Cough - OTC Treatment Options PDF

Cough Understanding the Basics and Exploring OTC Treatment Options 12/13/23 1 Outlines • Introduction • Types and Causes of Cough • Treatments options for Cough • OTC Medications for Cough Management • Non-Medication Approaches for Cough Management • Proper Use of OTC Medications • Cough Manage...

Cough Understanding the Basics and Exploring OTC Treatment Options 12/13/23 1 Outlines • Introduction • Types and Causes of Cough • Treatments options for Cough • OTC Medications for Cough Management • Non-Medication Approaches for Cough Management • Proper Use of OTC Medications • Cough Management in special populations 12/13/23 2 Cough “Cough is an important defensive respiratory reflex for airway protection”. Cough is the most common symptom for which patients seek outpatient medical care. It also is a common reason for emergency department visits. 12/13/23 3 Pathophysiology of Cough x Cough is initiated by stimulation of chemically and mechanically sensitive, vagally mediated bronchopulmonary and extrapulmonary sensory nerves in airway epithelium. It starts with a deep inspiration, followed by closure of the glottis and forceful contraction of the chest wall, abdominal wall, and diaphragmatic muscles against the closed glottis. With reopening of the glottis, air is expelled, propelling mucus and foreign material out of the respiratory system. 12/13/23 4 Classification Etiologic Contributors Acute (duration of less than 3 weeks) • Viral upper respiratory tract infection (common cold), acute bacterial sinusitis, acute bronchitis, pertussis, allergic rhinitis. Subacute (duration of 3–8 weeks) • Postinfectious (e.g., Mycoplasma pneumoniae, Bordetella pertussis), congestive heart failure with fluid overload Chronic (duration of more than 8 weeks) • Upper airway cough syndrome (UACS), asthma or asthma-like conditions, gastroesophageal reflux (GERD), COPD, chronic bronchitis 12/13/23 5 Clinical Presentation of Cough Productive cough (a wet cough) serves a useful physiologic purpose: evacuation of secretions from the lower respiratory tract that, if retained, could impair ventilation and the lungs’ ability to resist infection. Non-productive cough (dry cough), which may be associated with viral and atypical bacterial infections, gastroesophageal reflux disease (GERD), cardiac disease, and some medications, serves no useful physiologic purpose. 12/13/23 6 Medications that have been associated with cough Medication groups associated with cough 12/13/23 • • • • • • • • • • ACE inhibitors Antiretrovirals Antifungals Beta-blockers Chemotherapy agents Inhaled medications Immunosuppressants Liposomal drug formulations Monoclonal antibodies (-“mab”) Recombinant DNA drugs (e.g., eltrombopag, filgrastim, erythrocyte stimulating agents, insulin glargine, dornase alfa) • NSAIDs • Tyrosine kinase inhibitors (“-inib”) 7 Medications that have been associated with cough – continue Individual drugs associated with cough >10% 12/13/23 • • • • • • • • • Atovaquone Cinacalcet Desloratadine Glutamine Immune globulin Nicotine Octreotide Pamidronate Sacubitril and valsartan (9%) 8 Treatments 12/13/23 9 Treatment Goals Reduce the number and severity of coughing episodes. Prevent complications. Treatment is symptomatic. Recognition of the underlying condition—the basis for the cough—is required for effective and definitive management. 12/13/23 10 Treatment options Nonpharmacologic Therapy Pharmacologic Therapy • Expectorants for wet cough • Antitussives (cough suppressants) fordrycough • Antihistamines 12/13/23 11 Nonpharmacologic Therapy we Nonmedicated lozenges and hard candies may reduce cough by stimulating production of saliva, thereby decreasing throat irritation. Humidifiers increase the amount of moisture in inspired air, which may soothe irritated airways. Maintaining adequate hydration promotes formation of less viscous secretions that are easier to expel. 12/13/23 12 Pharmacologic Therapy Selection of a medication for self-care for cough depends on the nature and underlying cause of the cough. 12/13/23 13 Pharmacologic Therapy drug list Category Drug name Availability Legal status in Saudi Arabia Systemic antitussives Codeine Not available NA Chlophedianol Not available NA Dextromethorphan Available Prescription Diphenhydramine Available OTC Available OTC Available OTC Antihistamines Expectorants Topical Antitussives 12/13/23 Guaifenesin wetcough Camphor- and mentholcontaining ointments, creams, and solutions 14 Systemic Antitussives • Dextromethorphan is a nonopioid with no analgesic, sedative, respiratory depressant, or addictive properties at usual antitussive doses. I • Dextromethorphan is indicated for the suppression of non-productive cough caused by chemical or mechanical respiratory tract irritation. • Dextromethorphan is abused for its phencyclidine-like euphoric effect. 