We've seen a lot of toxicity issues when individuals apply these to kids in the wrong places, the nose, the mouth, because then we have more toxic effects from these. Dr. Sean Kane 21:56 So we just talked about antitussives in terms of agents to help prevent, you know, the irritation of a cough, or to prevent cough that causes irritation. Where does guaifenesin fit in terms of why we're using it as a cough and cold product? Speaker 2 22:11 So guaifenesin falls under a class called protussive. So concept sounds a little bit, you know, contrary is written. We have cough, but now we're trying to produce more phlegm, and so this guaifenesin actually is for cough that is more of a productive cough that is a little bit thicker, and the patient's respiratory reflexes are not enough to bring up the cough from the chest. What it is going to do is basically thin out the mucus and loosen the mucus, making it more productive so your respiratory reflexes will be able to bring it out. Dr. Sean Kane 22:50 And really, like when you look at guaifenesin on a label, it won't say protussive, so typically it'll say expectorant, right, correct, which is funny, because patients don't know what an expectorant is, and you know it's important, again, from the pharmacy side to educate them why they're getting these different products. Some patients may not want to cough stuff up, and they might not be happy if they give them a medication that makes it so that they're spinning up more gunk, which probably is a good thing for them, but maybe that's not exactly what they want to pay money to have happen. Narrator - ? 23:19 Well, then why would they combine a protussive with an antitussive? So often you see those combination products that have both dextromethorphan and guaifenesin in them. Speaker 2 23:28 Yeah, that was always my pet peeve. One of the products available over the counter, it's like two negatives put together, and that kind of equalizes the effect. So what's the point of even using it? And that's where I think the URL SD or the scholar Mac approach comes a little bit more where you really tune down and see whether it's productive cough, whether it's dry cough, and trying to tell patients to use simple products and not combination products, if not needed, per Narrator - ? 23:55 se, that makes sense. And trying to figure out when the cough is happening and we're trying to suppress it. I, you know, I hear patients complain they're at work, or they're trying to sleep at night, or they're giving a presentation. And so these are all reasons that the antitussive would be important, whereas where I would recommend an expectorant, such as guaifenesin, is where they're okay coughing, so maybe they're at home and they want to get some of that stuff out that's obviously causing issues. And so that's where I would lean towards a protussive Dr. Sean Kane 24:26 like many of our older drugs, like guaifenesin, the efficacy of guaifenesin isn't well established as something that will absolutely just make all the mucus pop out of your lungs. You know, this is one of those medications that we've used for a long time, and we just don't have the kind of data that we would require now for any new product entering the market. Speaker 2 24:45 One thing we do want to educate the patient about is this product the way it's working. It needs some fluid to thin out the mucus, so make sure you're asking patients to drink plenty of fluids when they're taking the guaifenesin Speaker 1 24:58 and then, as much as you know. We talked about mechanistically, it sounds very simple. There are some adverse drug reactions that have been noted that we do have to watch for, things like nausea, vomiting, dizziness, headache, rash, diarrhea, drowsiness, stomach pain, very generalized, but just an awareness that those kinds of things can occur. Dr. Sean Kane 25:16 And again, just like our dextromethorphan, there are some dosage form things to know about with guaifenesin, specifically, there is a product called Mucinex, which typically has an extended release product that lasts 12 hours. So most of the time when you see guaifenesin, especially as a combo product or as a liquid, the immediate release has to be taken every four hours, whereas the Mucinex will actually be taken every 12 hours. So not every guaifenesin product is created equal. So the Mucinex is kind of like the Delsym of the guaifenesin market, and that it lasts a lot longer. And it depends on the patient and what their ability to redose is and how effective it is for them. Narrator - ? 25:58 like that. Sometimes just increasing their water intake, that's all they really need. So that's definitely a point I would make with patients. Dr. Sean Kane 26:05 So in terms of special populations, I understand that there's been a lot of discussion about the use of these cough and cold products for children, Narrator - ? 