1. COUGH AND COLD PREPARATIONS
ANTIHISTAMINE
Diphenhydramine
DECONGESTANTS
MUCOLYTICS
Acetylcysteine
EXPECTORANTS
Guaifenesin
COUGH SUPPRESSANTS
Codeine
DM (dextromethorphan)

2. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop Summary 2008
Mucolytic (mucokinetic, mucoregulator) agents. (ambroxol, erdosteine, carbocysteine, iodinated glycerol): Although a few patients with viscous sputum may benefit from mucolytics (124, 125), the overall benefits seem to be very small. Therefore, the widespread use of these agents cannot be recommended on the basis of the present evidence (Evidence D).

3. There is no evidence to support the use of heliox, DNase or mucolytics for the treatment of acute asthma in childhood.
UK, Feb 2009
British Guideline
on the Management of Asthma, 2008

4. Overview of the Evidence for Cold Therapies in Children Therapy
Table 2
Overview of the Evidence for Cold Therapies in Children
Therapy
Study findings
Cough (Cochrane review [seven studies])5; one RCT10
Antihistamines
Two studies: no benefit
Antihistamine/decongestant combination
Codeine plus guaifenesin (Robitussin AC)
One study: no benefit
Dextromethorphan (Delsym)
Dextromethorphan plus guaifenesin (Robitussin DM)
Dextromethorphan plus salbutamol*
Mucolytic (e.g., Letosteine*)
One study: benefit
Other combinations
Congestion and rhinorrhea (Cochrane reviews [four studies]6)
Two studies (one using astemizole†): benefit
Decongestants
No studies
2007 American Academy of Family Physicians.

5. Antihistamines
Drugs that directly compete with histamine for specific receptor sites
Two histamine receptors
H1 (histamine1)
H2 (histamine2)
H1 histamine receptor- found on smooth muscle, endothelium, and central nervous system tissue; causes vasodilation, bronchoconstriction, smooth muscle activation, and separation of endothelia cellss (responsible for hives), and pain and itching due to insect stings
H1 antagonists are commonly referred to as antihistamines
Antihistamines have several properties
Antihistaminic
Anticholinergic
Sedative

6. Antihistamines: Indications
Management of:
Nasal allergies
Seasonal or perennial allergic rhinitis (hay fever)
Allergic reactions
Motion sickness
Histamine-mediated disorders
Allergic rhinitis (hay fever, mould and dust allergies)
Anaphylaxis
Angioneurotic edema
Drug fevers
Insect bite reactions
Urticaria (itching)

7. ACCP Cough guideline
Patients with acute cough (as well as postnasal drip [PND] and throat clearing) associated with the common cold can be treated with a first-generation antihistamine/decongestant (A/D) preparation (brompheniramine and sustained-release pseudoephedrine). Naproxen can also be administered to help decrease cough in this setting. Level of evidence, fair; benefit, substantial; grade of recommendation, A
In patients with the common cold, newer generation nonsedating antihistamines are ineffective for reducing cough and should not be used. Level of evidence, fair; benefit, none; grade of recommendation, D
Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006 Jan;129(1 Suppl):72S-4S.

8. Antihistamines Ex: Diphenhydramine, chlorphenamine, brompheniramine
MOA: H1 blocker; competes with receptor sites in resp. tract, GI, blood vessels
Adv eff:
CNS drowsiness, headache, fatigue, nervousness, dizziness
Anticholinergic (drying) effects, most common
Dry mouth
Difficulty urinating
Constipation
Changes in vision
Arrhythmia, hallucinations, heart block, paradoxic excitability, respiratory depression, sedation, tachycardia,
GIT: appetite increase, weight gain, diarrhea, n/v
Arthralgia, pharyngitis

9. Antihistamines:
Contraindicated in the presence of acute asthma attacks and lower respiratory diseases
Use with caution in increased intraocular pressure, cardiac or renal disease, hypertension, asthma, COPD, peptic ulcer disease, BPH, or pregnancy

10. Nonsedating/Peripherally Acting Antihistamines
Developed to eliminate unwanted side effects, mainly sedation
Work peripherally to block the actions of histamine; thus, fewer CNS side effects
Longer duration of action (increases compliance)
Examples: cetirizine (virlix), fexofenadine(allegra)

11. ACCP Evidence-based Clinical Practice Guidelines,
In patients with the common cold, newer generation nonsedating antihistamines are ineffective for reducing cough and should not be used. Level of evidence, fair; benefit, none; grade of recommendation, D
Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006 Jan;129(1 Suppl):72S-4S.