12/13/23 15 Antihistamines I • Diphenhydramine, a nonselective (first-generation) antihistamine with significant sedating and anticholinergic properties, acts centrally in the medulla to raise the cough threshold. tho e • Second-generation antihistamines (e.g., loratadine, fexofenadine) lack antitussive activity. no caused by chemical or mechanical respiratory tract irritation. • Diphenhydramine is indicated for the suppression of non-productive cough 12/13/23 16 Expectorants EEE see • Guaifenesin is indicated for the symptomatic relief of acute, ineffective productive cough. • Guaifenesin is not indicated for chronic cough associated with chronic lower ooo respiratory tract diseases such as asthma, COPD, or emphysema, or for smoker’s cough. • Guaifenesin purportedly loosens and thins lower respiratory tract secretions, I making minimally productive coughs more productive. 12/13/23 17 Topical Antitussives h I • Camphor and menthol are Locally and internationally approved topical antitussives. • Mechanism of action is not well described, inhaled camphor and menthol vapors stimulate sensory neuron within the nose and mucosa, creating a local anesthetic sensation and a sense of improved airflow; cough reflex sensitivity may be suppressed with these agents. see • Camphor- and menthol- are available in form of ointments, creams, and solutions. • These products are toxic if ingested. Toxic effects include burning sensations in the mouth, nausea and vomiting, epigastric distress, restlessness, excitation, delirium, seizures, and death. 12/13/23 18 Dosage Guidelines for OTC 161 I Dosage (maximum daily dose) Drug Adults/Children ≥12 Years Children 6 to <12 Years Children 2 to <6 Years Diphenhydramine citrate 38 mg every 4 hrs PRN (228 mg) 19 mg every 4 hrs PRN (114 mg) 9.5 mg every 4 hrs PRN (57 mg) Diphenhydramine HCl 25 mg every 4 hrs PRN (150 mg) 12.5 mg every 4 hrs PRN (75 mg) 6.25 mg every 4 hrs PRN (37.5 mg) Guaifenesin 200–400 mg every 4 hrs PRN (2.4 g) 100–200 mg every 4 hrs PRN (1.2 g) 50–100 mg every 4 hrs PRN (600 mg) 12/13/23 19 Complications of cough • Common include exhaustion, sleep deprivation, musculoskeletal pain, hoarseness, excessive perspiration, social embarrassment, and urinary incontinence. • Less common complications include cardiac dysrhythmias, syncope, stroke, pneumothorax, and rib fractures. Mechanical irritation from coughing may cause sore throat. • Cough may lead to prolonged absence from work or school, withdrawal from social activities, and anxiety from fear that the cough is a symptom of a serious illness, such as cancer or tuberculosis. 12/13/23 20 Cough treatment algorithm Patient with cough Obtain medical history and medication history including complementary and alterative medicine: intended use, length/ frequency of use g so 1 Yes Medical referral Exclusion for self care (see next slide) • • No Dry (nonproductive) cough? No • • • Expectorant + Nonpharmacologic treatment Antitussive if the cough affect sleep Reevaluate in 7 day 12/13/23 Yes Yes • Antitussive Nonmedicated lozenges or another topical antitussive Reevaluate in 7 day Yes Symptom improved ? No Medical referral Yes Continue in the treatment until cough gone. Reevaluate as needed 21 When to seek medical attention (Red flags) • Cough with thick yellow sputum or green phlegm infection • Very high temperature • Shortness of breath accompanied by a cough or difficulties of breathing • Chest pain other than solely with coughing. • Haemoptysis (coughing up blood) • Any cough that persists for longer than 21 days • History or symptoms of chronic diseases associated with cough such as asthma, congestive heart failure, chronic obstructive pulmonary disease. • Cough that worsens during self-treatment • Development of new symptoms during self-treatment 12/13/23 22 When to seek medical attention (Red flags) – continue • Children less that 4 years old • Immunocompromised patients • Suspicion of inhaled foreign body • Abnormal respiratory exam (e.g., wheezing, crackles, stridor) • Cyanosis (e.g., bluish or purplediscoloration of lips/mouth, or fingers/hands, which may feel cold to the touch) • Dysphagia • Significant systemic illness • Change in mental status • Dyspnea (breathlessness) 12/13/23 23 Special Populations Non-prescription cough medicines should not be used in infants and children younger than 2 years because of the risk of serious side effects Diphenhydramine is commonly used during pregnancy 9125 Wig Diphenhydramine is excreted in breast milk and may cause unusual excitation and irritability in the infant; it may also decrease the flow of milk. 12/13/23 24 Special Populations - continue First generation antihistamines have potential to be inappropriate medications in older adults because they are more likely to experience dizziness, excessive sedation, syncope, confusion, and hypotension with these medication. Controlled studies on the use of guaifenesin during pregnancy or breastfeeding are lacking. No special considerations have emerged regarding use of guaifenesin by older adults 12/13/23 25 Reading material 12/13/23 Handbook of non-prescription drugs: an interactive approach to self-care. 20th Edition, 2021 (Chapter 12) 26 Thank you 12/13/23 27