Ginseng: Cold & Flu Prevention

• Differentiating the common cold from the flu is critical when considering dietary supplements for prevention and treatment.
• Determining whether supplements are for prevention or treatment is essential as some may only be beneficial in preventing illness, not treating it.

Ginseng

• American Ginseng (Panax ginseng) is primarily used to support immune system function and prevent repeated cold infections.
• It might reduce the risk of respiratory tract infections in immunocompromised patients; use caution due to its immune system effects.
• Siberian Ginseng (Eleutherococcus senticosus), sometimes referred to as Korean Ginseng, has limited evidence suggesting that when combined with andrographis, it may reduce common cold symptoms and shorten their duration.
• American ginseng is preferred over Siberian ginseng.
• Ginseng is not for use during pregnancy or lactation due to potential teratogenic effects.
• Short-term use (up to ten days) is considered safe for adults at doses of 100 to 3000 milligrams per day.
• Short-term use of lower doses (up to 30 milligrams of extracts) has been used in children ages 6 to 17 years without significant adverse effects.
• American ginseng can be standardized to 3 to 5% ginsenosides.
• Siberian ginseng contains eleutherosides, and standardized extracts are usually between 0.1 to 0.3%. It is essential to differentiate based on extract composition.
• Major drug interaction: Ginseng should not be used in patients on warfarin therapy, as it interferes with the INR value and the effectiveness of warfarin.
• Moderate drug interactions: CNS-active drugs, anti-diabetic and anti-hypertensive drugs, and monoamine oxidase inhibitors (MAOIs). These are not contraindications but should be noted.
• Ginseng interferes with the digoxin SCA, leading to falsely elevated digoxin levels.

Echinacea

• Three different species of echinacea preparations are derived: Echinacea pallida, Echinacea angustifolia, and Echinacea purpurea, which are all in the Asteraceae family.
• Echinacea is more of a preventive strategy and might reduce cold symptoms by 50 to 60% in clinical trials if taken preventively.
• It is important to distinguish between the species used, either the roots of Echinacea purpurea or the herb (above-ground parts) of Echinacea angustifolia or Echinacea pallida.
• A lack of consistent clinical study designs exists due to differences in echinacea species and extracts used.
• Most evidence supports echinacea in the prevention of the common cold rather than treatment.
• Most preparations are liquid hydroalcoholic extracts, but some are available in tablet or capsule form.
• The usual dosing is 5 milliliters, two to six times daily, for either prevention or treatment of cold symptoms.
• Root extracts are standardized to alkamides and polysaccharides, while herb (above ground) extracts are standardized to echinacosides and complex polysaccharides.
• There is no identified active ingredient, so standardization may not be linked to effectiveness.
• Traditionally, echinacea has been used for colds, rattlesnake bites, and wound healing and saw wide use among Native Americans.
• Clearer evidence exists for the prevention of the common cold and some anti-inflammatory effects mediated through the inhibition of cyclooxygenase enzymes (COX).
• The aerial parts of Echinacea purpurea are standardized to contain 3.5% echinacoside and can be given in 900 milligrams per day divided into three doses.
• The inhibition of cyclooxygenase two (COX-2) seems to be echinacea's mechanism.
• Root extracts of Echinacea pallida may exert some antiviral and antifungal activities, but the specific compounds responsible are unclear.
• Echinacea should only be taken orally.
• It may cause potential allergic reactions in individuals allergic to the Asteraceae family.
• Use caution with patients on immunosuppressant drugs, as it may interfere with their effectiveness.
• There is no contraindication for use during pregnancy and lactation if standardized doses are adhered to.
• Clinical trials show some evidence that it may reduce the duration and incidence of the common cold if used before symptom onset, but most differences are not statistically significant compared to placebo.
• Allergy has been observed as an adverse effect, as well as mild GI upsetness.
• Concomitant use of chemotherapeutic agents and immunosuppressant drugs should be avoided or carefully monitored.
• Short-term use in children at lower doses and during pregnancy seems safe but should not exceed ten days.
• The most important drug interaction to remember is with immunosuppressant drugs.
• Echinacea may interact with CYP3A4 substrates, but these are generally considered minor.

