Drugs for Cough and Cold

Question 1

What are the drugs for a beneficial cough?

Answer 1

None, do not medicate

Question 2

What are the drugs for a non-beneficial dry cough?

Answer 2

Antitussives:
1) Codeine
2) Dextromethorphan
3) Diphenhydramine

Question 3

What are the drugs for a productive non-beneficial cough?

Answer 3

1) Expectorants:
- Guanifesin

2) Mucolytics:
- Acetylcysteine
- Carbocisteine

3) Mucokinetic
- Bromhexine/ambroxol

Question 4

What are the drugs for rhinorrhoea/nasal congestion/post-nasal drip?

Answer 4

1) Mucoregulator
- Ipratropium

2) Mast cell stabiliser
- cromoglicic acid

3) Antihistamine

4) Decongestants
- sympathomimetics
- nasal glutocorticoids

Question 5

What is the moa of ipratropium?

Answer 5

Mucoregulator:
- SAMA → blocks M3 activation of submucosal/goblet cells mucus secretion
- ↓mucus and sputum

(does not dry basal secretion/↑ viscosity)

Question 6

What are 2 AEs of ipratropium?

Answer 6

Few as little enters systemic circulation via intranasal route:
- unpleasant taste
- dry mouth
- urinary retention in elderly

Question 7

Why is compliance in px Rx Ipratropium and Cromoglicic acid a concern?

Answer 7

Both have unpleasant/bitter taste

Question 8

What is the moa of Cromoglicic acid?

Answer 8

Mast cell stabiliser:
Controls Cl- channels → inhibit cellular activation
1) ↓mast cell granulation by IgE FcεRI crosslinking

2) ↓secretion of inflammatory mediators from eosinophils, neutrophils, macrophages

3) ↑secretion of annexin A1 → inhibit prostaglandin and leukotriene production

Question 9

What are 2 AEs of cromoglicic acid?

Answer 9

1) Unpleasant/bitter taste
2) Throat/nasal irritation
3) Mouth dryness
4) Cough

Question 10

What are 2 nasal glucocorticoids used as nasal decongestants?

Answer 10

1) Fluticasone (rose water odor)
2) Mometasone

Question 11

What is the moa of nasal glucocorticoids (eg. fluticasone, mometasone)?

Answer 11

Anti-inflammatory (COX inhibition → ↓PGI2 and PGE2) → ↓congestion and mucus secretions

Question 12

What is the main AE of nasal glucocorticoids (eg. fluticasone, mometasone)?

Answer 12

Local mucosal dryness and irritation
(Systemic side effects limited by intranasal delivery)

Question 13

How is ipratropium administered?

Answer 13

Intranasal/oral inhalation

Question 14

How is Cromoglicic acid administered?

Answer 14

Intranasal/inhaled

Question 15

How are nasal glucocorticoids (eg. fluticasone, mometasone) administered?

Answer 15

Intranasal

Question 16

How are sympathomimetics used ass decongestants administered?

Answer 16

Oral or intranasal

Question 17

What are 3 examples of sympathomimetic agents used as nasal decongestants?

Answer 17

1) Direct α adrenoceptor agonists
a) α-1 selective: Phenylephrine (oral or intranasal)
b) Non-selective: Oxymetazoline (intranasal) / naphazoline (intranasal)

2) Indirect ↑ NE/E release
a) Pseudoephedrine (oral) / Ephedrine (intransal)

Question 18

What is the moa of sympathomimetics used as nasal decongestants?

Answer 18

α-agonism / Indirect → ↑NE/E
→ Vasoconstriction of nasal blood vessels → ↓ inflammation and mucus secretion

Question 19

What are 3 AEs of sympathomimetic agents used as nasal decongestants (eg. phenylephrine, pseudoephedrine)?

Answer 19

1) Rebound congestion
- prolonged (>days) use of topical intranasal decongestants

2) CNS stimulation
- more likely with oral decongestants
- restlessness, tremors, irritability, anxiety, insomnia

3) CVS
- more likely with oral decongestants
- HTN (2° to vasoconstriction)
- Tachycardia (indirect sympathomimetics eg. pseudoephedrine)

Question 20

When are nasal glucocorticoids (eg. fluticasone, mometasone) contraindicated?

Answer 20

<4 y/o

Question 21

When are sympathomimetic agents used as nasal decongestants (eg. phenylephrine, pseudoephedrine) contraindicated?

Answer 21

Caution in elderly and <12 y/o

Question 22

What are 3 antitussives?