12. Decongestants

13. Oral Decongestants Prolonged decongestant effects, but delayed onset
Effect less potent than topical
No rebound congestion
MOA: Exclusively adrenergics
Example: pseudoephedrine, Sinutab, Dristan, Tylenol cold, Sudafed
Adverse effect:
agitation, anorexia, dysrhythmia, dystonic reactions, headache, hypertension, irritability, nausea, palpitations, seizure, sleeplessness, tachycardia, vomiting

14. Phenylpropanolamine has been associated with an increased risk of hemorrhagic stroke (bleeding into the brain or into tissue surrounding the brain) in women. Men may also be at risk. Although the risk of hemorrhagic stroke is low, the U.S. Food and Drug Administration (FDA) recommends restricted use of phenylpropanolamine.

15. Topical Nasal Decongestants
MOA: Adrenergics
Constrict small blood vessels that supply URI structures
As a result these tissues shrink, and nasal secretions in the swollen mucous membranes are better able to drain
Topical adrenergics
Prompt onset
Potent
Sustained use over several days causes rebound congestion, making the condition worse
COMPOSITION: Each 1 mL of solution contains:         Phenylephrine HCl        5 mg         Pheniramine Maleate        2 mg

16. Nasal Decongestants:
Decongestants may cause hypertension, palpitations, and CNS stimulation
Repeated use of nasal decongestants causes a decreased sensitivity to their vasoconstrictor effect and a rebound phenomenon with increased nasal congestion and discharge.
Clients on medication therapy for hypertension should check with their physician before taking OTC decongestants
Assess for drug allergies

17. Topical Nasal Decongestants (cont’d)
Intranasal steroids
beclomethasone dipropionate
flunisolide
fluticasone

18. MUCOLYTICS

19. Mucolytics ACETYLCYSTEINE
MOA: free sulfhydryl grp opens up disulfide bonds in mucoproteins
= ↓ viscosity
Adv rxns: GI n/v; unpleasant odor
CNS: drowsiness, chills
Resp: bronchospasm, rhinorrhea, hemoptysis
local irritation, clamminess, rash
Dose: 1 sachet through inh.

20. Mucolytic Ambroxol
MOA: breakdown of acid mucopolysaccharide fibers; stimulates synthesis and release of surfactant by type II pneumocytes; stimulates the ciliary activity thereby improving mucokinesis (transport of mucous),
Ambroxol is a metabolite of bromhexine
Adv effects: allergic responses such as skin eruption, urticaria or engioneurotic edema may occur. While used for a long time, epigastric pain, nausea and dizziness may occur.

21. Expectorants

22. Expectorants: Reflex stimulation
Agent causes irritation of the GI tract
Loosening and thinning of respiratory tract secretions occur in response to this irritation
Example: guaifenesin
Direct stimulation
The secretory glands are stimulated directly to increase their production of respiratory tract fluids
Examples: iodine-containing products such as iodinated glycerol and potassium iodide

23. COUGH AND COLD PREPARATIONS Expectorants
GUAIFENESIN MOA: stimulates resp tract secretions = ↑ secretions ↓ viscosity Adv rxns: GI n/v, stomach pains CNS drowsiness, headaches Rashes Dose:100 mg q 4-6