Elderberry

• Elderberry has emerged recently as an immunostimulant or immunomodulatory drug.
• Primarily the flowering parts are used.
• Historically elderberry was used as a laxative and flavoring agent due to the tasty berries.
• There is some evidence of use and benefit of the extract to activate the immune system and potentially benefit people with influenza symptoms.
• There is no well-established dose range for elderberry.
• A dried berry extract is given in ranges of 400 milligrams to 2 grams.
• In in vitro studies, elderberry extracts prevent the hemagglutination and release of viral particles for both influenza A and B strains.
• Anthocyanins and plant lectins are primarily considered the active ingredients and seem to be responsible for the prevention of hemagglutination.
• There are some moderate drug interactions between elderberry and immunosuppressant drugs.
• The use of dried berry extract is not contraindicated during pregnancy or lactation.

Green Tea

• Green tea is associated with antioxidant and immune modulatory effects.
• Associated traditional benefits include a slight diuretic effect, a stimulant effect due to caffeine, neuroprotective and nootropic effects, and antimicrobial activity.
• One should not exceed 500 milligrams of pure caffeine per day, and this is usually hard to reach with green tea.
• For antioxidant and antiviral activity, the primary focus is on polyphenols, specifically epigallocatechin gallate (EGCG), which is responsible for the antiviral effect.
• Caffeine is responsible for the stimulant and nootropic effects. Note that coffee beans usually have much larger concentrations of caffeine than green tea leaves.
• L-theanine in green tea leaves causes a calming effect via activation of GABAa receptors in the central nervous system.
• The antiviral effect is mediated through catechins, and epigallocatechin gallate is a strong antioxidant with antiviral effects, which has been shown in clinical studies.
• An FDA-approved green tea extract, marketed under the names VERIGEN and polyphenol E, is used for the external treatment of genital warts.
• EGCG and some derivatives are referred to as catechins in this formulation.
• Frequent consumption of green tea and green tea extracts may lead to the prevention of cold and flu symptoms.
• Moderate drug interactions exist due to the caffeine content, primarily with diuretics and antihypertensive agents.
• Major drug interaction with Ephedra, a stimulant (though less commonly encountered now).
• More commonly seen today are interactions with pseudoephedrine or ephedrine, used as nasal decongestants, and they should not be taken together with green tea.

Vitamin C (Ascorbic Acid)

• There has been a lot of controversy around the benefits of vitamin C, especially regarding high doses for preventing or treating the common cold and more so in the treatment of cancer.
• There seem to be some modest effects by reducing the common cold duration by about a day or one and a half days, but results are inconsistent.
• Usually, more than two grams per day are necessary for this modest effect, and it needs to be taken for multiple days.
• With doses above two grams per day over time, there is a higher risk of adverse effects, specifically kidney stones and GI upsetness, primarily diarrhea.
• Kidney stones are a concern for individuals with a history of kidney stones or older individuals with lower kidney function.
• There is really no relationship between vitamin C supplementation and a reduced risk of contracting the common cold in adults or children alike.
• The only route for supplementation is orally.

Zinc

• Zinc is a micronutrient mineral essential in several enzymatic and cellular processes.
• The upper daily limit of intake is forty milligrams.
• Most oral supplementation with zinc lozenges can contain between nine to thirty-four milligrams of zinc in its sulfate or acetate salt form.
• Zinc has been shown (although inconsistently) to reduce the severity and duration of the common cold if taken at symptom onset.
• Zinc nasal sprays remain very controversial because they lead to relatively high absorption, which can displace copper as a central atom in enzymatic processes, potentially leading to copper deficiency.
• Lozenges can be taken every two hours until symptom improvement, but not more than six lozenges per day in adults and four in children should be taken.
• Short-term use of zinc is generally regarded as safe.
• Potential adverse effects are constipation.
• Certain Zicam products that are no longer available were associated with a loss of smell in frequent users, sometimes permanent.