Answer 22

In order of potency, decreasing order of addictiveness

Opioid:
1) Codeine

Non-opioid:
2) Dextromethorphan
3) Diphenhydramine

Question 23

What are 2 AEs of using codeine as an antitussive?

Answer 23

1) CNS sedation
2) Abuse @ high dose (weak opioid)
3) Respiratory depress (only at @ dose)
- risk in px with severe respiratory insufficiency
4) Do not combine with other CNS depressants
5) Do not combine with CYP2D6 ultra-rapid metabolisers

Question 24

What are 2 AEs of using dextromethorphan as an antitussive?

Answer 24

1) CNS:
- drowsiness, dizziness, confusion, insomnia, excitement, nervousness

2) GIT
- nausea, vomiting, stomach pain

3) Abuse at high dose
- dissociative anaesthetic-like effect

4) Others:
- nonselective serotonin reuptake inhibitor
- sigma-1 receptor agonist
- (at high-dose) NMDA receptor block

Question 25

What are 2 AEs of using Diphenhydramine as an antitussive?

Answer 25

1) Sedative 2) Anticholinergic

Question 26

How antitussives (eg. codeine, diphenhydramine, dextromethorphan) administered?

Answer 26

Oral

Question 27

How are expectorants (eg. guaifenesin) administered?

Answer 27

Oral

Question 28

When is codeine contraindicated?

Answer 28

1) <18 2) With other CNS depressants 3) With other CYP2D6 ultra-rapid metabolisers

Question 29

When is dextromethorphan not recommended?

Answer 29

<4 years old

Question 30

What is the moa of guaifenesin?

Answer 30

↑ production of respiratory tract fluids → liquefy + ↓ viscosity of tenacious secretions

Question 31

What are 2 AEs of guaifenesin?

Answer 31

1) GI disturbances 2) Nausea

Question 32

What should px taking guaifenesin be advised?

Answer 32

Take adequate fluid to make secretions less viscous and protect renal function (nephrolithiasis reported on overdose)

Question 33

When is guaifenesin contraindicated?

Answer 33

1) <2 y/o (caution <6) 2) persistent cough associated with asthma or smoking

Question 34

When are mucolytics (eg. acetylcysteine, carbocisteine) contraindicated?

Answer 34

1) Elderly or debilitated px with severe respiratory insufficiency 2) px with asthma 3) Carbocisteine for px with active PUD

Question 35

How are mucolytics (eg. acetylcysteine, carbocisteine) administered?

Answer 35

1) Inhalation 2) Effervescent tablets 3) Oral granule/syrups

Question 36

What is the moa of mucolytics (eg. acetylcysteine, carbocisteine)?

Answer 36

Free sulfhydryl group opens disulphide bonds in mucoproteins → ↓ mucous viscosity

Question 37

What are 2 AEs of mucolytics (eg. acetylcysteine, carbocisteine)?

Answer 37

1) Bronchospasm 2) Anaphylactoid rxns (rash, hypotension, dyspnea, wheezing) 3) GI disturbances

Question 38

What are 2 examples of mucolytics?

Answer 38

1) Acetylcysteine 2) Carbocisteine

Question 39

What is an example of an expectorant?

Answer 39

Guaifenesin

Question 40

What is an example of a mucokinetic?

Answer 40

Bromhexine and its active metabolite ambroxol

Question 41

What is the moa of mucokinetics (eg. bromhexine, ambroxol)

Answer 41

Mucokinetic: promotes mucus clearance 1) ↑ ciliary beat frequency 2) ↑ adherence of mucus to cilia 3) Stimulate surfactant production (prevent mucus sticking to walls) 4) Antioxidant as free radical scavenger 5) Anti-inflammatory by ↓ cytokines 6) Suppresses influenza virus multiplication 7) Local anesthetic by blocking voltage-gated Na+ channel

Question 42

What are 2 AEs of mucokinetics (eg. bromhexine, ambroxol)?

Answer 42

1) Allergic rxn 2) Cutaneous AEs

Question 43

When should mucokinetics (eg. bromhexine, ambroxol) be avoided?

Answer 43

1) px with Hx of asthma and PUD 2) caution <6 y/o 3) contraindicated <2y/o

Question 44

What is the best medication for cough and cold in pediatric px?

Answer 44

None, just observe, mostly self-limiting.

Question 45

Which of the cough and cold medications are safe for pediatric use?

Answer 45

None <2y/o

Question 46

Which of the cough and cold medications are safe for geriatric use?

Answer 46

1) expectorants (Guaifenesin) 2) Mast cell stabilisers (Cromoglicic acid) 3) Mucoregulators (Ipratropium) 4) Nasal glucocorticoids (fluticasone, mometasone)