26:14 there are some safety issues, mostly around improper dosing, or children getting into the medications unsupervised, ending up in the emergency department. And so back in 2008 2009 is where we started seeing some changes around these products. And so in 2008 that's where the FDA warned against using all these cough and cold products and children under the age of two. And then as more data came available about some of these dosing issues and overdosing, if you will, in 2009 most manufacturers of cough and cold products that had joined this whole charge to voluntarily change their labeling, and so they decided to stick on their label do not use in children under The age of four. So it became, if you will, more strict than the FDA. Dr. Sean Kane 27:04 We actually saw something similar that happened with Tylenol dosing, where the FDA said four grams a day was the mix, and then the manufacturer of Tylenol said, hey, you know what? We're going to decrease it voluntarily to three grams per day, right? Speaker 2 27:15 That happens all the time, and it kind of ties our hands, per se, what to do for those little kiddos. They're, you know, in between the two and four, where FDA really wanted to be less than two, but the labeling says less than four. And working in a family practice clinic, I get this frustration and questions all the time, and my silly recommendations for a lot of better term of, you know, increase in humidity and make sure their fluid intake is higher. Does not fly by because, you know, moms come, they are severely in distress, along with their kids, and they're really looking for some help. Speaker 1 27:52 And then one other thing to note, with these, these age recommendations, come a little bit of clarity, more recently, about the dispensing devices. So you want to make sure that you are dosing a medication, and we do respect the medication dose, it appropriately. So they said into that you have the FDA guidance that you have to include some sort of a dosing device, whether it's a cup or whether it's a little spoon to go with it. And the device has to be caliber to the dose that's recommended. So it's supposed to be a teaspoon, than a teaspoon, a tablespoon, than a tablespoon, and really only use it with that particular product. And it needs to be remain visible in the markings, even when the liquids on the device. So you kind of want to make sure that you can still measure and again, just to make sure you are getting the dose that you're Speaker 2 28:28 supposed to be getting, that that's kind of pertains to not just cough and cold products, but any over the counter children, products that are there. And sometimes it becomes harder for when the kids are traveling and mom's carrying, you know, one bottle and one measurement that's more generic, and that's pretty much a no. No. Is what those guidelines are trying to say, is that you have to carry specific measuring device that pertains to a specific product. Dr. Sean Kane 28:51 So in terms of another special population, or the pregnant patient, or the female patient who's lactating, in terms of some of the medications that we discussed, codeine is a category C. Clearly, we're worrying about respiratory depression of the baby, so it's really a risk versus benefit in terms of how bad that cough is. Dextromethorphan is also category C, as we discussed, we're going to get less respiratory depression from dextromethorphan than codeine, but it's still the same category diphenhydramine, Benadryl, Category B, as we discussed, especially in the younger population, even though we view Benadryl or diphenhydramine as a sedating medication, you can get this paradoxic excitation or irritability for the infant, and it may also decrease breast milk production. And then finally, guaifenesin is category C, really. We have very little evidence for its use in pregnancy, and again, thinking about the efficacy of it, given that we have not a lot of data and not a lot of efficacy, I don't know that this is something that I'd be readily recommending to a patient. Speaker 1 29:49 So then within the elderly, we also have to be concerned. You know, both spectrums, so in the elderly and codeine induction with orphan, you do have to watch for some of the things we've alluded to, excess. Of sedation and drowsiness. So, you know, body's ability to metabolize the drugs a little bit lesser. So you may see that increased risk of these side effects if somebody gets older, the other one too, is diphenhydramine, you know, as a first generation antihistamine, is on the according to beers, list as potentially an inappropriate medication to watch for because, again, of the sedation and of the anticholinergic effects and potential, you know, worsening of whether it's cognition or whether it's urinary retention, BPH, certain things like that we do have to be aware of. Dr. Sean Kane 30:28 So given how common cough and cold is, I'm sure we just have a wealth of data to sift through to know what are the most effective medications, what order should we be recommending them in? And things like that, right? You are Narrator - ? 