General Considerations for Supplement Use

• The data is quite limited, and supplements should only be considered complementary in addition to pharmacotherapy.
• Avoid recommending supplement use in immunocompromised patients, toddlers, and the elderly, except for vitamin C supplementation in moderate amounts.
• Echinacea effectiveness depends on the extract formulation and dosing (root extracts vs. herb extracts).
• Green tea polyphenol-rich extracts exert antiviral effects, and special formulations (VERIGEN, polyphenol E) are FDA approved for external treatment of genital warts.

Self-Care Management of Allergic Rhinitis

• Allergic Rhinitis is Characterized by Predominantly Bilateral Symptoms, worse in the Morning and at Night.
• Key symptoms include Sneezing, Rhinorrhea, and Pruritus, variable Nasal Congestion or Obstruction.
• Other Possible Symptoms: Conjunctivitis, Pain in the Sinus or Throat, Coughing.
• Physical Signs: Allergic Shiners, Mouth Breathing, Allergic Salute, Allergic Crease.
• Systemic Symptoms: Fatigue and Irritability.

Differentiation of Allergic Rhinitis from Non-Allergic Rhinitis

• Allergic Rhinitis is Predominantly Bilateral with Watery discharge, and Non-Allergic Rhinitis can be Unilateral/Bilateral with Watery, thick, or mucopurulent discharge.
• Timing: Allergic Rhinitis is worse in the morning and at night, and Non-Allergic Rhinitis is present throughout the entire day.
• Sneezing and Pruritus is Common with Allergic Rhinitis and less common with Non-Allergic Rhinitis.

Classification of Allergic Rhinitis

• Intermittent Allergic Rhinitis: Symptoms occur less than four days per week and for less than four weeks.
• Persistent Allergic Rhinitis: Symptoms occur greater than or equal to four days per week and for greater than four weeks.

Severity of Allergic Rhinitis

• Mild: -Symptoms do not impair sleep or daily activities. -No troublesome symptoms.
• Moderate to Severe: -Symptoms impair sleep or daily activities. -May be troublesome symptoms.

Steps To Determine Duration and Severity:

• To classify allergic rhinitis, two steps must be taken. -Step 1: Determine the duration, whether the allergic rhinitis is intermittent or persistent. -Step 2: Determine the severity, whether the symptoms are mild or moderate to severe.

Exclusion Criteria for Self-Treatment

• Referral to a PCP is necessary for those with: -Children under 12 years old: Due to potential cases of undiagnosed asthma. -Exception: If diagnosed with allergic rhinitis by a provider and nonprescription therapy has been approved. -Pregnant or lactating women: Due to potential risks to the fetus or infant. -Exception: If diagnosed with allergic rhinitis by a provider and nonprescription therapy has been approved. -Symptoms of non-allergic rhinitis: Requires different management strategies. -Symptoms of sinusitis, bronchitis, otitis media, or other infection: These infectious processes likely need antibiotic treatment. -Symptoms of undiagnosed asthma: Symptoms mimicking allergic rhinitis might be asthma exacerbations. -Uncontrolled asthma: Allergic rhinitis treatment might worsen underlying respiratory conditions. -Severe unacceptable side effects to recommended over-the-counter (OTC) medications: May require prescription medication for management.

Goals of Therapy

• When recommending treatment, either non-drug or drug, the goals are to: -Manage appropriate expectations: Inform the patient that allergic rhinitis cannot be cured. -Reduce symptoms. -Improve quality of life. -Improve functional status: Especially if symptoms are impacting activities of daily living (work, leisure, school).