24. Antitussives

25. COUGH AND COLD PREPARATIONS ANTITUSSIVES: OPIOIDS
CODEINE
MOA:: central; depression of medullary center
binds to opiate receptors in the CNS,
= altered perception & response to pain
Analgesic / Narcotic / Antitussive
Adv effects
CNS: drowsiness, dizziness, light- headedness, malaise, headache, restlessness  CNS depression
Resp: shortness of breath, dyspnea
CVS: tachycardia or bradycardia, hypotension
GIT: anorexia, nausea, vomiting
Hepatic: altered liver enzymes (ALT, AST)
gut: decreased iromatopm. Iretera; spasm
Derma: rash, urticaria, burning at IV site
Dose: 30 mg q 6-8h; SR 60 mg BID max 120 mg/day

26. COUGH AND COLD DRUGS ANTITUSSIVES
DEXTROMETHORPHAN (DM) MOA: central: depresses medullary center but lacking narcotic properties exc in overdose • Suppress the cough reflex by numbing the stretch receptors in the respiratory tract and preventing the cough reflex from being stimulated Adv reactions CNS: drowsiness, dizziness, coma Resp depression GIT: n/v, constipation, abdominal discomfort Dose: 10-20mg q 4 or 30 mg q 6-8

27. OTC Restrictions for cough and cold preparations
Medicine and Healthcare products Regulatory Agency in the UK has banned the sale of over the counter cough and cold medicines for babies and young children under the age of 2 as a precautionary measure against accidental overdose because of an increase in reports of adverse reactions linked to overdose.
The cough and cold medicines which will no longer be licensed for children under the age of 2 years, contain the ingredients:
brompheniramine, chlorphenamine & diphenhydramine (antihistamines);
dextromethorphan and pholcodine (antitussives);
guaifenesin and ipecacuanha (expectorants);
phenylephrine, pseudoephedrine, ephedrine, oxymetazoline and xylometazoline (decongestants).
Royal Pharm Society Great Brit, Mar 2009

28. OTC cough and cold restrictions
Health Canada has advised the public that certain over-the-counter cough and cold medicines should not be used in children under 6 years
of age, following a review of additional data. The Agency also says that cough and cold medicines marketed for use in children will require enhanced labelling and packaging and that it is working with
manufacturers to revise the labelling of these products.
New Zealand(2). In December 2007, the Medicines Adverse Reactions Committee (MARC) reviewed the safety and efficacy of cough and cold
medicines in children and recommended that these products should be
contraindicated in children under two years of age, based on limited evidence for efficacy in this age group, an absence of evidence-based dosing, and evidence of significant toxicity in overdose.
The affected products are those containing bromhexine, brompheniramine,
chlorpheniramine, dextromethorphan, diphenhydramine, doxylamine,
guaifenesin, ipecacuanha, oxymetazoline, phenylephrine, pholcodine, promethazine, pseudoephedrine, triprolidine and xylometazoline.
No.2, 2009

29. COUGH AND COLD PREPARATIONS
COMBINATION PREPARATIONS
Colvan: DM + Guaifenesin + Chlorpheniramine + paracetamol
Dynatussin DM + Guaifenesin + Phenylpropanolamine + Na citrate
Tuseran DM + phenylpropanolamine + guiafenesin
Eurocof Guaiafenesin + chlorpheniramine + Na citrate

31. ACCP cough guideline
In patients with cough and acute upper respiratory tract infection (URTI), because symptoms, signs, and even sinus imaging abnormalities may be indistinguishable from acute bacterial sinusitis, the diagnosis of bacterial sinusitis should not be made during the first week of symptoms. (Clinical judgment is required to decide whether to institute antibiotic therapy.) Level of evidence, fair; benefit, none; grade of recommendation, D
Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006 Jan;129(1 Suppl):72S-4S.

32. Other Pharmacologic Treatments
Management of Stable COPD
Other Pharmacologic Treatments
Antibiotics: Only used to treat infectious exacerbations of COPD
Antioxidant agents: No effect of n-acetylcysteine on frequency of exacerbations, except in patients not treated with inhaled glucocorticosteroids
Mucolytic agents, Antitussives, Vasodilators: Not recommended in stable COPD

33. The art of medicine consists of amusing the patient while nature cures the disease. - Voltaire