30:40 correct, but unfortunately, we don't have a lot of direction that's been handed to us. When you look at the reviews that we have available and the guidelines that we have available, it's conflicting, and a lot of times it's looking at just how safe are these products in our patients. If I'm comfortable that the patient will use it correctly and it will be safe for the patient, go ahead and try it, as Dr. Patel mentioned, stay away from combination products. Focus on what's most troublesome to the patient, and pick the active ingredient that's going to help them the most and go from there. Speaker 2 31:12 So we really do not have any good evidence of the products. We summarize in terms of dextromethorphan, codeine, or diphenhydramine — even, as Dr. Kane repeated, they're effective for acute cough in adults or children. The evidence for topical antitussives, like menthol and camphor, is even less than what we have available for those oral ones. And as you summarized earlier, Dr. Angelo, that ACCP 2006 guidelines suggest that the common cause of cough is that post nasal drip, and so they're really recommending that first generation antihistamine plus a decongestant to treat the cough, Dr. Sean Kane 31:51 and then, of course, for kind of the symptomatic relief for the patient that really needs to reduce coughing, for a presentation or for the irritation of the throat, something like codeine, dextromethorphan are reasonable for the short term use. They really don't recommend guaifenesin at all. Given the the level of evidence that's available to us about that product, Narrator - ? 32:09 I think as we wrap all of this up, it, you know, as any patient can relate, it's no fun to have a cough, and in some cases, it's very troublesome. And we talked about reasons to refer them, but also things we need to do, as pharmacists and Dr. Patel mentioned, is it an antitussive or a protussive that we're looking for? And so really, what is that chief complaint, and what are they trying to accomplish? Do we want topical or systemic therapy for the patient? Is it going to be safe? Is it going to be effective? And if we can figure out what's causing the cough, that might be helpful as we try to narrow down what our treatment options are. Dr. Sean Kane 32:42 So to kind of wrap up, you know, we've talked about primarily things related to cough and cold, we will be talking about nasal congestion, which is another common symptom with patients who have cough and cold at a future episode. But for right now, just to kind of summarize, one thing that I think is important is that for both dextromethorphan and guaifenesin, we have ER extended release products, and we have our immediate release products, and they are dosed differently. In terms of the ER products, you don't have to take them as long. So Mucinex is a 12 hour formulation. Delsym is a 12 hour formulation. And if you just looked at the active ingredients, you wouldn't appreciate that the dose is different, that the duration is different. So in selecting a product, not only are you looking at the active ingredient, but you're also looking at the formulation to see how it's dosed. Speaker 1 33:27 I know one thing I like to focus on is, again, Benadryl, diphenhydramine, a great medication. One thing to look for and to be aware of just is that it does have those anticholinergic side effects. So again, things like dry mouth, blurred vision. You have to be careful if somebody has benign prosthetic hyperplasia or BPH. Got to watch that they have glaucoma ulcers, and then it does have some of those excitatory effects that happen in some individuals. So you do have to be aware of things like hyperthyroidism, cardiovascular diseases, hypertension, things like that too. And so just be aware that they can potentially exacerbate some of those things. Speaker 2 34:02 Yeah, and segueing off of some of those, you know, special population. We're talking about our tiny patients, you know, who, according to the FDA recommendation, as well as the manufacturer labeling, we can't use some of these product in the less than four year old patients. So what can we do over here? Narrator - ? 34:18 Right? And having Sick Kids is nobody's favorite thing. I'm a huge proponent of humidifiers and vaporizers when we're dealing with kids who have coughing episodes, I think again, our options are limited, but that could be a great opportunity to add moisture to the air, but we could also use a vaporizer if we wanted to add some camphor/menthol as an inhalation option. Speaker 2 34:42 Yeah, and then we didn't previously talk about this, but making sure that, you know, parents know to follow proper vaccine schedules, and making sure their kids have updated whooping cough vaccine as well, because it could be very detrimental in little kiddos. It's a great point. Dr. Sean Kane 34:57 Well, again, that wraps up the cough and cold. At a future episode, we'll be covering nasal congestion, allergies, runny nose, so stay tuned for that. We just couldn't fit it all into one episode. Dr. Angelo, thank you very much for coming. My pleasure. For the audience again, we love five star reviews in the iTunes Store to help us get noticed and climb the chart of the medical podcast. So please do so if you have a chance to give us a five star review with that. I'm Dr. Kane, I'm Dr. Schuman, Speaker 2 35:24 I'm Dr. Patel, and thank you, Dr. Angela, for being here. Thank you for inviting me. You all study very hard. Narrator - Dr. Abel 35:31 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 35:42 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.