Non-Drug Measures

• They can be recommended for all patients as applicable.
• The main non-drug measure is avoidance or reduced exposure to allergens. -Help the patient figure out what allergens (outdoor or indoor) cause their symptoms -Outdoor Allergens (Pollen, Dandruff): -Check pollen counts and air quality online. -Limit or avoid time outdoors when pollen counts are high or air quality is low. -Keep house and car windows shut. -Indoor Allergens (House Dust Mites, Tobacco Smoke, Mold, Cockroaches): -Dust Mites: -Lower household humidity. -Remove carpets, upholstered furniture, stuffed animals, and bookshelves from the bedroom. -Encase mattresses and pillows in dust-mite-resistant coverings. -Reduce Humidity: Ensure proper ventilation in the bedroom, bathroom, and kitchen. -Cockroaches: -Keep kitchen areas clean. -Keep food tightly sealed. -General Measures: Wash bedding in hot water every week.
• Nasal Saline Solutions and Nasal Irrigation: Recommended to all patients with minimal side effects. -Examples: Saline sprays, NetiPot (nasal irrigation). -Mechanism: Relieves nasal irritation and dryness by removing dried mucus and clearing nasal passages. -Important Note for Nasal Irrigation (e.g., NetiPot): Use only distilled, sterile, or boiled tap water to reduce the risk of infection. -Alone or in Combination: Can be used by itself or with drug therapy. -Improved Medication Effectiveness: Using nasal saline or irrigation prior to intranasal medications can improve their effectiveness by increasing contact time with the nasal mucosa.

Drug Therapy Options

• The following medications can be used to treat allergic rhinitis: -Intranasal Corticosteroids -Oral Antihistamines -Intranasal Antihistamines -Oral Decongestants -Intranasal Decongestants -Intranasal Cromolyn
• Timing of Treatment: Ideally, begin treatment at least one week before symptoms typically appear or before an expected allergen exposure, if exposure is predictable.
• Duration of Therapy: Is individualized based on the duration and severity of symptoms and the pattern of allergen exposure (e.g., seasonal pollen, limited exposure).

Simplified Treatment Algorithm/Decision Tree

• The treatment options are listed in order of tiered recommendations, with first-line, second-line, and third-line options.
• Treatment choices are based on the classification of allergic rhinitis, whether the allergic rhinitis is intermittent/persistent and mild/moderate to severe.

Mild Intermittent Allergic Rhinitis:

-First-line: Oral antihistamine OR intranasal antihistamine (assuming no contraindications). -Second-line: Intranasal corticosteroid (if first-line fails or is not suitable). -Reassessment: In one to two weeks. -Controlled Symptoms: Continue therapy as needed. -Uncontrolled Symptoms: -Assess patient adherence. -Try switching to an alternative drug. -Reassess in one to two weeks. -If still no improvement, refer to a PCP for prescription therapy.

Persistent Allergic Rhinitis:

-First-line: Intranasal corticosteroid [N/A - not explicitly stated in the excerpt but implied by the general recommendation for persistent symptoms]. -Reassessment: In one to two weeks. -Controlled Symptoms: Continue for about a month or as long as allergen exposure typically lasts. -Uncontrolled Symptoms: -Review adherence. -If still not managed, refer to a PCP for prescription therapy.

Intranasal Corticosteroids

• Symptoms Managed: Itching, rhinorrhea, sneezing, and congestion.
• Especially Beneficial For: Managing congestion symptoms compared to other drugs discussed.
• Examples: Budesonide, fluticasone furoate, fluticasone propionate, mometasone, triamcinolone. -Example Product: Flonase Sensimist (active ingredient: fluticasone furoate).
• Efficacy: All have similar efficacy and are more effective in managing nasal symptoms compared to oral antihistamines.
• Side Effects: -Nasal discomfort -Bleeding -Sneezing -Cough -Pharyngitis
• Limiting/Preventing Side Effects: Proper technique for using intranasal sprays/products is important.
• Long-Term Side Effects (Important Considerations): -Potential changes in vision -Glaucoma -Increased risk of infection -Growth inhibition in children: Use the lowest effective dose and assess impact on growth with long-term use in children.

Oral Antihistamines

• Symptoms Managed: Itching, rhinorrhea, sneezing (typical allergy symptoms).
• Classes: Divided into first-generation and second-generation.
• Major distinctions between them: -First Generation Oral Antihistamines -Examples: Brompheniramine, diphenhydramine, doxylamine -Much more sedating. -Readily cross the blood-brain barrier. -More common CNS Side Effects (drowsiness). -May cause Paradoxical Excitation (Children). -Present Anticholinergic Effects. -Common Anticholinergic Side Effects: Dry mouth, constipation, urinary retention, dry eyes -Generally not preferred for allergic rhinitis because of the side effect profile, specifically sedation. -Second Generation Oral Antihistamines -Cetirizine, loratadine, fexofenadine. -Cause minimal sedation (less likely to cause drowsiness). -Do not readily cross the blood-brain barrier. -Less common CNS Side Effects. -Not a typical concern for Paradoxical Excitation (Children). -Minimal Anticholinergic Effects. -Less likely to see Common Anticholinergic Side Effects. -Preferred due to more favorable side effect profile.

Intranasal Antihistamines

• Over-the-Counter Example: Astepro (azelastine).
• Symptoms Managed: Similar to oral antihistamines, itching, rhinorrhea, sneezing.
• Also Manages: Congestion, but less effectively than intranasal corticosteroids.
• Side Effects: -Bitter taste -Nasal stinging or burning -Drowsiness

Oral Decongestants

• Symptoms Managed: Nasal congestion.
• Role in Therapy: Considered adjunct therapy or add-on for short-term use only if significant nasal congestion is not managed by other medications.
• Examples: Pseudoephedrine and phenylephrine. -Oral Phenylephrine: Not shown to be efficacious at recommended OTC doses for relieving nasal congestion and not recommended for use. May eventually be pulled from the market due to lack of efficacy. -Recommended Oral Decongestant: Pseudoephedrine (for nasal congestion).
• Side Effects (Pseudoephedrine): Linked to CNS and cardiovascular stimulation due to its sympathomimetic action. -Increased blood pressure -Tachycardia (rapid heart rate) -Palpitations -Restlessness -Insomnia -Tremors -Anxiety
• Cautions: Use cautiously in patients sensitive to these side effects, such as those with underlying cardiovascular conditions like hypertension.
• Duration of Use: Recommend for short-term use only as an add-on therapy.

Intranasal Decongestants

• Symptoms Managed: Nasal congestion.
• Examples: Oxymetazoline and phenylephrine.
• Side Effects: Local effects: burning, stinging, sneezing, and local dryness. Systemic side effects are less likely due to local action.
• Role in Therapy: Can be considered as add-on therapy for nasal congestion.
• Risk of Rhinitis Medicamentosa (Rebound Congestion): Prolonged use can lead to rebound vasodilation causing persistent nasal congestion.
• Duration of Use: Recommend for up to three days only to minimize the risk of rhinitis medicamentosa. Not for routine use.

Intranasal Cromolyn

• Primary Role/Use: Prevention of symptoms before exposure to allergens.
• Timing of Treatment: Begin treatment at least one week prior to expected allergen exposure (e.g., seasonal allergies).
• Side Effects: Sneezing, nasal stinging, and burning (topical side effects).
• Drug of Choice in Pregnancy and Lactation: If allergic rhinitis is diagnosed and approved for use by their PCP.

Combination Therapy

• Availability: Over-the-counter products with multiple active ingredients exist.
• Recommendation: Treat and manage a patient's symptoms with a single-entity product whenever possible.
• Adding Other Agents: Can be done if symptoms are not adequately managed with a single agent.
• Risk of Adverse Events: The more active ingredients a product has, the greater the risk of adverse events.
• Goal: Manage with a single-entity product whenever possible.

Important Counseling Points

• Allergen Avoidance: The mainstay of therapy is educating the patient to avoid exposure to their triggers.
• Appropriate Expectations: -Expect relief of symptoms, but AR cannot be cured. -Some initial relief may be experienced in the first three to four days, with maximum benefits seen in about one to four weeks.
• Regular Use: Medications are most effective when taken on a regular basis instead of as needed, especially for persistent allergic rhinitis. However, for episodic rhinitis, use may be limited to the exposure period.
• Adherence: For regularly scheduled medications, patients should follow the dosing recommendations for the specific product.

Common Cold: Signs and Symptoms

• The common cold is a viral infection of the upper respiratory tract.
• Symptoms onset between one to three days after infection. The initial symptom is typically a sore throat. Nasal symptoms develop two to three days later starting with congestion and clear watery secretions which progresses to thicker yellow or green colored secretions. Cough is present in approximately 30% of patients. Other symptoms: sneezing, chills, headache, fatigue, muscle aches.
• Symptoms usually persist for seven to fourteen days.

Potential risks and complications to consider

• Sinusitis, middle ear infection, bronchitis, pneumonia, and exacerbation of respiratory conditions
• Patients at higher risk: Asthma. COPD. chronic conditions, the immunocompromised, frail and infants.

Exclusion criteria for self-treatment (referral criteria)

• Fever with temperature greater than 100.4 degrees Fahrenheit
• Chest pain, shortness of breath, or worsening symptoms
• Infants under the age of three months

Goals of therapy

• Reduce and manage symptoms that are self-limiting within 7-14 days
• Improve patient functioning and prevent patients from transmitting illness.

Non-Drug Measures

• Recommendations:
• REST: increase fluid intake and maintain balanced diet
• Saline nasal sprays, warm liquids, gargles, nasal strips, aromatic oils, position the body upright
• Perform nasal suction

Preventing transmission

• Focus on hand hygiene, coughing and sneezing etiquette, and regular desensitization of surfaces.

Drug Therapy

• Target specific symptoms
• Recommend decongestants, oral antihistamines, local anesthetics, systemic analgesics, antitussives, and expectorants.

Systemic Decongestants

• Relieve sinus and nasal congestion.
• Example: Phenylephrine
• Common Side Effects: cardiovascular stimulation and CNS stimulation.
• Can exacerbate conditions like hypertension, coronary artery disease and ischemic heart disease.

Intranasal Decongestants

• Relieve sinus and nasal congestion
• Examples: Oxymetazoline and phenylephrine.
• Less intense compared to oral pseudoephedrine
• Recommend for no more than three days to prevent rebound congestion.

Oral Antihistamines

• Manages rhinorrhea and sneezing.
• First-generation examples: More sedating, has anticholinergic effects, and benefit adults.
• Second-generation examples: Less sedating and no anticholinergic effects.

Local Anesthetics for Sore Throat

• Benzocaine: Diclonine and phenol are available as lozenges, or ODT.
• Side effects: Numbness of the mouth. Be aware of potential benzocaine allergies and do not recommend for children.
• Cautiously educate patients to allow the product to dissolve in their mouth rather than consuming.

Systemic Analgesics

• Manage body aches and pain.
• Common analgesics include Ibuprofen and naproxen. Do not recommend Aspirin for any patient recovering from chickenpox.

Antitussives and expectorants.

• Antitussives are used to help manage dry cough, Dextromethorphan is a main product
• Expectorants: used for productive cough.

Combination Therapy

• Try to manage products with a single set of symptoms and be aware of nighttime side effects. When treating products with multiple ingredients, check the label and avoid medications for patients that do not have the symptom.

Special Populations: Pregnancy and Lactation

• Recommend non-drug therapy with topical decongestants line oxymetazoline. Avoid systemic decongestants like pseudoephedrine and use cautiously and monitor.

Special Populations: Pediatrics

• Products non-recommended for children, products must come with a liquid device specified for the product and is only calibrated and do not substitute.

Signs and Symptoms of Cough

• Coughing is a defensive respiratory reflex to expel foreign products from the respiratory tract or lungs.
• Physical effects include fatigue, musculoskeletal pain, sleep deprivation, hoarseness of the throat, and urinary incontinence.
• Psychological effects include embarrassment and avoidance of social situations.

Types of Cough

• Productive cough: Wet cough that helps release secretions (phlegm/gunk) associated with chest congestion due to infections.
• Nonproductive cough: Dry or hacking cough that serves no physiological purpose, such as responses to medications like ACE inhibitors, gastroesophageal reflux disease (GERD), or hypersensitivity secondary to an infection.

Duration of Cough

• Acute: Less than 3 weeks
• Subacute: 3 to 8 weeks
• Chronic: Greater than 8 weeks

Complications of Cough

• Exhaustion
• Musculoskeletal pain
• Sleep deprivation
• Hoarseness of the throat
• Social embarrassment
• Urinary incontinence
• Perspiration
• Sore throat

Exclusion Criteria for Self-Treatment

• Difficulty breathing, shortness of breath, or dyspnea
• Cyanosis (pale or blue lips or skin)
• Hemoptysis (coughing up blood)
• Weight loss
• Night sweats
• Worsening cough after three to five days
• Cough that does not subside after two to three weeks
• Children under the age of four
• Temperature greater than or equal to 100.4°F (38°C) or a temperature greater than 100°F that lasts greater than three days
• Barking cough with an inspiratory stridor
• Severe coughing spell ending with a whooping sound during inspiration
• Sudden cough without fever or upper respiratory infection symptoms
• Immunocompromised patients
• Risk factors for HIV infection
• Individuals whose cough could complicate other infectious diseases
• History of exposure to tuberculosis
• Chronic illnesses

Goals of Therapy

• Reduce the number and severity of coughing episodes
• Prevent complications associated with coughing

Non-Drug Recommendations

• Recommend for all patients
• Non-medicated lozenges or hard candies
• Cool mist humidifier or vaporizer
• Rubber bulb nasal syringe for young children
• Appropriate hydration

Drug Therapy Options

• Target specific symptoms
• Dry (nonproductive) cough: Oral or topical antitussive
• Wet (productive) cough: Guaifenesin

Antitussives (for Nonproductive Cough)

• Codeine: Narcotic opioid with side effects like nausea, vomiting, sedation, dizziness, and constipation.
• Dextromethorphan: Suppresses the cough reflex in the central nervous system, with side effects like drowsiness, nausea, vomiting, stomach discomfort, and constipation.
• Diphenhydramine: First-generation antihistamine with antitussive properties, causing significant sedating and anticholinergic effects.
• Topical Antitussives: Menthol and camphor vapors inhaled from products like Vicks VapoRub, causing skin, nose, and eye burning sensations and irritation.

Expectorant (for Productive Cough)

• Guaifenesin: Purportedly helps loosen and thin out respiratory secretions, with side effects like nausea, vomiting, dizziness, headache, rash, diarrhea, drowsiness, and stomach pain.
• Studies have not proven efficacy as an expectorant.

General Treatment Considerations

• Use single-ingredient products to minimize the risk of adverse events
• Match the patient's symptoms to the ingredient being recommended
• There is a general lack of good evidence for using antitussives, expectorants, and antihistamines to manage acute cough
• Refer to evidence-based guidelines for managing cough symptoms
• Cough symptoms are generally self-limiting
• The patient shoudl be transferred to a primary care provider for worsening symptoms

Specific Population Considerations

• Pregnancy: Dextromethorphan and diphenhydramine are generally considered safe.
• Pediatrics: Use only the dosing device packaged with the product. Non-prescription medications are not indicated for children under the age of four.
• Elderly: May be more sensitive to sedating and anticholinergic side effects; know their medication history before making a recommendation.